1 NEBRASKA MEDICAID PREFERRED DRUG LIST Implementation

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NEBRASKA MEDICAID PREFERRED DRUG LIST August Classes 2009 – as approved 8/26/09 (SEE LEGEND BELOW TABLE) Implementation date: October 14, 2009 THERAPEUTIC PREFERRED NON-PREFERRED DRUG CLASS DRUGS DRUGS ANTIBIOTICS, VAGINAL clindamycin (vaginal) CLEOCIN OVULES (clindamycin, METROGEL (metronidazole, vaginal) vaginal suppositories) metronidazole (vaginal) CLINDESSE (clindamycin, vaginal)

ANTIFUNGALS, ORAL fluconazole ANCOBON (flucytosine) GRIS-PEG (griseofulvin) clotrimazole (mucous membrane, troche) griseofulvin suspension GRIFULVIN V (griseofulvin) ketoconazole LAMISIL GRANULES (terbinafine) nystatin NOXAFIL (posaconazole) terbinafine SPORANOX (itraconazole) VFEND (voriconazole) ANTIFUNGALS, ANTIFUNGAL TOPICAL clotrimazole OTC and RX BENSAL HP (benzoic acid/salicylic acid) econazole ciclopirox cream/gel/suspension ketoconazole ciclopirox nail lacquer (solution) ketoconazole shampoo ERTACZO (sertaconazole) miconazole OTC EXTINA (ketoconazole) NAFTIN (naftifine) LOPROX SHAMPOO (ciclopirox) nystatin MENTAX (butenafine) selenium sulfide 1% OXISTAT (oxiconazole) selenium sulfide 2.5% selenium sulfide 2.25% terbinafine OTC VUSION (miconazole/ zinc oxide) XOLEGEL (ketoconazole) tolnaftate OTC

ANTIFUNGAL/STEROID COMBINATIONS clotrimazole/betamethasone nystatin/triamcinolone ANTIHYPERURICEMICS allopurinol ULORIC (febuxostat) colchicine probenecid probenecid/colchicine

ANTIPARASITICS, EURAX (crotamiton) lindane TOPICAL permethrin 1% OTC malathion

permethrin 5% RX NR OVIDE (malathion) ULESFIA (benzyl alcohol)

BRAND PRODUCTS IN UPPER CASE, generic products in lower case. If only the generic name is listed as preferred, then the BRAND name of that product is non-preferred; unless the brand name product is ALSO listed as preferred. QL indicates quantity limits. NR indicates product was not reviewed. New Drug criteria will apply.

2 THERAPEUTIC PREFERRED NON-PREFERRED DRUG CLASS DRUGS DRUGS ANTIVIRALS, ORAL ANTI-HERPETIC DRUGS acyclovir famciclovir VALTREX (valacyclovir) FAMVIR (famciclovir)

ANTI-INFLUENZA DRUGS amantadine RELENZA (zanamivir) inhalationQL rimantadine TAMIFLU (oseltamivir) QL ANTIVIRALS, TOPICAL DENAVIR (penciclovir) ZOVIRAX Cream (acyclovir) ZOVIRAX Ointment (acyclovir) BRONCHODILATORS, INHALERS ANTICHOLINERGIC ATROVENT HFA (ipratropium) COMBIVENT (albuterol/ipratropium) SPIRIVA (tiotropium) INHALATION SOLUTION ipratropium solution albuterol/ipratropium BRONCHODILATORS, INHALERS-Short Acting BETA AGONIST PROAIR HFA (albuterol) MAXAIR (pirbuterol) VENTOLIN HFA (albuterol) PROVENTIL HFA (albuterol) XOPENEX HFA (levalbuterol) INHALERS – Long Acting FORADIL (formoterol) SEREVENT (salmeterol) INHALATION SOLUTION albuterol albuterol low dose (0.63mg/3ml) albuterol/ipratropium BROVANA (arformoterol) PERFOROMIST (formoterol) XOPENEX (levalbuterol) ORAL albuterol metaproterenol terbutaline CEPHALOSPORINS (Oral) BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS and RELATED amoxicillin/clavulanate tablets and suspension AUGMENTIN XR (amoxicillin/clavulanate) ANTIBIOTICS AUGMENTIN 125 Suspension (all forms of brand name AUGMENTIN are AUGMENTIN 250 Suspension non-preferred, except 125 and 250mg/5ml) CEPHALOSPORINS – First Generation cephalexin (oral) cefadroxil (oral) CEPHALOSPORINS – Second Generation cefuroxime (oral) cefaclor (oral) cefprozil (oral) CEFTIN (cefuroxime)

CEPHALOSPORINS – Third Generation cefdinir (oral) CEDAX (ceftibuten) SUPRAX (cefixime) cefpodoxime (oral) SPECTRACEF (cefditoren)

3 THERAPEUTIC PREFERRED NON-PREFERRED DRUG CLASS DRUGS DRUGS FLUOROQUINOLONES, AVELOX (moxifloxacin) CIPRO Suspension (ciprofloxacin) ORAL ciprofloxacin ciprofloxacin ER FACTIVE (gemifloxacin) LEVAQUIN (levofloxacin) NOROXIN (norfloxacin) ofloxacin PROQUIN XR (ciprofloxacin)

GLUCOCORTICOIDS, GLUCOCORTICOIDS INHALED AEROBID (flunisolide) ALVESCO (ciclesonide) AEROBID-M (flunisolide) ASMANEX (mometasone) AZMACORT (triamcinolone) PULMICORT FLEXHALER (budesonide) FLOVENT DISKUS (fluticasone) FLOVENT HFA (fluticasone) QVAR (beclomethasone) GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR (fluticasone/salmeterol)

ADVAIR HFA

SYMBICORT (budesonide/ formoterol)

INHALATION SOLUTION PULMICORT RESPULES (budesonide)

budesonide respules

INTRANASAL RHINITIS ANTICHOLINERGICS DRUGS ipratropium ANTIHISTAMINES ASTELIN (azelastine) ASTEPRO (azelastine)

PATANASE (olopatadine)

CORTICOSTEROIDS fluticasone BECONASE AQ (beclomethasone) NASONEX (mometasone) flunisolide VERAMYST (fluticasone) NASACORT AQ (triamcinolone) OMNARIS (ciclesonide) RHINOCORT AQUA (budesonide)

LEUKOTRIENE MODIFIERS ACCOLATE (zafirlukast) ZYFLO CR (zileuton) SINGULAIR (montelukast) MACROLIDES AND KETOLIDES KETOLIDES (Oral) KETEK (telithromycin) MACROLIDES

azithromycin clarithromycin ER erythromycin clarithromycin IR ZMAX (azithromycin) ZITHROMAX (azithromycin)

4 THERAPEUTIC PREFERRED NON-PREFERRED DRUG CLASS DRUGS DRUGS OPHTHALMICS, FLUOROQUINOLONES ANTIBIOTICS ciprofloxacin IQUIX (levofloxacin) CILOXAN oint. (ciprofloxacin) QUIXIN (levofloxacin) ofloxacin ZYMAR (gatifloxacin) VIGAMOX (moxifloxacin) BESIVANCE (besifloxacin)NR MACROLIDES erythromycin AZASITE (azithromycin) AMINOGLYCOSIDES gentamicin tobramycin TOBREX ointment (tobramycin) OTHER ANTIBIOTICS bacitracin NATACYN (natamycin) bacitracin/polymyxin B neomycin/polymyxin B/gramicidin polymyxin B/trimethoprim sulfacetamide triple antibiotic (neomycin/bacitracin/polymyxin B) TETRACYCLINES doxycycline demeclocycline minocycline ORACEA (doxycycline) tetracycline SOLODYN (minocycline)