Therapeutic Drug Class

MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ERYGEL (erythromycin) EVOCLIN (clindamycin) KLARON (sulfacetamide) sulfacetamide RETINOIDS RETIN-A (tretinoin) adapalene tretinoin cream AVITA (tretinoin) ATRALIN (tretinoin) DIFFERIN (adapalene) FABIOR (tazarotene) RETIN-A MICRO (tretinoin) tazarotene TAZORAC (tazarotene) tretinoin gel tretinoin micro COMBINATION DRUGS/OTHERS EPIDUO (adapalene/benzoyl peroxide) ACANYA (benzoyl peroxide/clindamycin) erythromycin/benzoyl peroxide adapalene/benzoyl peroxide sodium sulfacetamide/sulfur cream/foam/gel AKTIPAK ( erythromycin/benzoyl peroxide)NR BENZACLIN GEL (benzoyl peroxide/clindamycin) BENZACLIN KIT (benzoyl peroxide/ clindamycin) 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ALPHA-1 PROTEINASE INHIBITORS ARALAST (alpha-1 proteinase inhibitor) GLASSIA (alpha-1 proteinase inhibitor) PROLASTIN C (alpha-1 proteinase inhibitor) ZEMAIRA (alpha-1 proteinase inhibitor)

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ALZHEIMER’S AGENTS SmartPA CHOLINESTERASE INHIBITORS donepezil (Tablets and ODT) 5mg, 10mg ARICEPT (donepezil) All Agents EXELON PATCHES (rivastigmine) ARICEPT 23 MG (donepezil)  Documented diagnosis for both Galantamine ARICEPT ODT (donepezil) preferred and Non-Preferred galantamine ER donepezil 23mg Non-Preferred Criteria rivastigmine capsules EXELON Capsules (rivastigmine)  Have tried 2 different preferred agents EXELON Solution (rivastigmine) in the past 6 months RAZADYNE (galantamine) RAZADYNE ER (galantamine) rivastigmine patches NMDA RECEPTOR ANTAGONIST memantine NAMENDA TABS (memantine) NAMENDA SOLUTION(memantine) NAMENDA XR (memantine) COMBINATION AGENTS NAMZARIC (memantine/donepezil) Namzaric  Documented diagnosis AND  30 days of concurrent therapy with donepezil + memantine in the past 6 months ANALGESICS, NARCOTIC - SHORT ACTING acetaminophen/codeine ABSTRAL (fentanyl) Quantity Limits codeine ACTIQ (fentanyl) Applicable quantity limit in 31 rolling dihydrocodeine/ APAP/caffeine butalbital/APAP/caffeine/codeine days. hydrocodone/APAP butalbital/ASA/caffeine/codeine  62 tablets – codeine, oxycodone/ibuprofen, meperidine, hydromorphone butorphanol tartrate (nasal) hydromorphone, fentanyl, meperidine DEMEROL (meperidine) bultalbital/codeine combinations, morphine DILAUDID (hydromorphone) morphine, tapentadol, dihydrocodeine oxycodone capsules fentanyl combinations, oxycodone,tramadol, oxycodone/APAP FENTORA (fentanyl) pentazocine oxycodone/aspirin FIORICET W/ CODEINE  62 tablets CUMULATIVE – 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

4 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANALGESICS, NARCOTIC - LONG ACTING SmartPA

EMBEDA (morphine/naltrexone) ARYMO ER (morphine) Minimum Age Limit fentanyl patches BELBUCA (buprenorphine)  18 years – Xartemis XR, Zohydro ER morphine ER tablets BUTRANS (buprenorphine)

CONZIP ER (tramadol) Quantity Limits DOLOPHINE (methadone) Applicable quantity limit per rolling days DURAGESIC (fentanyl)  31 tablets/31 days - Conzip ER, EXALGO (hydromorphone) Exalgo ER, Hysingla ER, Ryzolt , Ultram ER hydromorphone ER  62 tablets/31 days – Arymo ER, HYSINGLA ER (hydrocodone) Embeda, Kadian, Methadone, KADIAN (morphine) Morphabond, Morphine ER, Opana methadone ER, oxycodone ER, Oxycontin,

MORPHABOND (morphine) Xtampza ER, Zohydro ER morphine ER capsules  10 patches/31 days – Duragesic MS CONTIN (morphine)  4 patches/31 days – Butrans NUCYNTA ER (tapentadol)  40 tablets/10 days – Xartemis XR OPANA ER (oxymorphone) oxycodone ER Non-Preferred Criteria OXYCONTIN (oxycodone)  Have tried 2 different preferred agents in the past 6 months OR oxymorphone ER  Documented diagnosis of cancer OR RYZOLT (tramadol) Antineoplastic therapy AND 90 tramadol ER consecutive days on the requested ULTRAM ER (tramadol) agent in the past 105 days XARTEMIS XR (oxycodone/APAP) XTAMPZA (oxycodone myristate) Xartemis XR – MANUAL PA ZOHYDRO ER (hydrocodone bitartrate)  Have tried 2 different preferred agents in the past 30 days  Maximum duration of therapy = 20 days per calendar year

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANALGESICS/ANESTHETICS (Topical)

VOLTAREN Gel (diclofenac sodium) SmartPA capsaicin Non-Preferred Criteria NR DICLO GEL KIT(diclofenac sodium)  Have tried 1 preferred agent in the diclofenac sodium 1% gelNR past 6 months diclofenac sodium solution FLECTOR (diclofenac epolamine) SmartPA Lidoderm FROTEK (lidocaine/hydrocortisone)NR  Documented diagnosis of Herpetic LIDAMANTLE HC (lidocaine/hydrocortisone) Neuralgia OR LIDO TRANS PAK (lidocaine) NR  Documented diagnosis of Diabetic lidocaine Neuropathy lidocaine/prilocaine LIDODERM (lidocaine) SmartPA LIDTOPIC MAX (lidocaine)NR PENNSAID Solution (diclofenac sodium ) SmartPA xylocaine SYNERA (lidocaine/tetracaine) TRANZAREL (lidocaine)NR XRYLIDERM (lidocaine) NR ZOSTRIX (capsaicin) ANDROGENIC AGENTS SmartPA

ANDRODERM (testosterone patch) ANDROGEL (testosterone gel) All Agents testosterone gel packets ANDROXY (fluoxymesterone)NR  Limited to male gender AXIRON (testosterone gel) FORTESTSA (testosterone gel) Non-Preferred Criteria  Have tried 2 different preferred agents NATESTO (testosterone) in the past 6 months STRIANT (testosterone) TESTIM (testosterone gel) testosterone pump VOGELXO (testosterone)

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANGIOTENSIN MODULATORS SmartPA ACE INHIBITORS benazepril ACCUPRIL (quinapril) Minimum Age Limit captopril ALTACE (ramipril)  ≤ 6 years – Epaned Smart PA will enalapril EPANED (epalapril) automatically be issued for this age LOTENSIN (benazepril) fosinopril MAVIK (trandolapril) Non-Preferred Criteria lisinopril moexipril  Have tried 2 different preferred single quinapril perindopril entity agents in the past 6 months OR ramipril PRINIVIL (lisinopril)  90 consecutive days on the requested trandolapril QBRELIS (lisinopril) agent in the past 105 days UNIVASC (moexipril) VASOTEC (enalapril) ZESTRIL (lisinopril)

ACE INHIBITOR COMBINATIONS benazepril/amlodipine ACCURETIC (quinapril/HCTZ) Non-Preferred Criteria benazepril/HCTZ LOTENSIN HCT (benazepril/HCTZ) ACE Inhibitor/CCB captopril/HCTZ LOTREL(benazepril/amlodipine)  Have tried 2 different preferred enalapril/HCTZ moexipril/HCTZ ACEI/CCB agents in the past 6 months OR fosinopril/HCTZ PRESTALIA (perindopril/amlodipine) TARKA (trandolapril/verapamil)  90 consecutive days on the requested lisinopril/HCTZ agent in the past 105 days UNIRETIC (moexipril/HCTZ) trandolapril/verapamil VASERETIC (enalapril/HCTZ) quinapril/HCTZ ACE Inhibitor/Diuretic ZESTORETIC (lisinopril/HCTZ)  Have tried 2 different preferred ACEI/Diuretic agents in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days

ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. irbesartan ATACAND (candesartan) Non-Preferred Criteria losartan AVAPRO (irbesartan)  Have tried 2 different preferred single MICARDIS (telmisartan) BENICAR (olmesartan) entity agents in the past 6 months OR telmisartan candesartan  90 consecutive days on the requested agent in the past 105 days valsartan COZAAR (losartan) DIOVAN (valsartan) EDARBI (azilsartan) eprosartan olemesartan TEVETEN (eprosartan) ARB COMBINATIONS irbesartan/HCTZ ATACAND-HCT (candesartan/HCTZ) Non-Preferred Criteria ARB/Beta losartan/HCTZ AVALIDE (irbesartan/HCTZ) Blocker, ARB/CCB or MICARDIS-HCT (telmisartan/HCTZ) AZOR (olmesartan/amlodipine) ARB/CCB/Diuretic telmisartan/HCTZ BENICAR-HCT (olmesartan/HCTZ)  Have tried 1 preferred ARB/CCB agent in the past 6 months OR valsartan/amlodipine BYVALSON (nebivolol/valsartan)  90 consecutive days on the requested valsartan/amlodipine/HCTZ candesartan/HCTZ agent in the past 105 days valsartan/HCTZ DIOVAN-HCT (valsartan/HCTZ) EDARBYCLOR (azilsartan/chlorthalidone) ARB/Diuretic ENTRESTO (valsartan/sacubitril)  Have tried 2 different preferred EXFORGE (valsartan/amlodipine) ARB/Diuretic products in the past 6 EXFORGE HCT (valsartan/amlodipine/HCTZ) months OR HYZAAR (losartan/HCTZ)  90 consecutive days on the requested olemesartan/amlodipine agent in the past 105 days olemesartan/amlodipine/HCTZ olemesartan/HCTZ Entresto – MANUAL PA telmisartan/amlodipine  Age > 18 years TEVETEN-HCT (eprosartan/HCTZ)  HF (NYHA Class II-IV)  EF < 40% TRIBENZOR (olmesartan/amlodipine/HCTZ)  No concurrent therapy with an ACEI TWYNSTA (telmisartan/amlodipine) or ARB

DIRECT RENIN INHIBITORS TEKTURNA (aliskiren) Non-Preferred Criteria  Documented diagnosis of 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

months OR  90 consecutive days on the requested agent in the past 105 days ANTIBIOTICS (GI) ALINIA (nitazoxanide) DIFICID (fidaxomicin) Xifaxan – MANUAL PA metronidazole FLAGYL ER (metronidazole)  Documented diagnosis of Hepatic neomycin TINDAMAX (tinidazole) Encephalopathy AND tinidazole VANCOCIN (vancomycin)  One trial of Lactulose OR vancomycin  Failure or intolerance to lactulose OR XIFAXAN (rifaximin)  Hospital discharge on Xifaxan OR  One claim in the past 365 days

ANTIBIOTICS (MISCELLANEOUS) KETOLIDES KETEK (telithromycin) LINCOSAMIDE ANTIBIOTICS clindamycin capsules CLEOCIN (clindamycin) clindamycin solution CLEOCIN SOLUTION (clindamycin)

MACROLIDES 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

azithromycin BIAXIN (clarithromycin) clarithromycin ER BIAXIN XL (clarithromycin) clarithromycin IR E.E.S. (erythromycin ethylsuccinate) E.E.S. Suspension 400 (erythromycin E.E.S. Suspension 200 (erythromycin ethylsuccinate) ethylsuccinate) E-MYCIN (erythromycin) ERY-TAB (erythromycin) ERYC (erythromycin) erythromycin ERYPED Suspension (erythromycin ethylsuccinate) ERYTHROCIN (erythromycin stearate) erythromycin estolate PCE (erythromycin) ZITHROMAX (azithromycin) ZMAX (azithromycin) NITROFURAN DERIVATIVES nitrofurantoin FURADANTIN (nitrofurantoin) nitrofurantoin monohydrate macrocyrstals MACROBID (nitrofurantoin monohydrate macrocyrstals) MACRODANTIN (nitrofurantoin)

Oxazolidinones SIVEXTRO (tedizolid) Sivextro, Zyvox - MANUAL PA ZYVOX (linezolid) Quantity Limit  6 tablets/month - Sivextro ANTIBIOTICS (Topical) bacitracin ALTABAX (retapamulin) bacitracin/polymixin BACTROBAN OINTMENT (mupirocin) BACTROBAN cream (mupirocin) CORTISPORIN (bacitracin/neomycin/ gentamicin sulfate polymyxin/HC) mupirocin ointment mupirocin cream ANTIBIOTICS (VAGINAL) CLEOCIN OVULES (clindamycin) AVC (sulfanilamide) clindamycin CLEOCIN CREAM (clindamycin) CLINDESSE (clindamycin) METROGEL (metronidazole) 10 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

DVT Prophylaxis - following knee replacement XARELTO 10MG & ELIQUIS  70 total days of therapy per calendar year  Documented diagnosis of knee replacement AND duration of therapy limited to 12 days

Non-Preferred Criteria  Have tried 2 different preferred agents in the past 6 months OR  1 claim with the same agent in the past 90 days

LOW MOLECULAR WEIGHT HEPARIN (LMWH)

enoxaparin ARIXTRA (fondaparinux) LMWH – All Agents

FRAGMIN (dalteparin)  LMWH therapy in the past 3 months

fondaparinux AND 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

LOVENOX (enoxaparin) Prefilled Syringe o Documented diagnosis of cancer OR o Female and age 8 to 51 years OR  NO LMWH therapy in the past 3 months AND o Duration of therapy is < 17 days OR o Documented diagnosis of cancer OR o Female and age 8 to 51 years OR o Total hip/knee replacement or hip fracture surgery in the past 6 months AND duration of therapy < 35 days

LMWH Non-Preferred Criteria  Have tried 1 different preferred agent in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days ANTICONVULSANTS SmartPA ADJUVANTS carbamazepine APTIOM (eslicarbazepine) Minimum Age Limit carbamazepine XR BANZEL (rufinamide)  1 year - Banzel DEPAKOTE ER (divalproex) BRIVIACT (brivaracetam)  2 years – Onfi DEPAKOTE SPRINKLE (divalproex) CARBATROL (carbamazepine) Quantity Limit divalproex DEPAKENE (valproic acid)  3 Twin Packs/31 days - Diastat divalproex ER DEPAKOTE (divalproex)

EQUETRO (carbamazepine) EPITOL (carbamazepine) gabapentin felbamate GABITRIL (tiagabine) FELBATOL (felbamate) lamotrigine FYCOMPA (perampanel)

levetiracetam GRALISE (gabapentin) levetiracetam ER HORIZANT (gabapentin) 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SPRITAM (levetiracetam) STAVZOR (valproic acid) Topiramate ER – Step Edit TEGRETOL (carbamazepine)  90 consecutive days on the requested TEGRETOL XR (carbamazepine) agent in the past 105 days AND tiagabine documented diagnosis of seizure OR TOPAMAX TABLET (topiramate)  30 day trial with topiramate IR in the past 6 months TOPAMAX Sprinkle (topiramate)

topiramate ER (generic Qudexy XR) Step Edit TRILEPTAL Tablets (oxcarbazepine) TROKENDI XR (topiramate) ZONEGRAN (zonisamide) SELECTED BENZODIAZEPINES DIASTAT (diazepam rectal) diazepam rectal gel ONFI (clobazam)

HYDANTOINS DILANTIN (phenytoin) PEGANONE (ethotoin) PHENYTEK (phenytoin)

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SUCCINIMIDES ethosuximide CELONTIN (methsuximide) ZARONTIN (ethosuximide)

ANTIDEPRESSANTS, OTHER SmartPA bupropion APLENZIN (bupropion HBr) Minimum Age Limit bupropion SR desvenlafaxine  18 years - all drugs bupropion XL DESYREL (trazodone)  Cymbalta – automatic approval for TRINTELLIX (vortioxetine) EFFEXOR (venlafaxine) ages 7-17 with a diagnosis of GAD (Generalized Anxiety Disorder) mirtazapine EFFEXOR XR (venlafaxine)

trazodone EMSAM (selegiline transdermal) Non-Preferred Criteria venlafaxine FETZIMA ER (levomilnacipran)  Have tried 2 different preferred venlafaxine ER capsules FORFIVO XL (bupropion) ‘Antidepressants, Other’ Class in the VIIBRYD (vilazodone) IRENKA (duloxetine) past 6 months OR KHEDEZLA ER (desvenlafaxine)  Have tried BOTH a preferred MARPLAN (isocarboxazid) ‘Antidepressant, SSRI’ and NARDIL (phenelzine) ‘Antidepressants, Other’ in the past 6 nefazodone months OR OLEPTRO ER (trazodone)  90 consecutive days on the requested agent in the past 105 days PRISTIQ (desvenlafaxine)

REMERON (mirtazapine) Cymbalta (see Fibromyalgia Agents) tranylcypromine venlafaxine XR venlafaxine ER tablets WELLBUTRIN (bupropion) WELLBUTRIN SR (bupropion) WELLBUTRIN XL (bupropion HCl) ANTIDEPRESSANTS, SSRIs SmartPA citalopram CELEXA (citalopram) Minimum Age Limits escitalopram fluoxetine DR  6 years - Zoloft 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

PAXIL CR (paroxetine) Citalopram Criteria PAXIL SUPENSION (paroxetine) PAXIL Tablets (paroxetine)  <18 years and 90 consecutive days on citalopram in the past 105 days PEXEVA (paroxetine) OR PROZAC (fluoxetine)  < 60 years AND max daily dose < 40 SARAFEM (fluoxetine) mg/day OR ZOLOFT (sertraline)  > 60 years AND max daily dose < 20 mg/day

Non-Preferred Criteria  Have tried 2 different preferred agents in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days ANTIEMETICS SmartPA 5HT3 RECEPTOR BLOCKERS ondansetron ANZEMET (dolasetron) Quantity Limits ondansetron ODT granisetron  4 tablets/31 days - Varubi ondansetron solution SANCUSO (granisetron)  6 tablets/31 days – Akynzeo ZOFRAN (ondansetron)  30 tablets/31 days – Zofran ZOFRAN ODT (ondansetron) tablets/ODT ZUPLENZ (ondansetron)  100 ml/31 days – Zofran solution

Non-Preferred Agents  Have tried 1 preferred agent in the past 6 months

Injectables in this class closed to point of sale. PA required if not administered

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. in clinic/hospital ANTIEMETIC COMBINATIONS AKYNZEO (netupitant/palonosetron) Akynzeo - MANUAL PA DICLEGIS (doxylamine/pyridoxine)  Documented diagnosis of cancer OR Antineoplastic history AND  Chemotherapy regimen includes use of a highly or moderately emetogenic chemotherapeutic agent AND  History of prior use of preferred combination antiemetic therapy AND  Concurrent use of dexamethasone per PI CANNABINOIDS CESAMET (nabilone) MARINOL (dronabinol) dronabinol SYNDROS (dronabinol) NMDA RECEPTOR ANTAGONIST EMEND (aprepitant) aprepitant Varubi - MANUAL PA VARUBI (rolapitant)  Documented diagnosis of cancer OR Antineoplastic history AND  Chemotherapy regimen includes use of a highly or moderately emetogenic chemotherapeutic agent AND  History of prior use of preferred combination antiemetic therapy AND Concurrent use of dexamethasone per PI ANTIFUNGALS (Oral) SmartPA clotrimazole ANCOBON (flucytosine) ^ Minimum Age Limit fluconazole CRESEMBA (isavuconazonium)  4-12 years – Lamisil Granules Smart griseofulvin microsize suspension DIFLUCAN (fluconazole) PA will automatically be issued for 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Sporanox  HIV opportunistic infection criteria OR  Documented diagnosis of a transplant OR  History of an immunosuppressant in the past 6 months OR  Have tried 2 different preferred agents in the past 6 months ANTIFUNGALS (Topical) SmartPA ANTIFUNGALS ciclopirox cream/gel/solution/suspension BENSAL HP (benzoic acid/salicylic acid) Non-Preferred Criteria clotrimazole CICLODAN KIT (ciclopirox kit)  Have tried 2 different preferred agents ketoconazole shampoo ciclopirox kit/shampoo in the past 6 months 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANTIFUNGAL/STEROID COMBINATIONS clotrimazole/betamethasone cream clotrimazole/betamethasone lotion nystatin/triamcinolone LOTRISONE (clotrimazole/betamethasone) ANTIFUNGALS (VAGINAL) clotrimazole vaginal cream GYNAZOLE 1 (butoconazole) miconazole 1, 3 cream, 7cream, miconazole 3 vaginal suppository TERAZOL 3 Cream (terconazole) – currently TERAZOL 3 Suppository (terconazole) unavailable from manufacturer TERAZOL 7 (terconazole) terconazole tioconzaole VAGISTAT 3 (miconazole) VAGISTAT 1 (tioconazole) 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANTIHISTAMINES, MINIMALLY SEDATING AND COMBINATIONS SmartPA MINIMALLY SEDATING ANTIHISTAMINES cetirizine CLARINEX (desloratadine) Non-Preferred Criteria loratadine levocetirizine  Documented diagnosis of allergy or XYZAL Solution (levocetirizine) urticaria AND XYZAL Tablets (levocetirizine)  Have tried 2 different preferred agents in the past 12 months

MINIMALLY SEDATING ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine ALLEGRA-D (fexofenadine/ pseudoephedrine) loratadine/pseudoephedrine CLARITIN-D (loratadine/pseudoephedrine) CLARINEX-D (desloratadine/ pseudoephedrine) fexofenadine/pseudoephedrine ZYRTEC-D (cetirizine/pseudoephedrine) ANTIMIGRAINE AGENTS, TRIPTANS SmartPA ORAL eletriptan almotriptan Minimum Age Limit – ALL rizatriptan AMERGE (naratriptan) FORMULATIONS rizatriptan ODT AXERT (almotriptan)  6 years – Maxalt sumatriptan tablets FROVA (frovatriptan)  12-17 years – Axert, Treximet, Zomig nasal spray Smart PA will IMITREX (sumatriptan) automatically be issued for this age MAXALT (rizatriptan) range MAXALT MLT(rizatriptan)  18 years – Amerge, Frova, Imitrex, naratriptan Onzetra Xsail, Relpax, Zembrace RELPAX (eletriptan) Symtouch, Zomig tablets TREXIMET (sumatriptan/naproxen) zolmitriptan Quantity Limit - ORAL ZOMIG (zolmitriptan)  6 tablets/31 days - Axert, Relpax Zomig  9 tablets/31 days - Amerge, Frova, Imitrex, Treximet

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Non-Preferred Criteria - ORAL  Have tried 2 preferred preferred oral agents in the past 90 days

NASAL sumatriptan IMITREX (sumatriptan) Quantity Limit - NASAL ONZETRA Xsail (sumatriptan)  1 box/31 days ZOMIG (zolmitriptan) Non-Preferred Criteria - NASAL  Have tried 2 preferred oral agents in the past 90 days AND  Have tried either a preferred nasal sumatriptan or injectable sumatriptan in the past 90 days INJECTABLES sumatriptan IMITREX (sumatriptan) CUMULATIVE Quantity Limit - SUMAVEL (sumatriptan) INJECTION ZEMBRACE (sumatriptan) 4 injections/31 days OTHER ZECUITY PATCH (sumatriptan) Quantity Limit  4 patches/31 days

Zecuity  Have tried 2 preferred agents (oral, nasal, or injectable) in the past 90 days

*ANTINEOPLASTICS – SELECTED SYSTEMIC ENZYME INHIBITORS AFINITOR (everolimus) ALECENSA (alectinib) Farydak - MANUAL PA

BOSULIF (bosutinib) ALUNBRIG (brigatnib)  Documented diagnosis of multiple CAPRELSA (vandetanib) CABOMETYX (cabozantinib s-malate) myeloma AND COMETRIQ (cabozantinib) FARYDAK (panobinostat) COTELLIC (cobimetinib) GLEOSTINE (lomustine)  Used in combination with bortezomib 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

GLEEVEC (imatinib mesylate) KISQALI (ribociclib)  History of 2 prior regimens including SmartPA ICLUSIG (ponatinib) LENVIMA (lenvatinib) bortezomib and an IMBRUVICA (ibrutnib) SmartPA LYNPARZA (olaparib) immunomodulatory agent INLYTA (axitinib) NERLYNX (neratinib maleate)NR IRESSA (gefitinib) RUBRACA (rucaparib) Ibrance JAKAFI (ruxolitinib) RYDAPT (midostaurin) MEKINIST (trametinib dimethyl sulfoxide)  Documented diagnosis of WD-DDLS TAGRISSO (osimertinib) for retroperitoneal sarcoma NEXAVAR (sorafenib) XATMEP (methotrexate)  Documented diagnosis of breast SPRYCEL (dasatinib) ZELJULA (niraparib) STIVARGA (regorafenib) cancer AND SUTENT (sunitinib)  Concurrent therapy with letrozole OR TAFINLAR (dabrafenib)  History of therapy with fulvestrant in TARCEVA (erlotinib) the past 60 days AND TASIGNA (nilotinib)  History of endocrine therapy in the TYKERB (lapatinib ditosylate) past 720 days vandetanib VOTRIENT (pazopanib) XALKORI (crizotinib) ZELBORAF (vemurafenib) Lenvima ZYDELIG (idelalisib)  Documented diagnosis of thyroid ZYKADIA (ceritnib) cancer OR  Documented diagnosis of renal cell carcinoma AND  History of 1 claim for everolimus in the past 30 days AND  History of 1 anti-angiogenic agent in the past 2 years.

Lynparza Capsules  Documented diagnosis of ovarian cancer AND  History of 3 prior chemotherapy agents in the past 2 years

Lynparza Tablets

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANTIPARASITICS (Topical) SmartPA PEDICULICIDES permethrin 1% lindane Minimum Age/Weight Limit for NATROBA (spinosad) malathion Pediculicides SKLICE (ivermectin) OVIDE (malathion)  50 kg - lindane shampoo ULESFIA (benzyl alcohol)  2 months – permethrin 1%(OTC)  6 months – Natroba, SKLICE, Ulesfia  2 years – piperonyl/pyrethrins (OTC)  6 years – Ovide

Non-Preferred Criteria  History of 2 preferred topical lice agents in the past 90 days

Ulesfia Ulesfia is no longer covered due to no longer being rebated. SCABICIDES permethrin 5% ELIMITE (permethrin) Minimum Age/Weight Limit for STROMECTOL Tablet (ivermectin) EURAX CREAM (crotamiton) Topical Scabicides EURAX LOTION (crotamiton)  50 kg - lindane lotion  2 months – permethrin 5%  18 years – Eurax

Non-Preferred Criteria  History of permethrin 5% in the past 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANTIPARKINSON’S AGENTS (Oral) SmartPA ANTICHOLINERGICS benztropine COGENTIN (benztropine) Non-Preferred Criteria trihexyphenidyl  Documented diagnosis of Parkinson’s disease AND  Have tried 2 different preferred agents in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone) tolcapone DOPAMINE AGONISTS ropinirole MIRAPEX (pramipexole) MIRAPEX ER (pramipexole) NEUPRO (rotigotine) pramipexole pramipexole ER REQUIP (ropinirole) REQUIP XL (ropinirole) ropinirole ER

MAO-B INHIBITORS selegiline AZILECT (rasagiline)ELDEPRYL (selegiline) Xadago: Rasagiline  Documented diagnosis of XADAGO (safinamide) Parkinson’s disease AND ZELAPAR (selegiline)  History of a preferred carbidopa/levodopa

combination product in the past 30 days AND  History of selegiline product in the past 45 days 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANTIPSYCHOTICS SmartPA ORAL amitriptyline/perphenazine ABILIFY (aripiprazole) Minimum Age Limits

aripiprazole ADASUVE (loxapine)  2 years- Droperidol

clozapine aripiprazole solution  3 years - Haldol fluphenazine aripiprazole ODT  5 years – Risperdal, thioridazine

haloperidol chlorpromazine  6 years – Abilify,trifluoperazine

olanzapine clozapine ODT  10 years – Saphris, Seroquel, perphenazine CLOZARIL (clozapine) Symbyax

risperidone FANAPT (iloperidone)  12 years- Molidone, perphenazine, pimozole, thiothixene SAPHRIS (asenapine) FAZACLO (clozapine)  13 years – Latuda, Zyprexa quetiapine GEODON (ziprasidone)  18 years – quetiapine XR HALDOL (haloperidol) Amitriptyline/perphenazine, Clozaril, thioridazine INVEGA (paliperidone) Fanapt, fluphenazine, Geodon, thiothixene LATUDA (lurasidone) Invega, loxapine, Nuplazid, Rexulti, trifluoperazine NAVANE (thiothixene) Vraylar,

ziprasidone NUPLAZID (pimavanserin)

olanzapine/fluoxetine Concurrent Therapy Limits – Ages 0- paliperidone 17 years REXULTI (brexpiprazole)  90 days with >2 typical antipsychotics in the last 120 days will require a RISPERDAL (risperidone) manual PA SEROQUEL (quetiapine) 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SEROQUEL XR (quetiapine) Non-Preferred Criteria

SYMBYAX (olanzapine/fluoxetine)  Have tried 2 preferred atypical

ZYPREXA (olanzapine) antipsychotic agents in the past 12 VRAYLAR (cariprazine) months OR  30 consecutive days on the requested agent in the past 180 days

Latuda  Females of childbearing age o > 13 years will approve automatically  Males see Non-Preferred Criteria noted above

Nuplazid  Documented diagnosis of Parkinson’s disease

SmartPA INJECTABLE, ATYPICALS ABILIFY (aripiprazole) Effective 11-1-2012, injectable ARISTADA ER (aripiprazole lauroxil) antipsychotics are closed to POS GEODON (ziprasidone) except for Long Term Care (LTC) beneficiaries. INVEGA SUSTENNA (paliperidone palmitate)

INVEGA TRINZA (paliperidone) Minimum Age Limits RISPERDAL CONSTA (risperidone) all injectable agents ZYPREXA (olanzapine)  18 years –

ZYPREXA RELPREVV (olanzapine)

LTC Long Acting Injectable Criteria  Minimum Age AND  Documented diagnosis AND  Non-Compliant with the oral formulation OR  History of the requested injectable agent in the past 90 days 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Invega Trinza  Minimum Age AND  Documented diagnosis AND  History of 4 claims of Invega Sustenna in the past 180 days

SmartPA ANTIRETROVIRALS INTEGRASE STRAND TRANSFER INHIBITORS ISENTRESS (raltegravir potassium) ISENTRESS HD (raltegravir potassium)NR Non-Preferred Criteria TIVICAY (dolutegravir sodium) VITEKTA (elvitegravir)  1 claim with the requested agent in the past 105 days NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate RETROVIR (zidovudine) didanosine DR capsule VIDEX EC (didanosine) EMTRIVA (emtricitabine) EPIVIR (lamivudine) lamivudine ZERIT (stavudine) stavudine VIDEX SOLUTION (didanosine) ZIAGEN (abacavir sulfate) VIREAD (tenofovir disoproxil fumarate) zidovudine

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR (NNRTI) EDURANT (rilpivirine) INTELENCE (etravirine) nevirapine RESCRIPTOR (delavirdine mesylate) nevirapine ER VIRAMUNE (nevirapine) SUSTIVA (efavirenz) VIRAMUNE ER (nevirapine) PHARMACOENHANCER – CYTOCHROME P450 INHIBITOR TYBOST (cobicistat) Tybost - MANUAL PA

PROTEASE INHIBITORS (PEPTIDIC) 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

PROTEASE INHIBITORS (NON-PEPTIDIC) PREZISTA (darunavir ethanolate) APTIVUS (tipranavir) PREZCOBIX (darunavir/cobicistat) ENTRY INHIBITORS – CCR5 CO-RECEPTOR ANTAGONISTS SELZENTRY (maraviroc) ENTRY INHIBITORS – FUSION INHIBITORS FUZEON (enfuvirtide) COMBINATION PRODUCTS - NRTIs abacavir/lamivudine COMBIVIR (lamivudine/zidovudine) abacavir/lamivudine/zidovudine EPZICOM (abacavir/lamivudine) lamivudine/zidovudine JULUCA (dolutegravir/rilpivirine)NR TRIZIVIR (abacavir/lamivudine/zidovudine)

COMBINATION PRODUCTS – NUCLEOSIDE & NUCLEOTIDE ANALOG RTIs DESCOVY (emtricitabine/tenofovir alafenam) TRUVADA (emtricitabine/tenofovir)

COMBINATION PRODUCTS – NUCLEOSIDE & NUCLEOTIDE ANALOGS & INTEGRASE INHIBITORS GENVOYA STRIBILD Stribild – MANUAL PA (elvitegravir/cobicistat/emtricitabine/tenofovir) (elvitegravir/cobicistat/emtricitabine/tenofovir)  Genotype testing supporting TRIUMEQ (abacavir/lamivudine/ dolutegravir) resistance to other regimens OR  Intolerance or contraindication to preferred combination of drugs AND  Medical reasoning beyond convenience or enhanced compliance 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Triumeq – MANUAL PA  Medical reasoning beyond convenience or enhanced compliance over the preferred agents (Epzicom + Tivicay) COMBINATION PRODUCTS – NUCLEOSIDE & NUCLEOTIDE ANALOGS & NON-NUCLEOSIDE RTIs ATRIPLA (efavirenz/emtricitabine/tenofovir) COMPLERA (emtricitabine/rilpivirine/tenofovir) ODEFSEY (emtricitabine/rilpivirine/tenofovir AF)

COMBINATION PRODUCTS – PROTEASE INHIBITORS KALETRA (lopinavir/ritonavir) lopinavir/ritonavir

ANTIVIRALS (Oral) – ANTIHERPETIC AGENTS acyclovir famciclovir valacyclovir FAMVIR (famciclovir) SITAVIG (acyclovir) VALTREX (valacyclovir) ZOVIRAX (acyclovir) ANTIVIRALS (Topical) ZOVIRAX Cream (acyclovir) DENAVIR (penciclovir) XERESE (acyclovir/hydrocortisone) ZOVIRAX Ointment (acyclovir) AROMATASE INHIBITORS anastrozole AROMASIN (exemestane) ARIMIDEX (anastrozole) FEMARA (letrozole) exemestane letrozole

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Dupixent & Eucrisa - MANUAL PA

BETA BLOCKERS, ANTIANGINALS & SINUS NODE AGENTSSmartPA acebutolol BETAPACE (sotalol) Bystolic – Step Edit atenolol betaxolol  90 consecutive days on the requested bisoprolol CORGARD (nadolol) agent in the past 105 days OR BYSTOLIC (nebivolol) Step Edit HEMANGEOL (propranolol)  Have tried 1 preferred agent in the INDERAL LA (propranolol) past 6 months metoprolol INNOPRAN XL (propranolol) metoprolol XL LEVATOL (penbutolol) Non-Preferred Criteria – All Agents nadolol LOPRESSOR (metoprolol)  Have tried 2 different preferred agents pindolol SECTRAL (acebutolol) in the past 6 months OR propranolol SOTYLIZE (sotalol)  90 consecutive days on the requested sotalol TENORMIN (atenolol) agent in the past 105 days timolol TOPROL XL (metoprolol) ZEBETA (bisoprolol) BETA- AND ALPHA-BLOCKERS carvedilol carvedilol CR Coreg CR labetalol COREG (carvedilol)  Documented diagnosis for COREG CR (carvedilol) hypertension AND TRANDATE (labetalol)  Have tried generic carvedilol AND 1 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANTIANGINALS RANEXA (ranolazine) Ranexa  Documented diagnosis of angina AND  1 claim for a calcium channel blocker, beta-blocker, nitrate, or combination agent in the past 30 days OR  90 consecutive days on the requested agent in the past 105 days SINUS NODE AGENTS CORLANOR (ivabradine) Corlanor - MANUAL PA BILE SALTS ursodiol ACTIGALL (ursodiol) CHENODAL (chenodiol) CHOLBAM (cholic acid) OCALIVA (obeticholic acid) URSO (ursodiol) URSO FORTE (ursodiol) 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

RAPAFLO (silodosin) Non-Preferred Criteria - MALE UROXATRAL (alfuzosin)  Have tried 2 different preferred agents in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days

5-ALPHA-REDUCTASE (5AR) INHIBITORS finasteride AVODART (dutasteride) PROSCAR (finasteride) PDE5 INHIBITORS

CIALIS (tadalafil) Cialis – MANUAL PA  Male gender AND  Documented diagnosis for Benign Prostatic Hypertrophy AND  NO history of Erectile Dysfunction AND  Signed waiver stating treatment is NOT for Erectile Dysfunction AND  Have tried 2 different preferred agents in the past 6 months

BRONCHODILATORS & COPD AGENTS ANTICHOLINERGICS & COPD AGENTS ATROVENT HFA (ipratropium) DALIRESP (roflumilast) ipratropium INCRUSE ELLIPTA (umeclidinium) SPIRIVA HANDIHALER (tiotropium) SEEBRI (glycopyrrolate) 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ANTICHOLINERGIC-BETA AGONIST COMBINATIONS albuterol/ipratropium ANORO ELLIPTA (umeclidinium/vilanterol) COMBIVENT RESPIMAT (albuterol/ipratropium) BEVESPI (glycopyrrolate/formoterol) STIOLTO RESPIMAT (tiotropium/olodaterol) UTIBRON (indacaterol/glycopyrrolate)

BRONCHODILATORS, BETA AGONIST INHALERS, SHORT-ACTING PROAIR HFA (albuterol) XOPENEX HFA (levalbuterol) SmartPA Minimum Age Limit PROAIR RESPICLICK (albuterol)  4 years - Xopenex HFA PROVENTIL HFA (albuterol) VENTOLIN HFA (albuterol) Non-Preferred Criteria  1 claim for a preferred agent in the past 6 months

SmartPA INHALERS, LONG ACTING SEREVENT (salmeterol) ARCAPTA (indacaterol) Minimum Age Limit STRIVERDI RESPIMAT (olodaterol)  4 years – Serevent  18 years – Arcapta, Striverdi Respimat

Arcapta & Striverdi Respimat  Documented diagnosis of COPD AND  Have tried 1 preferred agent in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Xopenex  1 claim for a albuterol in the past 30 days

ORAL albuterol VOSPIRE ER (albuterol) metaproterenol terbutaline

CALCIUM CHANNEL BLOCKERS SmartPA SHORT-ACTING diltiazem CALAN (verapamil) Quantity Limit - nimodipine nicardipine CARDIZEM (diltiazem)  252 tablets/ 21 days nifedipine isradipine  2520 mL/21 days verapamil nimodipine PROCARDIA (nifedipine) Non-Preferred Criteria  Have tried 2 different preferred Short Acting CCB agents in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days

nimodipine

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

LONG-ACTING amlodipine ADALAT CC (nifedipine) Non-Preferred Criteria DILT XR 24 HR Caps (diltiazem) CALAN SR (verapamil)  Have tried 2 different preferred Long diltiazem ER Cap 24 HR (generic Cardizem CD) CARDENE SR (nicardipine) Acting CCB agents in the past 6 diltiazem ER Cap 24 HR CARDIZEM CD (diltiazem) months OR  90 consecutive days on the requested felodipine ER CARDIZEM LA (diltiazem) agent in the past 105 days nifedipine ER DILACOR XR (diltiazem) verapamil ER diltiazem ER Cap 12 HR diltiazem ER Tab 24 HR nisoldipine NORVASC (amlodipine) PROCARDIA XL (nifedipine) SULAR (nisoldipine) TIAZAC (diltiazem) verapamil ER PM VERELAN/VERELAN PM (verapamil)

CALORIC AGENTS BOOST (includes all Boost) COMPLEAT Non-Preferred Agents - MANUAL PA BREAKFAST ESSENTIALS EO28 SPLASH BRIGHT BEGINNINGS FIBERSOURCE CARNATION INSTANT BREAKFAST ISOSOURCE DUOCAL JEVITY ENSURE KINDERCAL JUVEN PEPTAMEN GLUCERNA PROMOTE NUTREN (includes all Nutren) SIMPLY THICK OSMOLITE TOLEREX PEDIASURE VITAL PROMOD VIVONEX 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS amoxicillin/clavulanate AUGMENTIN 125 and 250 (amoxicillin/clavulanate) amoxicillin/clavulanate XR Suspension AUGMENTIN (amoxicillin/clavulanate) Tablets AUGMENTIN XR (amoxicillin/clavulanate) MOXATAG (amoxicillin)

SmartPA CEPHALOSPORINS – First Generation cefadroxil cephalexin tablets Non-Preferred Criteria – all cephalexin capsules KEFLEX (cephalexin) generations  Have tried 2 different preferred agents in the past 6 months

SmartPA CEPHALOSPORINS – Second Generation cefaclor capsules cefaclor ER cefprozil cefaclor suspension cefuroxime tablets cefuroxime suspension CEFTIN (cefuroxime) SmartPA CEPHALOSPORINS – Third Generation cefdinir suspension CEDAX (ceftibuten) Maximum Age Limit cefdinir capsules cefditoren  18 years – cefdinir suspension cefpodoxime ceftibuten SPECTRACEF (cefditoren) SUPRAX (cefixime) COLONY STIMULATING FACTORS

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

LEUKINE (sargramostim) NEULASTA (pegfilgrastim) GRANIX (tbo-filgrastim) NEUPOGEN Syringe and Vial (filgrastim) ZARXIO (filgrastim)

SmartPA CYSTIC FIBROSIS AGENTS BETHKIS (tobramycin) CAYSTON (aztreonam) Age Limits KITABIS (tobramycin) COLY-MYCIN M (colistimethate sodium)  3 months - Pulmozyme KALYDECO (ivacaftor)  2 years – Coly-Mycin M, Kalydeco ORKAMBI (lumacaftor/ivacaftor)  6 years – Bethkis, Kitabis, Orkambi PULMOZYME (dornase alfa) 100/125mg,, TOBI, TOBI Podhaler TOBI (tobramycin)  7 years – Cayston

TOBI PODHALER (tobramycin)  12 years – Orkambi 200/125mg tobramycin

All Agents  Documented diagnosis Cystic Fibrosis

Kalydeco  Requires 1 claim with Kalydeco in the past 105 days OR  NEW STARTS – MANUAL PA o Diagnosis of CFTR mutation responsive to Kalydeco AND o Prescriber is a CF specialist or pulmonologist AND o Negative for one of the following infections: Burkholderia cenocepacia, dolosa, or Mycobacterium abcessus

Orkambi – MANUAL PA

TOBI Podhaler – MANUAL PA  Therapy with a preferred tobramycin 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

CYTOKINE & CAM ANTAGONISTS COSENTYX (secukinumab) SmartPA ACTEMRA (tocilizumab) Orencia IV Infusion, Remicade IV ENBREL (etanercept) CIMZIA (certolizumab) Infusion and Stelara (first dose) are for administration in hospital or clinic HUMIRA (adalimumab) ENTYVIO (vedolizumab) setting. PA will not be issued at Point of ILARIS (canakinumab) methotrexate Sale without justification. INFLECTRA (infliximab) KEVZARA (sarilumab) Cosentyx KINERET (anakinra)  > 18 years = Minimum Age ORENCIA (abatacept)  Documented diagnosis of plaque OTEZLA (apremilast) psoriasis, psoriatic arthritis or OTREXUP (methotrexate) ankylosing spondylitis in the past 2 RASUVO (methotrexate) years AND REMICADE (infliximab)  90 consecutive days of Humira in the RENFLEXIS (infliximab-abda) past year RHEUMATREX (methotrexate) SILIQ (brodalumab) SIMPONI (golimumab) STELARA (ustekinumab) TALTZ (ixekizumab) TREMFYA (guselkumab) TREXALL (methotrexate) XELJANZ (tofacitinib) XELJANZ XR (tofacitinib)

ERYTHROPOIESIS STIMULATING PROTEINS SmartPA ARANESP (darbepoetin) MIRCERA (methoxy polyethylene glycol-epoetin- Mircera EPOGEN (rHuEPO) beta)  Documented diagnosis chronic renal failure in the past 2 years AND 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

FIBROMYALGIA AGENTS duloxetine CYMBALTA (duloxetine) SmartPA Cymbalta (see Antidepressant, LYRICA (pregabalin) Other) SAVELLA (milnacipran) Minimum Age Limit – automatic

approval for ages 7-17 with a diagnosis of GAD (Generalized Anxiety Disorder)

FLUOROQUINOLONES (Oral) SmartPA ciprofloxacin tablets AVELOX (moxifloxacin) Non-Preferred Criteria levofloxacin tablets BAXDELA (delaflozacin)NR  1 claim for a preferred agent in past ciprofloxacin ER 30 days CIPRO (ciprofloxacin) Cipro Suspension for age < 12 years CIPRO XR (ciprofloxacin)  Anthrax infection or exposure OR FACTIVE (gemifloxacin)  Cystic Fibrosis OR LEVAQUIN (levofloxacin)  Pneumonic plague OR tularemia AND levofloxacin suspension history of doxycycline in the past 3 moxifloxacin months OR NOROXIN (norfloxacin)  7 days of therapy with a preferred ofloxacin agent from 2 of the classes below in the past 3 months o Penicillin, 2nd or 3rd generation cephalosporin, or macrolide

Levaquin solution for age < 12 years  Anthrax infection or exposure OR  7 days of therapy with a preferred agent from 2 of the classes below in the past 3 months AND o Penicillin, 2nd or 3rd generation 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

ASMANEX HFA (mometasone) NOTE: Institutional sized products are budesonide 1mg Non-Preferred FLOVENT Diskus (fluticasone) FLOVENT HFA (fluticasone) PULMICORT (budesonide) Respules ArmonAir - MANUAL PA QVAR (beclomethasone diproprionate)*

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS

ADVAIR Diskus (fluticasone/salmeterol) AIRDUO Respiclick (fluticasone/salmeterol) Non-Preferred Criteria ADVAIR HFA (fluticasone/salmeterol) BREO ELLIPTA (fluticasone/vilanterol)  90 consecutive days on the requested DULERA (mometasone/formoterol) agent in the past 105 days OR SYMBICORT (budesonide/formoterol)  Have tried 2 different preferred agents in the past 6 months

AirDuo - MANUAL PA GI ULCER THERAPIES H2 RECEPTOR ANTAGONISTS cimetidine AXID (nizatidine) famotidine tablet famotidine suspension PEPCID (famotidine) nizatidine ranitidine capsule ranitidine syrup

ranitidine tablet ZANTAC (ranitidine) PROTON PUMP INHIBITORS NEXIUM Rx(esomeprazole) ACIPHEX SPRINKLE (rabeprazole) esomeprazole DR ACIPHEX Tablet (rabeprazole) omeprazole Rx DEXILANT (dexlansoprazole) pantoprazole lansoprazole Rx PROTONIX PACKET (pantoprazole) omeprazole sod. bicarb. PREVACID Rx (lansoprazole) PREVACID SOLU-TAB (lansoprazole) PRILOSEC RX (omeprazole) PROTONIX (pantoprazole) rabeprazole OTHER

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

GROWTH HORMONE SmartPA NORDITROPIN (somatropin) GENOTROPIN (somatropin) All Agents for Age > 18 years NUTROPIN AQ (somatropin) HUMATROPE (somatropin)  Documented diagnosis of OMNITROPE (somatropin) craniopharyngioma, SAIZEN (somatropin) panhypopituitarism, Prader-Willi Syndrome, Turner Syndrome or an SEROSTIM (somatropin) approvable indication OR TEV-TROPIN (somatropin)  Documented procedure of cranial irradiation

Non-Preferred Criteria  Have tried 1 preferred agent in the past 6 months OR  84 consecutive days on the requested agent in the past 105 days H. PYLORI COMBINATION TREATMENTS PYLERA (bismuth subcitrate potassium, OMECLAMOX (omeprazole, clarithromycin, Quantity Limit metronidazole, tetracycline) amoxicillin)  1 treatment course/year PREVPAC (lansoprazole, amoxicillin, clarithromycin)

HEPATITIS B TREATMENTS entecavir adefovir dipivoxil EPIVIR HBV SOLUTION (lamivudine) BARACLUDE (entecavir) lamivudine HBV EPIVIR HBV TABLET (lamivudine) VIREAD (tenofovir disoproxil fumarate) HEPSERA (adefovir dipivoxil) TYZEKA (telbivudine) VEMLIDY (tenofovir alafenamide fumarate)

HEPATITIS C TREATMENTS 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

RIBAPAK DOSEPACK (ribavirin) ribavirin tablets ZEPATIER (elbasvir/grazoprevir)∞ ribavirin capsules RIBASPHERE (ribavirin) SOVALDI (sofosbuvir)∞ TECHNIVIE (ombitasvir/paritaprevir/ritonavir) ∞ VIEKIRA (ombitasvir/paritaprevir/ritonavir)∞ VIEKIRA XR (ombitasvir/paritaprevir/ritonavir)∞ VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)∞

HEREDITARY ANGIOEDEMA BERINERT (C1 esterase inhibitor) CINRYZE VIAL (C1 esterase inhibitor) FIRAZYR SYRINGE (icatibant acetate) HAEGARDA (C1 esterase inhibitor) KALBITOR VIAL (ecallantide) RUCONEST VIAL (C1 esterase inhibitor, recombinant)

HYPERURICEMIA & GOUT SmartPA allopurinol colchicine tablet Non-Preferred Criteria colchicine capsule COLCRYS (colchicine)  Have tried 2 different preferred agents probenecid DUZALLO (lesinurad/allopurinol)NR in the past 6 months probenecid/colchicine MITIGARE (colchicine) Zurampic Criteria ULORIC (febuxostat)  Have tried a xanthine oxidase ZURAMPIC (lesinurad) inhibitor in the past 6 months AND ZYLOPRIM (allopurinol)  Concurrent use with a xanthine oxidase infibitor per PI

HYPOGLYCEMICS, BIGUANIDES SmartPA

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

HYPOGLYCEMICS, DPP4s and COMBINATON SmartPA JANUMET (sitagliptin/metformin) alogliptinNR MANUAL PA JANUMET XR (sitagliptin/metformin) alogliptin/metforminNR  Required with concomitant use of JANUVIA (sitagliptin) alogliptin/pioglitazoneNR GLP-1 product in the past 30 days JENTADUETO (linagliptin/metformin) JENTADUETO XR (linagliptin/metformin) OR TRADJENTA (linagliptin) KAZANO (alogliptin/metformin)  Addition of a fourth concurrent oral agent in a different drug class KOMBIGLYZE XR (saxagliptin/metformin) o Concurrent therapy with the NESINA (alogliptin) incoming claim is defined as 20 or ONGLYZA (saxagliptin) more days’ supply of the drug in OSENI (alogliptin/pioglitazone) the past 30 days o Combination agents count as 2 classes

Kombiglyze XR and Onglyza Criteria  90 consecutive days on the requested agent in the past 105 days

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS SmartPA BYDUREON (exenatide) ADLYXIN (lixisenatide) MANUAL PA VICTOZA (liraglutide) BYDUREON BCISE (exenatide)NR  Required with concomitant use of BYETTA (exenatide) DPP-4 product in the past 30 days SOLIQUA (insulin glargine/lixisenatide) OR  Addition of a fourth concurrent oral SYMLIN (pramlintide) agent in a different drug class TANZEUM (albiglutide) o Concurrent therapy with the 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. TRULICITY (dulaglutide) incoming claim is defined as 20 or XULTOPHY (insulin degludec/ liraglutide) more days’ supply of the drug in the past 30 days o Combination agents count as 2 classes

Symlin is excluded from all criteria

HYPOGLYCEMICS, INSULINS AND RELATED AGENTS SmartPA HUMALOG VIAL (insulin lispro) AFREZZA (insulin) Insulin pen formulations are not HUMALOG MIX VIAL (insulin lispro/ lispro APIDRA (insulin glulisine) covered for Long Term Care (LTC) protamine) BASAGLAR (insulin glargine) beneficiaries.

HUMULIN VIAL (insulin) HUMALOG JR (insulin lispro) Non-Preferred Criteria LANTUS SOLOSTAR & VIAL (insulin glargine) HUMALOG KWIKPEN (insulin lispro)  Documented diagnosis of Diabetes LEVEMIR FLEXPEN & VIAL (insulin detemir) HUMALOG MIX KWIKPEN (insulin lispro/ lispro Mellitus AND NOVOLOG FLEXPEN & VIAL (insulin aspart) protamine)  Have tried 1 preferred product in the NOVOLOG MIX FLEXPEN & VIAL (insulin aspart/ HUMULIN KWIKPEN (insulin) past 6 months aspart protamine) NOVOLIN FLEXPEN (insulin) NOVOLIN VIAL (insulin) TOUJEO (insulin glargine) TRESIBA (insulin degludec)

HYPOGLYCEMICS, MEGLITINIDES SmartPA nateglinide PRANDIMET (repaglinide/metformin) MANUAL PA repaglinide PRANDIN (repaglinide)  Addition of a fourth concurrent oral repaglinide/metformin agent in a different drug class STARLIX (nateglinide) o Concurrent therapy with the incoming claim is defined as 20 or

more days’ supply of the drug in the past 30 days o Combination agents count as 2 classes 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITORS SmartPA HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITORS FARXIGA (dapaglifozin) INVOKANA (canagliflozin) MANUAL PA JARDIANCE (empagliflozin)  Addition of a fourth concurrent oral agent in a different drug class o Concurrent therapy with the incoming claim is defined as 20 or more days’ supply of the drug in the past 30 days o Combination agents count as 2 classes

HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITOR COMBINATIONS SYNJARDY (empagliflozin/meformin) GLYXAMBI (empagliflozin/linagliptin) INVOKAMET (canaglifozin/metformin) INVOKAMET XR (canaglifozin/metformin) QTERN (dapaglifozin/saxagliptin)NR SYNJARDY XR (empagliflozin/meformin) XIGDUO XR (dapaglifozin/metformin)

HYPOGLYCEMICS, TZDS THIAZOLIDINEDIONES pioglitazone ACTOS (pioglitazone) MANUAL PA AVANDIA (rosiglitazone)  Addition of a fourth concurrent oral agent in a different drug class o Concurrent therapy with the incoming claim is defined as 20 or more days’ supply of the drug in the past 30 days o Combination agents count as 2 classes

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

IDIOPATHIC PULMONARY FIBROSIS SmartPA ESBRIET (pirfenidone) All Agents OFEV (nintedanib)  Documented diagnosis Idiopathic Pulmonary Fibrosis Esbriet & OFEV  No concurrent therapy with either agent IMMUNOSUPPRESSIVE (ORAL) SmartPA AZASAN (azathioprine) ASTAGRAF XL (tacrolimus) Minimum Age Limit azathioprine ENVARSUS XR (tacrolimus)  13 years - Rapamune CELLCEPT (mycophenolate) HECORIA (tacrolimus)  18 years - Zortress cyclosporine PROGRAF (tacrolimus) Astagraf, Cellcept, Envarsus XR, cyclosporine modified Hecoria, Prograf GENGRAF (cyclosporine)  Documented diagnosis for heart mycophenolate mofetil transplant, kidney transplant, liver MYFORTIC (mycophenolic acid) transplant, or a State accepted NEORAL (cyclosporine) diagnosis RAPAMUNE (sirolimus) SANDIMMUNE (cyclosporine) Azasan sirolimus  Documented diagnosis of kidney tacrolimus transplant, RA, or a State accepted ZORTRESS (everolimus) diagnosis

Gengraf, Neoral, Sandimmune  Documented diagnosis of heart transplant, kidney transplant, liver transplant, psoriasis, RA, or a State – 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Myfortic  Documented diagnosis of kidney transplant or psoriasis

Rapamune & Zortress  Documented diagnosis of kidney transplant

IMMUNE GLOBULINS CARIMUNE NF BIVIGAM FLEBOGAMMA DIF CUVITRU GAMASTAN SD GAMMAGARD SD GAMMAGARD GAMMAPLEX GAMMAKED PRIVIGEN GAMUNEX-C HIZENTRA HYQVIA OCTAGAM INTRANASAL RHINITIS AGENTS ANTICHOLINERGICS ipratropium ATROVENT (ipratropium) ANTIHISTAMINES PATANASE (olopatadine) ASTEPRO (azelastine) azelastine olopatadine

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SmartPA ANTIHISTAMINE/CORTICOSTEROID COMBINATION DYMISTA (azelastine/fluticasone) TICALAST (azelastine/fluticasone)NR

SmartPA CORTICOSTEROIDS FLONASE (fluticasone) BECONASE AQ (beclomethasone) Non-Preferred Criteria fluticasone budesonide  Documented diagnosis for allergic QNASL (beclomethasone) FLONASE ALLERGY OTC (fluticasone) rhinitis AND flunisolide  Have tried 2 different preferred agents in the past 6 months NASONEX (mometasone)

OMNARIS (ciclesonide) Budesonide RHINOCORT AQUA (budesonide) Smart PA will be issued for pregnant

TICANASE KIT (flonase kit) women. triamcinolone  A documented diagnosis of VERAMYST (fluticasone) pregnancy OR a pregnancy indicator XHANCE (fluticasone)NR submitted on the pharmacy claim at ZETONNA (ciclesonide) Point of Sale

IRON CHELATING AGENTS FERRIPROX (deferiprone) JADENU (deferasirox) EXJADE (deferasirox) JADENU SPRINKLES (deferasirox)

IRRITABLE BOWEL SYNDROME/SHORT BOWEL SYNDROME AGENTS/SELECTED GI AGENTS SmartPA IRRITABLE BOWEL SYNDROME CONSTIPATION AMITIZA (lubiprostone) MOVANTIK (naloxegol) Minimum Age Limit All Subclasses LINZESS (linaclotide) RELISTOR (methylnaltrexone)  18 years –except Bentyl, Levsin SYMPROIC (naldemedine)NR

TRULANCE (plecanatide) Gender Limits  Female - Amitiza 8mcg

Chronic Idiopathic Constipation 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

All CIC Agents:  Documented diagnosis of CIC in the past year AND  No history of GI or bowel obstruction

Non Preferred CIC Agents  Above CIC criteria AND  30 days of therapy with 2 preferred agent in the past 6 months OR  1 claim with the same agent in the past 105 days

Irritable Bowel Syndrome – Constipation Dominant (IBS-C) AMITIZA 8MCG, LINZESS 290 MCG  Documented diagnosis of IBS-C in the past year AND  No history of GI or bowel obstruction

Opioid Induced Constipation (OIC) AMITIZA 24MG, MOVANTIK, RELISTOR, SYMPROIC

All OIC Agents:  Documented diagnosis of OIC in the past year AND  1 claim for an opioid in the past 30 days AND  No history of GI or bowel obstruction AND  Documented diagnosis of chronic pain in the past year

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Non Preferred OIC Agents  Above OIC criteria AND  30 days of therapy with 1 preferred agent in the past 6 months OR  1 claim with the same agent in the past 105 days

Relistor Injection  Above OIC criteria AND  Documented diagnosis of active cancer in the past year AND  Documented diagnosis of palliative care in the past 6 months

IRRITABLE BOWEL SYNDROME DIARRHEA dicyclomine alosetron Viberzi hyoscyamine BENTYL (dicyclomine)  Documented diagnosis of Irritable VIBERZI (eluxadoline) LEVSIN (hyoscyamine) Bowel Syndrome – Diarrhea LEVSIN-SL (hyoscyamine) Dominant (IBS-D) in the past year LOTRONEX (alosetron) Lotronex  1 claim for the same agent in the past 105 days OR  MANUAL PA - All new patients require manual review.

Xifaxan - (see Antibiotics, GI)

SHORT BOWEL SYNDROME AND SELECTED GI AGENTS FULYZAQ (crofelemer) GATTEX (teduglutide) MYTESI (crofelemer) Carcinoid Syndrome Agent NUTRESTORE POWDER PACK (glutamine) XERMELO XERMELO (telotristat ethyl)  Documented diagnosis of carcinoid 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

HIV/AIDS Non-infectious Diarrhea FULYZAQ, MYTESI  Documented diagnosis of HIV/AIDS in the past year AND  Documented diagnosis of non- infectious diarrhea in the past year AND  1 claim for an antiretroviral in the past 30 days

Short Bowel Syndrome (SBS) GATTEX, NUTRESTORE, ZORBTIVE

Gattex or Zorbtive  1 claim for the same agent in the past 105 days OR  MANUAL PA - All new patients require manual review.

Nutrestore - MANUAL PA

LEUKOTRIENE MODIFIERS SmartPA ACCOLATE (zafirlukast) SINGULAIR Tablets (montelukast) Minimum Age Limit montelukast granules SINGULAR GRANULES (montelukast granules)  12 years – Zyflo & Zyflo CR montelukast tablets ZYFLO CR (zileuton) zafirlukast Non-Preferred Criteria  Have tried 2 different preferred agents zileuton in the past 6 months

SmartPA LIPOTROPICS, OTHER (Non-statins) BILE ACID SEQUESTRANTS 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Non-Preferred Criteria  Have tried 2 different preferred Non- statin Lipotropic agents in the past 6 months OMEGA-3 FATTY ACIDS LOVAZA (omega-3-acid ethyl esters) VASCEPA (icosapent ethyl) Non-Preferred Criteria  Have tried 2 different preferred Non- statin Lipotropic agents in the past 6 months

CHOLESTEROL ABSORPTION INHIBITORS ZETIA (ezetimibe) ezetimibe Zetia does not have to meet the trial of 1 statin or statin combination agent in the past year FIBRIC ACID DERIVATIVES

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

APOLIPOPROTEIN B-100 SYNTHESIS INHIBITOR KYNAMRO (mipomersen) MANUAL PA

NIACIN niacin ER NIASPAN (niacin) Non-Preferred Criteria NIACOR (niacin)  Have tried 2 different preferred Non- statin Lipotropic agents in the past 6 months PCSK-9 INHIBITOR PRALUENT (alirocumab) MANUAL PA REPATHA (evolocumab)

LIPOTROPICS, STATINS SmartPA STATINS 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

pravastatin LIPITOR (atorvastatin) Non-Preferred Criteria rosuvastatin LIVALO (pitavastatin)  Have tried 2 different preferred statin simvastatin MEVACOR (lovastatin) or statin combination agents in the PRAVACHOL (pravastatin) past 6 months OR ZOCOR (simvastatin)  90 consecutive days on the requested agent in the past 105 days STATIN COMBINATIONS SIMCOR (simvastatin/niacin) atorvastatin/amlodipine Non-Preferred Criteria VYTORIN (simvastatin/ezetimibe) ADVICOR (lovastatin/niacin)  Have tried 2 different preferred statin CADUET (atorvastatin/amlodipine) or statin combination agents in the LIPTRUZET (atorvastatin/ezetimibe) past 6 months OR  90 consecutive days on the requested agent in the past 105 days

MISCELLANEOUS BRAND/GENERIC CLONIDINE CATAPRES-TTS (clonidine) clonidine patches clonidine tablets CATAPRES (clonidine)

EPINEPHRINE epinephrine autoinject pens (labeler 49502) ADRENACLICK (epinephrine) Quantity Limits AUVI-Q (epinephrine)  2 kits/31 days EPIPEN (epinephrine) EPIPEN JR (epinephrine)

MISCELLANEOUS alprazolam alprazolam ERSmartPA Alprazolam ER CUMULATIVE hydroxyzine hcl syrup hydroxyzine hcl tablets quantity limit hydroxyzine pamoate KORLYM (mifepristone)  31 tablets/31 days  Exception –previously stable on 2 MAKENA (hydroxyprogesterone caproate) MEGACE ES (megestrol) tablets/day in the past 90 days 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SUBLINGUAL ALLERGEN EXTRACT IMMUNOTHERAPY GRASTEK ORALAIR RAGWITEK

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

MOVEMENT DISORDER AGENTS AUSTEDO (deutetrabenazine)SmartPA Austedo: INGREZZA (valbenazine)  Documented diagnosis of tetrabenazineSmartPA Huntington’s Chorea AND SmartPA XENAZINE (tetrabenazine)  30 days of therapy with brand Xenazine in the past 6 months

tetrabenazine:  Brand Xenazine is the preferred Non- Preferred agent

Xenazine:  Documented diagnosis of Huntington’s Chorea

MULTIPLE SCLEROSIS AGENTS SmartPA

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Ampyra – MANUAL PA  18 years – minimum age limit AND  60 tablets/30 days (2 tablets/day) – quantity limit AND  Documented gait disorder associated with MS AND  NO seizure diagnosis or moderate to severe renal impairment AND  Initial authorization – requires a baseline Timed 25-foot Walk (T25FW) assessment and will be approved for 12 weeks OR  Additional prior authorizations - requires a benefit assessment measured by a 20% improvement in the T25FW from baseline. Renewal will not be approved if the 20% improvement is not maintained. A renewal will be issued in a 6 month interval MUSCULAR DYSTROPHY AGENTS EMFLAZA (deflazacort) Exondys-MANUAL PA EXONDYS (eteplirsen)

NSAIDS SmartPA

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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) Non-Preferred Criteria diclofenac/misoprostol  Have tried 2 different preferred non- 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

OPHTHALMIC ANTIBIOTICS bacitracin/neomycin/gramicidin AZASITE (azithromycin) bacitracin/polymyxin bacitracin CILOXAN Ointment (ciprofloxacin) BESIVANCE (besifloxacin) ciprofloxacin BLEPH-10 (sulfacetamide) erythromycin CILOXAN Solution (ciprofloxacin) gentamicin GARAMYCIN (gentamicin) polymyxin/trimethoprim gatifloxacin tobramycin levofloxacin TOBREX ointment (tobramycin) MOXEZA (moxifloxacin) VIGAMOX (moxifloxacin) moxifloxacin NR NATACYN (natamycin) neomycin/bacitracin/polymyxin b NEO-POLYCIN (neomy/baci/polymyxin b) 59 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

OPHTHALMIC ANTI-INFLAMMATORIES SmartPA dexamethasone ACULAR LS (ketorolac) Non-Preferred Criteria diclofenac ACUVAIL (ketorolac)  Have tried 2 different preferred agents DUREZOL (difluprednate) BROMDAY (bromfenac) in the past 6 months FLAREX (fluorometholone) bromfenac

flurbiprofen BROMSITE (bromfenac) FML SOP (fluorometholone) FML FORTE (fluorometholone) ketorolac ILEVRO (nepafenac) MAXIDEX (dexamethasone) LOTEMAX (loteprednol) prednisolone acetate NEVANAC (nepafenac) prednisolone NA phosphate OCUFEN (flurbiprofen) VEXOL (rimexolone) PROLENSA (bromfenac) PRED MILD (prednisolone) 60 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. PRED FORTE (prednisolone) VOLTAREN (diclofenac) OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS SmartPA cromolyn ALAMAST (pemirolast) Non-Preferred Criteria ketotifen OTC ALOCRIL (nedocromil)  Have tried 2 different preferred agents olopatadine ALOMIDE (lodoxamide) in the past 6 months ALREX (loteprednol) azelastine BEPREVE (bepotastine) ELESTAT (epinastine) EMADINE (emedastine) epinastine LASTACAFT (alcaftadine) OPTIVAR (azelastine) PATADAY (olopatadine) PATANOL (olopatadine) PAZEO (olopatadine) OPHTHALMIC, DRY EYE AGENTS RESTASIS droperette (cyclosporine) RESTASIS Multidose (cyclosporine) Minimum Age Limit XIIDRA (lifitegrast)Smart PA  16 years – Restasis  17 years – Xiidra

Quantity Limits  5.5 mL/31 days – Restasis Multidose  60 units/31 days – Restasis droperette, Xiidra

Xiidra Criteria:  History of 4 claims for Restasis in the past 6 months

61 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

COMBINATION AGENTS COMBIGAN (brimonidine/timolol) COSOPT (dorzolamide/timolol) dorzolamide/timolol COSOPT PF(dorzolamide/timolol) SIMBRINZA (brinzolamide/brimonidine)

PARASYMPATHOMIMETICS pilocarpine CARBOPTIC (carbachol) ISOPTO CARBACHOL (carbachol) ISOPTO CARPINE (pilocarpine) PHOSPHOLINE IODIDE (echothiophate iodide) PILOPINE HS (pilocarpine)

PROSTAGLANDIN ANALOGS latanoprost bimatoprost TRAVATAN Z (travoprost) LUMIGAN (bimatoprost) RESCULA (unoprostone) travoprost XALATAN (latanoprost) VYZULTA (latananoprostene bunod)NR 62 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

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

OPIATE DEPENDENCE TREATMENTS DEPENDENCE naltrexone tablets buprenorphine tablets Buprenorphine/Naloxone and SUBOXONE FILM (buprenorphine/naloxone)SmartPA buprenorphine/naloxone tablets buprenorphine: BUNAVAIL (buprenorphine/naloxone) Suboxone ZUBSOLV (buprenorphine/naloxone)  Detailed buprenorphine/naloxone and buprenorphine criteria found here

Non-Preferred Criteria:  Bunavail is preferred over Zubsolv and other generic forms of buprenorphine/naloxone

Bunavail NOTE: Bunavail is not indicated for induction therapy  History of Suboxone therapy within the past 6 months OR  History of Bunavail therapy within the past 3 months AND  All other buprenorphine/naloxone criteria found here

TREATMENT 63 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

OTIC ANTIBIOTICS

CIPRO HC (ciprofloxacin/hydrocortisone) Age Edit ciprofloxacin Maximum Age Limit

CIPRODEX (ciprofloxacin/dexamethasone) Age Edit CORTISPORIN-TC (colistin/neomycin/  9 years - Cipro HC COLY-MYCIN S (colistin/neomycin/ hydrocortisone)  15 years - Ciprodex hydrocortisone) DERMOTIC (fluocinolone) neomycin/polymyxin/hydrocortisone OTOVEL (ciprofloxacin/fluocinolone) ofloxacin

SmartPA PANCREATIC ENZYMES CREON (pancreatin) PANCREAZE (pancrelipase) Non-Preferred Criteria ZENPEP (pancrelipase) pancrelipase  Have tried 3 different preferred agents PERTZYE (pancrelipase) in the past 6 months ULTRESA (pancrelipase) VIOKACE (pancrelipase) PARATHYROID AGENTS calcitriol doxercalciferol ergocalciferol DRISDOL (ergocalciferol) paricalcitol HECTOROL (doxercalciferol) NATPARA (parathyroid hormone) RAYALDEE (calcifediol) ROCALTROL (calcitriol) SENSIPAR (cinacalcet) ZEMPLAR (paricalcitol)

PHOSPHATE BINDERS calcium acetate AURYXIA (ferric citrate) ELIPHOS (calcium acetate) FOSRENOL (lanthanum) PHOSLYRA (calcium acetate) lanthanum RENAGEL (sevelamer HCl) PHOSLO (calcium acetate) RENVELA (sevelamer carbonate) 64 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

PLATELET AGGREGATION INHIBITORS SmartPA AGGRENOX (dipyridamole/aspirin) DURLAZA (aspirin) Zontivity – MANUAL PA BRILINTA (ticagrelor) PERSANTINE (dipyridamole)  Documented diagnosis of myocardial cilostazol PLAVIX (clopidogrel) infarction or peripheral artery disease clopidogrel prasugrel AND  No diagnosis of stroke, transient dipyridamole PLETAL (cilostazol) ischemic attack or intracranial EFFIENT (prasugrel) ticlopidine Clinical Edit hemorrhage AND pentoxifylline ZONTIVITY (vorapaxar)  Concurrent therapy with aspirin and/or clopidogrel

Non-Preferred Criteria  Documented diagnosis AND  Have tried 2 different preferred agents in the past 6 months OR  90 consecutive days on the requested agent 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. PRENATAL PLUS Tablet CITRANATAL 90 DHA PACK SE-NATAL CHEWABLE Tablet CITRANATAL ASSURE COMBO PACK TARON-C DHA Capsule CITRANATAL B-CALM PACK TRICARE PRENATAL Tablet CITRANATAL DHA PACK VOL-PLUS Tablet CITRANATAL HARMONY Capsule VOL-TAB Rx CITRANATAL RX Tablet COMPLETE NATAL DHA COMPLETENATE Tablet CHEW CONCEPT OB Capsule CORENATE-DHA COMBO PACK 65 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Conduent’s SmartPA Pharmacy Application (SmartPA) is a proprietary electronic prior authorization system used for Medicaid fee for service claims. MSCAN plans may/may not have electronic PA functionality. However, they must adhere to Medicaid’s PA criteria. 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 PAIRE OB PLUS DHA COMBO PACK 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 PRENATAL VITAMINS Tablet PRENATE DHA SOFTGEL PRENATE ELITE Tablet PRENATE ESSENTIAL SOFTGEL PRENATE PLUS Tablet PRENAVITE Tablet PRENEXA Capsule PREQUE 10 Tablet 66 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

PSEUDOBULBAR AFFECT AGENTS NUEDEXTA (dextromethorphan/quinidine) Non-Preferred Criteria  90 consecutive days on the requested agent in the past 105 days OR  Documented diagnosis for Pseudobulbar Affect PULMONARY ANTIHYPERTENSIVESSmartPA ENDOTHELIN RECEPTOR ANTAGONIST TRACLEER (bosentan) LETAIRIS (ambrisentan)* All PAH Agents – Preferred and Non- OPSUMIT (macitentan) Preferred  Documented diagnosis of pulmonary hypertension

Non-Preferred Criteria  Have tried 1 preferred PAH agent in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days

PDE5’s sildenafil ADCIRCA (tadalafil) Non-Preferred Criteria REVATIO (sildenafil)  Have tried 1 preferred PAH agent in 67 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Revatio suspension or sildenafil 25mg, 50mg, or 100mg  < 12 years of age AND documented diagnosis of Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation OR history of heart transplant OR 90 consecutive days on the requested agent in the past 105 days

Revatio tablets  < 1 year of age AND documented diagnosis of Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation OR 90 consecutive days on the requested agent in the past 105 days  > 18 years of age AND Non- Preferred Criteria

PROSTACYCLINS ORENITRAM ER (treprostinil) TYVASO (treprostinil) Non-Preferred Criteria VENTAVIS (iloprost)  Have tried 1 preferred PAH agent in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days

SELECTIVE PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI (selexipag) Non-Preferred Criteria  Have tried 1 preferred PAH agent in the past 6 months OR 68 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SOLUABLE GUANYLATE CYCLASE STIMULATORS ADEMPAS (riociguat) Adempas  Have tried 1 preferred PAH agent in the past 6 months OR  90 consecutive days on the requested agent in the past 105 days OR  MANUAL PA for PAH WHO Group 4

ROSACEA TREATMENTS metronidazole (cream, gel, lotion) AVAR (sulfacetamide sodium/sulfur) FINACEA (azelaic acid) METROCREAM (metronidazole cream) METROGEL (metronidazole gel) METROLOTION (metronidazole lotion) MIRVASO (brimonidine) NORITATE (metronidazole) OVACE (sulfacetamide sodium) Topical Sulfonamides used for Rosacea RHOFADE (oxymetazoline HCl) will require a manual PA for >21 years. ROSULA (sodium sulfacetamide/sulfur) Other labeled indications are limited to sodium sulfacetamide/sulfur (cleanser, pads, <21 years. suspension) SOOLANTRA (ivermectin) SUMADAN(sodium sulfacetamide/sulfur wash) SUMAXIN(sodium sulfacetamide/sulfur pads) SUMAXIN TS(sodium sulfacetamide/sulfur suspension)

SEDATIVE HYPNOTICS SmartPA BENZODIAZEPINES

69 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

temazepam (7.5mg and 22.5mg) Quantity Limits – CUMULATIVE triazolam Quantity limit per rolling days for all strengths. SmartPA will allow an early refill override for one dose or therapy change per year.  31 units/31 days - all strengths

Triazolam – CUMULATIVE Quantity limit per rolling days for all strengths  10 units/31 days  60 units/365 days SmartPA OTHERS zaleplon AMBIEN (zolpidem) Quantity Limits – CUMULATIVE zolpidem AMBIEN CR (zolpidem) Quantity limit per rolling days for all BELSOMRA (sovorexant) strengths. SmartPA will allow an early refill override for one dose or therapy EDLUAR (zolpidem) change per year. eszopiclone  31 units/31 days HETLIOZ (tasimelteon)  1 canister/31 days – Zolpimist & INTERMEZZO (zolpidem) male LUNESTA (eszopiclone)  1 canister/62 days – Zolpimist & ROZEREM (ramelteon) female SILENOR (doxepin) SONATA (zaleplon) Gender and Dose Limits for zolpidem zolpidem ER  Female - Ambien 5mg, Ambien CR zolpidem SLNR 6.25mg, Intermezzo 1.75 mg ZOLPIMIST (zolpidem)  Male – all zolpidem strengths

Non-Preferred Criteria  Have tried 2 different preferred agents in the past 6 months

70 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SELECT CONTRACEPTIVE PRODUCTS INJECTABLE CONTRACEPTIVES medroxyprogesterone acetate IM DEPO-PROVERA IM (medroxyprogesterone acetate) DEPO-SUBQ PROVERA 104 (medroxyprogesterone acetate)

SmartPA ORAL CONTRACEPTIVES ALL CONTRACEPTIVES ARE PREFERRED AMETHIA (levonorgestrel/ethinyl estradiol) Non-Preferred Criteria EXCEPT FOR THOSE SPECIFICALLY AMETHYST (levonorgestrel/ethinyl estradiol)  1 claim with the requested agent in INDICATED AS NON-PREFERRED BEYAZ (ethinyl the past 105 days estradiol/drospirenone/levomefolate) BRIELLYN (norethindrone/ethinyl estradiol) CAMRESE (levonorgestrel/ethinyl estradiol) CAMRESE LO (levonorgestrel/ethinyl estradiol) ethinyl estradiol/drospirenone GENERESS FE (norethindrone/ethinyl estradiol/fe) Gianvi (ethinyl estradiol/drospirenone) GILDAGIA (norethindrone/ethinyl estradiol) INTROVALE (levonorgestrel/ethinyl estradiol) JOLESSA (levonorgestrel/ethinyl estradiol) LOESTRIN 24 FE (norethindrone/ethinyl estradiol) LO LOESTRIN FE (norethindrone/ethinyl estradiol) LORYNA (ethinyl estradiol/drospirenone) NATAZIA (estradiol valerate/dienogest) norethindrone/ethinyl estradiol/fe chew tab OCELLA (ethinyl estradiol/drospirenone) OVCON-35 (norethindrone/ethinyl estradiol) PHILITH (norethindrone/ethinyl estradiol) 71 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

SKELETAL MUSCLE RELAXANTS SmartPA baclofen AMRIX (cyclobenzaprine ER) Non-Preferred Agents chlorzoxazone carisoprodol  Documented diagnosis for an cyclobenzaprine 5mg, 10mg carisoprodol compound approvable indication AND methocarbamol cyclobenzaprine 7.5mg, 15mg  Have tried 2 different preferred agents in the past 6 months tizanidine tablets cyclobenzaprine ER

dantrolene Carisoprodol FEXMID (cyclobenzaprine)  Documented diagnosis of acute LORZONE (chlorzoxazone) musculoskeletal condition AND metaxalone  NO history with meprobamate in the orphenadrine past 90 days AND orphenadrine compound  1 claim for cyclobenzaprine in the PARAFON FORTE DSC (chlorzoxazone) past 21 days OR a documented ROBAXIN (methocarbamol) intolerance to cyclobenzaprine AND SKELAXIN (metaxalone)  Quantity Limits SOMA (carisoprodol) o 18 tablets - to allow tapering off tizanidine capsules o 84 tablets/6 months ZANAFLEX (tizanidine) SMOKING DETERRENT 72 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Quantity Limits  Chantix 0.5 mg, 1mg tablets and continuing pack – 336 tablets/year  Chantix Starter – 2 treatment courses/year STEROIDS (Topical) SmartPA LOW POTENCY CAPEX (fluocinolone) alclometasone Non-Preferred Criteria desonide DERMA-SMOOTHE-FS (fluocinolone)  Have tried 2 different preferred low hydrocortisone cr, oint, soln. DESONATE (desonide) potency agents in the past 6 months DESOWEN (desonide) fluocinolone oil hydrocortisone lotion PEDIACARE HC (hydrocortisone) PEDIADERM (hydrocortisone) VERDESO (desonide) MEDIUM POTENCY fluocinolone betamethasone valerate foam Non-Preferred Criteria hydrocortisone CLODERM (clocortolone)  Have tried 2 different preferred mometasone cr, oint. CUTIVATE (fluticasone) medium potency agents in the past 6 prednicarbate cr DERMATOP (prednicarbate) months PANDEL (hydrocortisone probutate) ELOCON (mometasone) fluticasone 73 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

VERY HIGH POTENCY CLOBEX (clobetasol) clobetasol emollient Non-Preferred Criteria clobetasol shampoo clobetasol propionate foam, gel, sol  Have tried 2 different preferred very clobetasol propionate cream DIPROLENE (betamethasone diprop/prop gly) high potency agents in the past 6 clobetasol propionate ointment HALONATE months

halobetasol cream (halobetasol/ammonium lactate)

halobetasol ointment HALAC (halobetasol/ammoium lac) TEMOVATE Cream (clobetasol propionate) TEMOVATE Ointment (clobetasol propionate) OLUX (clobetasol)

74 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

STIMULANTS AND RELATED AGENTS SmartPA SHORT-ACTING amphetamine salt combination ADDERALL (amphetamine salt combination) Minimum Age Limit dexmethylphenidate IR DESOXYN (methamphetamine)  3 years - Adderall, Evekeo, FOCALIN (dexmethylphenidate) dextroamphetamine IR Procentra, Zenzedi METHYLIN chewable tablets (methylphenidate) dextroamphetamine solution  6 years – Desoxyn, Focalin, Methylin

METHYLIN solution (methylphenidate) EVEKEO (amphetamine) Maximum Age Limit methylphenidate IR methamphetamine  21 years – diagnosis of ADD/ADHD methylphenidate chewable PROCENTRA (dextroamphetamine) is required methylphenidate solution ZENZEDI (dextroamphetamine) Quantity Limits Applicable quantity limit per rolling days  62 tablets/31 days –Adderall, Desoxyn, Evekeo, Methylin, Zenzedi  310 mL/31 days – Methylin solution, Procentra

Non-Preferred Criteria  Have tried 2 different preferred Short Acting agents in the past 6 months OR  1 claim for a 30 day supply with the requested agent in the past 105 days

LONG-ACTING amphetamine salt combination ER ADDERALL XR (amphetamine salt combination) Minimum Age Limit APTENSIO XR (methylphenidate) ADZENYS XR ODT (amphetamine)  6 years – Adderall XR, Adzenys XR ODT, Aptensio XR, Concerta, 75 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

methylphenidate ER Caps (generic Ritalin LA) VYVANSE (lisdexamfetamine) Maximum Age Limit VYVANSE CHEWABLE(lisdexamfetamine) methylphenidate ER Tabs (generic Ritalin SR)  18 years – Cotempla XR ODT MYDAYIS (amphetamine salt combination)  21 years – diagnosis of ADD/ADHD NUVIGIL (armodafinil) is required PROVIGIL (modafinil) RITALIN LA (methylphenidate) Quantity Limits RITALIN SR (methylphenidate) Applicable quantity limit per rolling days  31 tablets/31 days – Adderall XR, Adzenys XT ODT, Aptensio XR, Concerta 18, 27, & 54 mg, Daytrana, Dexedrine Spansule, Focalin XR, Metadate CD, Methylin ER, Nuvigil 150 & 200 mg, Provigil 200mg, Quillichew, Ritalin LA & SR, Vyvanse  46.5 tablets/31 days – Provigil 100 mg  62 tablets/31 days – Concerta 36mg, Nuvigil 50mg  248 mL/31 days – Dyanavel XR  372 mL/31 days – Quillivant XR

Provigil  Documented diagnosis of Narcolepsy, Obstructive Sleep Apnea, or Shift Work Disorder

Non-Preferred Criteria  Have tried 2 different preferred Long Acting agents in the past 6 months 76 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Nuvigil  Documented diagnosis of Narcolepsy, Obstructive Sleep Apnea, or Shift Work Disorder AND  1 claim for a 30 day supply with the requested agent in the past 105 days OR  30 days of therapy with Provigil in the past 6 months AND 30 days of therapy in the past 6 months with a preferred stimulant that is indicated for the treatment of Narcolepsy, Obstructive Sleep Apnea, or Shift Work Disorder NON-STIMULANTS atomoxetine clonidine ER Minimum Age Limit guanfacine ER Step Edit INTUNIV (guanfacine ER) 6 years – Intuniv, Kapvay, Strattera

KAPVAY (clonidine extended-release) Maximum Age Limit STRATTERA (atomoxetine)  18 years – Intuniv, Kapvay  21 years – diagnosis of ADD/ADHD is required

Quantity Limits Applicable quantity limit per rolling days  31 tablets/31 days – Intuniv, Strattera  124 tablets/31 days – Kapvay

Guanfacine ER  Have tried the short acting product in the past 6 months  1 claim for a 30 day supply with 77 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

Kapvay & Intuniv  Diagnosis for ADD or ADHD AND  Have tried 1 Short or Long Acting stimulant in the past 6 months OR  Have tried 1 preferred Non-Stimulant in the past 6 months OR  Have tried the short acting product in the past 6 months

TETRACYCLINES SmartPA doxycycline hyclate caps/tabs ACTICLATE (doxycyline) Non-Preferred Agents doxycycline monohydrate caps (50mg & 100mg) ADOXA (doxycycline monohydrate)  Have tried 2 different preferred agents minocycline caps IR demeclocycline in the past 6 months tetracycline doxycycline monohydrate caps (75mg & 150mg) Demeclocycline doxycycline monohydrate tabs  Documented diagnosis of Diabetes DYNACIN (minocycline) Insipidus or SIADH will allow minocycline ER automatic approval. minocycline tabs OKEBO (doxycycline)NR ORACEA (doxycycline) SOLODYN (minocycline) TARGADOX (doxycycline)NR VIBRAMYCIN cap/susp/syrup XIMINO (minocycline)NR SmartPA ULCERATIVE COLITIS and CROHN’S AGENTS *See Cytokine & CAM Antagonists Class for additional agents ORAL APRISO (mesalamine) ASACOL HD (mesalamine) Gender Limits balsalazide AZULFIDINE (sulfasalazine)  Male - Giazo sulfasalazine AZULFIDINE ER (sulfasalazine) budesonide EC Non-Preferred Criteria  90 consecutive days on the requested COLAZAL (balsalazide) 78 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 1/01/2018 UNIVERSAL PREFERRED DRUG LIST Version 2018.7a (For All Medicaid, MSCAN and CHIP Beneficiaries) Updated: 11-28-2017

RECTAL CANASA (mesalamine) SFROWASA (mesalamine) mesalamine UCERIS Foam (budesonide)

79 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. Drugs highlighted in yellow denote a change in PDL status. *Existing users will be grandfathered; grandfathering is defined as approving a Non-Preferred agent for an existing user; all other changes will not qualify for grandfathering. To search the PDL, press CTRL + F