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Home , Azelaic acid, Deserpidine, Sodium thiosulfate

MISSISSIPPI DIVISION OF MEDICAID PREFERRED LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) AGENTS, TOPICAL Acne agents will be authorized only for AKNE-MYCIN () patients under 21 years of age. erythromycin CLINDAGEL (clindamycin) EVOCLIN (clindamycin) CLINDAREACH (clindamycin) TAZORAC () DIFFERIN () RETIN-A MICRO (tretinoin) OTHERS BENZACLIN (/clindamycin) AZELEX (azelaic acid) benzoyl peroxide BENZAMYCIN PAK (benzoyl DUAC (benzoyl peroxide/clindamycin) peroxide/erythromycin) NUOX (benzoyl peroxide/) BENZIQ (benzoyl peroxide) BREVOXYL (benzoyl peroxide) SUPHERA (sodium sulfacetamide/sulfur) CLINAC BPO (benzoyl peroxide) ZACLIR (benzoyl peroxide) erythromycin/benzoyl peroxide - no PA required INOVA (benzoyl peroxide) INOVA 4/1 (benzoyl peroxide/) KLARON (sodium sulfacetamide) LAVOCLEN (benzoyl peroxide) NEOBENZ MICRO (benzoyl peroxide) SULFOXYL (benzoyl peroxide/sulfur) TRIAZ (benzoyl peroxide) ZIANA (clindaymcyin/tretinoin) ZODERM (benzoyl peroxide) ALDOSTERONE RECEPTOR INSPRA (eplerenone) ANTAGONISTS ALZHEIMER’S AGENTS INHIBITORS ARICEPT (donepezil) COGNEX (tacrine) ARICEPT ODT (donepezil) RAZADYNE (galantamine) EXELON Oral (rivastigmine) RAZADYNE ER (galantamine) EXELON Patches (rivastigmine) NMDA NAMENDA (memantine)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 1 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) ANALGESICS, NARCOTIC - acetaminophen/codeine ACTIQ (fentanyl transmucosal) SHORT-ACTING /codeine COMBUNOX (oxycodone/) (Non-parenteral) butalbital/APAP/caffeine/codeine DARVON N (propoxyphene) butalbital/ASA/caffeine/codeine FENTORA (fentanyl) codeine LYNOX (oxycodone/APAP) dihydrocodeine/ APAP/caffeine MAGNACET (oxycodone/APAP) fentanyl transmucosal OPANA (oxymorphone) hydrocodone/APAP PANLOR (dihydrocodeine/APAP/caffeine) hydrocodone/ibuprofen REPREXAIN (hydrocodone/ibuprofen) hydromorphone SUBOXONE (buprenorphine/) SUBUTEX (buprenorphine) meperidine SYNALGOS DC morphine (dihydrocodeine/APAP/caffeine) oxycodone VOPAC (codeine/APAP) oxycodone/APAP XODOL (hydrocodone/APAP) oxycodone/aspirin ZYDONE (hydrocodone/APAP) pentazocine/APAP pentazocine/naloxone propoxyphene propoxyphene/APAP propoxyphene/ASA/caffeine tramadol/APAP ANALGESICS, NARCOTIC - AVINZA (morphine) oxycodone ER LONG-ACTING fentanyl patches OPANA ER (oxymorphone) (Non-parenteral) KADIAN (morphine) OXYCONTIN (oxycodone) ULTRAM ER (tramadol) morphine SR ANALGESICS, TOPICAL FLECTOR (diclofenac)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 2 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) ANGIOTENSIN MODULATORS ACE INHIBITORS ALTACE (ramipril) ACEON (perindopril) benazepril captopril enalapril fosinopril lisinopril moexepril quinapril trandolapril ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/HCTZ captopril/HCTZ enalapril/HCTZ fosinopril/HCTZ lisinopril/HCTZ moexepril/HCTZ quinapril/HCTZ ANGIOTENSIN II RECEPTOR BLOCKERS AVAPRO (irbesartan) ATACAND (candesartan) BENICAR (olmesartan) COZAAR (losartan) DIOVAN (valsartan) MICARDIS (telmisartan) TEVETEN (eprosartan) ARB/DIURETIC COMBINATIONS AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ) BENICAR-HCT (olmesartan/HCTZ) HYZAAR (losartan/HCTZ) DIOVAN-HCT (valsartan/HCTZ) MICARDIS-HCT (telmisartan/HCTZ) TEVETEN-HCT (eprosartan/HCTZ) DIRECT RENIN INHIBITOR TEKTURNA (aliskerin) ANGIOTENSIN ACE INHIBITOR/CCB COMBINATIONS MODULATOR/ benazepril/amlodipine LEXXEL (enalapril/felodipine) CHANNEL BLOCKER LOTREL (benazepril/amlodipine) TARKA (trandolapril/verapamil) COMBINATIONS ARB/CCB COMBINATIONS EXFORGE (valsartan/amlodipine) AZOR (olmesartan/amlodipine)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 3 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) ANTIBIOTICS, GI ALINIA (nitazoxanide) FLAGYL ER (metronidazole) metronidazole MEPRON () TINDAMAX (tinadazole) ANTIBIOTICS, CLEOCIN Pediatric Solution (clindamycin) VANCOCIN (vancomycin) MISCELLANEOUS clindamycin ZYVOX (linezolid) ANTIBIOTICS, TOPICAL ANTISTAPHYLOCOCCAL BACTROBAN (mupirocin) OTHERS bacitracin CORTISPORIN bacitracin/polymyxin (polymyxin/neomycin/hydrocortisone) gentamicin triple ANTIBIOTICS, VAGINAL CLINDAMAX (clindamycin) CLEOCIN (clindamcyin) CLINDESSE (clindamycin) metronidazole triple sulfa , ARIXTRA (fondaparinux) FRAGMIN (dalteparin) INJECTABLE LOVENOX (enoxaparin) INNOHEP (tinzaparin) ANTICONVULSANTS HYDANTOINS DILANTIN (phenytoin) PEGANONE (ethotoin) PHENYTEK (phenytoin) phenytoin SUCCINIMIDES ethosuximide CELONTIN (methsuximide)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 4 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) ADJUVANTS carbamazepine FELBATOL (felbamate) CARBATROL (carbamazepine) lamotrigine - no PA required DEPAKOTE (divalproex) DEPAKOTE ER (divalproex) EQUETRO (carbamazepine) gabapentin GABITRIL (tiagabine) KEPPRA (levetiracetam) LAMICTAL (lamotrigine) LYRICA (pregabilin) TEGRETOL XR (carbamazepine) TOPAMAX (topiramate) TRILEPTAL (oxcarbazepine) valproic acid zonisamide ANTIDEPRESSANTS, SSRIs LEXAPRO () PROZAC WEEKLY (fluoxetine) PAXIL CR (paroxetine) PEXEVA (paroxetine) SARAFEM (paroxetine) ANTIDEPRESSANTS, OTHER IR bupropion XL - no PA required bupropion SR CYMBALTA () EFFEXOR XR () EMSAM (selegiline transdermal) mirtazapine NARDIL (phenelzine) - no PA required venlafaxine PARNATE (tranylcypromine) WELLBUTRIN XL (bupropion) ANTIDEPRESSANTS, TCAs SURMONTIL () VIVACTIL ()

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 5 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) ANTIEMETICS CANNABINOIDS All injectable 5HT3 receptor blockers closed to point of sale. CESAMET (nabilone) MARINOL (dronabinol) 5HT3 RECEPTOR BLOCKERS ondansetron ANZEMET (dolasetron) ondansetron ODT KYTRIL (granisetron) ZOFRAN (ondansetron) ZOFRAN ODT (ondansetron) NMDA RECEPTOR ANTAGONIST EMEND (aprepitant) OTHERS meclizine SCOPACE (scopolamine) promethazine TRANSDERM SCOP (scopolamine) , ORAL ANCOBON () - no PA required GRIFULVIN V (griseofulvin) SPORANOX () GRIS-PEG (griseofulvin) VFEND () itraconazole LAMISIL () terbinafine ANTIFUNGALS, TOPICAL ANTIFUNGALS ERTACZO () clotrimazole EXELDERM () LAMISIL (terbinafine) ketoconazole LOPROX (ciclopirox) MENTAX () NAFTIN () OXISTAT () nystatin PENLAC (ciclopirox) VERSICLEAR (sodium /salicylic VUSION (miconazole/petrolatum/ oxide) acid) XOLEGEL (ketoconazole) /STEROID COMBINATIONS clotrimazole/betamethasone nystatin/triamcinolone Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 6 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) ANTIFUNGALS, VAGINAL clotrimazole GYNAZOLE-1 () miconazole nystatin ANTIHISTMINES, FIRST GENERATION generic legend and covered OTC antihistamines PALGIC (carbinoxamine) VAZOBID () VAZOL (brompheniramine) /DECONGESTANT COMBINATIONS generic legend and covered OTC antihistamine/decongestant combinations VAZOL D (brompheniramine/phenylephrine) ANTIHISTAMINES, MINIMALLY ANTIHISTAMINES Cetirizine OTC and Zyrtec OTC are non- SEDATING CLARINEX (desloratadine) ALLEGRA (fexofenadine) covered OTC products. fexofenadine XYZAL (levocetirizine) loratadine ZYRTEC Rx (cetirizine) ANTIHISTAMINE/DECONGESTANT COMBINATIONS CLARINEX-D ALLEGRA-D (desloratadine/pseudoephedrine) (fexofenadine/pseudoephedrine) loratadine/pseudoephedrine ZYRTEC-D (cetirizine/pseudoephedrine) ANTIMIGRAINE AGENTS, ORAL

TRIPTANS IMITREX (sumatriptan) AMERGE (naratriptan)

MAXALT (rizatriptan) AXERT (almotriptan) FROVA (frovatriptan) RELPAX (eletriptan) ZOMIG (zolmitriptan) NASAL IMITREX (sumatriptan) ZOMIG (zolmitriptan) INJECTABLE IMITREX (sumitriptan) ANTIPRURITICS, TOPICAL PRUDOXIN (doxepin) ZONALON (doxepin)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 7 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) , ATYPICAL ABILIFY (aripiprazole) INVEGA (paliperidone) Injectable dosage forms require a PA except GEODON () SEROQUEL () for benficiaries residing in long term care facilities. RISPERDAL (risperidone) SEROQUEL XR (quetiapine) SYMBYAX (olanzapine/fluoxetine) ZYPREXA ANTIPSYCHOTICS, chlorpromazine MOBAN (molindone) CONVENTIONAL fluphenazine ORAP (pimozide) (Oral) haloperidol perphenazine prochlorperazine trifluoperazine thioridazine thiothixene ANTIVIRALS, ORAL ANTI-CMV ganciclovir VALCYTE (valganciclovir) ANTIHERPETIC AGENTS acyclovir famciclovir - no PA required VALTREX (valacyclovir) FAMVIR (famciclovir) ANTIVIRALS, TOPICAL DENAVIR (penciclovir) ZOVIRAX (acyclovir) ANXIOLYTICS alprazolam VISTARIL (hydroxyzine) Single source brand benzodiazepines and buspirone barbiturates are NOT covered. No PAs will be issued. chlordiazepoxide clonazepam clorazepate hydroxyzine lorazepam oxazepam ATOPIC DERMATITIS ELIDEL (pimecrolimus) PROTOPIC (tacrolimus)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 8 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) BETA BLOCKERS BETA BLOCKERS (Oral) acebutolol CARTROL atenolol INNOPRAN XL (propranolol) betaxolol LEVATOL () bisoprolol metoprolol pindolol propranolol sotalol timolol TOPROL XL (metoprolol) BETA- AND ALPHA- BLOCKERS carvedilol COREG (carvedilol) COREG CR (carvedilol) labetalol / DIURETIC COMBINATIONS atenolol/chlorthalidone bisoprolol/HCTZ metoprolol/HCTZ nadolol/bendroflumethiazide propranolol/HCTZ timolol/HCTZ BLADDER RELAXANT DETROL (tolterodine) OXYTROL (oxybutynin) PREPARATIONS DETROL LA (tolterodine) SANCTURA (trospium) ENABLEX (darifenacin) VESICARE (solifenacin) flavoxate oxybutynin BONE RESORPTION BISPHOSPHONATES SUPPRESSION AND RELATED BONIVA (ibandronate) ACTONEL (risedronate) AGENTS FOSAMAX (alendronate) ACTONEL WITH CALCIUM (Oral) FOSAMAX PLUS D (alendronate/vitamin D) (risedronate/calcium) OTHER BONE RESORPTION SUPPRESSION AND RELATED AGENTS EVISTA (raloxifene) FORTEO (teriparatide) MIACALCIN (calcitonin) FORTICAL (calcitonin) Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 9 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) BPH AGENTS ALPHA BLOCKERS CARDURA XL (doxazosin) FLOMAX (tamsulosin) terazosin UROXATRAL (alfuzosin) 5-ALPHA-REDUCTASE (5AR) INHIBITORS AVODART () BRONCHODILATORS, ANTICHOLINERGICS ANTICHOLINERGIC ipratropium ATROVENT HFA (ipratropium) SPIRIVA (tiotropium) ANTICHOLINERGIC-BETA AGONIST COMBINATIONS albuterol/ipratropium COMBIVENT (albuterol/ipratropium) DUONEB (albuterol/ipratropium) BRONCHODILATORS, BETA INHALERS, SHORT-ACTING AGONIST albuterol ALUPENT (metaproterenol) MAXAIR (pirbuterol) PROAIR HFA (albuterol) PROVENTIL HFA (albuterol) VENTOLIN HFA (albuterol) XOPENEX HFA (levalbuterol) INHALERS, LONG-ACTING FORADIL (formoterol) SEREVENT (salmeterol) INHALATION SOLUTION albuterol ACCUNEB (albuterol) metaproterenol BROVANA (arformoterol) XOPENEX (levalbuterol) ORAL albuterol metaproterenol terbutaline

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 10 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) CALCIUM CHANNEL SHORT-ACTING BLOCKERS diltiazem (Oral) isradipine nicardipine verapamil LONG-ACTING amlodipine CARDENE SR (nicardipine) diltiazem ER CARDIZEM LA (diltiazem) felodipine ER COVERA-HS (verapamil) nifedipine ER DYNACIRC CR (isradipine) verapamil ER SULAR (nisoldipine) VERELAN PM (verapamil) CEPHALOSPORINS AND BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS RELATED ANTIBIOTICS amoxicillin/clavulanate (Oral) AUGMENTIN (amoxicillin/clavulanate) AUGMENTIN XR (amoxicillin/clavulanate) CEPHALOSPORINS – First Generation cefadroxil cephalexin CEPHALOSPORINS – Second Generation cefaclor RANICLOR (cefaclor) cefprozil CEFTIN Suspension (cefuroxime) cefuroxime CEPHALOSPORINS – Third Generation cefdinir CEDAX (ceftibuten) cefpodoxime SPECTRACEF (cefditoren) OMNICEF (cefdinir) SUPRAX (cefixime) COLONY STIMULATING LEUKINE (sargramostim) FACTORS (CSFs) NEULASTA (pegfilgrastim) NEUPOGEN (filgrastim)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 11 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) CYTOKINE & CAM ENBREL (etanercept) AMEVIVE (alefacept) Amevive, Orencia and Remicade are for ANTAGONISTS HUMIRA (adalimumab) KINERET (anakinra) administration in hospital or clinic setting. PA will not be issued at Point of Sale without RAPTIVA (efalizumab) ORENCIA (abatacept) justification. REMICADE (infliximab) DIURETICS amiloride ALDACTAZIDE (spironolacton/HCTZ) amiloride/HCTZ CLOPRES (/chlorthalidone) bumetanide DIUTENSIN R (/methyclothiazide) chlorthalidone EDECRIN (ethacrynic acid) chlorothiazide ENDURONYL FORTE furosemide (deserpidine/methyclothiazide) hydrochlorothiazide MINIZIDE (/polythiazide) indapamide NAQUA (trichlormethiazide) methyclothiazide RENESE (polythiazide) metolazone SALURON (hydroflumethiazide) torsemide triamterene triamterene/HCTZ ERYTHROPOIESIS ARANESP (darbepoetin) EPOGEN (rHuEPO) STIMULATING PROTEINS PROCRIT (rHuEPO) ORAL Estratest, Estratest HS and esterified ACTIVELLA (estradiol/norethindrone) estrogens/ are DESI and are, therefore, not covered. estropipate CENESTIN PREMARIN (estrogens, conjugated) (conjugated estrogens, synthetic) PREMPHASE (estrogens, ENJUVIA (conjugated estrogens, synthetic) conjugated/medroxyprogesterone) FEMHRT (estradiol/norethindrone) PREMPRO (estrogens, FEMTRACE (estradiol) conjugated/medroxyprogesterone) MENEST (estrogens, esterified) PREFEST (estradiol/norgestimate) INJECTABLE DELESTROGEN (estradiol valerate) DEPO-ESTRADIOL (estradiol) PREMARIN (estrogens, conjugated)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 12 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) TRANSDERMAL estradiol ALORA (estradiol) CLIMARA (estradiol) CLIMARA PRO (estradiol/) COMBIPATCH (estradiol/norethindrone) ELESTRIN (estradiol) ESCLIM (estradiol) ESTRADERM (estradiol) ESTRASORB (estradiol) ESTROGEL (estradiol) MENOSTAR (estradiol) VIVELLE (estradiol) VIVELLE-DOT (estradiol) VAGINAL PREMARIN (estrogens, conjugated) ESTRACE (estradiol) ESTRING (estradiol) FEMRING (estradiol) OGEN (estropipate) VAGIFEM (estadiol) FLUOROQUINOLONES, ORAL AVELOX (moxifloxacin) CIPRO (ciprofloxacin) ciprofloxacin FACTIVE (gemifloxacin) ofloxacin LEVAQUIN (levofloxacin) NOROXIN (norfloxacin) PROQUIN XR (ciprofloxacin) GLUCOCORTICOIDS, INHALED GLUCOCORTICOIDS ASMANEX (mometasone) AEROBID (flunisolide) FLOVENT DISKUS (fluticasone) AEROBID-M (flunisolide) FLOVENT HFA (fluticasone) AZMACORT (triamcinolone) PULMICORT (budesonide) QVAR (beclomethasone) GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR (fluticasone/salmeterol) SYMBICORT (budesonide/formoterol)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 13 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) GROWTH SOMATROPIN GENOTROPIN (somatropin) HUMATROPE (somatropin) NUTROPIN (somatropin) OMNITROPE (somatropin) NORDITROPIN (somatropin) ZORBTIVE (somatropin) NUTROPIN AQ (somatropin) SAIZEN (somatropin) SEROSTIM (somatropin) TEV-TROPIN (somatropin) MECASERMIN INCRELEX (mecasermin) IPLEX (mecasermin rinfabate) H2 RECEPTOR BLOCKERS AXID (nizatidine) famotidine PEPCID (famotidine) nizatidine ranitidine capsules ranitidine syrup ZANTAC (ranitidine) ranitidine tablets HEPATITIS B TREATMENTS HEPSERA (adefovir) HEPATITIS C TREATMENTS RIBAVIRIN ribavirin COPEGUS (ribavirin) REBETOL Syrup (ribavirin) HYPOGLYCEMICS, ALPHA- GLYSET (miglitol) GLUCOSIDASE INHIBITOR PRECOSE (acarbose) HYPOGLYCEMICS, metformin FORTAMET (metformin) BIGUANIDES GLUMETZA (metformin) RIOMET (metformin) HYPOGLYCEMICS, INCRETIN BYETTA (exenatide) SYMLIN (pramlintide) MIMETICS/ENHANCERS JANUMET (sitagliptin/metformin) JANUVIA (sitagliptin) HYPOGLYCEMICS, INSULIN APIDRA (insulin glulisine) HUMALOG (insulin lispro) LANTUS (insulin glargine) HUMALOG MIX (insulin lispro/lispro LEVEMIR (insulin detemir) ) NOVOLIN (insulin) HUMULIN (insulin) NOVOLOG (insulin aspart) ILETIN (insulin) NOVOLOG MIX (insulin aspart/aspart RELION (insulin) protamine) Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 14 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) HYPOGLYCEMICS, STARLIX (nateglinide) PRANDIN (repaglinide) MEGLITINIDES HYPOGLYCEMICS, acetohexamide SULFONYLUREAS chlorpropamide glimepiride glipizide glipizide/metformin glyburide glyburide/metformin tolbutamide tolazamide HYPOGLYCEMICS, TZDS THIAZOLINEDIONES ACTOS (pioglitazone) AVANDIA (rosiglitazone) TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) AVANDAMET (rosiglitazone/metformin) AVANDARYL (rosiglitazone/glipizide) DUETACT (pioglitazone/glimepiride) IMMUNOLOGIC AGENTS ARAVA (leflunomide) INFLAMMATORY BOWEL ENTOCORT EC (budesonide) DISEASE INTRANASAL RHINITIS AGENTS ANTIHISTAMINES ASTELIN (azelastine) CORTICOSTEROIDS FLONASE (fluticasone) BECONASE AQ (beclomethasone) flunisolide NASACORT AQ (triamcinolone) fluticasone NASAREL (flunisolide) NASONEX (mometasone) OMNARIS (ciclesonide) RHINOCORT AQUA (budesonide) VERAMYST (fluticasone)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 15 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) LAXATIVES AMITIZA (lubiprostone) COLYTE (PEG Combination) CONSTULOSE (lactulose) GOLYTLELY (PEG Combination) ENULOSE (lactulose) HALFLYTELY (PEG Combination) GLYCOLAX (PEG Solution) KRISTALOSE (lactulose) PEG 3350 MIRALAX (PEG Combination) PEG 3350/Electrolye Solution MOVIPREP (PEG Combination) NULYTELY (PEG Combination) OCL (PEG Combination) OSMOPREP (sodium phosphate salts) TRILYTE (PEG Combination) VISICOL (sodium phosphate salts) LEUKOTRIENE MODIFIERS SINGULAIR (montelukast) ACCOLATE (zafirlukast) LIPOTROPICS, OTHER BILE ACID SEQUESTRANTS (non-statins) cholestyramine WELCHOL (colesevalam) colestipol CHOLESTEROL ABSORPTION INHIBITORS ZETIA (ezetimibe) FIBRIC ACID DERIVATIVES fenofibrate ANTARA (fenofibrate) gemfibrozil TRIGLIDE (fenofibrate) TRICOR (fenofibrate) NIACIN NIASPAN (niacin) NIACOR (niacin) OMEGA-3 FATTY ACIDS LOVAZA (omega-3 fatty acids) LIPOTROPICS, STATINS STATINS LIPITOR (atorvastatin) ALTOPREV (lovastatin) lovastatin CRESTOR (rosuvastatin) pravastatin LESCOL (fluvastatin) simvastatin LESCOL XL (fluvastatin) STATIN COMBINATIONS ADVICOR (lovastatin/niacin) CADUET (atorvastatin/amlodipine) VYTORIN (simvastatin/ezetimibe)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 16 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) MACROLIDES / KETOLIDES KETOLIDES KETEK (telithromycin) MACROLIDES azithromycin ZMAX (azithromycin) BIAXIN XL (clarithromycin) clarithromycin erythromycin erythromycin/sulfisoxazole MAST CELL STABILIZERS cromolyn sodium TILADE (nedocromil) INTAL (cromolyn sodium)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 17 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) NSAIDS NONSELECTIVE diclofenac etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketorolac naproxen oxaprozin piroxicam sulindac ketoprofen meclofenamate mefenamic acid nabumetone tolmetin NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) PREVACID NAPRAPAC (naproxen/lansoprazole) COX-II SELECTIVE meloxicam CELEBREX (celecoxib) OPHTHALMIC AZASITE (azithromycin) CILOXAN (ciprofloxacin) FLUOROQUINOLONES / ciprofloxacin QUIXIN (levofloxacin) MACROLIDES OCUFLOX (ofloxacin) VIGAMOX (moxifloxacin) ofloxacin ZYMAR (gatifloxacin) OPHTHALMICS FOR ALLERGIC ALAMAST (pemirolast) ALOMIDE (lodoxamide) Drugs in this class with post-operative CONJUNCTIVITIS ALOCRIL (nedocromil) ALREX (loteprednol) indications (Acular, Lotemax) do not require cromolyn EMADINE (emedastine) PA. ELESTAT (epinastine) PATADAY (olopatadine) ketotifen OPTIVAR (azelastine) PATANOL (olopatadine)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 18 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) OTIC ANTIBIOTICS FLUOROQUINOLONES CIPRODEX (ciprofloxacin/dexamethasone) CIPRO HC (ciprofloxacin/hydrocortisone) FLOXIN (ofloxacin) ofloxacin OTHER acetic acid PEDIOTIC acetic acid/hydrocortisone (neomycin/polymyxin/hydrocortisone) neomycin/polymyxin/hydrocortisone COLY-MYCIN S pramoxine/chloroxylenol/hydrocortisone (neomycin/colistin/hydrocortisone) CORTISPORIN TC (neomycin/colistin/hydrocortisone) PRAMOTIC (pramoxine/chloroxylenol) CORTANE-B (pramoxine/chloroxylenol/hydrocortisone) PENICILLINS amoxicillin GEOCILLIN (carbenicillin) ampicillin dicloxacillin penicillin V PHOSPHATE BINDERS FOSRENOL (lanthanum) MAGNEBIND Rx (calcium//folic acid) PHOSLO (calcium acetate) RENAGEL (sevelamer) PLATELET AGGREGATION AGGRENOX (dipyridamole/aspirin) INHIBITORS dipyridamole PLAVIX (clopidogrel) PROGESTINS INJECTION medroxyprogesterone acetate suspension DEPO-PROVERA (progesterone) progesterone in oil ORAL medroxyprogesterone acetate PROMETRIUM (progesterone, micronized) norethindrone acetate TOPICAL FIRST PROGESTERONE MC cream (progesterone) PROCHIEVE GEL 4% (progesterone) - 8% closed to point of sale Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 19 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) PROTON PUMP INHIBITORS PREVACID (lansoprazole) ACIPHEX (rabeprazole) (Oral) ZEGERID (omeprazole/sodium bicarbonate) NEXIUM (esomeprazole) omeprazole PROTONIX (pantoprazole) SEDATIVE HYPNOTICS BENZODIAZEPINES Single source brand benzodiazepines and temazepam barbiturates are NOT covered. No PAs will be issued. triazolam estazolam flurazepam OTHERS AMBIEN CR (zolpidem) SONATA (zaleplon) LUNESTA (eszopiclone) ROZEREM (ramelteon) zolpidem SKELETAL MUSCLE baclofen FEXMID () RELAXANTS chlorzoxazone SKELAXIN (metaxolone) cyclobenzaprine ZANAFLEX (tizanidine) dantrolene tizanidine AND MUCOUS ANTINEOPLASTIC AND PREMLIGNANT LESION AGENTS MEMBRANE AGENTS, fluorouracil CARAC (fluorouracil) MISCELLANEOUS EFUDEX (fluorouracil) FLUOROPLEX (fluorouracil) PANRETIN (alitretinoin) SOLARAZE (diclofenac) TARGRETIN (bexarotene) ANTIPSORIATIC AGENTS DOVONEX (calcipotriene) DRITHO-SCALP (anthralin) PSORIATEC (anthralin) TACLONEX (calcipotriene/betamethasone) DIABETIC ULCER PREPARATIONS REGRANEX (becaplermin) IMMUNOMODULATORS ALDARA (imiquimod)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 20 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) podofilox AKURZA (salicylic acid) salicylic acid CONDYLOX (podofilox) urea DERMA-CAS (resorcinol/phenol) HYDRO 40 (salicylic acid) KERAFOAM (salicylic acid) KERALAC (salicylic acid) KERALYT (salicylic acid) PODOCON-25 (podophyllum resin) SALEX (salicylic acid) UMECTA (salicylic acid) MUCOUS MEMBRANE/SUBCUTANEOUS ENZYMES papain/urea SANTYL (collegenase) papain/urea/chlorophylin trypsin/balsam peru/castor oil MUCOSITIS/STOMATITIS ORAMAGIX RX (acemannan) SALICEPT (acemannan) ORAL AGENTS ACCUTANE (isotretinoin) SORIATANE (acitretin) SCABICIDES AND PEDICULOCIDES EURAX (crotamiton) lindane OVIDE (malathion) permethrin piperonyl/pyrethrins

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 21 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) STIMULANTS AND RELATED STIMULANTS

AGENTS ADDERALL XR ( salt DESOXYN () combination) RITALIN LA () amphetamine salt combination VYVANSE (lisdexamfetamine) CONCERTA (methylphenidate) DAYTRANA (methylphenidate) dextroamphetamine FOCALIN (dexmethylphenidate) FOCALIN XR (dexmethylphenidate) METADATE CD (methylphenidate) METHYLIN chewable tablets (methylphenidate) METHYLIN solution (methylphenidate) methylphenidate NON-STIMULANTS STRATTERA () SULFONAMIDES GANTRISIN Suspension (sulfisoxazole) sulfadiazine sulfamethoxazole/trimethoprim sulfasalazine demeclocycline ADOXA () doxycycline DORYX (doxycycline) DYNACIN (minocycline) MONODOX (doxycycline) ORACEA (doxycycline) SOLODYN (minocycline) VIBRAMYCIN (doxycycline)

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 22 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent. MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST Updated: January 24, 2008 THERAPEUTIC PREFERRED NON-PREFERRED NOTES DRUG CLASS AGENTS AGENTS (Require PA unless otherwise indicated) ULCERATIVE COLITIS AGENTS ORAL ASACOL (mesalamine) COLAZAL (balsalazide) DIPENTUM (olsalazine) LIALDA (mesalamine) PENTASA (mesalamine) sulfasalazine RECTAL CANASA (mesalamine) mesalamine XANTHINE DERIVATIVES aminophylline dyphylline oxtriphylline theophylline

Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. 23 In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price of the brand product is lower than the generic equivalent.