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MISSISSIPPI DIVISION OF MEDICAID PREFERRED/NON-PREFERRED DRUG LIST Effective JULY 1, 2007

Therapeutic Drug Preferred Drugs Non-Preferred Drugs Class (Override Not Required) (Override IS Required) ANALGESICS Cox-2 celecoxib (Celebrex) NSAIDs diclofenac potassium diclofenac epolamine (Flector Patch) diclofenac etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium NSAID/GI Protectant Combinations diclofenac/misoprostol (Arthrotec) naproxen/lansoprazole (Prevacid NapraPAC) Immediate-Release OPIOID Analgesics/CENTRALLY ACTING Analgesics/Misc. butalbital/codeine/APAP/caffeine buprenorphine (Subutex) butalbital/codeine/ASA/caffeine codeine/APAP (Vopac) codeine codeine/APAP

dihydrocodeine/APAP/caffeine dihydrocodeine/APAP/caffeine (Panlor DC, Synalgos DC

fentanyl (lozenges, patches) fentanyl citrate buccal/transmucosal (Fentora/ Actiq) hydrocodone/APAP hydrocodone/APAP (Zydone, Xodol) hydrocodone/ibuprofen hydrocodone/ibuprofen (Reprexain) hydromorphone /buprenorphine (Suboxone) levorphanol oxycodone/APAP (Lynox, Magnacet) meperidine oxycodone/ibuprofen (Combunox) methadone oxymorphone-plain and ER (Opana,Opana ER) morphine IR tramadol (Ultram ER) oxycodone IR oxycodone IR/APAP oxycodone IR/ASA pentazocine/APAP pentazocine/naloxone propoxyphene propoxyphene/APAP tramadol IR tramadol/APAP Sustained-Release OPIOID Analgesics fentanyl transdermal oxycodone SA (generic & Oxycontin) morphine sulfate morphine sulfate ER (Avinza, Kadian)

1 ANTI-INFECTIVE AGENTS ANTI-FUNGAL troche (Ancobon) microsize (Grifulvin V) (Sporanox Kit & Soln.) griseofulvin ultramicrosize (Gris-PEG) (Vfend) itraconazole terbenafine (Lamisil) ANTI-PROTOZOAL metronidazole (Mepron) nitazoxanide (Alinia) metronidazole (Flagyl ER) tinadazole (Tindamax) ANTI-VIRAL acyclovir famciclovir (Famvir) adefovir (Hepsera) ganciclovir ribavirin caps ribavirin tabs&soln (Copegus, Rebetol) valacyclovir (Valtrex) valgancyclovir (Valcyte) CEPHALOSPORINS cefaclor cefditoren (Spectracef ) cefadroxil ceftibuten (Cedax) cefdinir (& Omnicef brands ) cephradine (Velosef) cefixime ( Suprax Suspension ) cefpodoxime cefprozil cefuroxime tablets (Ceftin Suspension) cephalexin FLUOROQUINOLONES ciprofloxacin & ciprofloxacin ER Cipro Suspension , Proquin XR moxifloxacin (Avelox) gatifloxacin (Tequin) ofloxacin gemifloxacin (Factive) levofloxacin (Levaquin) lomefloxacin (Maxaquin) naldixic acid (Neggram) norfloxacin (Noroxin) sparfloxacin (Zagam) KETOLIDES none telithromycin (Ketek) MACROLIDES azithromycin azithromycin (Zmax) clarithromycin (& Biaxin XL) erythromycin (ERYC 250,PCE 333, PCE 500) erythromycin erythromycin/sufisoxazole PENICILLINS amoxicillin carbenicillin (Geocillin) amoxicillin/potassium clav (Augmentin / Augmentin XR) ampicillin dicloxacillin penicillin v potassium SULFONAMIDES sulfadiazine sulfamethoxazole/trimethoprim sulfasalazine sulfisoxazole (& Gantrisin Ped. Susp) TETRACYLINES

2 doxycycline (Adoxa,Doryx,Monodox, Oracea, Vibramycin demeclocycline Syrup) doxycycline minocycline (Dynacin, Solodyn) minocycline tetracycline MISCELLANEOUS clindamycin (& Cleocin Pediatric Solution) linezolid (Zyvox) vancomycin (Vancocin) OTIC ANTI- INFECTIVES acetic acid/ acetic acid + hydrocortisone ciprofloxacin/hydrocortisone (Cipro HC) ciprofloxacin/dexamethasone (Ciprodex) neomycin/polymyxin B/buffers/hc (Pediotic) neomycin/polymyxin B/hydrocortisone neomycin/colistin/hc (Coly-Mycin S,CortisporinTC) ofloxacin (Floxin) pramoxine/chloroxylenol (Pramotic) pramoxine/chloroxylenol/hydrocortisone (Cortane-B Lotion pramoxine/chloroxylenol/hydrocortisone ) CARDIOVASCULAR AGENTS ACE INHIBITORS benazepril perindopril (Aceon) captopril enalapril fosinopril lisinopril moexipril quinapril ramipril (Altace) trandolapril All generic diuretic combinations ACE Inhibitors/CCB Combinations benazepril/amlodipine (& brand Lotrel) enalapril/felodipine (Lexxel) trandolapril/verapamil (Tarka) Aldosterone Receptor Antagonists spironolactone eplerenone (Inspra) ARBs & ARB/Diuretic Combinations irbesartan (Avapro/Avalide) candesartan (Atacand/Atacand HCT) olmesartan (Benicar/Benicar HCT) eprosartan (Teveten/Teveten HCT) valsartan (Diovan/Diovan HCT) losartan (Cozaar/Hyzaar) telmisartan (Micardis/Micardis HCT) ARB/CCB Combinations valsartan/amlodipine (Exforge) ANTIHYPERLIPIDEMICS Bile Acid Sequestrants cholestyramine colesevalam (Welchol) colestipol granules & tabs Fibric Acid Derivatives fenofibrate generics (& Tricor) fenofibrate (Antara, Lofibra, Triglide) gemfibrozil Niacin Products Niaspan Niacor Omega-3 Fatty Acid omega-3 acid ethyl esters(Lovaza formerly Omacor)

Selective Cholesterol Absorption Inhibitor ezetimibe (Zetia) Statins atorvastatin (Lipitor) fluvastatin (Lescol) lovastatin lovastatin ER (Altoprev) pravastatin rosuvastatin (Crestor) simvastatin

3 Statin Combinations ezetimibe/simvastatin (Vytorin) pravastatin/ASA (Pravigard PAC) lovastatin/niacin (Advicor ) BETA BLOCKERS acebutolol cartelolol (Cartrol) atenolol penbutolol (Levatol) betaxolol propranolol (Innopran XL) bisoprolol carvedilol (Coreg, Coreg CR ) labetalol metoprolol succinate (& brand Toprol XL) metorolol tartrate nadolol pindolol propranolol sotalol timolol All generic diuretic combinations CALCIUM CHANNEL BLOCKERS amlodipine amlodipine (Norvasc) diltiazem IR & ER diltiazem (Cardizem-CD/LA/SR, Dilacor) felodipine isradipine (Dynacirc,Dynacirc CR) nicardipine nicardipine (CardeneSR) nifedipine ER nisoldipine (Sular) verapamil IR & ER verapamil (Calan,Covera HS, Isoptin,Verelan PM) CCB/Antihyperlipidemic amlodipine/atorvastatin (Caduet) DIURETICS amiloride & amiloride/HCTZ clorothiazide (Diuril Oral Susp) bumetanide clonidine/chlorthalidone (Clorpres) chlorothalidone deserpidine/methyclothiazide (Enduronyl-Forte) chlorothiazide ethacrynic acid (Edecrin) furosemide hydroflumethiazide (Saluron) hydrochlorothiazide polythiazide (Renese) indapamide prazosin/polythiazide (Minizide) methyclothiazide reserpine/methyclothiazide (Diutensin-R) metolazone spironolactone/hctz (Aldactazide 50/50) torsemide trichlormethazide (Naqua) triamterene & triamterene/HCTZ RENIN INHIBITORS aliskiren (Tekturna) CENTRAL NERVOUS SYSTEM AGENTS ADHD AGENTS

amphetamine mixture (generics & Adderall XR) amphetamine mixture (Adderall) atomoxetine (Strattera) lisdexamfetamine (Vyvanse) dexmethylphenidate (Focalin, Focalin XR) methamphetamine (Desoxyn) dextroamphetamine (generics) methylphendidate ( Ritalin LA)

methylphendidate (generics, Concerta, Daytrana Patch, Metadate CD, Methylin Chewable & Soln) ALZHEIMERS AGENTS donepezil (Aricept) galantamine (Razadyne, Reminyl) memantine (Namenda) tacrine (Cognex) rivastigmine (Exelon) ANTICONVULSANTS carbamazepine (Tegretol) NTI rules apply- see Pharm. carbamazepine(Carbatrol, Equetro, Tegretol XR Manual Section 31.11 divalproex sodium(Depakote,Depakote ER) ethotoin (Peganone) ethosuximide felbamate (Felbatol)

4 gabapentin methsuximide (Celontin) lamotrigine (Lamictal) levetiracetam (Keppra) oxcarbazepine (Trileptal) phenytoin (Dilantin, Phenytek) pregabalin (Lyrica) primidone tiagabine (Gabitril) topiramate (Topamax) valproic acid zonisamide ANTIDEPRESSANTS Aminoketones bupropion IR & SR (& brand Wellbutrin XL) MAOIs none phenelzine (Nardil) selegeline (Emsam Patch) tranylcypromine(Parnate) SNRIs venlafaxine duloxetine (Cymbalta) venlafaxine XR (Effexor XR) SSRIs citalopram escitalopram (Lexapro) fluoxetine fluoxetine (Prozac Weekly, Sarafem) paroxetine paroxetine (Paxil & Paxil CR) sertraline paroxetine mesylate (Pexeva) TCAs amitriptylline protriptyline (Vivactil) desipramine trimipramine (Surmontil) doxepin imipramine hcl & pamoate nortriptyline Tetracyclics mirtazapine (tabs & soltabs) Triazolopyride trazodone ANTIEMETICS* meclizine aprepitant (Emend) ondansetron (& brand Zofran) dolasetron (Anzemet) promethazine dronabinol (Marinol) granisetron (Kytril) scopolamine (Scopace, Transderm Scop) *Note-All 5-HT3 Receptor Antagonist injections closed to point of sale ANTIPSYCHOTICS Atypicals risperidone (Risperdal)* aripiprazole (Abilify) ziprasidone (Geodon)* olanzapine (Zyprexa) olanzapine/fluoxetine (Symbyax) palperidone (Invega) quetiapine (Seroquel) * injectable forms require PA (except for beneficiaries residing in a long term care facility First Generation Antipsychotics & Misc. chlorpromazine molindone (Moban) fluphenazine pimozide (Orap) haloperidol loxapine perphenazine prochlorperazine trifluoperazine thioridazine

5 thiothixene ANXIOLYTICS alprazolam hydroxyzine pamoate (Vistaril Suspension) buspirone chlordiazepoxide clonazepam clorazepate hydroxyzine (hcl & pamoate) oxazepam Note:SingleSource Brand Benzodiazepines and Barbiturates are NOT covered. No PA s will be issued. MIGRAINE AGENTS rizatriptan(Maxalt) almotriptan(Axert) sumatriptan(Imitrex) eletriptan(Relpax) frovatriptan(Frova) naratriptan(Amerge) zolmitriptan(Zomig) SEDATIVE/HYPNOTICS estazolam zaleplon (Sonata) eszopiclone (Lunesta) flurazepam lorazepam phenobarbital ramelteon(Rozerem) temazepam triazolam zolpidem (& brand Ambien CR) Note:SingleSource Brand Benzodiazepines and Barbiturates are NOT covered. No PA s will be issued. SKELETAL MUSCLE RELAXANTS baclofen cyclobenzaprine (Fexmid) cyclobenzaprine metalaxone (Skelaxin) dantrolene tizanidine caps (Zanaflex) tizanidine tabs

ENDOCRINE & METABOLIC AGENTS ANTIDIABETICS Alpha Glucosidase Inhibitors (Oral) none acarbose (Precose) miglitol (Glyset) Amylin Analog pramlintide acetates (Symlin) Biguanides metformin IR & ER metformin (Fortamet, Glumetza, Riomet Liq) DPP-4 Inhibitors sitagliptin (Januvia) DPP-4 Inhibitor/Biguanide Combinations sitagliptin/metformin (Janumet) Incretin Mimetics exenatide (Byetta) Insulin

Apidra (insulin glulisine) Exubera (human regular insulin powder for inhalation) Lantus (insulin glargine) Humalog (human insulin lispro (rDNA) Levemir Humalog Mix Novolin N, Novolin R, Novolin 70/30 Humulin Novolog (human insulin aspart (rDNA) Iletin Novolog Mix 70/30 Relion Meglitinides natelglinide (Starlix) repaglinide (Prandin) Sulfonylureas

6 acetohexamide chlorpropamide glimepiride glipizide glyburide tolbutamide tolazamide Thiazolidinediones pioglitazone (Actos) rosiglitazone (Avandia) Combination Products glipizide/metformin glyburide/metformin pioglitazone/glimepiride (Duetact) pioglitazone/metformin(Actoplus Met) rosiglitazone/metformin (Avandamet) rosiglitazone/glimeperide(Avandaryl) ESTROGENS-PROGESTINS Oral conjugated estrogens (Premarin) estradiol acetate (Femtrace) conjugated estrogens/m-prog (Premphase) estradiol/noreth. (Activella) conjugated estrogens/m-progest (Prempro) estradiol/norgestimate (Prefest) estradiol estrogens-conj.synthetic A (Cenestin) estropipate estrogens-conj.synthetic B (Enjuvia) estrogens-esterified (Menest) ethinyl estradiol/noreth (FemHRT) *Note-G.E.& Brand Estratest & Estratest HS are Desi Drugs,therefore not covered Topical None Estrasorb,Estrogel, Elestrin Transdermal estradiol patch estradiol (Alora,Climara, Esclim,Estraderm, Menostar,Vivelle, Vivelle Dot) estradiol/levonorgestrel (ClimaraPro) estradiol/norethindrone (CombiPatch) Vaginal

Premarin Vaginal Cream estradiol (Estrace Cream, Estring, Femring,Vagifem) Injection conjugated estrogens (Premarin) estradiol valerate (Delestrogen) estradiol (Depo-Estradiol) PROGESTINS Oral medroxyprogesterone acetate progesterone,micronized (Prometrium) norethindrone acetate Topical none First Progesterone MC Cream Prochieve Gel 4% (8% closed to point of sale ) Injection

progesterone in oil Depo-Provera 400mg/ml(150mg/ml does not require PA) GROWTH HORMONES somatropin (Genotropin, Norditorpin, somatropin (Humatrope, Omnitrope, Zorbtive) Nutropin,Nutropin AQ, Saizen, Serostim, mecasermin (Increlex) Tev-Tropin) mecasermin rinfabate (Iplex) OSTEOPOROSIS alendronate (Fosamax/Fosamax D) calcitonin (Fortical) calcitonin (Miacalcin) risedronate (Actonel/Actonel w/Calcium) ibandronate (Boniva) teriparatide (Forteo) raloxifene (Evista) THYROID/ANTI-THYROID AGENTS

7 All Brand and Generic Agents None GASTROINTESTINAL AGENTS H2- Antagonists cimetidine famotidine (Pepcid RPD,Pepcid Susp) famotidine nizatidine (Axid Solution) ranitidine (generic capsules , Zantac EFFERdose, Zantac nizatidine Syrup) ranitidine generic tablets & syrup Inflammatory Bowel Disease mesalamine (generic enema,Asacol, Canasa, Lialda, Pentasa) balsalazode (Colazal) olsalazine(Dipentum) budesonide (Entocort EC) mesalamine(Rowasa) LAXATIVES lactulose (Constulose,Enulose) lactulose (Kristalose Packet) PEG Combinations (Colyte, Golytely, Halflytely, Miralax, lubiprostone (Amitiza) Moviprep, Nulytely. OCL, Trilyte) PEG 3350/Electrolyte Solution sodium phosphate salts (Osmoprep, Visicol) PEG Solution (Glycolax Powder) polyethylene Glycol 3350 Proton Pump Inhibitors lansoprazole (Prevacid) esomeprazole (Nexium) omeprazole (Zegerid) legend generic omeprazole pantoprazole (Protonix) rabeprazole (Aciphex) HEMATOLOGICAL AGENTS -INJECTABLE fondaparinux (Arixtra) dalteparin (Fragmin) enoxaparin (Lovenox) tinzaparin (Innohep) HEMATOPOIETIC darbepoietin (Aranesp) epoetin alfa(Epogen) epoetin alfa (Procrit) filgrastim(Neupogen) pegfilgrastim (Neulasta) sargramostim(Leukine) Platelet Aggregation Inhibitors aspirin aspirin/dipyridamole (Aggrenox) clopidogrel dipyridamole IMMUNOLOGIC AGENTS adalimumab (Humira) abatacept (Orencia)* efalizumab (Raptiva) alefacept (Amevive)* etanercept (Enbrel) anakinra (Kineret) infliximab (Remicade)* leflunomide (Arava)

*administer in hospital or clinic setting-Prior Auth will not be issued for Point of Sale without justification NEPHROLOGIC AGENTS calcium acetate (PhosLo) calcium/magnesium/FA (Magnebind Rx) lanthanum(Fosrenol) sevelamer(Renagel) RESPIRATORY AGENTS ALLERGY-ANTIHISTAMINES

8 Generic Legend & Covered OTC antihistamines & antihist/decong combinations fexofenadine/pseudoephedrine (Allegra-D) azelastine (Astelin Nasal Spray) brompheniramine (Vazol, Vazol D) carbinoxamine (Palgic) cetirizine (Zyrtec) desloratadine (Clarinex) fexofenadine loratadine OTC (tabs,D-12hr,D-24hr syrup) ALLERGY- NASAL CORTICOSTEROIDS flunisolide beclomethasone (Beconase AQ) fluticasone (& brand Flonase) budesonide (Rhinocort Aqua) mometasone (Nasonex) ciclesonide (Omnaris) flunisolide (Nasarel) fluticasone furoate (Veramyst) triamcinolone (Nasacort AQ) ANTIASTHMATICS Anticholinergics ipratropium solution for inhalation ipratropium (Atrovent MDI) tiotropium (Spiriva) Inhaled Corticosteroids budesonide (Pulmicort Flexhaler/ Respules/Turbuhaler) beclomethasone (QVAR) fluticasone (Flovent HFA & Diskus) flunisolide (Aerobid, Aerobid M) mometasone (Asmanex) triamcinolone (Azmacort) Leukotriene Modifiers montelukast (Singulair ) zafirlukast (Accolate) Mast Cell Stabilizers cromolyn sodium solution for inhalation nedocromil (Tilade Inhaler) cromolyn sodium (Intal Inhaler) Smooth Muscle Relaxants aminophylline dyphylline oxtriphylline theophylline Sympathomimetics albuterol (soln.for inhal., syrup, tabs IR & ER) albuterol (AccuNeb) albuterol HFA (ProAir HFA, Proventil HFA, Ventolin HFA) arformoterol soln.for inhalation (Brovana) levalbuterol (Xopenex Inhalation Sol) formoterol (Foradil) levalbuterol (Xopenex HFA) metaproterenol (Alupent Aerosol) metaproterenol tabs,soln,syrup salmeterol (Serevent Diskus) pirbuterol (Maxair) terbutaline Sympathomimetics Combinations albuterol/ipratropium (Combivent) formoterol/budesonide (Symbicort) albuterol/ipratropium (DuoNeb) salmeterol/fluticasone (Advair) TOPICAL AGENTS Acne Preparations (Under Age 21 Only) benzoyl peroxide (& Zaclir) adapalene (Differin) benzoyl peroxide/clindamycin (Benzaclin, azelaic acid (Azelex) Duac) benzoyl peroxide/erythromycin (Benzamycin Pak) benzoyl peroxide/ (Nuox) benzoyl peroxide/sulfur (Sulfoxyl)

clindamycin ( & Evoclin) clindamycin (Clindagel),clinadmycin/tretinoin (Ziana Gel) erythromycin erythromycin (Akne-Mycin oint) sodium sulfacetamide (Klaron) sodium sulfacetamide/sulfur (Suphera)

9 tazarotene (Tazorac) tretinoin tretinoin (Retin-A Micro) Antibacterial Agents bacitracin oint mupirocin (Bactroban) 2% Cr & Nasal bacitracin/polymyxin oint polymixin B/neomycin/HC (Cortisporin) Cr & Oint gentamicin 0.1% cr & oint mupirocin 2% oint triple antibiotic oint Antibacterial Vaginal Products clindamycin 2 % vaginal cream (Clindamax, Clindesse) clindamycin (Cleocin Vaginal Ovules) metronidazole 0.75% vaginal gel triple sulfa vaginal cream Agents benzoic acid/ (Bensal HP oint) (Mentax) 1% cream 0.77% cream & solution ciclopirox (Loprox) 0.77% Gel, 1% Shampoo clotrimazole 1% cream & solution ciclopirox (Penlac) 8% Soln. clotrimazole/betamethasone cream & lotion (Oxistat) 1% cream & lotion 1% cream (Ertaczo) 2% cream ketoconazole 2% cream & shampoo sodium /sal acid (Versiclear Lotion) 2% cream (Exelderm) 1% cream and solution miconazole nitrate/zinc oxide (Vusion) oint 1% soln (Lamisil) (Naftin) 1% cream & gel nystatin cream,oint,powder nystatin/trimacinalone cream & oint 1% cream & powder otc Antifungal Vaginal Products clotrimazole 1 & 2% vaginal cream (Gynazole-1) Cream miconazole 2% vaginal cream miconazole 200 mg vaginal supp miconazole 3 combo pack nystatin vag tablet 0.4 & 0.8% vaginal cr & suppos. Anti-Inflammatory Agents All Generics - Too numerous to list All Brands not listed - Too numerous to list Antipruritic Agents doxepin generic (Prudoxin) doxepin (Zonalon) Antiviral Agents None penciclovir (Denavir) 1% Cream acyclovir (Zovirax) 5% Cream and Ointment

Miscellaneous Skin/Mucous Membrane Agents

` AntiNeoplastic & Premalignant Lesion Agents fluorouracil 5% cr, 2 % & 5% Soln alitretinoin (Panretin) bexarotene (Targretin) diclofenac (Solaraze) fluorouracil (Carac, Efudex, Fluoroplex) Antipsoriatic Agents anthralin 1% cream generic (Drithocreme HP) anthralin (Dritho-Scalp, Psoriatec) tazarotene (Tazorac) calcipotriene (Dovonex) calcipotriene/betamet.diprop. (Taclonex) Diabetic Ulcer Preps becaplermin (Regranex) Immunomodulators imiquimod (Aldara) Immunosuppressive Agents pemicrolimus (Elidel) tacrolimus(Protopic) Keratolytics podofilox 0.5% Top.Soln podofilox (Condylox) salicylic acid podophyllum resin (Podocon-25) urea cream, gel, lotion generic resorcinol/phenol (Derma-Cas)

10 salicylic acid (Akurza, Keralyt Gel, Salex) urea (Hydro 40 Foam, Kerafoam, Keralac, Keralac Nail, Umecta) Mucous Membr/Subcut Enzymes papain/urea generics collegenase (Santyl Ointment) papain/urea/chlorophylin generics trypsin/balsam peru/castor oil generis Mucositis/Stomatitis acemannan (Salicept, OramagicRx)) Oral Agents isotretinoin (Amnesteem,Claravis, Sotret) isotretinoin (Accutane) acitretin (Soriatane) Scabicides and Pediculicides crotamiton (Eurax) lindane 1% lotion , shampoo (generic) malathion (Ovide) permethrin (1% lotion, 1% cream rinse-OTC, 5% cream) piperonyl/pyrethrins OTC UROLOGICAL AGENTS Anticholinergic/Antispasmodics darifenacin (Enablex) oxybutynin (Oxytrol Patch) flavoxate solifenacin (VESIcare) oxybutynin tolterodine (Detrol, Detrol LA) trospium (Sanctura) BPH Agents alfuzosin (Uroxatral) dutasteride (Avodart) doxazosin finasteride tamsulosin (& brand Flomax) terazosin

*In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price is deemed to be lower for the branded counterpart than for the generic equivalent. * Drugs/drug classes not included as preferred on this list do not require a PDL override. Last update 6/29/07

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