South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 www.scdhhs.gov June 26, 2009 Phys Dent MC Hosp Med Clin MHRC HH Pharm MEDICAID BULLETIN

TO: Providers Indicated

SUBJECTS: South Carolina Medicaid Preferred Drug List

The Preferred Drug List (PDL) has been revised to include several additional therapeutic classes. Attached to this bulletin is a comprehensive listing of products within all therapeutic classes that comprise the PDL.

Effective with dates of service on or after July 22, 2009, hard edits will be activated (i.e., pharmacy claims without prior authorization [PA] approval will deny) for newly designated non- preferred products within the therapeutic classes listed below. The complete PDL (attached to this bulletin) includes the following changes:

Additional PDL DRUG CLASSES

1) Topical NSAID’s and Anesthetics

2) Ophthalmic NSAID’s

3) Calcitonins

4) Progestins for Cachexia

5) Ophthalmic Mast Cell Stabilizers

6) Topical Antivirals

7) Protein Tyrosine Kinase Inhibitors

8) Ranexa

9) Intranasal Antihistamines

CHANGES TO EXISTING PDL DRUG CLASSES

1) Topical Retinoids and Combinations

Fraud & Abuse Hotline 1-888-364-3224

Medicaid Bulletin

Page 2

PREFERRED NON-PREFERRED Topical NSAID’s and Anesthetics

FLECTOR® PATCH LIDODERM® PATCH VOLTAREN® GEL Ophthalmic NSAID’s ACULAR® OCUFEN® ACULAR LS® VOLTAREN® DROPS ACULAR PL® XIBROM® DICLOFENAC SODIUM FLURBIPROFEN SODIUM NEVANAC® Calcitonins FORTICAL® NASAL SPRAY MICALCIN® NASAL SPRAY CALCITONIN SALMON Progestins for Cachexia MEGESTEROL ORAL SUSP MEGACE® ORAL SUSPENSION MEGACE ES® ORAL SUSPENSION Ophthalmic Mast Cell Stabilizers ALAMAST® CROLOM® ALOCRIL® OPTICROM® ALOMIDE® CROMOLYN SODIUM Topical Antivirals ABREVA® DENAVIR® ZOVIRAX® OINTMENT ZOVIRAX® CREAM Protein Tyrosine Kinase Inhibitors GLEEVEC® SPRYCEL® SUTENT® TASIGNA® Ranexa RANEXA® Intranasal Antihistamines ASTELIN® PATANASE® ASTEPRO®

Topical Retinoids and Combinations DIFFERIN® Added to PDL ALTINAC® EPIDUO® Added to PDL ATRALIN® RETIN-A MICRO PUMP® Added to PDL AVITA® RETIN-A MICRO® RETIN-A® TRETINOIN TAZORAC® TRETIN X® ZIANA

Fraud & Abuse Hotline 1-888-364-3224

Medicaid Bulletin

Page 3

Prescribers are strongly encouraged to write prescriptions for "preferred" products. However, if a prescriber deems that the patient’s clinical status necessitates therapy with a PA-required drug, the prescriber (or his/her designated office personnel) is responsible for initiating the PA request. A prospective, approved PA request will prevent rejection of prescription claims at the pharmacy due to the PA requirement.

All PA requests should be submitted via WebPA, telephone, or fax to the First Health Clinical Call Center by the prescriber or the prescriber’s designated office personnel. To access the WebPA tool, see: http://southcarolina.fhsc.com, click on Prescribers and WebPA. New users will need to click on “UAC” in the right hand corner to request a user id and password. The toll- free telephone and fax numbers for the Clinical Call Center are 866-247-1181 and 888-603- 7696, respectively. The First Health Clinical Call Center telephone number is reserved for use by healthcare professionals and should not be furnished directly to beneficiaries. [First Health’s South Carolina Medicaid beneficiary call center telephone number for Pharmacy Services is 800-834-2680. Providers may furnish the beneficiary call center telephone number to Medicaid beneficiaries for Pharmacy Services-related issues only.] Providers are reminded that questions about Medicare eligibility issues and Part D drug plans should be directed to 1-800- MEDICARE.

A pharmacy claim submitted for a PA-required product that has not been approved for Medicaid reimbursement will reject. If this occurs, the pharmacist should contact the prescriber so that a determination may be made regarding whether a drug not requiring PA is clinically appropriate for the patient.

Questions regarding this bulletin should be directed to the Department of Pharmacy Services at (803) 898-2876.

/S/ Emma Forkner Director

EF/mgad

Attachment

NOTE: To Sign up for Electronic Funds Transfer of your Medicaid payment, please go to: http://www.dhhs.state.sc.us/dhhsnew/hipaa/index.asp and select “Electronic Funds Transfer (EFT)” for instructions.

Fraud & Abuse Hotline 1-888-364-3224

South Carolina Department of Health and Human Services Preferred Drug List Products Within PDL Therapeutic Classes Are Available Without Prior Authorization (PA) Some therapeutic classes to have a PA requirement. These are noted within the posting. {Non-listed products belonging to therapeutic classes that comprise the PDL require PA} {Note that ALL therapeutic classes are not included on the PDL.} June, 2009 ANALGESIC Spectracef® Tablets Enalapril Nifedipine ER and SA Enalapril/HCTZ MACROLIDES/KETOLID Lisinopril CALCIUM CHANNEL NSAIDs ES Lisinopril/HCTZ BLOCKERS (CCB), Diclofenac Potassium Azithromycin NON- Diclofenac Sodium Clarithromycin ACEI, CCB DIHYDROPYRIDINES Diflunisal Clarithromycin XL COMBINATIONS Cartia XT® Etodolac EryPed® Lotrel® Diltia XT® Fenoprofen Ery-Tab® Tarka® Diltiazem Flurbiprofen Erythromycin Base Diltiazem ER and XR Ibuprofen Erythromycin Estolate ANGIOTENSIN Taztia XT® Indomethacin Erythromycin Ethylsuc. RECEPTOR BLOCKERS Verapamil Indomethacin SR Erythromycin Stearate (ARB) Verapamil ER Ketoprofen Erythrocin Stearate Verapamil SR Ketoprofen ER Avalide® Erythromycin & Sulfisox. Ketorolac Avapro® CCB/ARB Meclofenamate Sod. Benicar® QUINOLONES, 2ND AND Benicar HCT® COMBINATION Nabumetone 3RD GENERATION PRODUCTS Naproxen Cozaar® Naproxen Sodium Avelox® Diovan® Exforge® Oxaprozin Ciprofloxacin Diovan HCT® Exforge HCT® Piroxicam Ofloxacin Hyzaar® Sulindac Micardis® DIRECT RENIN Tolmetin Sodium Prescribers are Micardis HCT® INHIBITORS encouraged to ensure Teveten® Tekturna® compliance with FDA Teveten HCT® NSAIDs, RECEPTOR approved indications. Tekturna HCT®

SELECTIVE BETA BLOCKERS Celebrex® ANTIFUNGALS, ORAL  Prior authorization is Acebutolol required if an ARB has not Meloxicam been prescribed previously ONYCHOMYCOSIS Atenolol Atenolol/Chlorthalidone for the patient.  Class level PA is in effect AGENTS Betaxolol for this class. Once criteria ENDOTHELIN are met, the agents listed on Gris-Peg® Bisoprolol Fumarate RECEPTOR the PDL are preferred. Griseofulvin Bisoprolol/HCTZ ANTAGONISTS Terbinafine Carvedilol OPIOIDS, EXTENDED Labetolol Tracleer® RELEASE ANTIPROTOZOALS, Metoprolol Tartrate ORAL Duragesic® Patch Nadolol Patients currently established on non-preferred Kadian® Pindolol NITROIMIDAZOLES therapy will be grandfathered. Morphine Sulfate ER Propranolol Metronidazole Propranolol ER TOPICAL NSAIDS AND Propranolol/HCTZ ANESTHETICS ANTIVIRALS, ORAL Sotalol All agents in this class Timolol require Prior Authorization. HERPES ANTIVIRALS

Acyclovir ANTI-INFECTIVE Famciclovir LIPOTROPICS

Valtrex® ANTIBACTERIALS CALCIUM CHANNEL BILE ACID BLOCKERS (CCB), SEQUESTERING CEPHALOSPORINS, DIHYDROPYRIDINES RESINS 2ND GENERATION CARDIOVASCULAR Amlodipine Cholestyramine Cefprozil Dynacirc CR® Cholestyramine Light Cefuroxime ACE INHIBITORS (ACEI) Felodipine Colestipol CEPHALOSPORINS, Isradipine Welchol® 3RD GENERATION Benazepril Benazepril/HCTZ Nicardipine Cefdinir (all dosage forms) Captopril Nifedical XL®

First Health Clinical Call Center Telephone: 866-247-1181 (toll-free) Fax: 888-603-7696 (toll-free) South Carolina Department of Health and Human Services Preferred Drug List Products Within PDL Therapeutic Classes Are Available Without Prior Authorization (PA) Some therapeutic classes to have a PA requirement. These are noted within the posting. {Non-listed products belonging to therapeutic classes that comprise the PDL require PA} {Note that ALL therapeutic classes are not included on the PDL.} June, 2009 FIBRIC ACID Carbatrol® then Documents, then DERIVATIVES Epitol® Pharmacy Quantity Limits.)  Prior authorization is Gemfibrozil Oxcarbazepine ATTENTION DEFICIT required if patient is not Lofibra® HYPERACTIVITY currently receiving insulin Tricor® FIRST GENERATION DISORDER AGENTS therapy.

Trilipix® ANTICONVULSANTS Adderall XR® BIGUANIDES Celontin® Amphetamine Salt Metformin NIACIN DERIVATIVES Depakote ER® Combination Metformin ER Niaspan® Divalproex Sprinkles Dexmethylphenidate

Ethosuximide Immediate Release BIGUANIDE NIACIN/STATIN Felbatol® Dextroamphetamine COMBINATION AGENTS COMBINATIONS Mephobarbital Dextroamphetamine SR Advicor® Phenytoin Metadate ER® ActoPlus Met® Simcor® Phenytoin Sodium ER Methylin® Avandamet® Primidone Methylin ER® STATINS Valproic Acid Methylphenidate DPP-4 INHIBITORS AND Altoprev® Methylphenidate ER/SR COMBINATIONS Crestor®  Prior authorization is not Ritalin LA® Janumet® Lescol ® required for Dilantin® Concerta® Januvia® Lescol XL® if“Brand Medically Focalin XR® Lipitor® Necessary” criteria are met. Vyvanse®  Prior authorization is

Lovastatin required if metformin, a SECOND GENERATION Pravastatin  Generic agents considered thiazolidinedione or a ANTICONVULSANTS Simvastatin “first-line” when appropriate. sulfonylurea has not been prescribed previously for the Vytorin® Gabapentin MULTIPLE SCLEROSIS patient. Levetiracetam

CHOLESTEROL- Lamictal® AGENTS INCRELIN MIMETICS ABSORPTION Lyrica® Avonex® INHIBITORS Topiramate Avonex Administration Byetta® Zetia® Zonisamide Pack® Betaseron®  Prior authorization is required if metformin, a NON-NITRATE Copaxone® Rebif® thiazolidinedione or a ANTIANGINALS sulfonylurea product has not Ranexa® been prescribed previously PARKINSON’S AGENTS for the patient. CENTRAL

NERVOUS SYSTEM NON-ERGOT DOPAMINE RECEPTOR INSULINS

AGONISTS Lantus® Vial ALZHEIMER’S AGENTS Ropinirole Levemir® Vial

SEDATIVE/HYPNOTICS, Novolin® N CHOLINESTERASE NON-BARBITURATES Novolin® R INHIBITORS ANTI-MIGRAINE Novolin® 70/30 Aricept® tablets AGENTS Temazepam Zolpidem Novolog® Exelon® (Caps & Solution) Novolog® Mix 70/30 Galantamine SELECTIVE ENDOCRINE AND Humalog® 50/50 NMDA RECEPTOR SEROTONIN ANTAGONIST AGONISTS METABOLIC MEGLITINIDES

Namenda® Sumatriptan Tablets Starlix® ANTI-DIABETICS Sumatriptan Injection ANTI-CONVULSANT Sumatriptan Nasal Spray SULFONYLUREAS, AGENTS Treximet® ALPHA-GLUCOSIDASE SECOND GENERATION INHIBITORS  See the listing at: Glimepiride CARBAMAZEPINE Glyset® Glipizide DERIVATIVES http://southcarolina.fhsc.com for Acarbose the quantity limits for this Glipizide ER Carbamazepine (all class. (Click on Providers, AMYLIN ANALOGS Glyburide dosage forms) Symlin® Glyburide Micronized

First Health Clinical Call Center Telephone: 866-247-1181 (toll-free) Fax: 888-603-7696 (toll-free) South Carolina Department of Health and Human Services Preferred Drug List Products Within PDL Therapeutic Classes Are Available Without Prior Authorization (PA) Some therapeutic classes to have a PA requirement. These are noted within the posting. {Non-listed products belonging to therapeutic classes that comprise the PDL require PA} {Note that ALL therapeutic classes are not included on the PDL.} June, 2009  See the listing at: ANTICOAGULANTS – IMMUNOMODULATORS, THIAZOLIDINEDIONES http://southcarolina.fhsc.com for LOW MOLECULAR ORAL AND the quantity limits for this WEIGHT HEPARINS INJECTABLE Actos® class. (Click on Providers, Avandia® then Documents, then Arixtra® Pharmacy Quantity Limits.) Fragmin® HEPATITIS B THERAPY THIAZOLIDINEDIONE / Lovenox® Baraclude® SULFONYLUREA HISTAMINE-2 Epivir HBV® COMBINATIONS RECEPTOR HEMATOPOIETIC Hepsera® Avandaryl® ANTAGONISTS AGENTS Tyzeka® Duetact® Famotidine Aranesp® Ranitidine Procrit® *Viread® is unaffected by the  Prior authorization is PDL and is available without required if a single agent PROTON PUMP Prior Authorization. PLATELET INHIBITORS thiazolidinedione or INHIBITORS sulfonylurea product has not Aggrenox® HEPATITIS C THERAPY, been prescribed previously Nexium® Capsules Plavix® PEGYLATED for the patient. Prevacid® INTERFERONS* Omeprazole OTC PROTEIN TYROSINE Pegasys® & Conv. Pack ELECTROLYTE KINASE INHIBITORS Peg-Intron® & Redipen DEPLETERS  Class level PA is in effect Gleevec® Fosrenol® for this class. Once criteria are met, the agents listed on HEPATITIS C THERAPY, Phoslo® the PDL are preferred. RIBAVIRINS * Renagel® HORMONE RELATED Ribavirin ULCERATIVE COLITIS BIPHOSPHONATES - THERAPY THERAPY  Class level PA is in effect OSTEOPOROSIS Asacol® for all Hepatitis C medications. Once criteria Alendronate Balsalazide Disodium ANDROGENIC AGENTS are met, the agents listed on Canasa® Rectal Supp. Androderm® the PDL are preferred. CALCITONINS Mesalamine Enema Androgel® Calcitonin Nasal Spray Pentasa® Testim® Fortical® Nasal Spray Sulfasalazine IMMUNOSUPPRESSANT ANDROGEN HORMONE S PROGESTINS FOR INHIBITOR Azasan® CACHEXIA Avodart® Azathioprene GROWTH HORMONE Megestrol Oral Susp Finasteride Cellcept® Injection & Genotropin® Suspension Norditropin® GENITOURINARY IMMUNOLOGICS Cyclosporine Saizen® Gengraf® ALPHA BLOCKERS FOR IMMUNOMODULATORS, Imuran®  Class level PA is in effect BPH INJECTABLE Mycophenolate Mofetil for this class. Once criteria Flomax® Enbrel® Myfortic® are met, the agents listed on Uroxatral® Humira® Neoral® the PDL are preferred. Prograf®

ANTISPASMODICS IMMUNOMODULATORS, Rapamune® GASTROINTESTINAL Sandimmune® Detrol LA® TOPICAL

ANTI-EMETICS (ORAL) Enablex® Elidel®  Oxybutynin Protopic®  OPHTHALMICS

Oxytrol ® NK1 ANTAGONISTS Sanctura®  Prescribers: Please use ANTIHISTAMINES, Emend® VESIcare® these agents as advised by OPHTHALMIC the respective manufacturer Pataday® SEROTONIN and reserve for only those Patanol® HEMATOLOGICAL & patients who have failed RECEPTOR ONCOLOGICAL Elestat® ANTAGONISTS traditional eczema therapy. AGENTS Granisetron Ondansetron

First Health Clinical Call Center Telephone: 866-247-1181 (toll-free) Fax: 888-603-7696 (toll-free) South Carolina Department of Health and Human Services Preferred Drug List Products Within PDL Therapeutic Classes Are Available Without Prior Authorization (PA) Some therapeutic classes to have a PA requirement. These are noted within the posting. {Non-listed products belonging to therapeutic classes that comprise the PDL require PA} {Note that ALL therapeutic classes are not included on the PDL.} June, 2009 MAST CELL Ciprodex® TOPICAL STABILIZERS, Ofloxacin Otic Drops GLUCOCORTICOIDS ANTIINFECTIVES OPHTHALMIC

Alamast® RESPIRATORY INHALATION DEVICES TOPICAL ANTIBOTICS Alocril® Asmanex® Mupirocin Ointment Alomide® ANTI-CHOLINERGICS Azmacort® Altabax® Cromolyn Sodium Atrovent® HFA Flovent Diskus® Bactroban® Cream

Combivent® Flovent HFA® NSAIDs, OPHTHALMIC Spiriva® Qvar®  Generic agents should be Acular® considered “first line” therapy Acular LS® ANTIHISTAMINES, 2nd INTRANASAL when appropriate. Acular PL® GENERATION AND STEROIDS TOPICAL ANTIVIRALS Diclofenac Sodium DECONGESTANT Fluticasone propionate Flurbiprofen Sodium COMBINATIONS Nasonex® Abreva® Nevanac® Cetirizine Zovirax ® Ointment Loratadine OTC GLUCOCORTICOIDS GLAUCOMA THERAPY Loratadine-D OTC AND LONG-ACTING BETA-2 ADRENERGICS ALPHA-2 INTRANASAL Advair® Diskus ADRENERGICS ANTIHISTAMINES Advair® HFA Brimonidine Tartrate Astelin® Alphagan P® Asteopro®  Prescribers are reminded of the warnings associated BETA BLOCKERS BETA ADRENERGIC with the use of long acting beta agonists DEVICES, SHORT- Betaxolol HCl ACTING INHALERS Carteolol HCl LEUKOTRIENE Combigan® Ventolin® HFA RECEPTOR Levobunolol HCl Xopenex® HFA ANTAGONISTS Metipranolol Accolate® Timolol Maleate BETA ADRENERGIC Singulair® DEVICES, LONG-

ACTING METERED CARBONIC DOSE INHALERS TOPICAL AGENTS ANHYDRASE Serevent Diskus® FOR ACNE INHIBITORS Azopt®  Prescribers are reminded BENZOYL PEROXIDE/ Dorzolamide of the warnings associated CLINDAMYCIN Dorzolamide -Timolol with the use of long acting COMBOS beta agonists. Benzaclin® PROSTAGLANDIN Duac CS® AGONISTS BETA ADRENERGIC Lumigan® AGENTS, LONG- TOPICAL RETINOIDS ACTING NEBULIZERS Travatan® Differin® Travatan Z® Epiduo® Xalatan® Both agents in this class Retin-A Micro® require Prior Authorization. Retin-A Micro® Pump

QUINOLONES & Tretinoin BETA ADRENERGIC MACROLIDES, OPHTHALMIC AGENTS, SHORT- ACTING NEBULIZERS TOPICAL AGENTS Ciprofloxacin HCl FOR PSORIASIS Vigamox® Albuterol Metaproterenol Zymar® TOPICAL AGENTS FOR Xopenex® PSORIASIS OTICS  Generic agents should be Dovonex® considered as “first-line” Psoriatec® QUINOLONES, OTIC therapy when appropriate.

First Health Clinical Call Center Telephone: 866-247-1181 (toll-free) Fax: 888-603-7696 (toll-free) South Carolina Department of Health and Human Services Preferred Drug List Products Within PDL Therapeutic Classes Are Available Without Prior Authorization (PA) Some therapeutic classes to have a PA requirement. These are noted within the posting. {Non-listed products belonging to therapeutic classes that comprise the PDL require PA} {Note that ALL therapeutic classes are not included on the PDL.}

Listing Updated: December, 2008

A AVAPRO CELONTIN ABREVA AVELOX CETIRIZINE ACARBOSE AVODART CHOLESTYRAMINE ACCOLATE AVONEX ADMINISTRATION PACK CHOLESTYRAMINE LIGHT ACEBUTOLOL AVONEX CIPRODEX ACTOPLUS MET AZASAN CIPROFLOXACIN ACTOS AZATHIOPRENE CIPROFLOXACIN HCL ACULAR AZITHROMYCIN CLARITHROMYCIN ACULAR LS AZMACORT CLARITHROMYCIN XL ACULAR PL AZOPT COLESTIPOL ACYCLOVIR COMBIGAN ADDERALL XR B COMBIVENT ADVAIR DISKUS BACTROBAN CREAM CONCERTA ADVAIR HFA BALSALAZIDE DISODIUM COPAXONE ADVICOR BARACLUDE COZAAR AGGRENOX BENAZEPRIL CRESTOR ALAMAST BENAZEPRIL/HCTZ CROMOLYN SODIUM ALBUTEROL BENICAR HCT CYCLOSPORINE ALENDRONATE BENICAR ALOCRIL BENZACLIN D ALOMIDE BETASERON DEPAKOTE ER ALPHAGAN P BETAXOLOL DETROL LA DEXMETHYLPHENIDATE IMMEDIATE ALTABAX BETAXOLOL HCL RELEASE ALTOPREV BISOPROLOL FUMARATE DEXTROAMPHETAMINE AMLODIPINE BISOPROLOL/HCTZ DEXTROAMPHETAMINE SR AMPHETAMINE SALT COMBINATION BRIMONIDINE TARTRATE DICLOFENAC POTASSIUM ANDRODERM BYETTA DICLOFENAC SODIUM ANDROGEL DICLOFENAC SODIUM EYE DROPS ARANESP C DIFFERIN ARICEPT TABLETS CALCITONIN NASAL SPRAY DIFLUNISAL ARIXTRA CANASA RECTAL SUPP. DILTIA XT ASACOL CAPTOPRIL DILTIAZEM ASMANEX CARBAMAZEPINE DILTIAZEM ER AND XR ASTELIN CARBATROL DIOVAN ASTEPRO CARTEOLOL HCL DIOVAN HCT ATENOLOL CARTIA XT DIVALPROEX SPRINKLES ATENOLOL/CHLORTHALIDONE CARVEDILOL DORZOLAMIDE ATROVENT HFA CEFDINIR DORZOLAMIDE –TIMOLOL AVALIDE CEFPROZIL DOVONEX AVANDAMET CEFUROXIME DUAC CS AVANDARYL CELEBREX DUETACT AVANDIA CELLCEPT DURAGESIC PATCH First Health Clinical Call Center Telephone: 866-247-1181 (toll-free) Fax: 888-603-7696 (toll-free) South Carolina Department of Health and Human Services Preferred Drug List Products Within PDL Therapeutic Classes Are Available Without Prior Authorization (PA) Some therapeutic classes to have a PA requirement. These are noted within the posting. {Non-listed products belonging to therapeutic classes that comprise the PDL require PA} {Note that ALL therapeutic classes are not included on the PDL.} June, 2009 DYNACIRC CR G LESCOL XL GABAPENTIN LEVEMIR VIAL E GALANTAMINE LEVETIRACETAM ELESTAT GEMFIBROZIL LEVOBUNOLOL HCL ELIDEL GENGRAF LIPITOR EMEND GENOTROPIN LISINOPRIL ENABLEX GLEEVEC LISINOPRIL/HCTZ ENALAPRIL GLIMEPIRIDE LOFIBRA ENALAPRIL/HCTZ GLIPIZIDE LORATADINE OTC ENBREL GLIPIZIDE ER LORATADINE-D OTC EPIDUO GLYBURIDE LOTREL EPITOL GLYBURIDE MICRONIZED LOVASTATIN EPIVIR HBV GLYSET LOVENOX ERYPED GRANISETRON LUMIGAN ERY-TAB GRISEOFULVIN LYRICA ERYTHROCIN STEARATE GRIS-PEG ERYTHROMYCIN & SULFISOX. M ERYTHROMYCIN BASE H MECLOFENAMATE SOD. ERYTHROMYCIN ESTOLATE HEPSERA MEGESTEROL ORAL SUSPENSION ERYTHROMYCIN ETHYLSUC. HUMIRA MELOXICAM ERYTHROMYCIN STEARATE HUMALOG 50/50 MEPHOBARBITAL ETHOSUXIMIDE HYZAAR MESALAMINE ENEMA ETODOLAC METADATE ER EXELON I METAPROTERENOL EXFORGE IBUPROFEN METFORMIN EXFORGE HCT IMURAN METFORMIN ER INDOMETHACIN METHYLIN ER F INDOMETHACIN SR METHYLIN FAMCICLOVIR ISRADIPINE METHYLPHENIDATE FAMOTIDINE METHYLPHENIDATE ER/SR FELBATOL J METIPRANOLOL FELODIPINE JANUMET METOPROLOL TARTRATE FENOPROFEN JANUVIA METRONIDAZOLE FINASTERIDE MICARDIS FLOMAX K MICARDIS HCT FLOVENT DISKUS KADIAN MORPHINE SULFATE ER FLOVENT HFA KETOPROFEN MUPIROCIN OINTMENT FLURBIPROFEN KETOPROFEN ER MYCOPHENOLATE MOFETIL FLURBIPROFEN EYE DROPS KETOROLAC MYFORTIC FLUTICASONE PROPIONATE FOCALIN XR L N FORTICAL NASAL SPRAY LABETOLOL NABUMETONE FOSRENOL LAMICTAL NADOLOL FRAGMIN LANTUS VIAL NAMENDA LESCOL NAPROXEN First Health Clinical Call Center Telephone: 866-247-1181 (toll-free) Fax: 888-603-7696 (toll-free) South Carolina Department of Health and Human Services Preferred Drug List Products Within PDL Therapeutic Classes Are Available Without Prior Authorization (PA) Some therapeutic classes to have a PA requirement. These are noted within the posting. {Non-listed products belonging to therapeutic classes that comprise the PDL require PA} {Note that ALL therapeutic classes are not included on the PDL.} June, 2009 NAPROXEN SODIUM Q TRACLEER NASONEX QVAR TRAVATAN NEORAL TRAVATAN Z NEVANAC R TRETINOIN NEXIUM CAPSULES RANEXA TREXIMET RANITIDINE NIASPAN TRICOR RAPAMUNE NICARDIPINE TRILIPIX REBIF NIFEDICAL XL TYZEKA RENAGEL NIFEDIPINE ER AND SA RETIN-A MICRO NORDITROPIN U RETIN-A MICRO PUMP NOVOLIN UROXATRAL RIBAVIRIN NOVOLOG RITALIN LA V ROPINIROLE O VALPROIC ACID S OFLOXACIN VALTREX SAIZEN OFLOXACIN OTIC DROPS VENTOLIN HFA SANCTURA OMEPRAZOLE OTC VERAPAMIL SANDIMMUNE ONDANSETRON VERAPAMIL ER SEREVENT DISKUS OXAPROZIN VERAPAMIL SR SIMCOR OXCARBAZEPINE VESICARE SIMVASTATIN OXYBUTYNIN VIGAMOX SINGULAIR OXYTROL VYTORIN SOTALOL VYVANSE SPECTRACEF TABLETS P SPIRIVA PATADAY W STARLIX PATANOL WELCHOL SULFASALAZINE PEGASYS SULINDAC PEG-INTRON X SUMATRIPTAN PENTASA XALATAN SYMLIN PHENYTOIN XOPENEX

PHENYTOIN SODIUM ER X0PENEX HFA T PHOSLO TARKA PINDOLOL Y TAZTIA XT PIROXICAM TEKTURNA Z PLAVIX TEKTURNA HCT PRAVASTATIN ZETIA TEMAZEPAM PREVACID ZOLPIDEM TERBINAFINE PRIMIDONE ZONISAMIDE TESTIM PROCRIT ZOVIRAX OINTMENT TEVETEN PROGRAF ZYMAR OPHTHALMIC TEVETEN HCT PROPRANOLOL TIMOLOL PROPRANOLOL ER TIMOLOL MALEATE PROPRANOLOL/HCTZ TOLMETIN SODIUM PROTOPIC TOPIRAMATE PSORIATEC First Health Clinical Call Center Telephone: 866-247-1181 (toll-free) Fax: 888-603-7696 (toll-free)