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Therapeutic Drug Class

Therapeutic Drug Class

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

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) ERY (erythromycin) EVOCLIN (clindamycin) FINACEA (azelaic acid) KLARON (sulfacetamide) sulfacetamide

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

COMBINATION DRUGS/OTHERS DUAC (/clindamycin) ACANYA (benzoyl peroxide/clindamycin) EPIDUO (adapalene/benzoyl peroxide) BENZACLIN GEL (benzoyl peroxide/clindamycin) sodium sulfacetamide/ BENZACLIN KIT (benzoyl peroxide/ clindamycin) cream/cleanser/foam/gel/lotion/suspension BENZAMYCIN PAK (benzoyl peroxide/ erythromycin) benzoyl peroxide/clindamycin CLARIFOAM EF (sodium sulfacetamide/sulfur) CLENIA (sulfacetamide sodium/sulfur) erythromycin/benzoyl peroxide INOVA 4/1 (benzoyl peroxide/) INOVA 8/2 (benzoyl peroxide/salicylic acid) 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

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

KERATOLYTICS (BENZOYL PEROXIDES) benzoyl peroxide BENZEFOAM (benzoyl peroxide) ZACLIR (benzoyl peroxide) BENZEFOAM ULTRA (benzoyl peroxide) BP10 (benzoyl peroxide) BPO (benzoyl peroxide) INOVA (benzoyl peroxide) LAVOCLEN (benzoyl peroxide) OSCION (benzoyl peroxide)

ALZHEIMER’S AGENTS SmartPA CHOLINESTERASE INHIBITORS ARICEPT (donepezil) donepezil SmartPA Criteria: ARICEPT 23 MG (donepezil) galantamine • History of an approvable diagnosis in ARICEPT ODT (donepezil) galantamine ER the past 2 years EXELON (rivastigmine) RAZADYNE (galantamine) • History of at least 30 days of therapy EXELON Solution (rivastigmine) RAZADYNE ER (galantamine) with two different preferred Alzheimer’s rivastigmine 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 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS NMDA RECEPTOR ANTAGONIST NAMENDA TABS (memantine) NAMENDA SOLUTION(memantine) ANALGESICS, NARCOTIC - SHORT ACTING acetaminophen/codeine ABSTRAL () /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) meperidine DILAUDID (hydromorphone) morphine fentanyl oxycodone FENTORA (fentanyl) oxycodone/APAP FIORICET W/ CODEINE oxycodone/aspirin (butalbital/APAP/caffeine/codeine)

oxycodone/ibuprofen FIORINAL W/ CODEINE (butalbital/ASA/caffeine/codeine) pentazocine/APAP IBUDONE (hydrocodone/ibuprofen) tramadol levorphanol tramadol/APAP LORCET (hydrocodone/APAP) LORTAB (hydrocodone/APAP) MAGNACET (oxycodone/APAP) NORCO (hydrocodone/APAP) NUCYNTA (tapentadol) ONSOLIS (fentanyl) OPANA (oxymorphone) OXECTA (oxycodone) pentazocine/naloxone PERCOCET (oxycodone/APAP) PERCODAN (oxycodone/ASA) REPREXAINE (hydrocodone/ibuprofen) ROXICET (oxycodone/acetaminophen) RYBIX (tramadol) SUBSYS (fentanyl) 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SYNALGOS-DC (dihydrocodeine/ aspirin/caffeine) TREZIX (dihydrocodeine/ APAP/caffeine)NR TYLENOL W/CODEINE (APAP/codeine) TYLOX (oxycodone/APAP) ULTRACET (tramadol/APAP) ULTRAM (tramadol) VICODIN (hydrocodone/APAP) VICOPROFEN (hydrocodone/ibuprofen) XODOL (hydrocodone/acetaminophen) XOLOX (oxycodone/APAP) ZAMICET (hydrocodone/APAP) ZOLVIT (hydrocodone/APAP) ZYDONE (hydrocodone/acetaminophen)

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

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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

VOLTAREN Gel (diclofenac sodium) capsaicin SmartPA Criteria: EMLA (lidocaine/prilocaine) • History of at least 1 claim for a preferred FLECTOR (diclofenac epolamine) agent in the past 6 months LIDAMANTLE (lidocaine) • History of at least 90 days of therapy LIDAMANTLE HC (lidocaine/hydrocortisone) with the same agent as on the incoming lidocaine claim in the past 105 days lidocaine/prilocaine LIDODERM (lidocaine) Lidoderm: Diagnosis of post-herpetic LMX 4 (lidocaine) neuralgia or diabetic neuropathy in the past year. PENNSAID Solution (diclofenac sodium ) xylocaine SYNERA (lidocaine/tetracaine) ZOSTRIX (capsaicin)

ANDROGENIC AGENTS SmartPA TESTIM (testosterone gel) ANDRODERM (testosterone patch) SmartPA Criteria: ANDROGEL (testosterone gel) • Male Patient AXIRON (testosterone gel) • History of at least 30 days of therapy FORTESTSA (testosterone gel) with a preferred androgenic agents in the past 6 months 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

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

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

• ACEI/Calcium Channel Blocker combination product o History of at least 30 days of 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

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

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

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS DIRECT RENIN INHIBITORS TEKTURNA (aliskiren) SmartPA Criteria: • History of hypertension in the past 2 years • History of at least 90 days of therapy 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 (Topical) bacitracin ALTABAX (retapamulin) bacitracin/polymixin BACTROBAN OINTMENT (mupirocin) BACTROBAN cream (mupirocin) CORTISPORIN (bacitracin/neomycin/ gentamicin polymyxin/HC) mupirocin ointment mupirocin cream ANTIBIOTICS (GI) ALINIA (nitazoxanide) DIFICID () FLAGYL ER (metronidazole) neomycin VANCOCIN (vancomycin) TINDAMAX () vancomycin tinidazole XIFAXAN () 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIBIOTICS (VAGINAL) CLEOCIN OVULES (clindamycin) AVC () clindamycin CLEOCIN CREAM (clindamycin) METROGEL (metronidazole) CLINDESSE (clindamycin) VANDAZOLE (metronidazole) metronidazole vaginal

ANTICOAGULANTS

COUMADIN (warfarin) ARIXTRA (fondaparinux) SmartPA LMWH *Clinical Edit Pradaxa: SmartPA LMWH NR FRAGMIN (dalteparin) ELIQUIS (apixaban) • Age >/=18 years

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

PRADAXA (dabigatran)* fondaparinux SmartPA LMWH the past 2 years

XARELTO 10mg (rivaroxaban) Clinical Edit INNOHEP (tinzaparin) SmartPA LMWH • History absent of cardiac valve disease XARELTO 15 & 20mg (rivaroxaban) in the past 2 years • warfarin 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 o Age >/=75 years • Age >/=65 years, no risk factor present AND 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 ------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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS Clinical Edit for Xarelto: • Limited to 70 days use per calendar year • Use for Atrial Fibrillation will require a manual prior authorization • Covered for knee replacement and limited to

SmartPA Criteria for LMWH duration effective 7-15-12: • Is there history for a LMWH in the past year • Is the duration of therapy on the claim

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o History of a total hip replacement, total knee replacement, or hip fracture surgery in the past 60 days . Is the duration of therapy on the claim carbamazepine BANZEL (rufinamide) • Vimpat CARBATROL (carbamazepine) carbamazepine XR** oAge >/= 17 years DEPAKOTE ER (divalproex) DEPAKENE (valproic acid) oDiagnosis of partial-onset seizures in DEPAKOTE SPRINKLE (divalproex) DEPAKOTE (divalproex) the past 2 years

divalproex EQUETRO (carbamazepine) NR • Potiga FANATREX SUSPENSION (gabapentin) divalproex ER Age >/= 18 years felbamate o 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS EPITOL (carbamazepine) FELBATOL (felbamate) oDiagnosis of partial onset seizures in gabapentin GRALISE (gabapentin) the past 2 years

GABITRIL (tiagabine) HORIZANT (gabapentin) oHistory of at least 30 days of therapy lamotrigine KEPPRA (levetiracetam) with two different preferred anticonvulsants in the past 6 months levetiracetam KEPPRA XR (levetiracetam) History of at least 90 days of therapy LAMICTAL (lamotrigine) o oxcarbazepine with the same agent as on the LAMICTAL CHEWABLE (lamotrigine) TEGRETOL XR (carbamazepine) incoming claim in the past 105 days TOPAMAX Sprinkle (topiramate) LAMICTAL ODT (lamotrigine) topiramate LAMICTAL XR (lamotrigine) • Banzel levetiracetam ER TRILEPTAL Suspension (oxcarbazepine) oAge >/= 4 years NEURONTIN (gabapentin) valproic acid oDiagnosis of Lennox-Gastaut in the past oxcarbazepine suspension VIMPAT (lacosamide) NR 2 years OXTELLAR XR (oxcarbazepine) zonisamide oHistory of at least 30 days of therapy POTIGA (ezogabine) with two different preferred

SABRIL (vigabatrin) anticonvulsants in the past 6 months STAVZOR (valproic acid) oHistory of at least 90 days of therapy TEGRETOL (carbamazepine) with the same agent as on the tiagabine incoming claim in the past 105 days topiramate capsule • TRILEPTAL Tablets (oxcarbazepine) Keppra XR Age 15-20 years ZONEGRAN (zonisamide) o oHistory of at least 30 days of therapy with levetiracetam IR in the past 6 months oHistory of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

• Lamictal XR oDiagnosis of seizure in past 2 years AND oHistory 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • Non Preferred Drugs not listed above oHistory of at least 30 days of therapy with two different preferred anticonvulsants in the past 6 months oHistory of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days SELECTED BENZODIAZEPINES DIASTAT (diazepam rectal) diazepam rectal gel • Onfi ONFI (clobazam) Age >/= 2 years o oDiagnosis of Lennox-Gastaut in the past 2 years HYDANTOINS DILANTIN () PEGANONE (ethotoin) PHENYTEK (phenytoin) phenytoin SUCCINIMIDES ethosuximide CELONTIN (methsuximide) ZARONTIN (ethosuximide) ANTIDEPRESSANTS, OTHER SmartPA bupropion APLENZIN (bupropion HBr) SmartPA Criteria: EFFEXOR XR (venlafaxine) bupropion SR • Does the patient meet the age limit for mirtazapine bupropion XL the requested drug • PRISTIQ (desvenlafaxine) DESYREL (trazodone) History of at least 30 days of therapy with two different preferred trazodone EFFEXOR (venlafaxine) antidepressants in the past 6 months WELLBUTRIN XL (bupropion HCl) EMSAM (selegiline transdermal) NR • History of at least 30 days of therapy FORFIVO XL (bupropion) with BOTH a preferred antidepressant MARPLAN (isocarboxazid) and a preferred SSRI in the past 6 NARDIL (phenelzine) months • History of at least 90 days of therapy OLEPTRO ER (trazodone) with the same agent as on the REMERON (mirtazapine) incoming claim in the past 105 days tranylcypromine • Cymbalta 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS venlafaxine o Diagnosis of depression in the past venlafaxine ER 2 years venlafaxine XR o History of at least 30 days of VIIBRYD (vilazodone) therapy with two different preferred antidepressants from in the past 6 WELLBUTRIN (bupropion) months WELLBUTRIN SR 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 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 escitalopram • Does the patient meet the age limit for fluvoxamine LUVOX (fluvoxamine) the requested drug LEXAPRO (escitalopram) LUVOX CR (fluvoxamine) • History of at least 30 days of therapy paroxetine IR paroxetine CR with two different preferred SSRI 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PAXIL CR (paroxetine) paroxetine suspension antidepressants in the past 6 months PAXIL SUPENSION PAXIL Tablets (paroxetine) • History of at least 90 days of therapy sertraline 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 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:

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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 (Oral) SmartPA ANCOBON () SmartPA Criteria: DIFLUCAN (fluconazole) • History of at least 1 claim for two GRIFULVIN V () griseofulvin tablet different preferred oral antifungals in the griseofulvin suspension past 6 months

GRIS-PEG (griseofulvin) foam • Itraconazole ketoconazole LAMISIL () Diagnosis of HIV in the past 2 years MYCELEX (clotrimazole) o o History of a transplant in the past 2 terbinafine MYCOSTATIN Tablets (nystatin) years NIZORAL (ketoconazole) o History of an immunosuppressant in NOXAFIL () the past 6 months NR ONMEL (itraconazole) ORAVIG () SPORANOX (itraconazole) TERBINEX Kit (terbinafine/) VFEND () voriconazole

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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 ciclopirox kit//solution different preferred topical antifungals in ketoconazole cream CNL 8 (ciclopirox) the past 6 months

ketoconazole shampoo ERTACZO () miconazole OTC EXELDERM () nystatin EXTINA (ketoconazole) terbinafine OTC cream,gel,spray LAMISIL (terbinafine) solution tolnaftate OTC LOPROX (ciclopirox) MENTAX () NAFTIN () NIZORAL (ketoconazole) OXISTAT () PEDIADERM AF (nystatin) PENLAC (ciclopirox) VUSION (miconazole/petrolatum/zinc oxide) XOLEGEL (ketoconazole)

ANTIFUNGAL/STEROID COMBINATIONS clotrimazole/betamethasone cream clotrimazole/betamethasone lotion nystatin/triamcinolone LOTRISONE (clotrimazole/betamethasone)

ANTIHISTAMINES, MINIMALLY SEDATING AND COMBINATIONS SmartPA MINIMALLY SEDATING ANTIHISTAMINES cetirizine ALLEGRA (fexofenadine) SmartPA Criteria: CLARINEX (desloratadine) • History of allergy or urticaria in the past fexofenadine RX 2 years levocetirizine • History of at least 30 days of therapy XYZAL Solution (levocetirizine) with two different preferred antihistamines in the past 12 months XYZAL Tablets (levocetirizine) • History of at least 90 days of therapy 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZYRTEC (Rx and OTC) (cetirizine) with the same agent as on the incoming claim in the past 105 days 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 MAXALT (rizatriptan) AMERGE (naratriptan) SmartPA Criteria: MAXALT MLT(rizatriptan) AXERT (almotriptan) • Oral product RELPAX (eletriptan) FROVA (frovatriptan) o History of at least 1 claim for a TREXIMET (sumatriptan/naproxen) IMITREX (sumatriptan) preferred oral product in the past 365 days ZOMIG (zolmitriptan) naratriptan

rizatriptan Axert – SmartPA if age 12-17 years sumatriptan

NASAL IMITREX (sumatriptan) 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 *Note: Non-Preferred drugs will deny at NATROBA (spinosad) malathion POS, PDL criteria are not listed for this OVIDE (malathion) rule as it pertains to Natroba only.* 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SKLICE (ivermectin) • Natroba ULESFIA (benzyl alcohol) o History of permethrin in the past 90 days 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) NEUPRO (rotigotine) pramipexole REQUIP (ropinirole) REQUIP XL (ropinirole) ropinerole ER

MAO-B INHIBITORS selegiline AZILECT (rasagiline) ELDEPRYL (selegiline) ZELAPAR (selegiline)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OTHERS amantadine levodopa/carbidopa ODT Lodosyn will only be considered in bromocriptine LODOSYN (carbidopa) cases of augmentation of levodopa/carbidopa PARCOPA (levodopa/carbidopa) carbidopa/levodopa; patient must be PARLODEL (bromocriptine) currently taking a carbidopa/levodopa

SINEMET (levodopa/carbidopa) product. 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 HALDOL (haloperidol) the requested drug clozapine INVEGA (paliperidone) • Coverage of a non-preferred second FANAPT (iloperidone) NAVANE (thiothixene) generation antipsychotic product fluphenazine olanzapine requires an unsuccessful trial with a GEODON (ziprasidone) olanzapine/fluoxetine preferred second generation haloperidol quetiapine antipsychotic. LATUDA (lurasidone) RISPERDAL (risperidone) perphenazine SYMBYAX (olanzapine/fluoxetine) risperidone ziprasidone • *Abilify 10mg, 20mg and 30mg requires SAPHRIS (asenapine) ZYPREXA (olanzapine) splitting of tablet SEROQUEL (quetiapine) SEROQUEL XR (quetiapine) • Invega thioridazine o History of at least 30 days of therapy with risperidone in the past 12 thiothixene months trifluoperazine o History of at least 30 days of therapy with a preferred atypical antipsychotic in the past 12 months o History of at least 30 days of therapy with the same agent as on the incoming claim in the past 105 days

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS INJECTABLE, ATYPICALS ABILIFY (aripiprazole) Effective 11-1-2012, injectable GEODON (ziprasidone) antipsychotics are closed to POS INVEGA SUSTENNA (paliperidone palmitate) except for Long Term Care beneficiaries. RISPERDAL CONSTA (risperidone) ZYPREXA (olanzapine) ZYPREXA RELPREVV (olanzapine)

ANTIVIRALS (Oral) – ANTIHERPETIC AGENTS acyclovir famciclovir valacyclovir FAMVIR (famciclovir) VALTREX (valacyclovir) ZOVIRAX (acyclovir)

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

ATOPIC DERMATITIS SmartPA ELIDEL (pimecrolimus) PROTOPIC () SmartPA Criteria: • 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) 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS pindolol LEVATOL (penbutolol) • Sotalol propranolol LOPRESSOR (metoprolol) o History of atrial fibrillation in the past timolol SECTRAL (acebutolol) 2 years TOPROL XL (metoprolol) sotalol • TENORMIN (atenolol) Coreg CR History of hypertension in the past 2 ZEBETA (bisoprolol) o years o History of at least 30 days of therapy with and at least 30 days of therapy with a preferred Beta- Blocker in the past 6 months

*Bystolic: Requires unsuccessful trial with preferred beta-blocker

BETA- AND ALPHA-BLOCKERS carvedilol COREG (carvedilol) labetalol COREG CR (carvedilol) TRANDATE (labetalol)

BETA BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone CORZIDE (nadolol/bendroflumethiazide) 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)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS BLADDER RELAXANT PREPARATIONS SmartPA oxybutynin IR DETROL (tolterodine) Smart PA Criteria: TOVIAZ (fesoterodine fumarate) DETROL LA (tolterodine) • History of at least 30 days of therapy DITROPAN XL (oxybutynin) with two different preferred Bladder ENABLEX (darifenacin) Relaxant Preparations in the past 6 months GELNIQUE (oxybutynin)

MYRBETRIQ (mirabegron) oxybutynin ER OXYTROL (oxybutynin) SANCTURA (trospium) SANCTURA XR (trospium) tolterodine 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 • BINOSTO (alendronate) FOSAMAX (alendronate) History of at least 1 claim for two different preferred osteoporosis agents in the past FOSAMAX PLUS D (alendronate/vitamin D) ibandronate 6 months PROLIA (denosumab) • History of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days OTHERS FORTICAL (calcitonin) calcitonin salmon MIACALCIN (calcitonin) EVISTA (raloxifene) FORTEO (teriparatide)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

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

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

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

o Terazosin . History of an approvable diagnosis for terazosin in the past 2 years 5-ALPHA-REDUCTASE (5AR) INHIBITORS AVODART (dutasteride) PROSCAR (finasteride) finasteride

PDE5 INHIBITORS

CIALIS (tadalafil) • Male Patient: o Diagnosis of Benign Prostatic Hypertrophy (BPH) in the past 2 years o History absent of Erectile Dysfunction in the past 2 years

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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 TUDORZA PRESSAIR (aclidinium) SPIRIVA (tiotropium)

ANTICHOLINERGIC-BETA AGONIST COMBINATIONS albuterol/ipratropium COMBIVENT RESPIMAT (albuterol/ipratropium) COMBIVENT (albuterol/ipratropium) DUONEB (albuterol/ipratropium) BRONCHODILATORS, BETA AGONIST INHALERS, SHORT-ACTING PROVENTIL HFA (albuterol) MAXAIR (pirbuterol) SmartPA SmartPA: PROAIR HFA (albuterol) • Xopenex HFA inhaler VENTOLIN HFA (albuterol) o Age >/= 4 years SmartPA o History of at least 1 claim for an XOPENEX HFA (levalbuterol) albuterol inhaler in the past 30 days • Maxair o History of at least 1 claim for an albuterol inhaler 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 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS with a preferred LABA Inhaler 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 • 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

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ORAL albuterol VOSPIRE ER (albuterol) metaproterenol terbutaline

CALCIUM CHANNEL BLOCKERS SmartPA SHORT-ACTING diltiazem CALAN (verapamil) SmartPA Criteria: CARDIZEM (diltiazem) • History of at least 90 days of therapy 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

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- 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)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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 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) AUGMINTIN (amoxicillin/clavulanate) Tablets Suspension MOXATAG (amoxicillin) 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 past 6 months 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS CEFZIL (cefprozil)

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 cefpodoxime different preferred cephalosporins in the OMNICEF (cefdinir) past 6 months • Cefdinir suspension SPECTRACEF (cefditoren) Age < 18 years SUPRAX (cefixime) o

CYTOKINE & CAM ANTAGONISTS ENBREL (etanercept) AMEVIVE (alefacept) Amevive, Orencia, Remicade and HUMIRA (adalimumab) CIMZIA (certolizumab) Stelara are for administration in hospital KINERET (anakinra) or clinic setting. PA will not be issued at Point of Sale without justification. ORENCIA (abatacept) REMICADE (infliximab) SIMPONI (golimumab) STELARA (ustekinumab) XELJANZ (tofacitinib) ERYTHROPOIESIS STIMULATING PROTEINS SmartPA ARANESP (darbepoetin) EPOGEN (rHuEPO) SmartPA Criteria: PROCRIT (rHuEPO) OMONTYS (peginesatide) • 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

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS FLUOROQUINOLONES (Oral) SmartPA AVELOX () ER SmartPA Criteria: ciprofloxacin tablets CIPRO (ciprofloxacin) • Ciprofloxacin suspension or CIPRO XR (ciprofloxacin) solution FACTIVE () o Age <12 years . Diagnosis of anthrax infection or FLOXIN () exposure (022.X, V01.81) in the LEVAQUIN (levofloxacin) past 3 months levofloxacin . 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 . 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, Macrolides . 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

30 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS GENITAL WARTS & RELATED AGENTS ALDARA (imiquimod)* imiquimod *Aldara Age Edit: Payable for members CONDYLOX (podofilox) PICATO (ingenol) who are 12 years of age and older. podofilox

VEREGEN (sinecatechins) ZYCLARA (imiquimod)

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

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 NORDITROPIN (somatropin) OMNITROPE (somatropin) >18 yrs of age. NUTROPIN AQ (somatropin) SAIZEN (somatropin) SmartPA Criteria: SEROSTIM (somatropin) • Patient < 18 years of age TEV-TROPIN (somatropin) o History of at least 28 days of therapy ZORBTIVE (somatropin) with a preferred Growth Hormone in

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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, ) metronidazole, tetracycline) PREVPAC (lansoprazole, amoxicillin, OMECLAMOX (, clarithromycin, clarithromycin) amoxicillin)

HEPATITIS C TREATMENTS SmartPA INCIVEK (telaprevir)* INFERGEN (interferon alfacon-1) *Incivek & Victrelis require manual PA PEGASYS (peginterferon alfa-2a) ribavirin PEG-INTRON (peginterferon alfa-2b) REBETOL (ribavirin) • Other Hep C Treatments RIBAPAK DOSEPACK (ribavirin) RIBASPHERE (ribavirin) o Age >/= 18 years Diagnosis of chronic hepatitis C in VICTRELIS (boceprevir)* o 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 o Did the patient fail previous 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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) BYDUREON (exenatide) JANUMET (sitagliptin/metformin) JANUMET XR (sitagliptin/metformin) JANUVIA (sitagliptin) JENTADUETO (linagliptin/metformin) KOMBIGLYZE XR (saxagliptin/metformin) JUVISYNC (sitagliptin/) KAZANO (alogliptin/metformin)NR ONGLYZA (saxagliptin) NR TRADJENTA (linagliptin) NESINA (alogliptin) OSENI (alogliptin/pioglitazone)NR

SYMLIN (pramlintide) VICTOZA (liraglutide)

HYPOGLYCEMICS, INSULINS AND RELATED AGENTS SmartPA HUMALOG VIAL (insulin lispro) APIDRA (insulin glulisine) SmartPA Criteria: HUMALOG MIX VIAL (insulin lispro/ lispro HUMALOG KWIKPEN (insulin lispro) • History of Diabetes Mellitus in the past 2 protamine) HUMALOG MIX KWIKPEN (insulin lispro/ lispro years HUMULIN VIAL (insulin) protamine) • History of at least 30 days of therapy LANTUS SOLOSTAR & VIAL (insulin glargine) HUMULIN KWIKPEN (insulin) with a preferred product in the past 6 * months LEVEMIR FLEXPEN & VIAL (insulin detemir) NOVOLIN FLEXPEN (insulin) • History of at least 90 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS NOVOLIN VIAL (insulin) with the same agent as on the incoming NOVOLOG FLEXPEN & VIAL (insulin aspart) claim in the past 105 days NOVOLOG MIX FLEXPEN & VIAL (insulin aspart/ aspart protamine)

HYPOGLYCEMICS, MEGLITINIDES PRANDIN (repaglinide) nateglinide PRANDIMET (repaglinide/metformin) STARLIX (nateglinide)

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

TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) ACTOPLUSMET XR (pioglitazone/metformin) DUETACT (pioglitazone/glimepiride) AVANDARYL (rosiglitazone/glipizide) AVANDAMET (rosiglitazone/metformin) pioglitazone/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 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS RAPAMUNE () o Diagnosis of heart transplant, kidney SANDIMMUNE (cyclosporine) transplant, liver transplant, psoriasis, tacrolimus RA or an approvable indication for ZORTRESS (everolimus) cyclosporine, modified in the past 2 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 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

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS INTRANASAL RHINITIS AGENTS ANTICHOLINERGICS ipratropium ATROVENT (ipratropium) ANTIHISTAMINES ASTELIN (azelastine) ASTEPRO (azelastine) PATANASE (olopatadine) azelastine

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

LEUKOTRIENE MODIFIERS SmartPA ACCOLATE () montelukast SmartPA Criteria: SINGULAIR (montelukast) ZYFLO CR (zileuton) • History of at least 30 days of therapy zafirlukast 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

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS LIPOTROPICS, OTHER (Non-statins) SmartPA SEQUESTRANTS cholestyramine COLESTID (colestipol) SmartPA Criteria: colestipol QUESTRAN (cholestyramine) • All Lipotropics-Non Statin agents WELCHOL (colesevelam) regardless of PDL status will check for stable therapy. Stable therapy is defined as a 90 days of consecutive therapy shown in claims history in the past 105 days with the same agent as on the incoming claim. If stable therapy is found, a PA will be issued.

• All Lipotropics-Non Statin Agents regardless of PDL status will check for a trial of 30 days of therapy with a statin or statin combination product in the past year.

*Exemptions to prior statin therapy*:

• A female patient with a history of pregnancy in the past 280 days • A history of liver disease in the past 2 years • A history of hypertriglyceridemia in the past 2 years

A Bile Acid Sequestrant

. Clinical justification as to the reason the patient is unable to take a statin or why statin therapy is inappropriate.

All NON-PREFERRED agents must meet the following criteria.

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS • If the claim is for Welchol:

· A female patient with a history of pregnancy in the past 280 days

OR

· A history of 30 days of therapy with 2 different preferred Bile Acid Sequestrants in the past 6 months.

• If the claim is for a Fibric Acid Derivative:

· A history of 30 days of therapy with 2 different preferred Fibric Acid Derivatives in the past 6 months.

• Any other Non-Preferred agent must have a history of 30 days of therapy with 2 different preferred non-statin lipotropic agents 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 • Fibric Acid Derivative gemfibrozil fenofibrate nanocrystallized 145mg o History of at least 30 days of therapy TRICOR (fenofibrate nanocrystallized) FENOGLIDE (fenofibrate) with two different preferred fibric acid TRILIPIX (fenofibric acid) FIBRICOR (fenofibric acid) derivatives in the past 6 months

LIPOFEN (fenofibrate) LOFIBRA (fenofibrate) 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS LOPID (gemfibrozil) TRIGLIDE (fenofibrate) NIACIN NIACOR (niacin) NIASPAN (niacin)

LIPOTROPICS, STATINS SmartPA STATINS atorvastatin ALTOPREV () SmartPA Criteria: CRESTOR (rosuvastatin) LIVALO (pitavastatin) • History of at least 30 days of therapy LESCOL (fluvastatin) MEVACOR (lovastatin) with two different preferred statins/statin LESCOL XL (fluvastatin) PRAVACHOL (pravastatin) combinations in the past 6 months • History of at least 90 days of therapy LIPITOR (atorvastatin) ZOCOR (simvastatin) with the same agent as on the lovastatin incoming claim in the past 105 days pravastatin simvastatin STATIN COMBINATIONS atorvastatin/amlodipine ADVICOR (lovastatin/niacin) Prior to consideration of a non-preferred CADUET (atorvastatin/amlodipine) statin combination, the patient must first SIMCOR (simvastatin/niacin) have an unsuccessful trial with the preferred statin combination plus an VYTORIN (simvastatin/ezetimibe) unsuccessful trial with a preferred statin and calcium channel blocker (single agents) used together. MACROLIDES/KETOLIDES (Oral) KETOLIDES KETEK (telithromycin)

MACROLIDES

Azithromycin BIAXIN (clarithromycin) BIAXIN XL (clarithromycin) clarithromycin ER clarithromycin IR E.E.S. (erythromycin ethylsuccinate) 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS E.E.S. Suspension (erythromycin ethylsuccinate) E-MYCIN (erythromycin) ERYPED Suspension (erythromycin ERYC (erythromycin) ethylsuccinate) ERY-TAB (erythromycin)

erythromycin ERYTHROCIN (erythromycin stearate) erythromycin estolate PCE (erythromycin) ZITHROMAX (azithromycin) ZMAX (azithromycin) MISCELLANEOUS BRAND/GENERIC CLONIDINE CATAPRES-TTS (clonidine) clonidine patches clonidine tablets CATAPRES (clonidine)

MISCELLANEOUS MEGACE ES (megestrol) KALYDECO (ivacaftor) Suboxone References can be found at: SUBOXONE (buprenorphine/naloxone) KORLYM () http://www.medicaid.ms.gov/Documents megestrol suspension 625mg/5mL /Pharmacy/Suboxone%20Resources.pd f.

SELECT ORAL CONTRACEPTIVES ALL ORAL CONTRACEPTIVES ARE BEYAZ (ethinyl PREFERRED EXCEPT FOR THOSE //levomefolate) SPECIFICALLY INDICATED AS NON- Gianvi (ethinyl estradiol/drospirenone) PREFERRED norethindrone/ethinyl estradiol/fe chew tab Ocella (ethinyl estradiol/drospirenone)

SUBLINGUAL NITROGLYCERIN nitroglycerin lingual 12gm nitroglycerin lingual 4.9gm nitroglycerin sublingual NITROLINGUAL (nitroglycerin) 4.9gm NITROLINGUAL PUMPSPRAY (nitroglycerin) NITROMIST (nitroglycerin) 12gm NITROSTAT SUBLINGUAL (nitroglycerin)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MULTIPLE SCLEROSIS AGENTS SmartPA AVONEX (interferon beta-1a) AMPYRA (dalfampridine) SmartPA Criteria: COPAXONE (glatiramer) AUBAGIO (teriflunomide) • Diagnosis of multiple sclerosis (340.XX) REBIF (interferon beta-1a) BETASERON (interferon beta-1b) in the past 2 years • EXTAVIA (interferon beta-1b) History of at least 1 claim for two different preferred multiple sclerosis GILENYA (fingolimod) 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: 1. For patients that have a gait disorder associated with MS; and 2. Initial authorizations will be approved for 12 weeks with a baseline Timed 25- foot Walk (T25FW) assessment; and 3. Additional prior authorizations will be considered at 6 month intervals after assessing the benefit to the patient as measured by a 20% improvement in the T25FW from baseline. Renewal will not be approved if the 20% improvement is not maintained; and 4. Prior authorizations will not be considered for patients with a seizure diagnosis or in patients will moderate to severe renal impairment. 5. Max dose of 20 mg daily; and #60 units in 30 days; approved for ages 18 and above

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS NSAIDS NON-SELECTIVE diclofenac EC ADVIL (ibuprofen) • Non-Selective agents etodolac tab ANAPROX (naproxen) o History of at least 30 days of therapy flurbiprofen CAMBIA (diclofenac) with two different preferred NSAIDs in CATAFLAM (diclofenac) ibuprofen the past 6 months CLINORIL (sulindac) indomethacin DAYPRO (oxaprozin) ketorolac diclofenac SR naproxen etodolac cap sulindac etodolac tab SR FELDENE (piroxicam) fenoprofen INDOCIN (indomethacin) indomethacin cap ER ketoprofen ketoprofen ER meclofenamate mefenamic acid MOTRIN (ibuprofen) nabumetone NALFON (fenoprofen) NAPRELAN (naproxen) NAPROSYN (naproxen) NUPRIN (ibuprofen) Oxaprozin piroxicam PONSTEL (mefenamic acid) SPRIX NASAL SPRAY (ketorolac) tolmetin VOLTAREN XR (diclofenac) ZIPSOR (diclofenac)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) diclofenac/misoprostol DUEXIS (ibuprofen/famotidine) VIMOVO (naproxen/esomeprazole)

SmartPA COX II SELECTIVE meloxicam CELEBREX (celecoxib) SmartPA Criteria: MOBIC (meloxicam) • Is the incoming claim for a COX-II selective agent • 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

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OPHTHALMIC ANTIBIOTICS bacitracin AZASITE (azithromycin) bacitracin/neomycin/gramicidin BESIVANCE () bacitracin/polymyxin BLEPH-10 (sulfacetamide) erythromycin CILOXAN (ciprofloxacin) gentamicin ciprofloxacin MOXEZA (moxifloxacin) GARAMYCIN (gentamicin) neomycin/bacitracin/polymyxin b levofloxacin polymyxin/ IQUIX (levofloxacin) sulfacetamide NATACYN () tobramycin NEO-POLYCIN (neomy/baci/polymyxin b) VIGAMOX (moxifloxacin) NEOSPORIN (bacitracin/neomycin/gramicidin) (oxy-tcn/polymyx sul) TOBREX (tobramycin) oint OCUFLOX (ofloxacin) ofloxacin POLYTRIM (polymyxin/trimethoprim) QUIXIN (levofloxacin) ZYMAR () ZYMAXID (gatifloxacin)

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

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

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

FML SOP (fluorometholone) ILEVRO (nepafenac)NR MAXIDEX (dexamethasone) OCUFEN (flurbiprofen) NEVANAC (nepafenac) PRED MILD (prednisolone) prednisolone acetate PRED FORTE (prednisolone) prednisolone NA phosphate VOLTAREN (diclofenac) VEXOL ()

OPHTHALMICS FOR ALLERGIC SmartPA cromolyn ALAMAST (pemirolast) SmartPA Criteria: ketotifen OTC ALOCRIL (nedocromil) • History of at least 30 days of therapy LOTEMAX (loteprednol) ALOMIDE (lodoxamide) with two different preferred Ophthalmic OPTIVAR (azelastine) ALREX (loteprednol) Allergy Agents in the past 6 months • History of at least 90 days of therapy PATADAY (olopatadine) azelastine with the same agent at the same PATANOL (olopatadine) BEPREVE (bepotastine) brand/generic status as on the incoming CROLOM (cromolyn) claim in the past 105 days ELESTAT (epinastine) EMADINE (emedastine) epinastine LASTACAFT (alcaftadine)

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) timolol gel with two different preferred glaucoma 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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS levobunolol TIMOPTIC (timolol) agents in the past 6 months metipranolol • History of at least 90 days of therapy timolol solution with the same agent at the same 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 PF(dorzolamide/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 latanoprost LUMIGAN (bimatoprost) TRAVATAN Z (travoprost) RESCULA (unoprostone)NR XALATAN (latanoprost) ZIOPTAN (tafluprost)

SYMPATHOMIMETICS ALPHAGAN P 0.15% (brimonidine) ALPHAGAN P 0.1% (brimonidine) brimonidine dipivefrin PROPINE (dipivefrin)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OTIC ANTIBIOTICS CIPRO HC (ciprofloxacin/hydrocortisone) CETRAXAL (ciprofloxacin) CIPRODEX (ciprofloxacin/dexamethasone) ciprofloxacin COLY-MYCIN S (colistin/neomycin/ DERMOTIC (fluocinolone) hydrocortisone) ofloxacin CORTISPORIN-TC (colistin/neomycin/ hydrocortisone) neomycin/polymyxin/hydrocortisone

PANCREATIC ENZYMES SmartPA CREON (pancreatin) PANCRELIPASE SmartPA Criteria: PANCREAZE (pancrelipase) PERTZYE • History of at least 30 days of therapy ZENPEP (pancrelipase) ULTRESA with two different preferred pancreatic VIOKASE 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

PARATHYROID AGENTS calcitriol DRISDOL (ergocalciferol) ergocalciferol HECTOROL (doxercalciferol) ZEMPLAR (paricalcitol) ROCALTROL (calcitriol) SENSIPAR (cinacalcet)**

PHOSPHATE BINDERS ELIPHOS (calcium acetate) calcium acetate RENAGEL (sevelamer HCl) FOSRENOL (lanthanum) PHOSLYRA (calcium acetate) PHOSLO (calcium acetate) RENVELA (sevelamer carbonate)

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. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PLATELET AGGREGATION INHIBITORS SmartPA AGGRENOX (dipyridamole/aspirin) BRILINTA (ticagrelor) • Brilinta dipyridamole cilostazol oHistory of Acute Coronary Syndrome or PLAVIX (clopidogrel) clopidogrel Percutaneous Coronary Intervention in EFFIENT (prasugrel) the past 2 years History of at least 30 days of therapy PERSANTINE (dipyridamole) o with Brilinta in the past 6 months PLETAL (cilostazol)

ticlopidine • Pletal

oHistory of an approvable indication in the past 2 years oHistory of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days.

• Effient oHistory of Acute Coronary Syndrome or Percutaneous Coronary Intervention in the past 2 years

• Non Preferred Drugs not listed above: oHistory of an approvable indication in the past 2 years oHistory of at least 30 days of therapy with two different preferred products in the past 6 months oHistory of at least 90 days of therapy with the same agent as on the incoming claim in the past 105 days

PRENATAL VITAMINS CONCEPT DHA Capsule B-NEXA Tablet Products not listed here are assumed to FE C PLUS Tablet CAVAN-EC SOD DHA VITAMINS be non-preferred. PAIRE OB PLUS DHA COMBO PACK CITRANATAL 90 DHA PACK PRENATAL PLUS Tablet CITRANATAL ASSURE COMBO PACK PREQUE 10 TABLET CITRANATAL B-CALM PACK 48 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SE-NATAL CHEWABLE Tablet CITRANATAL DHA PACK TARON-C DHA Capsule CITRANATAL HARMONY Capsule TRICARE PRENATAL Tablet CITRANATAL HARMONY Capsule VOL-PLUS Tablet CITRANATAL RX Tablet COMPLETE NATAL DHA COMPLETENATE Tablet CHEW CONCEPT OB Capsule CORENATE-DHA COMBO PACK DUET DHA BALANCED COMBO PACK DUET DHA BALANCED COMBO PACK ED CYTE F Tablet FOLCAL DHA Capsule FOLCAPS OMEGA-3 Capsule FOLIVANE-EC CALCIUM DHA COMBO FOLIVANE-OB Capsule FOLIVANE-PRX DHA NF Capsule GESTICARE DHA COMBO PACK ICAR-C PLUS SR Capsule ICAR-C PLUS Tablet NATAFORT Tablet NATELLE ONE Capsule NESTABS DHA COMBO PACK NESTABS PRENATAL Tablet NEXA SELECT Capsule PNV-DHA SOFTGEL PNV-SELECT Tablet PR NATAL 400 COMBO PACK PR NATAL 430 COMBO PACK PR NATAL 430 EC COMBO PACK PREFERA OB Tablet PREFERA-OB ONE SOFTGEL PREFERA-OB PLUS DHA COMBO PACK PREFERA-OB PLUS DHA COMBO PACK PREFERA-OB Tablet PRENATABS FA Tablet PRENATAL 19 Tablet PRENATAL PLUS IRON Tablet 49 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PRENATAL VITAMINS Tablet PRENATE DHA SOFTGEL PRENATE ELITE Tablet PRENATE ESSENTIAL SOFTGEL PRENATE PLUS Tablet PRENAVITE Tablet PRENEXA Capsule PREQUE 10 Tablet PREQUE 10 Tablet RELNATE DHA PRENATAL SOFTGEL ROVIN-NV DHA Capsule ROVIN-NV Tablet SE-CARE CHEWABLE Tablet SELECT-OB + DHA PACK SELECT-OB CAPLET SE-NATAL 19 CHEWABLE Tablet SE-NATAL 19 Tablet SE-TAN DHA Capsule TARON-BC Tablet TARON-PREX PRENATAL DHA CAP PROTON PUMP INHIBITORS SmartPA ACIPHEX (rabeprazole) DEXILANT (dexlansoprazole) SmartPA Criteria: NEXIUM (esomeprazole) lansoprazole RX PROTONIX PACKET (pantoprazole) omeprazole RX • History of an approvable indication in omeprazole sod. bicarb. the past 2 years

pantoprazole • History of at least 30 days of therapy PREVACID Rx (lansoprazole) with two different preferred Proton PREVACID SOLU-TAB (lansoprazole) Pump Inhibitors in the past 6 months PRILOSEC RX (omeprazole) PROTONIX (pantoprazole) • 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

50 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PULMONARY ANTIHYPERTENSIVES – ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS () SmartPA Criteria: TRACLEER () • 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 PULMONARY ANTIHYPERTENSIVES – PDE5s SmartPA ADCIRCA (tadalafil) REVATIO (sildenafil) SmartPA Criteria: 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

PULMONARY ANTIHYPERTENSIVES – PROSTACYCLINS TYVASO (treprostinil) SmartPA Criteria: VENTAVIS (iloprost) • 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 51 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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

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 INTERMEZZO (zolpidem) claim plus history of all Zolpimist claims

SKELETAL MUSCLE RELAXANTS SmartPA baclofen AMRIX (cyclobenzaprine ER) SmartPA Criteria: chlorzoxazone carisoprodol • Carisoprodol 52 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS cyclobenzaprine carisoprodol compound o Diagnosis of an acute methocarbamol cyclobenzaprine ER musculoskeletal condition in the past tizanidine tablets dantrolene 3 months FEXMID (cyclobenzaprine) o History absent of therapy with meprobamate in the past 90 days FLEXERIL (cyclobenzaprine) History of at least 1 claim for LORZONE (chlorzoxazone) o cyclobenzaprine in the past 21 days metaxalone 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 cr, oint, soln. desonide lotion different preferred low potency products in the past 6 months DESOWEN (desonide) o History of at least 90 days of therapy fluocinolone oil with the same agent at the same 53 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS hydrocortisone lotion brand/generic status as on the PEDIACARE HC (hydrocortisone) incoming claim in the past 105 days PEDIADERM (hydrocortisone) VERDESO (desonide)

MEDIUM POTENCY fluocinolone CLODERM (clocortolone) SmartPA Criteria: hydrocortisone CUTIVATE (fluticasone) • Medium potency product mometasone cr, oint. DERMATOP (prednicarbate) o History of at least 1 claim for two prednicarbate cr ELOCON (mometasone) different preferred medium potency products in the past 6 months PANDEL (hydrocortisone probutate) fluticasone 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 MOMEXIN (mometasone) incoming claim in the past 105 days prednicarbate oint WESTCORT (hydrocortisone valerate)

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

54 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS VERY HIGH POTENCY clobetasol emollient clobetasol propionate foam clobetasol propionate cr, gel, oint, sol CLOBEX (clobetasol) halobetasol DIPROLENE (betamethasone diprop/prop gly) HALONATE (halobetasol/ammonium lactate) HALAC (halobetasol/ammoium lac) TEMOVATE (clobetasol propionate) OLUX (clobetasol) OLUX-E (clobetasol) ULTRAVATE (halobetasol)

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 methamphetamine SmartPA Criteria : FOCALIN (dexmethylphenidate) methylphenidate solution • Age >/= 6 years METHYLIN chewable tablets (methylphenidate) o Is the incoming claim for METHYLIN solution (methylphenidate) dextroamphetamine IR or mixed methylphenidate IR amphetamine salts IR . Age >/= 3 years PROCENTRA (dextroamphetamine) • 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 55 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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: *(Requires trial of Vyvanse before approval)* CONCERTA (methylphenidate) • Age >/= 6 years DAYTRANA (methylphenidate) DEXEDRINE (dextroamphetamine) • Age <21 years FOCALIN XR (dexmethylphenidate) dextroamphetamine ER o Diagnosis of ADD/ADHD in the past 2 years METADATE CD (methylphenidate) methylphenidate CD (generic Metadate CD) • Long-acting stimulant methylphenidate ER (generic Concerta) NUVIGIL (armodafinil) History of at least 30 days of therapy (lisdexamfetamine) PROVIGIL (modafinil) o NR with two different preferred LA QUILLIVANT XR (methylphenidate) stimulants in the past 6 months RITALIN LA (methylphenidate) • 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

**Adderall XR o Age >/= 3 years o Diagnosis of ADD/ADHD in the past 2 years o Recent trial with Vyvanse

• Nuvigil or Provigil o One of the following diagnoses in the past 2 years (Narcolepsy, Obstructive Sleep Apnea, Shift Work Sleep Disorder) 56 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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 STRATTERA (atomoxetine) INTUNIV (guanfacine ER) SmartPA Criteria : KAPVAY (clonidine extended-release) • Kapvay/Intuniv o Age 6-17 years o Diagnosis of ADD/ADHD in the past 2 years and: o History of trial with preferred amphetamine or methylphenidate OR, o History of trial with Strattera OR, o History of trial with generic, immediate release formulation (clonidine or guanfacine). SmartPA doxycycline hyclate caps/tabs ADOXA (doxycycline monohydrate) SmartPA Criteria: caps IR demeclocycline • History of at least 1 claim for two tetracycline doxycycline monohydrate caps (75mg, 100mg, different preferred agents in the past 6 150mg) months • doxycycline monohydrate tabs Demeclocycline History of Diabetes Insipidus or DYNACIN (minocycline) o SIADH in the past 2 years minocycline ER minocycline tabs ORACEA (doxycycline) SOLODYN (minocycline) VIBRAMYCIN cap/susp/syrup 57 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 04/01/2013 PREFERRED DRUG LIST Version 2013.13c Updated: 4-29-2013

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ULCERATIVE COLITIS AGENTS ORAL APRISO (mesalamine) ASACOL HD (mesalamine) • History of at least 30 days of therapy ASACOL (mesalamine) AZULFIDINE (sulfasalazine) with a preferred non-stimulant in the balsalazide AZULFIDINE ER (sulfasalazine) past 6 months • DIPENTUM (olsalazine) COLAZAL (balsalazide) History of at least 90 days of therapy NR with the same agent at the same PENTASA 250mg (mesalamine) GIAZO (balsalazide) brand/generic status as on the incoming sulfasalazine LIALDA (mesalamine) claim in the past 105 days PENTASA 500mg (mesalamine) UCERIS (budesonide)NR

RECTAL CANASA (mesalamine) SFROWASA (mesalamine) • History of at least 30 days of therapy mesalamine 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

58 This is not an all-inclusive list of available covered drugs and includes only managed categories. Unless otherwise stated, the listing of a particular brand or generic name includes all dosage forms of that drug. NR indicates a new drug that has not yet been reviewed by the P&T Committee. PREFERRED BRANDS will not count toward the two brand monthly Rx limit. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2013. **Users of these products as of 3-31-13 will be grandfathered To search the PDL, press CTRL + F

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