MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS AGENTS (Topical) ANTI-INFECTIVE AZELEX () ACZONE () Acne agents will be authorized only for AKNE-MYCIN () patients less than 21 years of age. erythromycin CLEOCIN-T (clindamycin) CLINDAGEL (clindamycin) CLINDAREACH (clindamycin) EVOCLIN (clindamycin) sulfacetamide

RETINOIDS RETIN-A MICRO () AVITA (tretinoin) ATRALIN (tretinoin) DIFFERIN (adapalene) RETIN-A (tretinoin) TAZORAC () TRETIN-X (tretinoin) tretinoin

COMBINATION DRUGS/OTHERS BENZACLIN GEL (/clindamycin) ACANYA (benzoyl peroxide/clindamycin) sodium sulfacetamide/ AVAR (sulfur/sulfacetamide) BENZACLIN KIT (benzoyl peroxide/ clindamycin) BENZAMYCIN PAK (benzoyl peroxide/ erythromycin) benzoyl peroxide/clindamycin benzoyl peroxide/urea CLARIFOAM EF (sodium sulfacetamide/sulfur) CLENIA (sulfacetamide sodium/sulfur) DUAC (benzoyl peroxide/clindamycin) EPIDUO (adapalene/benzoyl peroxide) erythromycin/benzoyl peroxide INOVA 4/1 (benzoyl peroxide/) NUOX (benzoyl peroxide/sulfur) PLEXION (sulfacetamide sodium/sulfur) 1 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PRASCION (sulfacetamide sodium/sulfur) ROSADERM (sulfacetamide sodium/sulfur) ROSANIL (sulfacetamide sodium/sulfur) ROSULA (sulfacetamide and sulfur) SE BPO (benzoyl peroxide) sodium sulfacetamide/sulfur/meratan SULFOXYL (benzoyl peroxide/sulfur) SULFATOL (sulfacetamide sodium/sulfur/urea) VELTIN (clindamycin/tretinoin) ZENCIA WASH (sulfacetamide sodium/sulfur) ZIANA (clindamycin/tretinoin)

KERATOLYTICS (BENZOYL PEROXIDES) benzoyl peroxide BENZAC WASH (benzoyl peroxide) PANOXYL (benzoyl peroxide) BENZEFOAM (benzoyl peroxide) ZACLIR (benzoyl peroxide) BENZEFOAM ULTRA (benzoyl peroxide) BREVOXYL (benzoyl peroxide) CLINAC BPO (benzoyl peroxide) DESQUAM (benzoyl peroxide) ETHEXDERM (benzoyl peroxide) INOVA (benzoyl peroxide) LAVOCLEN (benzoyl peroxide) OSCION (benzoyl peroxide) TRIAZ (benzoyl peroxide)

ALZHEIMER’S AGENTS SmartPA CHOLINESTERASE INHIBITORS ARICEPT (donepezil) ARICEPT 23 MG (donepezil) SmartPA Criteria: ARICEPT ODT (donepezil) COGNEX (tacrine) • History of an approvable diagnosis for EXELON (rivastigmine) donepezil donepezil in the past 2 years EXELON SOLUTION (rivastigmine) • History of an approvable diagnosis for galantamine galantamine in the past 2 years galantamine ER RAZADYNE (galantamine) • History of an approvable diagnosis for RAZADYNE ER (galantamine) memantine in the past 2 years rivastigmine 2 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • History of an approvable diagnosis for rivastigmine in the past 2 years

• History of an approvable diagnosis for tacrine in the past 2 years

• History of at least 30 days of therapy with two different preferred Alzheimer’s agents in the past 6 months

• History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days

NMDA RECEPTOR ANTAGONIST NAMENDA TABS (memantine) NAMENDA SOLUTION(memantine)

ANALGESICS, NARCOTIC - SHORT ACTING acetaminophen/codeine ABSTRAL (fentanyl) /codeine ACTIQ (fentanyl) codeine butalbital/APAP/caffeine/codeine dihydrocodeine/ APAP/caffeine butalbital/ASA/caffeine/codeine hydrocodone/APAP butorphanol tartrate (nasal) hydrocodone/ COMBUNOX (oxycodone/ibuprofen) hydromorphone DEMEROL (meperidine) IBUDONE (hydrocodone/ibuprofen) DILAUDID (hydromorphone) meperidine fentanyl morphine FENTORA (fentanyl) oxycodone FIORICET W/ CODEINE oxycodone/APAP (butalbital/APAP/caffeine/codeine)

oxycodone/aspirin FIORINAL W/ CODEINE (butalbital/ASA/caffeine/codeine) oxycodone/ibuprofen LAZANDA (fentanyl) NR pentazocine/APAP levorphanol tramadol LORCET (hydrocodone/APAP) tramadol/APAP LORTAB (hydrocodone/APAP) MAGNACET (oxycodone/APAP) NUCYNTA (tapentadol) 3 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ONSOLIS (fentanyl) OPANA (oxymorphone) OXYFAST (oxycodone) OXYIR (oxycodone) PANLOR (dihydrocodeine/ APAP/caffeine) pentazocine/naloxone PERCOCET (oxycodone/APAP) PERCODAN (oxycodone/ASA) REPREXAIN (hydrocodone/ibuprofen) ROXANOL (morphine) ROXICET (oxycodone/acetaminophen) RYBIX (tramadol) TALACEN (pentazocine/APAP) TALWIN NX (pentazocine/naloxone) TREZIX (dihydrocodeine/ APAP/caffeine)NR TYLENOL W/CODEINE (APAP/codeine) ULTRACET (tramadol/APAP) ULTRAM (tramadol) VICODIN (hydrocodone/APAP) VICOPROFEN (hydrocodone/ibuprofen) VOPAC (codeine/acetaminophen) XODOL (hydrocodone/acetaminophen) XOLOX (oxycodone/APAP) ZAMICET (hydrocodone/APAP) ZOLVIT (hydrocodone/APAP) ZYDONE (hydrocodone/acetaminophen)

ANALGESICS, NARCOTIC - LONG ACTING SmartPA fentanyl patches AVINZA (morphine) SmartPA Criteria: KADIAN (morphine) BUTRANS (buprenorphine) • Avinza methadone CONZIP ER (tramadol)NR o History of at least 30 days of therapy morphine ER DOLOPHINE (methadone) with Kadian or morphine ER in the DURAGESIC (fentanyl) past 6 months o Is the total quantity of the incoming EMBEDA (morphine/naltrexone) claim plus history of Avinza on the EXALGO (hydromorphone) incoming claim

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OPANA ER (oxymorphone) 239.XX) in the past 2 years oxycodone ER o History of at least 30 days of therapy OXYCONTIN (oxycodone) with Kadian, morphine ER , Avinza or fentanyl patch in the past 6 oxymorphone ER months RYZOLT (tramadol) o History of an antineoplastic in the tramadol ER past 6 months ULTRAM ER (tramadol) o Is the total quantity of the incoming claim plus history of OxyContin on the incoming claim

• History of at least 30 days of therapy with two different preferred LA narcotic analgesics in the past 6 months • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days • Is the total quantity of the incoming claim plus the past 31-day history of the product on the incoming claim meet the applicable quantity limit

ANALGESICS/ANAESTHETICS (Topical) SmartPA FLECTOR (diclofenac epolamine) capsaicin SmartPA Criteria: LIDODERM (lidocaine) EMLA (lidocaine/prilocaine) • History of at least 1 claim for two VOLTAREN Gel (diclofenac sodium) LIDAMANTLE (lidocaine) different preferred agents in the past 6 LIDAMANTLE HC (lidocaine/hydrocortisone) months

lidocaine • History of at least 90 days of therapy lidocaine/prilocaine with the same agent as on the incoming LMX 4 (lidocaine) claim in the past 105 days PENNSAID Solution (diclofenac sodium ) xylocaine SYNERA (lidocaine/tetracaine) ZOSTRIX (capsaicin)

ANDROGENIC AGENTS SmartPA ANDRODERM (testosterone patch) AXIRON (testosterone gel) SmartPA Criteria: ANDROGEL (testosterone gel) FORTESTSA (testosterone gel) • Male Patient • History of at least 30 days of therapy 5 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS TESTIM (testosterone gel) with two different preferred androgenic agents in the past 6 months • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

ANGIOTENSIN MODULATORS SmartPA ACE INHIBITORS benazepril ACCUPRIL (quinapril) SmartPA Criteria: captopril ACEON (perindopril) • History of at least 30 days of therapy enalapril ALTACE (ramipril) with two different preferred single-entity fosinopril CAPOTEN (captopril) ACEIs in the past 6 months • History of at least 90 days of therapy lisinopril LOTENSIN (benazepril) MAVIK (trandolapril) with the same agent as on the quinapril moexipril incoming claim in the past 105 days ramipril MONOPRIL (fosinopril) trandolapril perindopril

PRINIVIL (lisinopril)

UNIVASC (moexipril) VASOTEC (enalapril) ZESTRIL (lisinopril)

ACE INHIBITOR COMBINATIONS benazepril/amlodipine ACCURETIC (quinapril/HCTZ) SmartPA Criteria: benazepril/HCTZ CAPOZIDE (captopril/HCTZ) • ACEI/Diuretic combination product captopril/HCTZ LOTENSIN HCT (benazepril/HCTZ) o History of at least 30 days of therapy enalapril/HCTZ moexipril/HCTZ with two different preferred ACEI/Diuretic combination products fosinopril/HCTZ PRINZIDE (lisinopril/HCTZ) trandolapril/verapamil in the past 6 months lisinopril/HCTZ UNIRETIC (moexipril/HCTZ) o History of at least 90 days of LOTREL(benazepril/amlodipine) VASERETIC (enalapril/HCTZ) therapy with the same agent as on quinapril/HCTZ ZESTORETIC (lisinopril/HCTZ) the incoming claim in the past 105 TARKA (trandolapril/verapamil) days

• ACEI/Calcium Channel Blocker combination product o History of at least 30 days of therapy with two different preferred ACEI/Calcium Channel Blocker combination products in the past 6 6 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS months o History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) AVAPRO (irbesartan) ATACAND (candesartan) SmartPA Criteria: BENICAR (olmesartan) EDARBI (azilsartan) • History of at least 30 days of therapy COZAAR (losartan) eprosartan with two different preferred single-entity DIOVAN (valsartan) TEVETEN (eprosartan) ARBs in the past 6 months • History of at least 90 days of therapy losartan with the same agent as on the incoming MICARDIS (telmisartan) claim in the past 105 days

ARB COMBINATIONS AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ) SmartPA Criteria: AZOR (olmesartan/amlodipine) EDARBYCLOR (azilsartan/chlorthalidone)NR • ARB/Diuretic combination product BENICAR-HCT (olmesartan/HCTZ) losartan/HCTZ o History of at least 30 days of therapy DIOVAN-HCT (valsartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ) with two different preferred ARB/Diuretic combination products EXFORGE (valsartan/amlodipine) TWYNSTA (telmisartan/amlodipine) in the past 6 months EXFORGE HCT (valsartan/amlodipine/HCTZ) o History of at least 90 days of therapy HYZAAR (losartan/HCTZ) with the same agent as on the MICARDIS-HCT (telmisartan/HCTZ) incoming claim in the past 105 days TRIBENZOR (olmesartan/amlodipine/HCTZ) • ARB/Calcium Channel Blocker combination product o History of at least 30 days of therapy with two different preferred ARB/Calcium Channel Blocker combination products in the past 6 months o History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

DIRECT RENIN INHIBITORS TEKTURNA (aliskiren) SmartPA Criteria: • History of hypertension in the past 2 years • History of at least 90 days of therapy 7 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS with the same agent as on the incoming claim in the past 105 days • Direct Renin Inhibitor single-entity product o History of at least 30 days of therapy with two different preferred ACEI or ARB single-entity products in the past 6 months

DIRECT RENIN INHIBITOR COMBINATIONS AMTURNIDE (aliskiren/amlodipine/hctz) SmartPA Criteria: TEKAMLO (aliskiren/amlodipine) • History of at least 30 days of therapy TEKTURNA-HCT (aliskiren/hctz) with two different preferred ACEI or VALTURNA (aliskiren/valsartan) ARB Diuretic combination products in the past 6 months

• History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

ANTIBIOTICS (Topical) TOPICAL bacitracin ALTABAX (retapamulin) bacitracin/polymixin BACTROBAN OINTMENT (mupirocin) BACTROBAN cream (mupirocin) CORTISPORIN (bacitracin/neomycin/ gentamicin polymyxin/HC) mupirocin ointment

ANTIBIOTICS (GI) ALINIA (nitazoxanide) FLAGYL ER () DIFICID () metronidazole VANCOCIN (vancomycin) neomycin XIFAXAN () TINDAMAX (tinidazole)

ANTIBIOTICS (VAGINAL) CLEOCIN OVULES (clindamycin) AVC () clindamycin CLEOCIN CREAM (clindamycin) CLINDESSE (clindamycin) 8 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS metronidazole METROGEL (metronidazole) VANDAZOLE (metronidazole)

ANTICOAGULANTS

COUMADIN (warfarin) ARIXTRA (fondaparinux) SmartPA LMWH *Clinical Edit Pradaxa:

FRAGMIN (dalteparin) SmartPA LMWH enoxaparin SmartPA LMWH • Age >/=18 years

LOVENOX (enoxaparin) SmartPA LMWH fondaparinux SmartPA LMWH • Diagnosis of atrial fibrillation (427.31) in

PRADAXA (dabigatran)* INNOHEP (tinzaparin) SmartPA LMWH the past 2 years warfarin • History absent of cardiac valve disease XARELTO (rivaroxaban) in the past 2 years • History of one of the following in the past 2 years o Stroke o TIA o Systemic embolism o Diabetes mellitus (250.XX) o Left ventricular dysfunction o Heart failure • Age >/=75 years • Age >/=65 years • Diagnosis of hypertension in the past 2 years • History absent of active pathologic bleeding in the past 6 months • History absent of rheumatic heart disease and severe renal impairment in the past 2 years • History absent of mechanical valve prosthesis and dialysis in the past year • No active claims for rifampin • Requested quantity = 60 tablets ------SmartPA Criteria for LMWH duration: • Is there history for a LMWH in the past year • Is the duration of therapy on the claim

9 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • Female patient o History of a Pregnancy Code in the past 280 days • History of at least 30 days of therapy with two different preferred LMWHs in the past 6 months • History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days • Does the prescriber provide clinical justification for therapy including 1) condition being treated and 2) the requested length of therapy • History of cancer (140.xx-238.xx) in the past 2 years o Female Patient ƒ History of a Pregnancy Code in the past 280 days o History of a total hip replacement, total knee replacement, or hip fracture surgery in the past 60 days ƒ Is the duration of therapy on the claim

10 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • Does the prescriber provide clinical justification for therapy including 1) condition being treated and 2) the requested length of therapy

ANTICONVULSANTS SmartPA ADJUVANTS carbamazepine BANZEL (rufinamide) SmartPA Criteria: CARBATROL (carbamazepine) carbamazepine XR • History of at least 30 days of therapy DEPAKOTE ER (divalproex) DEPAKENE (valproic acid) with two different preferred DEPAKOTE SPRINKLE (divalproex) DEPAKOTE (divalproex) anticonvulsants in the past 6 months NR • History of at least 90 days of therapy divalproex FANATREX SUSPENSION (gabapentin) with the same agent as on the divalproex ER felbamate FELBATOL (felbamate) incoming claim in the past 105 days EPITOL (carbamazepine) NR EQUETRO (carbamazepine) GRALISE (gabapentin) HORIZANT (gabapentin) NR • Banzel gabapentin KEPPRA (levetiracetam) o Age >/= 4 years GABITRIL (tiagabine) o Diagnosis of Lennox-Gastaut in the KEPPRA XR (levetiracetam) LAMICTAL ODT (lamotrigine) past 2 years LAMICTAL (lamotrigine) LAMICTAL XR (lamotrigine) LAMICTAL CHEWABLE (lamotrigine) • Keppra lamotrigine levetiracetam ER levetiracetam o Age 15-20 years NEURONTIN (gabapentin) History of at least 30 days of oxcarbazepine NR o ONFI (clobazam) therapy with levetiracetam IR in the TEGRETOL XR (carbamazepine) SABRIL (vigabatrin) past 6 months TOPAMAX Sprinkle (topiramate) STAVZOR (valproic acid) o History of at least 90 days of topiramate TEGRETOL (carbamazepine) therapy with the same agent as on TRILEPTAL Suspension (oxcarbazepine) TRILEPTAL Tablets (oxcarbazepine) the incoming claim in the past 105 valproic acid VIMPAT (lacosamide) days zonisamide ZONEGRAN (zonisamide)

HYDANTOINS DILANTIN (phenytoin) PEGANONE (ethotoin) PHENYTEK (phenytoin) phenytoin SUCCINIMIDES ethosuximide CELONTIN (methsuximide) ZARONTIN (ethosuximide) 11 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIDEPRESSANTS, OTHER SmartPA bupropion APLENZIN (bupropion HBr) SmartPA Criteria: bupropion XL bupropion SR • Does the patient meet the age limit for mirtazapine DESYREL (trazodone) the requested drug nefazodone EFFEXOR (venlafaxine) • History of at least 30 days of therapy with two different preferred PRISTIQ (desvenlafaxine) EFFEXOR XR (venlafaxine) antidepressants in the past 6 months trazodone EMSAM (selegiline transdermal) • History of at least 30 days of therapy WELLBUTRIN XL (bupropion HCl) MARPLAN (isocarboxazid) with BOTH a preferred antidepressant NARDIL (phenelzine) and a preferred SSRI in the past 6

OLEPTRO ER (trazodone) months REMERON (mirtazapine) • History of at least 90 days of therapy tranylcypromine with the same agent as on the venlafaxine incoming claim in the past 105 days venlafaxine ER venlafaxine XR • Cymbalta VIIBRYD (vilazodone) o Diagnosis of depression in the past 2 years WELLBUTRIN (bupropion) o History of at least 30 days of WELLBUTRIN SR therapy with two different preferred antidepressants from in the past 6 months o History of at least 30 days of therapy with BOTH a preferred antidepressant and a preferred SSRI in the past 6 months o Diagnosis of anxiety disorder in the past 2 years o History of at least 30 days of therapy with two preferred antidepressants in the past 6 months o Diagnosis of DPN in the past 2 years o History of at least 30 days of therapy with pregabalin in the past 6 months o History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days 12 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o Diagnosis of fibromyalgia (729.0, 729.1) in the past 2 years o History of at least 30 days of therapy with BOTH pregabalin AND milnacipran in the past 6 month

ANTIDEPRESSANTS, SSRIs SmartPA citalopram CELEXA (citalopram) SmartPA Criteria: fluoxetine LEXAPRO (escitalopram) • Does the patient meet the age limit for fluvoxamine LUVOX (fluvoxamine) the requested drug LUVOX CR (fluvoxamine) paroxetine CR • History of at least 30 days of therapy paroxetine IR paroxetine suspension with two different preferred SSRI PAXIL SUPENSION PAXIL Tablets (paroxetine) antidepressants in the past 6 months sertraline PAXIL CR (paroxetine) • History of at least 90 days of therapy PEXEVA (paroxetine) with the same agent at the same PROZAC (fluoxetine) brand/generic status as on the RAPIFLUX (fluoxetine) incoming claim in the past 105 days SARAFEM (fluoxetine) ZOLOFT (sertraline) • Lexapro Age 12-17 years o o Diagnosis of depression in the past 2 years o History of at least 30 days of therapy with two different preferred SSRI antidepressants in the past 6 months o History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days o Diagnosis of anxiety disorder in the past 2 years o History of at least 30 days of therapy with two preferred antidepressants in the past 6 months

13 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIEMETICS SmartPA 5HT3 RECEPTOR BLOCKERS ondansetron ANZEMET (dolasetron) All injectable 5HT3 receptor blockers ondansetron solution granisetron closed to point of sale. GRANISOL (granisetron) KYTRIL (granisetron) Ondansetron ODT 4mg tablets & ondansetron ODT Zuplenz 4mg are covered without a PA SANCUSO (granisetron) for ages 4-11. ZOFRAN (ondansetron) ZOFRAN ODT (ondansetron) SmartPA Criteria: ZUPLENZ FILM (ondansetron) • History of at least 1 claim with a preferred antiemetic in the past 6 months • Ondansetron ODT 4mg or Zuplenz 4mg film o Age 4-11 years

CANNABINOIDS CESAMET (nabilone) MARINOL (dronabinol) dronabinol NMDA RECEPTOR ANTAGONIST EMEND (aprepitant) • Emend o Diagnosis of cancer (140.XX- 239.XX) in the past 2 years o History of an antineoplastic in the past 6 months

ANTIFUNGALS (Oral) SmartPA clotrimazole ANCOBON (flucytosine) SmartPA Criteria: fluconazole DIFLUCAN (fluconazole) • History of at least 1 claim for two GRIFULVIN V (griseofulvin) griseofulvin tablet different preferred oral antifungals in the griseofulvin suspension itraconazole past 6 months

GRIS-PEG (griseofulvin) ketoconazole foam • Itraconazole ketoconazole LAMISIL (terbinafine) o Diagnosis of HIV in the past 2 years nystatin MYCELEX (clotrimazole) o History of a transplant in the past 2 terbinafine MYCOSTATIN Tablets (nystatin) years NIZORAL (ketoconazole) o History of an immunosuppressant in 14 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS NOXAFIL (posaconazole) the past 6 months ORAVIG (miconazole) SPORANOX (itraconazole) TERBINEX Kit (terbinafine/ciclopirox) VFEND (voriconazole) voriconazole ANTIFUNGALS (Topical) SmartPA ANTIFUNGALS ciclopirox cream/gel/suspension BENSAL HP (benzoic acid/salicylic acid) SmartPA Criteria: clotrimazole CICLODAN KIT • History of at least 1 claim for two econazole ciclopirox kit//solution different preferred topical antifungals in ketoconazole cream CNL 8 (ciclopirox) the past 6 months

ketoconazole shampoo ERTACZO (sertaconazole) miconazole OTC EXELDERM (sulconazole) nystatin EXTINA (ketoconazole) terbinafine OTC cream,gel,spray KETOCON KIT (ketoconazole)

tolnaftate OTC KETOCON PLUS (ketoconazole) LAMISIL (terbinafine) solution LOPROX (ciclopirox) MENTAX (butenafine) MYCOSTATIN (nystatin) NAFTIN (naftifine) NIZORAL (ketoconazole) NUZOLE (miconazole) OXISTAT (oxiconazole) PEDIADERM AF (nystatin) PENLAC (ciclopirox) SPECTAZOLE (econazole) VUSION (miconazole/petrolatum/zinc oxide) XOLEGEL (ketoconazole)

ANTIFUNGAL/STEROID COMBINATIONS clotrimazole/betamethasone cream clotrimazole/betamethasone lotion nystatin/triamcinolone KETOCON PLUS (ketoconazole/hydrocortisone) LOTRISONE (clotrimazole/betamethasone) MYCOLOG (nystatin/triamcinolone) 15 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIHISTAMINES, MINIMALLY SEDATING AND COMBINATIONS SmartPA MINIMALLY SEDATING ANTIHISTAMINES cetirizine ALLEGRA (fexofenadine) SmartPA Criteria: loratadine CLARINEX (desloratadine) • History of allergy or urticaria in the past XYZAL (levocetirizine) fexofenadine RX 2 years levocetirizine • History of at least 30 days of therapy ZYRTEC (Rx and OTC) (cetirizine) with two different preferred antihistamines in the past 12 months

• History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

• Xyzal o History of at least 7 days of therapy with generic cetirizine, loratadine or fexofenadine product in the past 12 months

MINIMALLY SEDATING ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine ALLEGRA-D (fexofenadine/ pseudoephedrine) loratadine/pseudoephedrine CLARITIN-D (loratadine/pseudoephedrine) SEMPREX-D (acrivastine/pseudoephedrine) CLARINEX-D (desloratadine/ pseudoephedrine) fexofenadine/pseudoephedrine ZYRTEC-D (cetirizine/pseudoephedrine)

ANTIMIGRAINE AGENTS, TRIPTANS SmartPA ORAL RELPAX (eletriptan) AMERGE (naratriptan) SmartPA Criteria: sumatriptan ALSUMA (sumatriptan) • Oral product TREXIMET (sumatriptan/naproxen) AXERT (almotriptan)* o History of at least 1 claim for a CAMBIA (diclofenac potassium) preferred oral product in the past 365 days FROVA (frovatriptan)

IMITREX (sumatriptan) o Axert - Smart PA if age 12-17 years MAXALT (rizatriptan) naratriptan ZOMIG (zolmitriptan)

16 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS NASAL sumatriptan IMITREX (sumatriptan) SmartPA Criteria: ZOMIG (zolmitriptan) • Nasal product o History of at least 1 claim for a preferred nasal product in the past 365 days

INJECTABLE sumatriptan IMITREX (sumatriptan) SmartPA Criteria: • History of at least 1 claim for a preferred injectable product in the past 365 days

ANTIPARASITICS (Topical) EURAX (crotamiton) lindane malathion NATROBA (spinosad) permethrin OVIDE (malathion) ULESFIA (benzyl alcohol)

ANTIPARKINSON’S AGENTS (Oral) SmartPA ANTICHOLINERGICS benztropine COGENTIN (benztropine) SmartPA Criteria: trihexyphenidyl • Diagnosis of Parkinson’s disease (332.XX) in the past 2 years • History of at least 30 days of therapy with two different preferred antiparkinson‘s agents in the past 6 months • History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone)

DOPAMINE AGONISTS ropinirole MIRAPEX (pramipexole) MIRAPEX ER (pramipexole)

17 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS pramipexole REQUIP (ropinirole) REQUIP XL (ropinirole)

MAO-B INHIBITORS selegiline AZILECT (rasagiline) ELDEPRYL (selegiline) ZELAPAR (selegiline) OTHERS amantadine levodopa/carbidopa ODT bromocriptine LODOSYN (carbidopa) levodopa/carbidopa PARCOPA (levodopa/carbidopa) PARLODEL (bromocriptine)

SINEMET (levodopa/carbidopa) SINEMET CR (levodopa/carbidopa) STALEVO (levodopa/carbidopa/entacapone)

ANTIPSYCHOTICS SmartPA ORAL ABILIFY (aripiprazole) CLOZARIL (clozapine) SmartPA Criteria: amitriptyline/perphenazine FAZACLO (clozapine) • Does the patient meet the age limit for chlorpromazine HALDOL (haloperidol) the requested drug clozapine INVEGA (paliperidone) • Invega FANAPT (iloperidone) MELLARIL (thioridazine) o History of at least 30 days of therapy fluphenazine NAVANE (thiothixene) with risperidone in the past 12 GEODON (ziprasidone) olanzapine months haloperidol PROLIXIN (fluphenazine) o History of at least 30 days of therapy LATUDA (lurasidone) RISPERDAL (risperidone) with a preferred atypical MOBAN (molindone) STELAZINE (trifluoperazine) antipsychotic in the past 12 months perphenazine SYMBYAX (olanzapine/fluoxetine) o History of at least 30 days of therapy risperidone TRILAFON (perphenazine) with the same agent as on the SAPHRIS (asenapine) ZYPREXA (olanzapine) incoming claim in the past 105 days

SEROQUEL (quetiapine)

SEROQUEL XR (quetiapine) thioridazine thiothixene trifluoperazine 18 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS INJECTABLE, ATYPICALS ABILIFY (aripiprazole) Smart PA Criteria: GEODON (ziprasidone) • Does the prescriber stock the INVEGA SUSTENNA (paliperidone palmitate) medication in his office RISPERDAL CONSTA (risperidone) • The medication will be delivered by clinic or pharmacy personnel to the ZYPREXA (olanzapine) prescriber’s office to be administered by ZYPREXA RELPREVV (olanzapine) clinical staff only

o Risperdal Consta ƒ Diagnosis of schizophrenia/schizoaffective disorder or bipolar disorder in the past 2 years ƒ Is the patient non-compliant with oral risperidone ƒ History of at least 6 injections for Risperdal Consta in the past 90 days o Invega Sustenna ƒ Diagnosis of schizophrenia/ schizoaffective disorder in the past 2 years ƒ Is the patient non-compliant with oral paliperidone ƒ History of at least 3 claims for Invega Sustenna in the past 90 days o Zyprexa Relprevv ƒ Diagnosis of schizophrenia/schizoaffective disorder in the past 2 years ƒ Is the patient non-compliant with oral olanzapine ƒ History of at least 3 claims for Zyprexa Relprevv in the past 90 days ANTIVIRALS (Oral) – ANTIHERPETIC AGENTS acyclovir famciclovir valacyclovir FAMVIR (famciclovir)

19 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS VALTREX (valacyclovir) ZOVIRAX (acyclovir)

ANTIVIRALS (Topical) DENAVIR (penciclovir) XERESE (acyclovir/hydrocortisone) ZOVIRAX Ointment (acyclovir) ZOVIRAX Cream (acyclovir)

ATOPIC DERMATITIS SmartPA ELIDEL (pimecrolimus) SmartPA Criteria: PROTOPIC (tacrolimus) • Elidel or Protopic 0.03% o Age >/= 2 years • Age >/= 6 years

BETA BLOCKERS SmartPA acebutolol BETAPACE (sotalol) SmartPA Criteria: atenolol betaxolol • History of at least 30 days of therapy bisoprolol BLOCADREN (timolol) with two different preferred Beta- BYSTOLIC (nebivolol) CARTROL (carteolol) Blockers in the past 6 months • History of at least 90 days of therapy metoprolol CORGARD (nadolol) INDERAL LA (propranolol) with the same agent as on the metoprolol XL INNOPRAN XL (propranolol) incoming claim in the past 105 days nadolol KERLONE (betaxolol) pindolol LEVATOL (penbutolol) • Sotalol propranolol LOPRESSOR (metoprolol) o History of atrial fibrillation in the past timolol SECTRAL (acebutolol) 2 years sotalol TENORMIN (atenolol) • Coreg CR TOPROL XL (metoprolol) o History of hypertension in the past 2 ZEBETA (bisoprolol) years o History of at least 30 days of therapy with carvedilol and at least 30 days of therapy with a preferred Beta- Blocker in the past 6 months BETA- AND ALPHA-BLOCKERS carvedilol COREG (carvedilol) labetalol COREG CR (carvedilol) TRANDATE (labetalol)

20 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS BETA BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone CORZIDE (nadolol/bendroflumethiazide) NR bisoprolol/HCTZ DUTOPROL (metoprolol/HCTZ) metoprolol/HCTZ INDERIDE (propranolol/HCTZ) LOPRESSOR HCT (metoprolol/HCTZ) nadolol/bendroflumethiazide TENORETIC (atenolol/chlorthalidone) propranolol/HCTZ ZIAC (bisoprolol/HCTZ) timolol/HCTZ

BILE SALTS ursodiol ACTIGALL (ursodiol) CHENODAL (chenodiol) URSO (ursodiol) URSO FORTE (ursodiol) BLADDER RELAXANT PREPARATIONS SmartPA DETROL LA (tolterodine) DETROL (tolterodine) Smart PA Criteria: GELNIQUE (oxybutynin) DITROPAN (oxybutynin) • History of at least 30 days of therapy oxybutynin IR DITROPAN XL (oxybutynin) with two different preferred Bladder TOVIAZ (fesoterodine fumarate) ENABLEX (darifenacin) Relaxant Preparations in the past 6 months oxybutynin ER • History of at least 90 days of therapy OXYTROL (oxybutynin) with the same agent as on the incoming SANCTURA (trospium) claim in the past 105 days SANCTURA XR (trospium) trospium VESICARE (solifenacin)

BONE RESORPTION SUPPRESSION AND RELATED AGENTS SmartPA BISPHOSPHONATES ACTONEL (risedronate) ATELVIA (risedronate) SmartPA Criteria: ACTONEL WITH CALCIUM (risedronate/calcium) BONIVA (ibandronate) • Diagnosis of osteoporosis/osteopenia in alendronate DIDRONEL (etidronate) the past 2 years FOSAMAX PLUS D (alendronate/vitamin D) FOSAMAX (alendronate) • History of at least 1 claim for two different preferred osteoporosis agents in the past PROLIA (denosumab) 6 months

• History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

21 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OTHERS FORTICAL (calcitonin) EVISTA (raloxifene) MIACALCIN (calcitonin) FORTEO (teriparatide) calcitonin salmon

BPH AGENTS SmartPA ALPHA BLOCKERS doxazosin alfuzosin SmartPA Criteria FLOMAX (tamsulosin) CARDURA (doxazosin) • Male Patient JALYN (dutasteride/tamsulosin) CARDURA XL (doxazosin) o History of at least 30 days of therapy tamsulosin HYTRIN (terazosin) with two different preferred BPH agents in the past 6 months terazosin RAPAFLO (silodosin) o History of at least 90 days of therapy UROXATRAL (alfuzosin) with the same agent at the same brand/generic status as on the incoming claim in the past 105 days.

• Female Patient o Doxazosin IR ƒ History of an approvable diagnosis for doxazosin IR in the past 2 years

o Tamsulosin ƒ History of an approvable diagnosis for tamsulosin in the past 2 years

o Terazosin ƒ History of an approvable diagnosis for terazosin in the past 2 years

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

PDE5 INHIBITORS NR CIALIS (tadalafil) • Male Patient: o Diagnosis of Benign Prostatic Hypertrophy (BPH) in the past 2 22 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS years o History of absent of Erectile Dysfunction in the past 2 years o Has the prescriber signed a waiver indicating they are not treating the patient for erectile dysfunction o Has the patient had at least 30 days of therapy with two different preferred BPH agents in the past 6 months BRONCHODILATORS & COPD AGENTS ANTICHOLINERGICS & COPD AGENTS ATROVENT HFA (ipratropium) DALIRESP (roflumilast) ipratropium SPIRIVA (tiotropium)

ANTICHOLINERGIC-BETA AGONIST COMBINATIONS COMBIVENT (albuterol/ipratropium) albuterol/ipratropium DUONEB (albuterol/ipratropium)

BRONCHODILATORS, BETA AGONIST INHALERS, SHORT-ACTING PROVENTIL HFA (albuterol) MAXAIR (pirbuterol) SmartPA SmartPA: VENTOLIN HFA (albuterol) PROAIR HFA (albuterol) • Xopenex HFA inhaler SmartPA Age >/= 4 years XOPENEX HFA (levalbuterol) o o History of at least 1 claim for an albuterol inhaler in the past 30 days • Maxair o History of at least 1 claim for Ventolin HFA in the past 6 months

SmartPA INHALERS, LONG ACTING FORADIL (formoterol) ARCAPTA (indacaterol) SmartPA Criteria: SEREVENT (salmeterol) • History of at least 30 days of therapy with a preferred LABA Inhaler in the past 6 months

23 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days • Foradil o Age >/= 5 years • Serevent o Age >/= 4 years • Arcapta o Diagnosis of COPD in the past 2 years o Age >/= 18 years

SmartPA INHALATION SOLUTION albuterol ACCUNEB (albuterol) SmartPA Criteria: BROVANA (arformoterol) • History of at least 1 claim for 2 different levalbuterol preferred Beta Agonist Inhalation metaproterenol Solutions in the past 6 months • History of at least 3 claims with the PERFOROMIST (formoterol) same agent as on the incoming claim in XOPENEX (levalbuterol) the past 105 days

• Xopenex inhalation solution o Age >/= 6 years o History of at least 1 claim for albuterol inhalation solution in the past 30 days

• Brovana or Perforomist o Age >/= 18 years

ORAL albuterol VOSPIRE ER (albuterol) metaproterenol terbutaline

CALCIUM CHANNEL BLOCKERS SmartPA SHORT-ACTING diltiazem CALAN (verapamil) SmartPA Criteria: nicardipine CARDIZEM (diltiazem) • History of at least 90 days of therapy 24 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS nifedipine isradipine with the same agent as on the verapamil nimodipine incoming claim in the past 105 days NIMOTOP (nimodipine) PROCARDIA (nifedipine) • Short-acting CCB o History of at least 30 days of therapy with two different preferred Short- acting CCBs in the past 6 months

LONG-ACTING amlodipine ADALAT CC (nifedipine) SmartPA Criteria: COVERA-HS (verapamil) CALAN SR (verapamil) • History of at least 90 days of therapy diltiazem ER CARDENE SR (nicardipine) with the same agent as on the DYNACIRC CR (isradipine) CARDIZEM CD (diltiazem) incoming claim in the past 105 days

felodipine ER CARDIZEM LA (diltiazem) • Long-acting CCB nifedipine ER DILACOR XR (diltiazem) ISOPTIN SR (verapamil) o History of at least 30 days of therapy verapamil ER with two different preferred long- nisoldipine acting CCBs in the past 6 months NORVASC (amlodipine) PLENDIL (felodipine) PROCARDIA XL (nifedipine) SULAR (nisoldipine) TIAZAC (diltiazem) verapamil ER PM VERELAN/VERELAN PM (verapamil)

CALORIC AGENTS BOOST (includes all boost) COMPLEAT BRIGHT BEGINNINGS EO28 SPLASH CARNATION INSTANT BREAKFAST FIBERSOURCE DUOCAL ISOSOURCE ENSURE JEVITY JUVEN KINDERCAL GLUCERNA PEPTAMEN NUTREN (includes all Nutren) PROMOTE OSMOLITE SIMPLY THICK PEDIASURE TOLEREX POLYCOSE VITAL PROMOD VIVONEX 25 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS RESOURCE SCANDISHAKE TWOCAL HN

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

SmartPA CEPHALOSPORINS – First Generation cefadroxil DURICEF (cefadroxil) Smart PA Criteria: cephalexin KEFLEX (cephalexin) • History of at least 1 claim for two different preferred cephalosporins in the past 6 months

SmartPA CEPHALOSPORINS – Second Generation cefaclor CECLOR (cefaclor) SmartPA Criteria: cefprozil cefuroxime suspension • History of at least 1 claim for two cefuroxime tablets CEFTIN (cefuroxime) different preferred cephalosporins in the CEFZIL (cefprozil) past 6 months

SmartPA CEPHALOSPORINS – Third Generation cefdinir suspension (for patients <18 yr only) CEDAX (ceftibuten) SmartPA Criteria: cefdinir capsules cefditoren • History of at least 1 claim for two SUPRAX (cefixime) cefpodoxime different preferred cephalosporins in the OMNICEF (cefdinir) past 6 months • Cefdinir suspension SPECTRACEF (cefditoren) o Age < 18 years

CYTOKINE & CAM ANTAGONISTS ENBREL (etanercept) AMEVIVE (alefacept) Amevive, Orencia, Remicade and HUMIRA (adalimumab) CIMZIA (certolizumab) Stelara are for administration in hospital KINERET (anakinra) ORENCIA (abatacept) or clinic setting. PA will not be issued at 26 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS REMICADE (infliximab) Point of Sale without justification. SIMPONI (golimumab) STELARA (ustekinumab)

ERYTHROPOIESIS STIMULATING PROTEINS SmartPA PROCRIT (rHuEPO) ARANESP (darbepoetin) SmartPA Criteria: EPOGEN (rHuEPO) • Diagnosis of cancer (140.XX-239.XX) or chronic renal failure in the past 2 years • History of an antineoplastic in the past 6 months • History of Procrit in the past 6 months

FIBROMYALGIA AGENTS LYRICA (pregabalin) CYMBALTA (duloxetine) Cymbalta will be approved for patients SAVELLA (milnacipran) with diabetic neuropathy

FLUOROQUINOLONES (Oral) SmartPA AVELOX () ER SmartPA Criteria: ciprofloxacin tablets CIPRO (ciprofloxacin) • Ciprofloxacin suspension or CIPRO XR (ciprofloxacin) solution FACTIVE () o Age <12 years ƒ Diagnosis of anthrax infection or FLOXIN () exposure (022.X, V01.81) in the LEVAQUIN (levofloxacin) past 3 months levofloxacin ƒ Ciprofloxacin suspension NOROXIN () • Diagnosis of cystic fibrosis ofloxacin (277.0X) in the past 2 years PROQUIN XR (ciprofloxacin) • Diagnosis of pneumonic plague (020.3, 020.4, 020.5) or tularemia (021.X) in the past 3 months • History of in the past 3 months ƒ History of at least 7 days of therapy of a preferred agent from two of the categories below in the past 3 months. Penicillin’s, 2nd or 3rd Generation Cephalosporins, 27 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS Macrolides ƒ History of ciprofloxacin suspension in the past 3 months

• Levofloxacin o History of at least 1 claim for ciprofloxacin, moxifloxacin or SMX/TMP in the past 14 days • History of at least 1 claim for a preferred oral fluoroquinolone in the past 30 days

GLUCOCORTICOIDS (Inhaled) SmartPA GLUCOCORTICOIDS AEROBID (flunisolide) ALVESCO (ciclesonide) SmartPA Criteria: AEROBID-M (flunisolide) • History of at least 30 days of therapy ASMANEX (mometasone) with two different preferred inhaled budesonide glucocorticoids in the past 6 months • History of at least 90 days of therapy FLOVENT Diskus (fluticasone) with the same agent as on the FLOVENT HFA (fluticasone) incoming claim in the past 105 days PULMICORT (budesonide) Respules • Pulmicort Flexhaler PULMICORT (budesonide) Flexhaler o Age >/= 6 years QVAR (beclomethasone)

GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR Diskus (fluticasone/salmeterol) ADVAIR HFA (fluticasone/salmeterol) DULERA (mometasone/formoterol) SYMBICORT (budesonide/formoterol)

GROWTH HORMONE SmartPA GENOTROPIN (somatropin) HUMATROPE (somatropin) Prior authorization required for patients NUTROPIN (somatropin) NORDITROPIN (somatropin) >18 yrs of age. NUTROPIN AQ (somatropin) OMNITROPE (somatropin) SmartPA Criteria: SAIZEN (somatropin) • Patient < 18 years of age SEROSTIM (somatropin) o History of at least 28 days of therapy TEV-TROPIN (somatropin) 28 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZORBTIVE (somatropin) with a preferred Growth Hormone in the past 6 months o History of at least 84 days of therapy with the same agent as on the incoming claim in the past 105 days

• Zorbtive o History of short bowel syndrome in the past 2 years o History of craniopharyngioma, panhypopituitarism, Prader-Willi Syndrome or Turner Syndrome in the past 2 years o History of cranial irradiation in the past 2 years

H. PYLORI COMBINATION TREATMENTS HELIDAC (bismuth subsalicylate, metronidazole, PYLERA ) (bismuth subcitrate potassium, PREVPAC (lansoprazole, amoxicillin, metronidazole, tetracycline) clarithromycin)

HEPATITIS C TREATMENTS SmartPA PEGASYS (peginterferon alfa-2a) INCIVEK (telaprevir)* Peg-Intron will be approved for patients INFERGEN (interferon alfacon-1) with history of treatment failure and/or PEG-INTRON (peginterferon alfa-2b) age 3-17

VICTRELIS (boceprevir)* *Incivek & Victrelis require manual PA

• Other Hep C Treatments o Age >/= 18 years o Diagnosis of chronic hepatitis C in the past 2 years o History absent of decompensated liver disease in the past year o Currently active claims for peginterferon alfa and ribavirin o Victrelis: has the patient been previously untreated with interferon and ribavirin combination therapy 29 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o Did the patient fail previous interferon and ribavirin combination therapy

HYPERURICEMIA & GOUT SmartPA allopurinol ULORIC (febuxostat) SmartPA Criteria: COLCRYS (colchicine) ZYLOPRIM (allopurinol) • History of at least 30 days of therapy probenecid with two different preferred probenecid/colchicine antihyperuricemics in the past 6 months • History of at least 90 days of therapy

with the same agent as on the incoming claim in the past 105 days

• Colcrys o History of at least 1 claim for a preferred colchicine product in the past 6 months HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS BYETTA (exenatide) JANUMET XR (sitagliptin/metformin)NR JANUMET (sitagliptin/metformin) JENTADUETO (linagliptin/metformin)NR NR JANUVIA (sitagliptin) JUVISYNC (sitagliptin/simvastatin) KOMBIGLYZE XR (saxagliptin/metformin) SYMLIN (pramlintide) NR ONGLYZA (saxagliptin) TRADJENTA (linagliptin) VICTOZA (liraglutide) HYPOGLYCEMICS, INSULINS AND RELATED AGENTS SmartPA LANTUS (insulin glargine) APIDRA (insulin glulisine) Humalog-clinical edit limited to LEVEMIR (insulin detemir) HUMALOG (insulin lispro) beneficiaries up to age 5. NOVOLIN (insulin) HUMALOG MIX (insulin lispro/ lisproprotamine) SmartPA Criteria: NOVOLOG (insulin aspart) HUMULIN (insulin) • Humalog products NOVOLOG MIX (insulin aspart/ aspartprotamine) NOVOLIN Pens (insulin)* o Age

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS HYPOGLYCEMICS, MEGLITINIDES PRANDIN (repaglinide) nateglinide PRANDIMET (repaglinide/metformin) STARLIX (nateglinide)

HYPOGLYCEMICS, TZDS THIAZOLIDINEDIONES ACTOS (pioglitazone) AVANDIA (rosiglitazone)

TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) ACTOPLUSMET XR (pioglitazone/metformin) DUETACT (pioglitazone/glimepiride) AVANDARYL (rosiglitazone/glipizide) AVANDAMET (rosiglitazone/metformin)

IMMNOSUPPRESSIVE (ORAL) SmartPA AZASAN (azathioprine) SmartPA Criteria: azathioprine • Cyclosporine CELLCEPT (mycophenolate) o Diagnosis of heart transplant, kidney cyclosporine transplant, liver transplant, psoriasis, RA or an approvable indication for cyclosporine modified cyclosporine in the past 2 years GENGRAF (cyclosporine) o Diagnosis of Kimura’s disease or mycophenolate mofetil multifocal motor neuropathy in the MYFORTIC (mycophenolic acid) past 2 years NEORAL (cyclosporine) PROGRAF (tacrolimus) • Cyclosporine, modified RAPAMUNE (sirolimus) o Diagnosis of heart transplant, kidney SANDIMMUNE (cyclosporine) transplant, liver transplant, psoriasis, tacrolimus RA or an approvable indication for cyclosporine, modified in the past 2 ZORTRESS (everolimus) years

o Diagnosis of Kimura’s disease or multifocal motor neuropathy in the past 2 years

• Tacrolimus o Diagnosis of heart transplant, kidney transplant, liver transplant or an 31 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS approvable diagnosis for tacrolimus in the past 2 years

• Cellcept (mycophenolate mofetil) o Diagnosis of heart transplant, kidney transplant, liver transplant or an approvable diagnosis for Cellcept in the past 2 years

• Myfortic (mycophenolate sodium) o Diagnosis of kidney transplant or psoriasis in the past 2 years

• Age >/= 18 years o Diagnosis of kidney transplant in the past 2 years

• Sirolimus o Age >/= 13 years INTRANASAL RHINITIS AGENTS ANTICHOLINERGICS ipratropium ATROVENT (ipratropium)

ANTIHISTAMINES PATANASE (olopatadine) ASTELIN (azelastine) ASTEPRO (azelastine) azelastine

SmartPA CORTICOSTEROIDS BECONASE AQ (beclomethasone) FLONASE (fluticasone) SmartPA Criteria: flunisolide fluticasone • History of allergic rhinitis in the past 2 NASACORT AQ (triamcinolone) OMNARIS (ciclesonide) years NASAREL (flunisolide) RHINOCORT AQUA (budesonide) • History of at least 1 claim for two different preferred intranasal NASONEX (mometasone) triamcinolone corticosteroid in the past 6 months VERAMYST (fluticasone) • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

32 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS LEUKOTRIENE MODIFIERS SmartPA ACCOLATE (zafirlukast) ZYFLO CR (zafirlukast) SmartPA Criteria: SINGULAIR (montelukast) zafirlukast • History of at least 30 days of therapy with two different preferred leukotriene modifiers in the past 6 months • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days • Zyflo or Zyflo CR o Age >/= 12 years

LIPOTROPICS, OTHER (Non-statins) SmartPA BILE ACID SEQUESTRANTS cholestyramine COLESTID (colestipol) SmartPA Criteria: colestipol QUESTRAN (cholestyramine) • History of at least 90 days of therapy WELCHOL (colesevelam) with the same agent as on the incoming claim in the past 105 days • History of at least 30 days of therapy with a statin or statin combination product in the past year • Female Patient o History of a pregnancy code in the past 280 days • History of liver disease in the past 2 years • History of hypertriglyceridemia in the past 2 years • Current claim for a bile acid sequestrant • Does the physician provide a clinical reason the patient is unable to take a statin or that statin therapy is inappropriate • Welchol o Female Patient o History of a pregnancy code in the past 280 days o History of at least 30 days of therapy with two different preferred bile acid sequestrants in the past 6 months • History of at least 30 days of therapy 33 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS with two different preferred non-statin lipotropics in the past 6 months

OMEGA-3 FATTY ACIDS LOVAZA (omega-3-acid ethyl esters)

CHOLESTEROL ABSORPTION INHIBITORS ZETIA (ezetimibe)

FIBRIC ACID DERIVATIVES ANTARA (fenofibrate) fenofibrate nanocrystallized 145mg • Fibric Acid Derivative fenofibrate FENOGLIDE (fenofibrate) o History of at least 30 days of therapy gemfibrozil FIBRICOR (fenofibric acid) with two different preferred fibric acid TRICOR (fenofibrate nanocrystallized) LIPOFEN (fenofibrate) derivatives in the past 6 months

TRILIPIX (fenofibric acid) LOFIBRA (fenofibrate) LOPID (gemfibrozil) TRIGLIDE (fenofibrate) NIACIN NIACOR (niacin) NIASPAN (niacin)

LIPOTROPICS, STATINS SmartPA STATINS CRESTOR (rosuvastatin) atorvastatin SmartPA Criteria: LESCOL (fluvastatin) ALTOPREV (lovastatin) • History of at least 30 days of therapy LESCOL XL (fluvastatin) LIVALO (pitavastatin) with two different preferred statins/statin LIPITOR (atorvastatin) MEVACOR (lovastatin) combinations in the past 6 months • History of at least 90 days of therapy lovastatin PRAVACHOL (pravastatin) with the same agent as on the ZOCOR (simvastatin) pravastatin incoming claim in the past 105 days simvastatin STATIN COMBINATIONS CADUET (atorvastatin/amlodipine) ADVICOR (lovastatin/niacin) atorvastatin/amlodipine SIMCOR (simvastatin/niacin) VYTORIN (simvastatin/ezetimibe) 34 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MACROLIDES/KETOLIDES (Oral) KETOLIDES KETEK (telithromycin)

MACROLIDES

azithromycin BIAXIN (clarithromycin) clarithromycin IR BIAXIN XL (clarithromycin) erythromycin clarithromycin ER

E.E.S. (erythromycin ethylsuccinate) E-MYCIN (erythromycin) ERYC (erythromycin) ERYPED (erythromycin ethylsuccinate) ERY-TAB (erythromycin) ERYTHROCIN (erythromycin stearate) erythromycin estolate PCE (erythromycin) ZITHROMAX (azithromycin) ZMAX (azithromycin)

MULTIPLE SCLEROSIS AGENTS SmartPA AVONEX (interferon beta-1a) AMPYRA (dalfampridine)* SmartPA Criteria: BETASERON (interferon beta-1b) EXTAVIA (interferon beta-1b) • Diagnosis of multiple sclerosis (340.XX) COPAXONE (glatiramer) GILENYA (fingolimod) in the past 2 years REBIF (interferon beta-1a) • History of at least 1 claim for two different preferred multiple sclerosis

agents in the past 6 months • History of at least 3 claims for the same agent as on the incoming claim in the past 105 days

*Ampyra – Requires manual PA

NSAIDS NON-SELECTIVE etodolac tab ADVIL (ibuprofen) flurbiprofen ANAPROX (naproxen) ibuprofen ANSAID (flurbiprofen) CAMBIA (diclofenac) indomethacin 35 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ketoprofen CATAFLAM (diclofenac) ketorolac CLINORIL (sulindac) naproxen DAYPRO (oxaprozin) piroxicam diclofenac SR sulindac etodolac cap etodolac tab SR FELDENE (piroxicam) fenoprofen INDOCIN (indomethacin) indomethacin cap ER ketoprofen ER LODINE (etodolac) meclofenamate mefenamic acid MOTRIN (ibuprofen) nabumetone NALFON (fenoprofen) NAPRELAN (naproxen) NAPROSYN (naproxen) NUPRIN (ibuprofen) ORUDIS (ketoprofen) oxaprozin PONSTEL (mefenamic acid) SPRIX NASAL SPRAY (ketorolac) tolmetin VOLTAREN (diclofenac) ZIPSOR (diclofenac)

NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) DUEXIS (ibuprofen/famotidine) NR VIMOVO (naproxen/esomeprazole)

SmartPA COX II SELECTIVE meloxicam CELEBREX (celecoxib) SmartPA Criteria: MOBIC (meloxicam) • Is the incoming claim for a COX-II selective agent 36 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • History of one of the following in the past 2 years: osteoarthritis (OA), rheumatoid arthritis (RA), familial adenomatous polyposis (FAP) or ankylosing spondylitis • History of at least 30 days of therapy with a preferred COX-II selective NSAID in the past 6 months • History of at least 30 days of therapy with a preferred non-selective NSAID in the past 6 months • History of one of the following in the past 2 years o GI Bleed o GERD o PUD o GI Perforation o Coagulation Disorder • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days • History of at least 30 days of therapy with two different preferred NSAIDs in the past 6 months

OPHTHALMIC ANTIBIOTICS bacitracin AZASITE (azithromycin) bacitracin/polymyxin BESIVANCE () erythromycin CILOXAN (ciprofloxacin) gentamicin ciprofloxacin IQUIX (levofloxacin) levofloxacin MOXEZA (moxifloxacin) NATACYN (natamycin) polymyxin/ NEO-POLYCIN (neomy/baci/polymyxin b) sulfacetamide TERRAMYCIN-POLYMYX B tobramycin (oxy-tcn/polymyx sul) triple TOBREX (tobramycin) oint VIGAMOX (moxifloxacin) OCUFLOX (ofloxacin) ofloxacin QUIXIN (levofloxacin) 37 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZYMAR () ZYMAXID (gatifloxacin)

ANTIBIOTIC STEROID COMBINATIONS neomycin/bacitracin/polymyxin/hc neomycin//polymyxin/dexamethasone neomycin/polymyxin/hc POLY-PRED (prednisolone/neomycin/polymyxin) PRED-G (gentamicin/prednisolone) sulfacetamide/prednisolone TOBRADEX OINTMENT (tobramycin/dexamethasone) tobramycin/dexamethasone ZYLET (loteprednol/tobramycin)

OPHTHALMIC ANTI-INFLAMMATORIES SmartPA dexamethasone ACULAR LS (ketorolac) SmartPA Criteria: diclofenac ACULAR PF (ketorolac) • History of at least 1 claim for two FLAREX (fluorometholone) BROMDAY (bromfenac) different preferred ophthalmic flurbiprofen bromfenac antiinflammatory agents in the past 6 months FML FORTE (fluorometholone) DUREZOL (difluprednate)

FML SOP (fluorometholone) PRED MILD (prednisolone) LOTEMAX (loteprednol) PRED FORTE (prednisolone) MAXIDEX (dexamethasone) XIBROM (bromfenac) NEVANAC (nepafenac) prednisolone acetate prednisolone NA phosphate VEXOL (rimexolone)

OPHTHALMICS FOR ALLERGIC SmartPA cromolyn ACULAR (ketorolac) SmartPA Criteria: ELESTAT (epinastine) ACUVAIL (ketorolac) • History of at least 30 days of therapy EMADINE (emedastine) ALAMAST (pemirolast) with two different preferred Ophthalmic ketotifen OTC ALOCRIL (nedocromil) Allergy Agents in the past 6 months • History of at least 90 days of therapy OPTIVAR (azelastine) ALOMIDE (lodoxamide) with the same agent at the same PATADAY (olopatadine) ALREX (loteprednol) brand/generic status as on the incoming 38 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PATANOL (olopatadine) azelastine claim in the past 105 days BEPREVE (bepotastine) CROLOM (cromolyn) DUREZOL (difluprednate) epinastine LASTACAFT (alcaftadine) OPTICROM (cromolyn) OPHTHALMICS, GLAUCOMA AGENTS SmartPA BETA BLOCKERS betaxolol BETAGAN (levobunolol) SmartPA Criteria: BETIMOL (timolol) BETOPTIC S (betaxolol) • History of glaucoma in the past 2 years carteolol OPTIPRANOLOL (metipranolol) • History of at least 30 days of therapy ISTALOL (timolol) TIMOPTIC (timolol) with two different preferred glaucoma agents in the past 6 months levobunolol • History of at least 90 days of therapy metipranolol with the same agent at the same timolol brand/generic status as on the incoming claim in the past 105 days CARBONIC ANHYDRASE INHIBITORS AZOPT (brinzolamide) dorzolamide TRUSOPT (dorzolamide) COMBINATION AGENTS COMBIGAN (brimonidine/timolol) COSOPT (dorzolamide/timolol) dorzolamide/timolol PARASYMPATHOMIMETICS pilocarpine CARBOPTIC (carbachol) ISOPTO CARBACHOL (carbachol) ISOPTO CARPINE (pilocarpine) PHOSPHOLINE IODIDE (echothiophate iodide) PILOPINE HS (pilocarpine)

PROSTAGLANDIN ANALOGS TRAVATAN Z (travoprost) latanoprost XALATAN (latanoprost) LUMIGAN (bimatoprost)

39 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SYMPATHOMIMETICS ALPHAGAN P 0.1% (brimonidine) ALPHAGAN P 0.15% (brimonidine) brimonidine dipivefrin PROPINE (dipivefrin)

OTIC ANTIBIOTICS CETRAXAL (ciprofloxacin) CIPRO HC (ciprofloxacin/hydrocortisone) CIPRODEX (ciprofloxacin/dexamethasone) FLOXIN (ofloxacin) COLY-MYCIN S (colistin/neomycin/ ofloxacin hydrocortisone) CORTISPORIN-TC (colistin/neomycin/ hydrocortisone) neomycin/polymyxin/hydrocortisone

PANCREATIC ENZYMES SmartPA CREON (pancreatin) PANCREAZE (pancrelipase) SmartPA Criteria: PANCRELIPASE • History of at least 30 days of therapy ZENPEP (pancrelipase) with two different preferred pancreatic enzymes products in the past 6 months • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days PHOSPHATE BINDERS ELIPHOS (calcium acetate) FOSRENOL (lanthanum) calcium acetate PHOSLYRA (CALCIUM ACETATE)NR RENAGEL (sevelamer HCl) RENVELA (sevelamer carbonate)

PLATELET AGGREGATION INHIBITORS SmartPA AGGRENOX (dipyridamole/aspirin) BRILINTA (ticagrelor) SmartPA Criteria: dipyridamole cilostazol • History of an approvable indication in PLAVIX (clopidogrel) EFFIENT (prasugrel) the past 2 years PERSANTINE (dipyridamole) PLETAL (cilostazol) • Effient History of at least 30 days of therapy ticlopidine o with Plavix in the past 6 months

• History of at least 30 days of therapy 40 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS with two different preferred products in the past 6 months • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

PROTON PUMP INHIBITORS SmartPA DEXILANT (dexlansoprazole) ACIPHEX (rabeprazole) SmartPA Criteria: omeprazole RX lansoprazole RX • History of an approvable indication in PREVACID SOLU-TAB (lansoprazole) NEXIUM (esomeprazole) the past 2 years omeprazole sod. bicarb. • History of at least 30 days of therapy with two different preferred Proton pantoprazole Pump Inhibitors in the past 6 months PREVACID Rx (lansoprazole) • History of at least 90 days of therapy PRILOSEC RX (omeprazole) with the same agent at the same ZEGERID RX (omeprazole sod bicar) brand/generic status as on the incoming claim in the past 105 days

PULMONARY ANTIHYPERTENSIVES – ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS (ambrisentan) TRACLEER (bosentan)

PULMONARY ANTIHYPERTENSIVES – PDE5s SmartPA ADCIRCA (tadalafil) SmartPA Criteria: REVATIO (sildenafil) • Sildenafil o Age <12 years o Diagnosis of pulmonary hypertension (416.0) or patent ductus arteriosus (747.0) in the past 2 years o History of a heart transplant in the past 2 years • Diagnosis of pulmonary hypertension (416.0) in the past 2 years • History of at least 30 days of therapy with two different preferred PAH agents in the past 6 months • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days 41 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PULMONARY ANTIHYPERTENSIVES – PROSTACYCLINS TYVASO (treprostinil) VENTAVIS (iloprost)

SEDATIVE HYPNOTICS BENZODIAZEPINES estazolam DALMANE (flurazepam) Single source benzodiazepines and flurazepam DORAL (quazepam) barbiturates are NOT covered; PAs will temazepam (15mg and 30mg) HALCION (triazolam) not be issued for these drugs. RESTORIL (temazepam) triazolam temazepam (7.5mg and 22.5mg) Sedative/Hypnotics are limited to 31 cumulative units of all/any strengths per month. Any quantity required above these limits requires a PA. SmartPA OTHERS LUNESTA (eszopiclone) AMBIEN (zolpidem) SmartPA Criteria: zaleplon AMBIEN CR (zolpidem) • ZolpiMist zolpidem EDLUAR (zolpidem) o Is the total quantity of the incoming ROZEREM (ramelteon) claim plus history of all Zolpimist claims

SKELETAL MUSCLE RELAXANTS SmartPA baclofen AMRIX (cyclobenzaprine ER) SmartPA Criteria: chlorzoxazone carisoprodol • Carisoprodol cyclobenzaprine carisoprodol compound o Diagnosis of an acute methocarbamol cyclobenzaprine ER musculoskeletal condition in the past 3 months tizanidine dantrolene o History absent of therapy with FEXMID (cyclobenzaprine) meprobamate in the past 90 days FLEXERIL (cyclobenzaprine) o History of at least 1 claim for metaxalone cyclobenzaprine in the past 21 days 42 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS methocarbamol/ASA o Does the patient have a documented orphenadrine intolerance to cyclobenzaprine orphenadrine compound o Is the total quantity of the current PARAFON FORTE DSC (chlorzoxazone) claim plus history of carisoprodol in ROBAXIN (methocarbamol) the past 6 months

STEROIDS (Topical) SmartPA LOW POTENCY CAPEX (fluocinolone) alclometasone SmartPA Criteria: DESOWEN (desonide) lotion DERMA-SMOOTHE-FS (fluocinolone) • Low potency product desonide cr, oint. DESONATE (desonide) o History of at least 1 claim for two hydrocortisone desonide lotion different preferred low potency products in the past 6 months DESONIL PLUS (desonide) o History of at least 90 days of therapy DESOWEN (desonide) with the same agent at the same fluocinolone oil brand/generic status as on the PEDIACARE HC (hydrocortisone) incoming claim in the past 105 days PEDIADERM (hydrocortisone) SCALACORT DK (hydrocortisone) VERDESO (desonide)

MEDIUM POTENCY fluocinolone CLODERM (clocortolone) SmartPA Criteria: hydrocortisone CORDRAN (flurandrenolide) • Medium potency product mometasone cr, oint. CUTIVATE (fluticasone) o History of at least 1 claim for two different preferred medium potency 43 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS prednicarbate cr fluticasone products in the past 6 months PANDEL (hydrocortisone probutate) LOCOID (hydrocortisone butyrate) o History of at least 90 days of therapy LUXIQ (betamethasone) with the same agent at the same mometasone solution brand/generic status as on the incoming claim in the past 105 days MOMEXIN (mometasone)

prednicarbate oint

HIGH POTENCY amcinonide cr, lot amcinonide oint SmartPA Criteria: betamethasone dipropionate cr, gel, lotion betameth diprop/prop gly cr, lot, oint • High potency product betamethasone valerate cr, lotion, oint. betamethasone dipropionate oint. o History of at least 1 claim for two CAPEX (fluocinolone) desoximetasone different preferred high potency products in the past 6 months fluocinolone diflorasone o History of at least 90 days of therapy fluocinonide HALOG (halcinonide) with the same agent at the same triamcinolone KENALOG (triamcinolone) brand/generic status as on the halcinonide PEDIADERM TA (triamcinolone) incoming claim in the past 105 days VANOS (fluocinonide) • History of at least 1 claim for two different preferred very high potency products in the past 6 months • History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days

VERY HIGH POTENCY clobetasol emollient clobetasol propionate foam clobetasol propionate cr, gel, oint, sol CLOBEX (clobetasol) halobetasol HALONATE

(halobetasol/ammonium lactate) HALAC (halobetasol/ammoium lac) OLUX-E (clobetasol) OLUX-OLUX-E (clobetasol) ULTRAVATE (halobetasol)

44 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS STIMULANTS AND RELATED AGENTS SmartPA SHORT-ACTING amphetamine salt combination ADDERALL (amphetamine salt combination) Prior authorization required for patients dexmethylphenidate IR DESOXYN (methamphetamine) >21 years of age. dextroamphetamine IR DEXTROSTAT (dextroamphetamine) FOCALIN (dexmethylphenidate) methamphetamine Procentra is preferred for patients age METHYLIN chewable tablets (methylphenidate) methylphenidate solution 3-6 only. METHYLIN solution (methylphenidate) methylphenidate IR SmartPA Criteria : PROCENTRA (dextroamphetamine) • Age >/= 6 years o Is the incoming claim for dextroamphetamine IR or mixed amphetamine salts IR ƒ Age >/= 3 years • Age <21 years o Diagnosis of ADD/ADHD in the past 2 years • Short-acting stimulant o History of at least 30 days of therapy with two different preferred SA stimulants in the past 6 months o History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days • History of at least 30 days of therapy with a preferred non-stimulant in the past 6 months • History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days

LONG-ACTING ADDERALL XR (amphetamine salt combination) amphetamine salt combination ER SmartPA Criteria: CONCERTA (methylphenidate) DEXEDRINE (dextroamphetamine) • Age >/= 6 years DAYTRANA (methylphenidate) dextroamphetamine ER • Age <21 years FOCALIN XR (dexmethylphenidate) NUVIGIL (armodafinil) o Diagnosis of ADD/ADHD in the past 2 years METADATE CD (methylphenidate) PROVIGIL (modafinil) • Long-acting stimulant 45 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS methylphenidate ER (generic Concerta) RITALIN LA (methylphenidate) o History of at least 30 days of therapy VYVANSE (lisdexamfetamine) with two different preferred LA stimulants in the past 6 months • History of at least 30 days of therapy with a preferred non-stimulant in the past 6 months • History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days

• Nuvigil or Provigil o One of the following diagnoses in the past 2 years (Narcolepsy, Obstructive Sleep Apnea, Shift Work Sleep Disorder) o History of at least 30 days of therapy with a stimulant in the past 6 months o History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days o Age >/= 17 years o Provigil o Age >/= 16 years NON-STIMULANTS INTUNIV (guanfacine ER) Edit limited to patients ages 6-17 years KAPVAY (clonidine extended-release)* only. STRATTERA (atomoxetine) SmartPA Criteria : • Kapvay o Age 6-17 years o Diagnosis of ADD/ADHD in the past 2 years o History of at least 90 days of therapy with the same agent at the same brand/generic status as on the incoming claim in the past 105 days

46 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. MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 01/01/2012 PREFERRED DRUG LIST Version 2012.12a Updated: 4‐9‐2012

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SmartPA doxycycline hyclate caps/tabs ADOXA CK (doxycycline) SmartPA Criteria: caps IR ADOXA TT (doxycycline) • History of at least 1 claim for two tetracycline demeclocycline different preferred agents in the past 6 doxycycline monohydrate caps (75mg, 100mg, months 150mg) • Demeclocycline History of Diabetes Insipidus or doxycycline monohydrate tabs o SIADH in the past 2 years minocycline ER minocycline tabs NUTRIDOX (doxycycline) ORACEA (doxycycline) SOLODYN (minocycline) VIBRAMYCIN cap/susp/syrup

ULCERATIVE COLITIS AGENTS ORAL APRISO (mesalamine) ASACOL HD (mesalamine) ASACOL (mesalamine) COLAZAL (balsalazide) balsalazide LIALDA (mesalamine) DIPENTUM (olsalazine) PENTASA (mesalamine) sulfasalazine RECTAL CANASA (mesalamine) mesalamine SFROWASA (mesalamine)

47 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.