MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete

HIV / AIDS Related Treatments HIV Treatment and Prevention Website: http://www.aidsinfo.nih.gov/ Antiretrovirals

Hepatitis C Direct Acting Antivirals Elbasvir/grazoprevir (ZEPATIER) PA Ledipasvir/sofosbuvir (HARVONI) PA Glecaprevir/pibrentasvir (MAVYRET) PA Sofosbuvir/velpatasvir (EPCLUSA) PA Opportunistic Infections PCP infections Toxoplasmosis Fungal infections Co-trimoxazole, TMP/SMX Co-trimoxazole, TMP/SMX Amphotericin B* (BACTRIM/SEPTRA SS, DS)* (BACTRIM/SEPTRA SS, DS)* Clotrimazole (MYCELEX)* Dapsone Dapsone Ketoconazole (NIZORAL)* (not shampoo) Pentamidine (PENTAM)* Pyrimethamine (DARAPRIM) Terbinafine (LAMISIL)* Atovaquone (MEPRON) PA Leucovorin* Fluconazole (DIFLUCAN)* Primaquine* Azithromycin (ZITHROMAX)* Voriconazole (VFEND)* Trimethoprim* Clindamycin (CLEOCIN)* Itraconazole (SPORANOX)* Clindamycin (CLEOCIN)* Leucovorin* Posaconazole (NOXAFIL)* (DR tablets only) Mycobacterial infections Sulfadiazine Nystatin* Azithromycin (ZITHROMAX)* Atovaquone (MEPRON) PA Others Clarithromycin (BIAXIN)* Herpes infections Hepatitis A Vaccine Ethambutol (MYAMBUTOL)* Acyclovir (ZOVIRAX)* ST1 Hepatitis B Vaccine Rifabutin (MYCOBUTIN) Famciclovir (FAMVIR)* ST2 Pneumococcal Vaccine Ciprofloxacin (CIPRO)* Valacyclovir (VALTREX)* ST2 Influenza Vaccine Levofloxacin (LEVAQUIN)* CMV infections Ribavirin (REBETOL, RIBASPHERE, Cryptosporidiosis Cidofovir (VISTIDE) COPEGUS)* Paromomycin* Foscarnet* Interferon alfa-2b (INTRON-A) Atovaquone (MEPRON) PA Valganciclovir (VALCYTE)* Peginterferon alfa-2a (PEGASYS) Azithromycin (ZITHROMAX)* Peginterferon alfa-2b (PEG-INTRON KIT)

1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category. MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete

Analgesics Efavirenz /emtricitabine/tenofovir Cephalosporins Nonsteroidal Anti-inflammatory Agents (ATRIPLA) Cephalexin (KEFLEX)* Celecoxib (CELEBREX) Efavirenz/lamivudine/tenofovir (SYMFI, Ceftriaxone INJ (ROCEPHIN)* Diclofenac (VOLTAREN)* SIMFI LO) Diclofenac/misoprostol (ARTHROTEC) Elvitegravir/Cobicistat/Emtricitabine/ Quinolones Nabumetone* Tenofovir (STRIBILD, GENVOYA) Ciprofloxacin (CIPRO)* Ibuprofen 800mg (MOTRIN 800mg)* Emtricitabine (EMTRIVA) Levofloxicin (LEVAQUIN)* Emtricitabine/tenofovir (TRUVADA, Opiate Agonists DESCOVY) Macrolides Codeine* Emtricitabine/rilpivirine/tenofovir Azithromycin (ZITHROMAX)* Codeine/Acetaminophen (TYLENOL #3, (COMPLERA) Clarithromycin (BIAXIN*, BIAXIN XL) #4)* Enfuvirtide (FUZEON) Erythromycin* Fentanyl (DURAGESIC)* PA Etravirine (INTELENCE) Hydrocodone/Acetaminophen (VICODIN, Fosamprenavir (LEXIVA) Penicillins VICODIN ES, LORTAB)* Fostemsavir (RUKOBIA) Amoxicillin (TRIMOX, AMOXIL)* Methadone* PA Ibalizumab (TROGARZO) Amoxicllin/clavulanic acid (AUGMENTIN* Morphine (ROXANOL, MS-CONTIN)* Indinavir (CRIXIVAN) AUGMENTIN ES- 600, AUGMENTIN XR) Morphine (ORAMORPH SR) Lamivudine (EPIVIR)* Penicillin* Oxycodone (OXY-IR)* Lamivudine/tenofovir (CIMDUO) Penicillin INJ (BICILLIN LA) Oxycodone/Acetaminophen (PERCOCET)* Lamivudine/zidovudine (COMBIVIR)* Tramadol (ULTRAM)* Maraviroc (SELZENTRY) Tetracyclines Tramadol/Acetaminophen (ULTRACET)* Nelfinavir (VIRACEPT) Doxycycline* Oxycodone (OXYCONTIN) PA Nevirapine (VIRAMUNE)* Raltegravir (ISENTRESS) Vaginal Antimicrobials Rilpiviring (EDURANT) Metronidazole vag (METROGEL)* Anti-Infectives Rilpivirine/emtricitabine/tenofovir Antifungal Antibiotics (ODEFSEY) Ophthalmic Antimicrobials Amphotericin B (AMPHOCIN)* Ritonavir (NORVIR) Ciprofloxacin (CILOXAN)* Clotrimazole (MYCELEX)* Saquinavir (INVIRASE) Erythromycin* Fluconazole (DIFLUCAN)* Stavudine (ZERIT)* Ofloxacin (OCUFLOX)* Itraconazole (SPORANOX)* Tenofovir (VIREAD, VEMLIDY)* Ketoconazole (NIZORAL)*(excluding shampoo) Tipranavir (APTIVUS) Otic Antimicrobials Posaconazole (NOXAFIL)*(DR Tablets only) Zidovudine (RETROVIR)* Ciprofloxacin/dexamethasone (CIPRODEX) Terbinafine (LAMISIL)* Ciprofloxacin/HC (CIPRO HC) Voriconazole (VFEND)* Antituberculosis Agents Ethambutol (MYAMBUTOL)* Topical Antimicrobials Antiprotozoals, Miscellaneous Isoniazid* Acyclovir (ZOVIRAX) (adjunct to Isoniazid only) Atovaquone (MEPRON) PA Pyridoxine* Clindamycin (CLEOCIN-T)* Paromomycin * Pyrazinamide* Clotrimazole/betamethasone (LOTRISONE)* Pentamidine (PENTAM)* Rifabutin (MYCOBUTIN)* Erythromycin* Rifampin (RIFADIN)* Metronidazole (METROCREAM*, Antiretroviral Agents and Boosters METROGEL) Abacavir (ZIAGEN) Other Antivirals Nystatin* Abacavir/dolutegravir/lamivudine Acyclovir (ZOVIRAX)* ST1 (TRIUMEQ) Entecavir (BARACLUDE) Other Antimicrobials Abacavir/lamivudine (EPZICOM) Cidofovir (VISTIDE) Co-trimoxazole, TMP/SMX Abacavir/lamivudine/zidovudine (TRIZIVIR) Famciclovir (FAMVIR)* ST2 (BACTRIM / SEPTRA SS, DS)* Cobicistat (TYBOST) Foscarnet * Clindamycin (CLEOCIN)* Darunavir (PREZISTA) Oseltamivir (TAMIFLU) Dapsone Darunavir/Cobicistat (PREZCOBIX) Ribavirin (REBETROL, RIBASPHERE, Metronidazole (FLAGYL)* Darunavir/cobicistat/tenofovir/ COPEGUS) Primaquine emtricitabine (SYMTUZA) Rimantadine (FLUMADINE)* Pyrimethamine (DARAPRIM) Delavirdine (RESCRIPTOR) Valacyclovir (VALTREX)* ST2 Sulfadiazine Didanosine (VIDEX EC*, VIDEX soln) Valganciclovir (VALCYTE) Trimethoprim* Efavirenz (SUSTIVA) Zanamivir (RELENZA) 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete

Interferons Diuretics Skeletal Muscle Relaxants

Interferon alfa-2b (INTRON-A) Furosemide (LASIX)* Baclofen* Peginterferon alfa-2a (PEGASYS) Hydrochlorothiazide* Cyclobenzaprine (FLEXERIL)* Peginterferon alfa-2b (PEG-INTRON Hctz/triamterene (DYAZIDE, MAXZIDE)* Tizanidine (ZANAFLEX)* KIT) Spironolactone (ALDACTONE)* Smoking Cessation CNS Bupropion (ZYBAN) Cardiovasculars Nicotine patch (NICODERM CQ)* Angiotensin II Receptor Antagonists Anticonvulsants Divalproex sodium (DEPAKOTE, Nicotine lozenge Losartan (COZAAR)* ST1 Nicotine nasal spray (NICOTROL NS) Losartan/hctz (HYZAAR)* ST1 DEPAKOTE ER)* Gabapentin (NEURONTIN)* Nicotine inhaler (NICOTROL INH) Valsartan/hctz (DIOVAN HCT) ST2 Levetiracetam (KEPPRA)* Nicotine gum (NICORETTE)*

Phenytoin (DILANTIN)* Varenicline (CHANTIX) Angiotensin-Converting Enzyme

Inhibitors Antidepressants Substance Abuse Agents Benazepril (LOTENSIN)* Amitriptyline ST1* Acamprosate (CAMPRAL) Enalapril (VASOTEC)* Bupropion ST1 (WELLBUTRIN SR)* Buprenorphine (SUBUTEX)* Enalapril/hctz (VASERETIC)* Citalopram ST1 (CELEXA)* Buprenorphine/naloxone (SUBOXONE) Lisinopril (PRINIVIL, ZESTRIL)* Doxepin ST1* Naloxone injectable / Carpuject Syringe Lisinopril/hctz (PRINZIDE, Duloxetine (CYMBALTA)* Naloxone nasal spray (NARCAN) ZESTORETIC)* Escitalopram (LEXAPRO)* Quinapril (ACCUPRIL)* Fluoxetine ST1 (PROZAC)* Ramipril (ALTACE)* Endocrine Mirtazapine ST1 (REMERON)* Androgens

Paroxetine ST1 (PAXIL) * Oxandrolone (OXANDRIN)* Beta-Adrenergic Blocking Agents Sertraline ST1 (ZOLOFT)* Testostosterone injection (DEPO- Atenolol (TENORMIN)* Trazodone* TESTOSTERONE, DELATESTRYL) Atenolol/chlorthalidone (TENORETIC)* Venlafaxine (EFFEXOR)* Testostosterone topical Timolol* (ANDRODERM, ANDROGEL, Metoprolol (LOPRESSOR*, TOPROL XL Anxiolytics, Sedatives and Hypnotics TESTIM) PA Propranolol (INDERAL LA)* Buspirone (BUSPAR)*

Zolpidem (AMBIEN*, AMBIEN CR) Antiandrogen Calcium-Channel Blocking Agents Spironolactone (ALDACTONE)* Amlodipine (NORVASC)* Antipsychotics Dutasteride (AVODART)* Diltiazem (CARDIZEM, TAZTIA XT) * Aripiprazole (ABILIFY)* Finasteride (PROPECIA, Felodipine (PLENDIL) * Haloperidol (oral)* PROSCAR)* 1mg PA not covered for alopecia Nifedipine XL, ER (PROCARDIA, Chlorpromazine (oral)* ADALAT) * Olanzapine (ZYPREXA)* Antidiabetic: Combinations Verapamil (COVERA HS) Risperidone (RISPERDAL) Glyburide/metformin Verapamil (VERELAN, ISOPTIN SR, Quetiapine (SEROQUEL) * # low doses only (GLUCOVANCE)* CALAN, CALAN SR)* covered for tapering

Quetiapine XR (SEROQUEL XR)* Antidiabetic: Bigunanides Central Agonists Metformin (GLUCOPHAGE, Clonidine (CATAPRES)* Benzodiazepines GLUCOPHAGE XL)* Minoxidil* Alprazolam (XANAX)*

Clonazepam (KLONOPIN)* Antidiabetic: Sulfonylureas Lipid Lowering Agents Diazepam (VALIUM)* Glipizide (GLUCOTROL, XL) * Atorvastatin (LIPITOR)* Lorazepam (ATIVAN)* Glyburide (DIABETA,) * Cholestyramine (QUESTRAN)* Temazepam (RESTORIL)* Fenofibrate* (LOFIBRA) Antidiabetic: Thiazolidinediones Icosapent Ethyl (VASCEPA)* Mood Stabilizers Pioglitazone (ACTOS) PA Niacin (NIASPAN) Lithium carbonate Pravastatin (PRAVACHOL)* Lithium carbonate ER Antidiabetic: DPP-4 Inhibitors

Sitagliptin (JANUVIA) Nitrates and Nitrites Selective Serotonin Agonists Nitroglycerin sublingual tab, spray, cap* Sumatriptan (IMITREX)* 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete

Antidiabetic: GLP-1 OTC)* Liraglutide (VICTOZA) PA Leukotrene Modifier Histamine H2-Antagonists Montelukast (SINGULAIR)* Antidiabetic: Insulins Famotidine (PEPCID)* BASAGLAR Ranitidine (ZANTAC)* Nasal Corticosteroids NOVOLOG (all formulations) Beclomethasone (BECONASE AQ) NOVOLIN (all formulations) Anticholinergics/Motility NOVOLOG MIX FLEXPEN Dicyclomine (BENTYL)* Urologicals LANTUS, LANTUS SOLOSTAR Metoclopramide (REGLAN)* Oxybutynin (DITROPAN, DITROPAN HUMULIN (all formulations) XL)* HUMALOG (all formulations) Miscellaneous GI Tamsulosin (FLOMAX)* HUMALOG MIX Lactulose* Terazosin* Megestrol (MEGACE) Bone Metabolism Mesalamine, 5-ASA (ROWASA*, Alendronate (FOSAMAX)* ASACOL) Topical Agents Topical Anti-inflammatory Agents Corticosteroids Blood Modifiers, Nutritionals, Desonide (DESOWEN)* Prednisone* Hydrocortisone 2.5% cream* Electrolytes Triamcinolone cream, oint, lot* Estrogen and Estrogen Modifier Anticoagulants/Antiplatelets Estradiol (ESTRACE)* Cilostazol (PLETAL)* Miscellaneous Dermatological Agent Estradiol Transdermal Patch (ALORA; Clopidogrel (PLAVIX)* Imiquimod (ALDARA)* CLIMARA; DOTTI; MENOSTAR; Warfarin (COUMADIN)* Podofilox (CONDYLOX)* MINIVELL; VIVELLE-DOT)* Conjugated estrogens tablet, vaginal Hematopoietic Agents Ophthalmic Agents cream (PREMARIN) Epoetin alfa (EPOGEN, PROCRIT) PA Timolol (TIMOPTIC, TIMOPTIC -XE)* Filgrastim, G-CSF (NEUPOGEN) PA Progesterone Other Medroxyprogesterone acetate tablet Vaccines (PROVERA)*, IM INJ (DEPO- Respiratory Antihistamines Hepatitis B Vaccine PROVERA)* Hepatitis A Vaccine Cetirizine (ZYRTEC) OTC only Cetirizine/p-ephedrine (ZYRTEC-D) Pneumococcal Vaccine Thyroid Agents Influenza / H1N1 Vaccine Levothyroxine (LEVOXYL, OTC only Diphenhydramine (BENADRYL)* Gardasil 9 SYNTHROID) * Zoster Vaccine (SHINGRIX)age limit ≥50 years Fexofenadine (ALLEGRA)* Loratadine (CLARITIN) OTC only Gastrointestinal Other Antiemetics Short Acting Bronchodilators Aldesleukin (PROLEUKIN) * QL: max 20mg/day Dronabinol (MARINOL)* Albuterol (PROVENTIL HFA)* Epinephrine (EPIPEN) Prochlorperazine (COMPAZINE)* Hydroxyurea (HYDREA)* Promethazine (PHENERGAN)* Long Acting Bronchodilators Leucovorin* Trimethobenzamide (TIGAN)* Olodaterol (STRIVERDI RESPIMAT) Hydroxyurea (DROXIA)*

Antidiarrheal Agents Inhaled Anticholinergics Dental Products and Diabetes Supplies Diphenoxylate/atropine (LOMOTIL)* Ipratopium (ATROVENT)* PREVIDENT-5000 Loperamide (IMODIUM A-D)* Tiotropium (SPIRIVA) Insulin syringe Opium tincture Umeclidinium (INCRUSE ELLIPTA) Lancets TruTrack Blood Glucose Monitor Digestants Inhaled Corticosteroids TruTrack Teststrip Pancrelipase (LIPRAM-UL20, ULTRASE, Beclomethasone (QVAR REDIHALER) PANGESTYME, VIOKASE) Nutritional Supplements Budesonide (PULMICORT FLEXHALER) *QL: max 3cans/day, max Boost Nutritional Drink of 6 months Proton-Pump Inhibitors Combination Inhalers *QL: max 3cans/day, max Lansoprazole (PREVACID OTC) Ensure Nutritional Drink Fluticasone/salmeterol (AIRDUO)* of 6 months Omeprazole (PRILOSEC, PRILOSEC 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete

BARACLUDE 2 Cobicistat/atazanavir,1,2 Cobicistat/darunavir, 1,2 INDEX BASAGLAR, 4 Codeine, 2 A Beclomethasone, 4 Codeine/Acetaminophen, 2 BECLOVENT, 4 COMBIVIR, 1, 2 Abacavir, 1, 2 BECONASE AQ, 4 COMPAZINE, 4 Abacavir/dolutegravir/lamivudine 1,2 Benazepril, 3 COMPLERA, 1,2 Abacavir/lamivudine, 1, 2 BENTYL, 4 CONDYLOX, 4 Abacavir/lamivudine/zidovudine, 1, 2 BIAXIN, 1, 2 Conjugated estrogens tablet, vaginal cream, 4 Abilify, 3 BIAXIN XL, 2 COPEGUS, 1, 2 Acamprosate, 3 BICILLIN LA, 2 Co-trimoxazole, 1, 3 ACCUPRIL, 3 Bictegravir/emtricitabine/tenofovir 1,2 COUMADIN, 4 Acetaminophen, 2 BIKTARVY 1,2 COVERA-HS, 3 Acrivastine/pseudophedrine, 4 BOOST 1,4 COZAAR, 3 ACTOS, 3 Budesonide oral inhalation flexhaler, CRESTOR, 3 Acyclovir, 1, 2 1, 2 CRIXIVAN, 1, 2 ADALAT, 3 Buprenorphine/naloxone, 3 Cyclobenzaprine, 3 AIRDUO, 4 Bupropion, 3 Cymbalta, 3 Albuterol, 4 BUSPAR, 3 CYTOVENE, 1, 2 ALDARA, 4 Aldesleukin, 4 Alendronate, 4 C D ALLEGRA, 4 Dapsone, 1, 3 Alprazolam, 3 CAMPRAL, 3 DARAPRIM, 1, 3 ALTACE, 3 CARDIZEM, 3 DARVOCET-N, 2 AMBIEN, 3 Carpuject, 3 DARVON, 2 AMBIEN CR, 3 CATAPRESS, 3 Darunavir, 1, 2 Amitriptyline, 3 Ceftriaxone INJ, 2 Darunavir/Cobicistat, 1,2 Amlodipine, 3 CELEBREX, 2 Darunavir/cobicistat/tenofovir/ Amoxicillin, 2, 4 Celecoxib, 2 emtricitabine, 1,2 Amoxicllin/clavulanic acid, 2 CELEXA, 3 DELATESTRYL, 4 AMOXIL, 2 Cephalexin, 2 Delavirdine, 1, 2 AMPHOCIN, 1, 2 Cetirizine, 4 DELSTRIGO 1,2 Amphotericin B, 1, 2 Cetirizine/pseudoephedrine, 4 DEPAKOTE, 3 ANDRODERM, 4 CHANTIX, 3 DEPAKOTE ER, 3 ANDROGEL, 4 Chlorpromazine, 3 DEPO-TESTOSTERONE, 4 ANDROXY, 4 Cholestyramine, 3 DESCOVY, 1, 2 APTIVUS, 1, 2 Cidofovir, 2 Desonide, 4 Aripiprazole, 3 Cilostazol, 4 DESOWEN, 4 ARTHROTEC, 2 CILOXAN, 2 DIABETA, 3 Asa/codeine, 2 CIMDUO, 1,2 Diazepam, 3 ASACOL, 4 CIPRO, 1, 2 Diclofenac, 2 Atazanavir, 1, 2 CIPRO HC, 2 Diclofenac/misoprostol, 2 Atazanavir/Cobicistat, 1,2 CIPRODEX, 2 Dicyclomine, 4 Atenolol, 3 Ciprofloxacin, 1, 2 Didanosine, 1, 2 Atenolol/chlorthalidone, 3 Ciprofloxacin/dexamethasone, 2 DIFLUCAN, 1, 2 ATIVAN, 3 Ciprofloxacin/hc, 2 DILANTIN, 3 Atorvastatin, 3 Citalopram, 3 Diltiazem, 3 Atovaquone, 1, 2 Clarithromycin, 1, 2 DIOVAN, 3 ATROVENT, 4 CLARITIN, 4 DIOVAN HCT, 3 ATRIPLA, 1, 2 CLARITIN-D, 4 Diphenhydramine, 4 AUGMENTIN, 2 CLEOCIN, 1, 3 Diphenoxylate/atropine, 4 Azithromycin, 1, 2 CLEOCIN-T, 2 Clindamycin, 1, 2, 3 DITROPAN, 4

Clonazepam, 3 DITROPAN XL, 4 B Clonidine, 3 Divalproex sodium, 3 Clopidogrel, 4 Dolutegravir, 1,2 Baclofen, 3 Clotrimazole, 1, 2 Dolutegravir/Rilpivirine, 1,2 BACTRIM DS, 1,3 Clotrimazole/betamethasone, 2 Doravirine 1,2 BACTRIM SS, 1,3 Cobicistat 1,2 Doravirine/lamivudine/tenofovir DF 1,2 Doxepin, 3 Doxycycline, 2 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2)

MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category.

MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete Dronabinol, 4 FLUMADINE, 2 INDERAL LA, 3 Duloxetine, 3 Fluoxetine, 3 Indinavir, 1, 2 Dutasteride, 2 Fluticasone / Salmeterol, 4 Influenza Vaccine, 1, 4 DROXIA, 4 Folinic acid, 1, 4 Insulin glargine, 4 DURAGESIC, 2 Fomivirsen, 1, 2 Insulin syringe, 4 DYAZIDE, 3 FOSAMAX, 4 Interferon alfa-2b, 1, 3 Fosamprenavir, 1, 2 INTRON-A, 1, 3 Foscarnet, 1, 2 INVIRASE, 1, 2 E FOSCARVIR, 1, 2 Ipratropium, 4 Edurant, 1,2 Fostemasir, 1, 2 Isoniazid, 2 Efavirenz, 1, 2 Furosemide, 3 Itraconazole, 1, 2 Efavirenz/emtricitabine/tenofovir, FUZEON, 1, 2 1,2 J Efavirenz/lamivudine/tenofovir, G 1,2 JANUVIA, 4 JULUCA, 1,2 EFFEXOR, 3 G-CSF, 4 EFFEXOR XR, 3 Gabapentin, 3 ELAVIL, 3 Gardasil 9, 4 Gemfibrozil, 3 K Elbasvir/grazoprevir, 1 GENVOYA 1,2 Elvitegravir/Cobicistat/Emtricitabine/ KALETRA, 1, 2 Glecaprevir/pibrentasvir, 1 Tenofovir, 1,2 KEFLEX, 2 Glipizide, 3 Emtricitabine, 1, 2 KEPPRA, 3 GLUCOPHAGE, 3 Emtricitabine/tenofovir, 1, 2 Ketoconazole, 1, 2 GLUCOPHAGE XL, 3 Emtricitabine/rilpivirine/tenofovir, 1,2 KLONOPIN, 3 GLUCOTROL, 3 EMTRIVA, 1, 2 GLUCOTROL, XL, 3 Enalapril, 3 GLUCOVANCE, 3 L Enalapril/hctz, 3 Glyburide, 3 Enfuvirtide, 1, 2 Lactulose, 4 ENSURE, 1,4 Glyburide/metformin, 3 LAMISIL, 1, 2 Entecavir 2 LAMISIL AT, 2 EPCLUSA, 1 H Lamivudine, 1, 2 Epinephrine, 4 Lamivudine/tenofovir, 1,2 EPIPEN, 4 HALDOL, 3 Lamivudine/zidovudine, 1, 2 EPIVIR, 1, 2 Haloperidol, 3 Lancets, 4 Epoetin alfa, 4 HARVONI, 1 Lansoprazole OTC, 4 EPOGEN, 4 Hctz/triamterene, 3 LANTUS, 4 EPZICOM, 1, 2 Hepatitis A Vaccine, 1, 4 LANTUS SOLOSTAR, 4 Erythromycin, 2 Hepatitis B Vaccine, 1, 4 Ledipasvir/sofosbuvir, 1 Escitalopram, 3 HUMALOG, 4 Leucovorin, 1, 4 Estradiol oral, 2 HUMATIN, 1, 2 LEVAQUIN, 1, 2 Estradiol transdermal, 2 HUMULIN, 4 Levetiracetam, 3 Ethambutol, 1, 2 HYDREA, 4 Levofloxicin, 1, 2 EVOTAZ, 1,2 Hydrochlorothiazide, 3 Levothyroxine, 4 Ezetimibe, 3 Hydrocodone/Acetaminophen, 2 LEVOXYL, 4 Hydrocortisone 2.5% cream, 4 LEXAPRO, 3 Hydromorphone, 2 LEXIVA, 1, 2 F Hydroxyurea, 4 LIORESAL, 3 Famciclovir, 1, 2 HYTRIN, 4 Liraglutide, 4 Famotidine, 4 HYZAAR, 3 LIPITOR, 3 FAMVIR, 1, 2 LIPRAM-UL20, 4 Felodipine, 3 I Lisinopril, 3 Fenofibrate, 3 Lisinopril/hctz, 3 Fentanyl, 2 Ibalizumab, 1,2 Lithium carbonate, 3 Fexofenadine, 4 Ibuprofen, 2 Lithium carbonate ER, 3 Filgrastim, 4 Icosapent Ethyl 1, 2 LOFIBRA, 3 Finasteride 1mg, 2, 3 ISENTRESS 1,2 LOMOTIL, 4 Finasteride 5mg, 2 Imiquimod, 4 LONITEN, 3 FLAGYL, 3 IMITREX, 3 LONOX, 4 FLEXERIL, 3 IMODIUM, 4 Loperamide, 4 FLOMAX, 4 INCRUSE ELLIPTA, 1, 2 Lopinavir/ritonavir, 1, 2 Fluconazole, 1, 2 INDERAL, 3 LOPRESSOR, 3 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2)

MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete Loratadine, 4 Nifedipine XL, 3 PREZCOBIX, 1,2 Loratadine/pseudoephedrine, 4 Nitroglycerin sublingual tab, PREVACID OTC, 4 Lorazepam, 3 spray, cap, 3 NIZORAL, 1, 2 PREVIDENT, 4 NORVASC, 3 PREZISTA, 1, 2 LORTAB, 2 PRILOSEC, 4 Losartan, 3 NORVIR, 1, 2 Losartan/hctz, 3 NOVOLIN, 3 Primaquine, 1, 3 LOTENSIN, 3 NOVOLIN 70/30, 4 PRINIVIL, 3 LOTRISONE, 2 NOVOLOG, 3 PRINZIDE, 3 NOVOLOG MIX FLEXPEN, 4 PROCARDIA, 3 NOXAFIL DR TABLET 1,2 Prochlorperazine, 4 M Nystatin, 1, 2 PROCRIT, 4 PROLEUKIN, 4 Maraviroc 1,2 Promethazine, 4 MARINOL, 4 O Propoxyphene, 2 MAVYRET, 1 Propoxyphene/Acetaminophen, 2 MAXZIDE, 3 OCUFLOX, 2 Propranolol, 3 Medroxyprogesterone oral, 2 ODEFSEY, 1,2 PROVENTIL, 4 Medroxyprogesterone injectable, 2 Ofloxacin OPTH, 2 PROZAC, 3 MEGACE, 4 Olanzapine, 3 PULMICORT FLEXHALER, 1, 2 Megestrol, 4 Olodaterol, 1, 2 Pyrimethamine, 1, 3 MEPRON, 1, 2 Omeprazole, 4 Pyrazinamide, 2 Mesalamine, 4 Opium tincture, 4 Pyridoxine, 2 Metformin, 3 ORAMORPH SR, 2 Methadone, 2 Oxybutynin, 4 Methyltestosterone, 4 Oxycodone, 2 Q Metoclopramide, 4 Oxycodone/Acetaminophen, 2 Metoprolol, 3 OXYCONTIN, 2 QUESTRAN, 3 METROCREAM, 2 OXY-IR, 2 Quetiapine, 3 METROGEL, 2 Quetiapine XR, 3 Metronidazole, 2, 3 P Quinapril, 3 MICRONASE, 3 QVAR RediHaler, 4 Minoxidil, 3 PANCREASE, 4 Mirtazapine, 3 Pancrelipase, 4 R Montelukast, 4 PANGESTYME, 4 Morphine, 2 Paromomycin, 1, 2 Raltegravir 1, 2 MOTRIN, 2 Paroxetine, 3 Ramipril, 3 MS-CONTIN, 2 PAXIL, 3 Ranitidine, 4 MYAMBUTOL, 1, 2 PEGASYS, 1, 3 REBETOL, 1, 2 MYCELEX, 1, 2 Peginterferon alfa-2a, 1, 3 REGLAN, 4 MYCOBUTIN, 1, 2 Peginterferon alfa-2b, 1, 3 RELAFEN, 2 PEG-INTRON KIT, 1, 3 REMERON, 3 Penicillin, 2 RENVELA, 4 N PENTAM, 1, 2 RESCRIPTOR, 1, 2 Nabumetone, 2 Pentamidine, 1, 2 RESTORIL, 3 Naloxone, 3 PEN-VK, 2 RETROVIR, 1, 2 NARCAN, 3 PEPCID, 4 REYATAZ, 1, 2 Nelfinavir, 1, 2 PERCOCET, 2 RIBASPHERE, 1, 2 NEUPOGEN, 4 PHENERGAN, 4 Ribavirin, 1, 2 NEURONTIN, 3 Phenytoin, 3 Rifabutin, 1, 2 Nevirapine, 1, 2 PIFELTRO 1,2 Rifampin, 2 Niacin, 3 Pioglitazone, 3 RIFADIN, 2 NIASPAN, 3 PLAVIX, 4 Rilpivirine 1,2 NICODERM, 3 PLENDIL, 3 Rilpivirine, emtricitabine, tenofovir, 1,2 NICORETTE, 3 PLETAL, 4 Rimantadine, 2 Nicotine gum, 3 Pneumococcal Vaccine, 1, 4 RISPERDAL, 3 Nicotine lozenge, 3 Podofilox, 4 Risperidone, 3 Nicotine nasal spray, 3 Potassium chloride, 4 Ritonavir, 1, 2 Nicotine patch, 3 Posaconazole DR tablets, 1,2 ROCEPHIN INJ, 2 NICOTROL, 3 PRAVACHOL, 3 Rosuvastatin, 3 NICOTROL INH, 3 Pravastatin, 3 ROWASA, 4 NICOTROL NS, 3 Prednisone, 4 ROXANOL, 2 Nifedipine ER, 3 PREMARIN, 4 RUKOBIA, 1, 2 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2)

MICHIGAN DRUG ASSISTANCE PROGRAM Last Updated: 11/23/20 All Previous Versions Obsolete Trazodone, 3 Z Triamcinolone cream, oint, lot, 4 S TRICOR, 3 ZANAFLEX, 3 Saquinavir, 1, 2 TRIUMEQ 1,2 ZANTAC, 4 SELZENTRY 1,2 Trimethobenzamide, 4 ZEPATIER, 1 Trimethoprim, 1, 3 ZERIT, 1, 2 SEMPREX-D, 4 TRIMOX, 2 Zoster Vaccine 4 SEPTRA DS, 1,3 SEPTRA SS, 1,3 TRIZIVIR, 1, 2 ZESTORETIC, 3 SEROQUEL, 3 TROGARZO, 1,2 ZESTRIL, 3 SEROQUEL XR, 3 TRUVADA, 1, 2 ZETIA, 3 Sertraline, 3 TYBOST 1,2 ZIAGEN, 1, 2 Sevelarmer, 4 TYLENOL #3, 2 Zidovudine, 1, 2 SHINGRIX, 4 TYLENOL #4, 2 ZITHROMAX, 1, 2 Silvadene, 3 ZOLOFT, 3 SIMFI LO, 1,2 U Zolpidem, 3 SINGULAIR, 4 ZOVIRAX, 1, 2 Sitagliptin, 4 ULTRACET, 2 ZYBAN, 3 Sodium fluoride, 4 ULTRAM, 2 ZYPREXA, 3 Sofosbuvir/velpatasvir, 1 ULTRASE, 4 ZYRTEC, 4 SPIRIVA, 4 Umeclidinium 1, 2 ZYRTEC-D, 4 Spironolactone, 2 SPORANOX, 1, 2 5-ASA, 4 SSD, 2 V Stavudine, 1, 2 Valacyclovir, 1, 2 STRIBILD 1, 2 VALCYTE, 1, 2 STRIVERDI RESPIMAT, 1, 2 Valganciclovir, 1, 2 SUBOXONE, 3 VALIUM, 3 SUBUTEX, 3 Valsartan/hctz, 3 Sulfadiazine, 1, 3 VALTREX, 1, 2 SUSTIVA, 1, 2 Varenicline, 3 SYMTUZA, 1,2 VASCEPA 1,2 SYNTHROID, 4 VASORETIC, 3 SYMFI, 1,2 VASOTEC, 3 VEMLIDY, 1,2 T Venlafaxine, 3 Verapamil, 3 Tamsulosin, 4 VERELAN, 3 TAZTIA XT, 3 VFEND, 1, 2 Temazepam, 3 VICODIN, 2 Tenofovir, 1, 2 VICODIN ES, 2 TENORETIC, 3 VICTOZA, 4 TENORMIN, 3 VIDEX, 1, 2 Terazosin, 4 VIDEX EC, 1, 2 Terbinafine, 1, 2 VIOKASE, 4 Testostosterone injection, 4 VIRACEPT, 1, 2 Testostosterone oral, 4 VIRAMUNE, 1, 2 Testostosterone topical, 4 VIRAMUNE XR, 1,2 TESTRED, 4 VIREAD, 1, 2 Teststrip, 4 VISTIDE, 1, 2 THORAZINE, 3 VITRAVENE, 1, 2 TIGAN, 4 VOLTAREN, 2 Timolol, 3, 4 Voriconazole, 1, 2 TIMOPTIC XE, 4 Tiotropium, 4 Tipranavir, 1, 2 W Tivicay, 1,2 Warfarin, 4 Tizanidine, 3 WELLBUTRIN SR, 3 TMP/SMZ ,1,3 TOPROL XL, 3 Tramadol, 2 X Tramadol/Acetaminophen, 2 XANAX, 3 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2)