MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ACNE AGENTS ANTI-INFECTIVE AZELEX (azelaic acid) ACZONE (dapsone) Acne agents will be authorized only for clindamycin (gel, lotion, solution) AKNE-MYCIN (erythromycin) patients less than 21 years of age. ERYGEL (erythromycin) CLEOCIN-T (clindamycin) erythromycin CLINDAGEL (clindamycin) clindamycin foam ERY (erythromycin) EVOCLIN (clindamycin) FINACEA (azelaic acid) KLARON (sulfacetamide) sulfacetamide

RETINOIDS RETIN-A (tretinoin) adapalene TAZORAC (tazarotene) AVITA (tretinoin) tretinoin gel ATRALIN (tretinoin) DIFFERIN (adapalene) FABIOR (tazarotene) RETIN-A MICRO (tretinoin) tretinoin cream tretinoin micro

COMBINATION DRUGS/OTHERS DUAC (benzoyl peroxide/clindamycin) ACANYA (benzoyl peroxide/clindamycin) EPIDUO (adapalene/benzoyl peroxide) BENZACLIN GEL (benzoyl peroxide/clindamycin) sodium sulfacetamide/sulfur cream/foam/gel BENZACLIN KIT (benzoyl peroxide/ clindamycin) BENZAMYCIN PAK (benzoyl peroxide/ erythromycin) benzoyl peroxide/clindamycin erythromycin/benzoyl peroxide INOVA 4/1 (benzoyl peroxide/salicylic acid) INOVA 8/2 (benzoyl peroxide/salicylic acid) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PRASCION (sulfacetamide sodium/sulfur) ROSANIL (sulfacetamide sodium/sulfur) SE BPO (benzoyl peroxide) sodium sulfacetamide/sulfur lotion/suspension/cleanser/pads sodium sulfacetamide/sulfur/meratan sulfacetamide sodium/sulfur/urea VELTIN (clindamycin/tretinoin) ZENCIA WASH (sulfacetamide sodium/sulfur) ZIANA (clindamycin/tretinoin) KERATOLYTICS (BENZOYL PEROXIDES) benzoyl peroxide BPO (benzoyl peroxide) INOVA (benzoyl peroxide) LAVOCLEN (benzoyl peroxide) ISOTRETINOIN Amnesteem ABSORICA (isotretinoin) Claravis Myorisan Zenatane

ALZHEIMER’S AGENTS SmartPA CHOLINESTERASE INHIBITORS ARICEPT (donepezil) donepezil SmartPA Criteria: ARICEPT 23 MG (donepezil) EXELON Solution (rivastigmine)  Documented diagnosis (based on ARICEPT ODT (donepezil) galantamine labeled indication) found in the past 2 EXELON (rivastigmine) galantamine ER years medical claims – ALL DRUGS AND RAZADYNE (galantamine)

RAZADYNE ER (galantamine) Non-Preferred Criteria rivastigmine  30 days of therapy with 2 different preferred agents in the past 6 months OR  90 days completed therapy with the same agent in the past 105 days

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS NMDA RECEPTOR ANTAGONIST NAMENDA TABS (memantine) NAMENDA SOLUTION(memantine) NAMENDA XR (memantine) ANALGESICS, NARCOTIC - SHORT ACTING SmartPA acetaminophen/codeine ABSTRAL (fentanyl) SmartPA Criteria: codeine ACTIQ (fentanyl)  Suboxone/ Subutex concurrent therapy dihydrocodeine/ APAP/caffeine butalbital/APAP/caffeine/codeine o Opioids are limited to a 5 day supply hydrocodone/APAP butalbital/ASA/caffeine/codeine while on Suboxone or Subutex therapy with a maximum cumulative hydromorphone butorphanol tartrate (nasal) total of 10 days. IBUDONE (hydrocodone/ibuprofen) DEMEROL (meperidine) meperidine DILAUDID (hydromorphone) Other Criteria at the Point of Sale: morphine fentanyl Applicable quantity limit in 31 rolling oxycodone FENTORA (fentanyl) days. oxycodone/APAP FIORICET W/ CODEINE  62 tablets in 31 days – oxycodone/aspirin (butalbital/APAP/caffeine/codeine) codeine, oxycodone/ibuprofen,

oxycodone/ibuprofen FIORINAL W/ CODEINE meperidine, hydromorphone, pentazocine/APAP (butalbital/ASA/caffeine/codeine) fentanyl, bultalbital/codeine combinations, morphine, tramadol hydrocodone/ibuprofen tapentadol, dihydrocodeine tramadol/APAP levorphanol LORCET (hydrocodone/APAP) combinations, tramadol, LORTAB (hydrocodone/APAP) pentazocine, MAGNACET (oxycodone/APAP)  124 tablets in 31 days – NORCO (hydrocodone/APAP) butalbital/APAP 750 NUCYNTA (tapentadol)  145 tablets in 31 days – butalbital/APAP 650 ONSOLIS (fentanyl)  186 tablets in 31 days – OPANA (oxymorphone) butalbital/APAP 325, OXECTA (oxycodone) butalbital/ASA 325 pentazocine/naloxone  5mL (2 x 2.5 bottles) in 31 PERCOCET (oxycodone/APAP) days – butorphanol nasal PERCODAN (oxycodone/ASA) REPREXAINE (hydrocodone/ibuprofen) Applicable CUMULATIVE quantity limit ROXICET (oxycodone/acetaminophen) in 31 rolling days RYBIX (tramadol)  62 tablets in 31 days – SUBSYS (fentanyl) hydrocodone combinations, 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SYNALGOS-DC (dihydrocodeine/ aspirin/caffeine) oxycodone combinations TYLENOL W/CODEINE (APAP/codeine)  180 ml – oxycodone liquids TYLOX (oxycodone/APAP)  480 mL – hydrocodone liquids ULTRACET (tramadol/APAP) ULTRAM (tramadol) VICODIN (hydrocodone/APAP) VICOPROFEN (hydrocodone/ibuprofen) XODOL (hydrocodone/acetaminophen) ZAMICET (hydrocodone/APAP) ZOLVIT (hydrocodone/APAP) ZYDONE (hydrocodone/acetaminophen)

ANALGESICS, NARCOTIC - LONG ACTING SmartPA fentanyl patches AVINZA (morphine) SmartPA Criteria: methadone BUTRANS (buprenorphine)  Suboxone/ Subutex concurrent therapy morphine ER CONZIP ER (tramadol) o Opioids are limited to a 5 day supply OPANA ER (oxymorphone) DOLOPHINE (methadone) while on Suboxone or Subutex therapy with a maximum cumulative DURAGESIC (fentanyl) total of 10 days. EMBEDA (morphine/naltrexone)  Avinza EXALGO (hydromorphone) o 30 days of therapy with Opana ER KADIAN (morphine) or morphine ER in the past 6 months MS CONTIN (morphine) OR NUCYNTA ER (tapentadol) o 90 days completed therapy with the oxycodone ER same agent in the past 105 days OXYCONTIN (oxycodone) AND oxymorphone ER o Quantity limit of 31 tablets in 31 days RYZOLT (tramadol)  OxyContin o Documented diagnosis of cancer tramadol ER found in the past 2 years medical ULTRAM ER (tramadol) NR claims OR XARTEMIS XR (oxycodone/APAP) o Antineoplastic therapy in the past 6 ZOHYDRO ER (hydrocodone bitartrate) months AND o 30 days of therapy with Kadian, Opana ER, morphine ER , Avinza or Duragesic patch in the past 6 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS months AND o Quantity limit of 62 tablets in 31 days.  Non-Preferred Criteria o 30 days of therapy with 2 different preferred agents in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days AND o Applicable quantity limit in 31 rolling days.  31 tablets in 31 days – Exalgo ER, Ultram ER, Ryzolt, Conzip ER,  62 tablets in 31 days – Methadone, Kadian, Morphine ER, Embeda, oxycodone ER, Opana ER,  10 patches in 31 days – Duragesic  4 patches in 31 days - Butrans ANALGESICS/ANAESTHETICS (Topical) SmartPA

VOLTAREN Gel (diclofenac sodium) SmartPA capsaicin SmartPA Criteria: SmartPA FLECTOR (diclofenac epolamine) Non-Preferred Criteria LIDAMANTLE HC (lidocaine/hydrocortisone)  One claim for 1 preferred agent in the lidocaine past 6 months OR lidocaine/prilocaine  90 days completed therapy with the LIDODERM (lidocaine) SmartPA same agent in the past 105 days SmartPA PENNSAID Solution (diclofenac sodium )  Lidoderm xylocaine o Documented diagnosis found in the SYNERA (lidocaine/tetracaine) past years medical claims for ZOSTRIX (capsaicin) Herpetic Neuralgia OR o Documented diagnosis found in the 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS past years medical claims for Diabetic Neuropathy

ANDROGENIC AGENTS SmartPA TESTIM (testosterone gel) ANDRODERM (testosterone patch) SmartPA Criteria: ANDROGEL (testosterone gel)  Limited to male patients AND AXIRON (testosterone gel)  30 days of therapy with 1 different FORTESTSA (testosterone gel) preferred agent in the past 6 months OR

 90 days completed therapy with the same agent in the past 105 days ANGIOTENSIN MODULATORS SmartPA ACE INHIBITORS benazepril ACCUPRIL (quinapril) SmartPA Criteria: captopril ALTACE (ramipril)  ACE Inhibitor enalapril LOTENSIN (benazepril) o 30 days of therapy with 2 different MAVIK (trandolapril) fosinopril preferred single entity agents in the moexipril past 6 months OR lisinopril perindopril o 90 days completed therapy with the quinapril PRINIVIL (lisinopril) same agent in the past 105 days ramipril UNIVASC (moexipril) trandolapril VASOTEC (enalapril) ZESTRIL (lisinopril) ACE INHIBITOR COMBINATIONS benazepril/HCTZ ACCURETIC (quinapril/HCTZ)  ACE Inhibitor/CCB captopril/HCTZ benazepril/amlodipine o 30 days of therapy with 2 different enalapril/HCTZ LOTENSIN HCT (benazepril/HCTZ) preferred ACEI/CCB agents in the fosinopril/HCTZ moexipril/HCTZ past 6 months OR o 90 days completed therapy with the lisinopril/HCTZ trandolapril/verapamil UNIRETIC (moexipril/HCTZ) same agent in the past 105 days LOTREL(benazepril/amlodipine) quinapril/HCTZ VASERETIC (enalapril/HCTZ) ZESTORETIC (lisinopril/HCTZ)  ACE Inhibitor/Diuretic TARKA (trandolapril/verapamil) o 30 days of therapy with 2 different

preferred ACEI/Diuretic agents in the past 6 months OR 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o 90 days of completed therapy with the same agent in the past 105 days. ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) AVAPRO (irbesartan) ATACAND (candesartan)  ARB BENICAR (olmesartan) candesartan o 30 days of therapy with 2 different DIOVAN (valsartan) COZAAR (losartan) preferred single entity agents in the losartan EDARBI (azilsartan) past 6 months OR o 90 days competed therapy with the MICARDIS (telmisartan) eprosartan same agent in the past 105 days irbesartan telmisartan TEVETEN (eprosartan)

ARB COMBINATIONS AVALIDE (irbesartan/HCTZ) ATACAND-HCT (candesartan/HCTZ)  ARB/CCB (includes BENICAR-HCT (olmesartan/HCTZ) AZOR (olmesartan/amlodipine) ARB/CCB/Diuretic) DIOVAN-HCT (valsartan/HCTZ) candesartan/HCTZ o 30 days of therapy with 1 different EXFORGE (valsartan/amlodipine) EDARBYCLOR (azilsartan/chlorthalidone) preferred ARB/CCB agent in the past 6 months OR EXFORGE HCT (valsartan/amlodipine/HCTZ) irbesartan/HCTZ o 90 days completed therapy with the HYZAAR (losartan/HCTZ) losartan/HCTZ same agent in the past 105 days MICARDIS-HCT (telmisartan/HCTZ) telmisartan/amlodipine telmisartan/HCTZ  ARB/Diuretic TEVETEN-HCT (eprosartan/HCTZ) o 30 days of therapy with 2 different TRIBENZOR (olmesartan/amlodipine/HCTZ) preferred ARB/Diuretic products in TWYNSTA (telmisartan/amlodipine) the past 6 months OR o 90 days of completed therapy with the same agent in the past 105 days DIRECT RENIN INHIBITORS TEKTURNA (aliskiren)  Direct Renin Inhibitor o Documented diagnosis found in the past 2 years medical claims for hypertension AND o 30 days of therapy with 2 different preferred ACEI or ARB single-entity 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS products in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

DIRECT RENIN INHIBITOR COMBINATIONS AMTURNIDE (aliskiren/amlodipine/hctz)  Direct Renin Inhibitor Combinations TEKAMLO (aliskiren/amlodipine) o Documented diagnosis found in the TEKTURNA-HCT (aliskiren/hctz) past 2 years medical claims for VALTURNA (aliskiren/valsartan) hypertension AND o 30 days of therapy with 2 different

preferred ACEI or ARB diuretic agents in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days 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 (GI) ALINIA (nitazoxanide) DIFICID (fidaxomicin) *Xifaxan –requires a manual PA metronidazole FLAGYL ER (metronidazole)  Documented diagnosis of Hepatic neomycin tinidazole Encephalopathy on manual PA request TINDAMAX (tinidazole) VANCOCIN (vancomycin) AND vancomycin o One trial of Lactulose OR XIFAXAN (rifaximin) o Documented treatment failure or intolerance to lactulose OR

o Hospital discharge on Xifaxan OR o One claim for Xifaxan in the past 365 days

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIBIOTICS (VAGINAL) CLEOCIN OVULES (clindamycin) AVC (sulfanilamide) CLINDESSE (clindamycin) CLEOCIN CREAM (clindamycin) METROGEL (metronidazole) clindamycin VANDAZOLE (metronidazole) metronidazole vaginal ANTICOAGULANTS SmartPA SmartPA LMWH COUMADIN (warfarin) SmartPA ARIXTRA (fondaparinux) LMWH:

FRAGMIN (dalteparin) SmartPA LMWH ELIQUIS (apixaban)  30 days of therapy with 2 different SmartPA LMWH LOVENOX (enoxaparin) Prefilled Syringe SmartPA enoxaparin preferred agents in the past 6 months

LMWH fondaparinux SmartPA LMWH OR XARELTO 10mg (rivaroxaban) SmartPA PRADAXA (dabigatran) SmartPA  90 days completed therapy with the same agent in the past 105 days XARELTO 15 & 20mg (rivaroxaban)

warfarin  LMWH therapy is found in prescription history in the past 3months o AND documented diagnosis of cancer in the past 2 years medical claims o OR Female with a documented diagnosis of pregnancy found in the past 280 days medical claims OR  NO LMWH therapy is found in prescription history in the past 3months o AND duration of therapy is < 17 days o OR documented diagnosis of cancer in the past 2 years medical claims o OR Female with a documented diagnosis of pregnancy found in the past 280 days medical claims o OR documented diagnosis of total hip/knee replacement or hip fracture surgery in the past 6 months medical claims 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS  AND duration of therapy < 35 days

Warfarin:  Non-Preferred Criteria o 90 days completed therapy with the same agent in the past 105 days

DVT prophylaxis post knee or hip replacement surgery: Xarelto 10mg & Eliquis  Limited to 70 days of therapy per calendar year  Documented diagnosis of knee replacement in past 30 days of medical claims or submitted on pharmacy claim o AND therapy limits of < 12 days  OR documented diagnosis of hip replacement in past 30 days of medical claims or submitted on pharmacy claim AND therapy limits of < 35 days

Stroke and systemic embolism prophylaxis with nonvalvular atrial fibrillation: Eliquis, Pradaxa, Xarelto 15 & 20mg  1 claim with the same agent in the past 90 days OR  Documented diagnosis of atrial fibrillation found in the past 2 years medical claims AND o NO documented diagnosis of cardiac valve disease found in the past 2 years medical claims AND o 60 days therapy with warfarin in the past 6 months 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

Treatment of DVT/PE: Xarelto 15 & 20mg A manual PA is required.

ANTICONVULSANTS SmartPA ADJUVANTS carbamazepine APTIOM (eslicarbazepine) SmartPA Criteria: CARBATROL (carbamazepine) BANZEL (rufinamide) DEPAKOTE ER (divalproex) carbamazepine XR Banzel/Onfi: DEPAKOTE SPRINKLE (divalproex) DEPAKENE (valproic acid)  90 days completed therapy with the same agent in the past 105 days divalproex DEPAKOTE (divalproex) OR divalproex ER EQUETRO (carbamazepine) NR  Minimum Age Requirements – EPITOL (carbamazepine) FANATREX SUSPENSION (gabapentin) o Rufinamide – 4 years gabapentin felbamate o Clobazam – 2 years GABITRIL (tiagabine) FELBATOL (felbamate) AND LAMICTAL XR (lamotrigine) FYCOMPA (perampanel)  Documented diagnosis of Lennox-

GRALISE (gabapentin) Gastaut found in the past 2 years lamotrigine levetiracetam HORIZANT (gabapentin) medical claims KEPPRA (levetiracetam) levetiracetam ER AND KEPPRA XR (levetiracetam) oxcarbazepine  30 days of therapy with 1 different LAMICTAL (lamotrigine) preferred agents for Lennox-Gastaut in TEGRETOL XR (carbamazepine) LAMICTAL CHEWABLE (lamotrigine) the past 6 months topiramate LAMICTAL ODT (lamotrigine) topiramate capsule levetiracetam ER Non-Preferred Agents TRILEPTAL Suspension (oxcarbazepine) NEURONTIN (gabapentin)  30 days of therapy with 2 different valproic acid oxcarbazepine suspension preferred agents in the past 6 months VIMPAT (lacosamide) OXTELLAR XR (oxcarbazepine) OR zonisamide POTIGA (ezogabine)  90 days completed therapy with the SABRIL (vigabatrin) same agent in the past 105 days STAVZOR (valproic acid) TEGRETOL (carbamazepine) tiagabine TOPAMAX Sprinkle (topiramate) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS TRILEPTAL Tablets (oxcarbazepine) TROKENDI XR (topiramate) ZONEGRAN (zonisamide)

SELECTED BENZODIAZEPINES Diastat DIASTAT (diazepam rectal) diazepam rectal gel ONFI (clobazam)  Quantity limits of 3 Twin Packs/31 days HYDANTOINS PHENYTEK (phenytoin) DILANTIN (phenytoin) phenytoin PEGANONE (ethotoin)

SUCCINIMIDES ethosuximide CELONTIN (methsuximide) ZARONTIN (ethosuximide) ANTIDEPRESSANTS, OTHER SmartPA bupropion APLENZIN (bupropion HBr) SmartPA Criteria: bupropion SR bupropion XL  Minimum age requirement – 18 years mirtazapine BRINTELLIX (vortioxetine) (all drugs) PRISTIQ (desvenlafaxine) desvenlafaxine  30 days of therapy with 2 different Trazodone DESYREL (trazodone) preferred antidepressants, others class venlafaxine ER tablets EFFEXOR (venlafaxine) in the past 6 months OR WELLBUTRIN XL (bupropion HCl) EFFEXOR XR (venlafaxine)  30 days of therapy with BOTH preferred EMSAM (selegiline transdermal) SSRI and antidepressants, others class FETZIMA ER (levomilnacipran) in the past 6 months OR FORFIVO XL (bupropion)  90 days completed therapy with the KHEDEZLA ER (desvenlafaxine) same agent in the past 105 days MARPLAN (isocarboxazid) NARDIL (phenelzine) Cymbalta (see Fibromyalgia Agents) nefazodone OLEPTRO ER (trazodone) REMERON (mirtazapine) tranylcypromine

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS venlafaxine venlafaxine ER capsules venlafaxine XR VIIBRYD (vilazodone) WELLBUTRIN (bupropion) WELLBUTRIN SR ANTIDEPRESSANTS, SSRIs SmartPA citalopram CELEXA (citalopram) SmartPA Criteria: fluoxetine escitalopram  Minimum age requirements apply to all fluvoxamine LUVOX (fluvoxamine) drugs LEXAPRO (escitalopram) LUVOX CR (fluvoxamine) o Citalopram – 9 years paroxetine CR paroxetine suspension o Escitalopram – 12 years paroxetine IR PAXIL Tablets (paroxetine) o Fluoxetine – 7 years PAXIL CR (paroxetine) o Fluoxetine 90 mg – 18 years PAXIL SUPENSION PEXEVA (paroxetine) o Fluvoxamine – 8 years sertraline PROZAC (fluoxetine) o Fluvoxamine SR – 18 years

SARAFEM (fluoxetine) o Paroxetine – 18 years ZOLOFT (sertraline) o Sertraline – 6 years

 30 days of therapy with 2 different preferred SSRI’s in the past 6 months OR  90 days of completed therapy with the same agent in the past 105 days

ANTIEMETICS SmartPA 5HT3 RECEPTOR BLOCKERS ondansetron ANZEMET (dolasetron) All injectable 5HT3 receptor blockers ondansetron solution granisetron closed to point of sale. ondansetron ODT SANCUSO (granisetron) SmartPA Criteria: ZOFRAN (ondansetron)  Age requirements – ondansetron ODT ZOFRAN ODT (ondansetron) and Zuplenz 4mg strengths only ZUPLENZ (ondansetron) o 4-11 years 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o One claim with a preferred antiemetic in the past 6 months

ANTIEMETIC COMBINATIONS DICLEGIS (doxylamine/pyridoxine)

CANNABINOIDS CESAMET (nabilone) MARINOL (dronabinol) dronabinol NMDA RECEPTOR ANTAGONIST EMEND (aprepitant) Emend  Documented diagnosis of cancer found in past 2 years medical claims OR  Antineoplastic history in the past 6 months AND o One claim with a preferred antiemetic in the past 6 months ANTIFUNGALS (Oral) SmartPA clotrimazole ANCOBON (flucytosine) SmartPA Criteria: fluconazole DIFLUCAN (fluconazole)  Documented diagnosis of HIV found in GRIFULVIN V (griseofulvin, microsize) griseofulvin ultramicrosize tablet the past 2 years medical claims AND griseofulvin microsize tablets/capsules/susp itraconazole oral antifungal with a labeled indication for HIV opportunistic infection OR GRIS-PEG (griseofulvin) ketoconazole  One claim for 2 different preferred nystatin LAMISIL (terbinafine) agents in the past 6 months OR terbinafine MYCOSTATIN Tablets (nystatin)  Itraconazole NIZORAL (ketoconazole) o Documented diagnosis of transplant NOXAFIL (posaconazole) found in the past 2 years of medical ONMEL (itraconazole) claims OR SPORANOX (itraconazole) o History of an immunosuppressant in TERBINEX Kit (terbinafine/ciclopirox) the past 6 months OR VFEND (voriconazole) o One claim for 2 different preferred voriconazole agents in the past 6 months

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIFUNGALS (Topical) SmartPA ANTIFUNGALS ciclopirox cream/gel/suspension BENSAL HP (benzoic acid/salicylic acid) SmartPA Criteria: clotrimazole CICLODAN KIT  One claim for 2 preferred agents in the econazole ciclopirox kit/shampoo/solution past 6 months ketoconazole cream CNL 8 (ciclopirox) ketoconazole shampoo ERTACZO (sertaconazole) miconazole OTC EXELDERM (sulconazole) nystatin EXTINA (ketoconazole) terbinafine OTC cream,gel,spray ketoconazole foam tolnaftate OTC LAMISIL (terbinafine) solution LOPROX (ciclopirox) LUZU (luliconazole)NR MENTAX (butenafine) NAFTIN (naftifine) NIZORAL (ketoconazole) OXISTAT (oxiconazole) PEDIADERM AF (nystatin) PENLAC (ciclopirox) VUSION (miconazole/petrolatum/zinc oxide)

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) TERAZOL 3 Suppository (terconazole) tioconzaole TERAZOL 7 (terconazole) VAGISTAT 3 (miconazole) terconazole VAGISTAT 1 (tioconazole)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ANTIHISTAMINES, MINIMALLY SEDATING AND COMBINATIONS SmartPA MINIMALLY SEDATING ANTIHISTAMINES cetirizine ALLEGRA (fexofenadine) SmartPA Criteria: loratadine CLARINEX (desloratadine)  Documented diagnosis of allergy or fexofenadine RX urticaria in the past 2 years medical levocetirizine claims AND XYZAL Solution (levocetirizine)  30 days of therapy with 2 different preferred agents in the past 12 months XYZAL Tablets (levocetirizine) OR

 90 days completed therapy with the same agent in the past 105 days 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 RELPAX (eletriptan) AMERGE (naratriptan) SmartPA Criteria: TREXIMET (sumatriptan/naproxen) AXERT (almotriptan)  Minimum age requirements apply to all ZOMIG (zolmitriptan) FROVA (frovatriptan) drug formulations below IMITREX (sumatriptan) o Almotriptan – 12 years o Eletriptan – 18 years MAXALT (rizatriptan) o Frovatriptan – 18 years MAXALT MLT(rizatriptan) o Naratriptan – 18 years naratriptan o Rizatriptan – 6 years rizatriptan o Sumatriptan – 18 years sumatriptan o Sumatriptan/Naproxen – 18 years zolmitriptan o Zolmitriptan – 18 years

Oral products  One claim for a preferred oral agent in the past year  Exceptions, SmartPA will be issued if 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS beneficiary is in age range:  almotriptan – ages 12-17  rizatriptan – ages 6-17

Other Criteria at the Point of Sale: Applicable quantity limit in 31 rolling days.  12 tablets in 31 days - rizatriptan  9 tablets in 31 days – naratriptan, frovatriptan, sumatriptan, sumatriptan/naproxen  6 tablets in 31 days – almotriptan, zolmitriptan, eletriptan NASAL IMITREX (sumatriptan) sumatriptan Nasal Products ZOMIG (zolmitriptan)  One claim for a preferred nasal agent in the past year

Applicable quantity limit in 31 rolling days.  1 box in 31 days INJECTABLE sumatriptan IMITREX (sumatriptan) Injectable Products  One claim for a preferred injectable agent in the past year

Applicable CUMULATIVE quantity limit in 31 rolling days  4 injections in 31 days ANTINEOPLASTICS – SELECTED SYSTEMIC ENZYME INHIBITORS AFINITOR (everolimus) BOSULIF (bosutinib) CAPRELSA (vandetanib) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS COMETRIQ (cabozantinib) GILOTRIF (afatanib) GLEEVEC (imatinib mesylate) ICLUSIG (ponatinib) IMBRUVICA (ibrutnib) INLYTA (axitinib) IRESSA (gefitinib) JAKAFI (ruxolitinib) MEKINIST (trametinib dimethyl sulfoxide) NEXAVAR (sorafenib) SPRYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib) TAFINLAR (dabrafenib) TARCEVA (erlotinib) TASIGNA (nilotinib) TYKERB (lapatinib ditosylate) vandetanib VOTRIENT (pazopanib) XALKORI (crizotinib) ZELBORAF (vemurafenib) ZYKADIA (ceritnib)NR

ANTIPARASITICS (Topical) SmartPA PEDICULICIDESSmartPA NATROBA (spinosad)Step Edit lindane SmartPA Criteria: permethrin 1% malathion  Minimum age/weight requirements SKLICE (ivermectin) Step Edit OVIDE (malathion) apply to all drug formulations for the ULESFIA (benzyl alcohol) treatment of head lice: o Benzyl Alcohol Solution – 6 months

o Ivermectin – 6 months o Lindane Shampoo – 50 kg o Malathion – 6 years o Permethrin 1% – 2 months o Piperonyl/Pyrethrins – 2 years o Spinosad – 4 years 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS

 Natroba or Sklice step edit: o History of permethrin 1% topical lotion – OTC OR piperonyl/pyrethrin OTC in the past 90 days

 Non Preferred Agents o History of permethrin 1% topical OR piperonyl/pyrethrin in the past 90 days AND o History of Natroba or Sklice in the past 90 days SCABICIDES EURAX CREAM (crotamiton) ELIMITE (permethrin) Permethrin 5% age edit: EURAX LOTION (crotamiton)  Approved for ages 2 months – 17 permethrin 5% years

ANTIPARKINSON’S AGENTS (Oral) SmartPA ANTICHOLINERGICS benztropine COGENTIN (benztropine) SmartPA Criteria: trihexyphenidyl  Documented diagnosis of Parkinson’s disease in the past 2 years medical claims AND  30 days of therapy with 2 different preferred agents in the past 6 months OR  90 days completed therapy with the same agent in the past 105 days COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS DOPAMINE AGONISTS ropinirole MIRAPEX (pramipexole) MIRAPEX ER (pramipexole) NEUPRO (rotigotine) pramipexole REQUIP (ropinirole) REQUIP XL (ropinirole) ropinerole ER

MAO-B INHIBITORS selegiline AZILECT (rasagiline) ELDEPRYL (selegiline) ZELAPAR (selegiline) OTHERS amantadine levodopa/carbidopa ODT Lodosyn bromocriptine LODOSYN (carbidopa)  Approved for augmentation of levodopa/carbidopa PARCOPA (levodopa/carbidopa) carbidopa/levodopa only. PARLODEL (bromocriptine)  Pharmacy claims history of a SINEMET (levodopa/carbidopa) combination carbidopa/levodopa SINEMET CR (levodopa/carbidopa) product in the past 45 days must be STALEVO (levodopa/carbidopa/entacapone) present. ANTIPSYCHOTICS SmartPA ORAL SmartPA SmartPA ABILIFY (aripiprazole) CLOZARIL (clozapine) SmartPA Criteria: SmartPA Atypical Antipsychotics amitriptyline/perphenazine FAZACLO (clozapine) chlorpromazine SmartPA  Minimum age requirements apply to all SmartPA GEODON (ziprasidone) oral drug formulations below clozapine SmartPA o Aripiprazole – 6 years SmartPA HALDOL (haloperidol) FANAPT (iloperidone) SmartPA o Asenapine – 18 years INVEGA (paliperidone) fluphenazine o Clozapine – 18 years SmartPA NAVANE (thiothixene) o Haloperidol – 3 years haloperidol SmartPA o Iloperidone – 18 years SmartPA olanzapine LATUDA (lurasidone) SmartPA o Lurasidone – 18 years olanzapine/fluoxetine o Olanzapine – 13 years 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SmartPA perphenazine quetiapine o Olanzapine/Fluoxetine – 10 years SmartPA risperidone SmartPA o Paliperidone – 18 years RISPERDAL (risperidone) o Quetiapine IR – 10 years SmartPA SmartPA SAPHRIS (asenapine) SYMBYAX (olanzapine/fluoxetine) o Quetiapine SR – 10 years SmartPA SEROQUEL (quetiapine) VERSACLOZ (clozapine)NR o Risperidone – 5 years SmartPA SmartPA o Ziprasidone – 18 years SEROQUEL XR (quetiapine) ZYPREXA (olanzapine) thioridazine Abilify Tablets (all strengths, ODT thiothixene formulation excluded) trifluoperazine New Starts: SmartPA  2.5mg, 5mg, 7.5mg, 10mg, and 15 mg ziprasidone dosages will require tablet splitting. Use ½ tablet of the higher strength.  1 tablet splitter per year  Detailed Abilify Tablet Splitting; click here

Invega Tablets  30 days of therapy with risperidone in the past 12 months OR  30 days of therapy with the same agent in the past 105 days

Non Preferred Criteria  30 days of therapy with 1 preferred atypical antipsychotic agent in the past 12 months OR  30 days of therapy with the same agent in the past 105 days SmartPA INJECTABLE, ATYPICALS ABILIFY (aripiprazole) Effective 11-1-2012, injectable GEODON (ziprasidone) antipsychotics are closed to POS INVEGA SUSTENNA (paliperidone palmitate) except for Long Term Care beneficiaries. RISPERDAL CONSTA (risperidone)

ZYPREXA (olanzapine) SmartPA Criteria for Long Term Care 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZYPREXA RELPREVV (olanzapine) Long Acting Injectable Agents:  Minimum Age requirement AND  Documented diagnosis (based on labeled indications) found in the past 2 years medical claims AND  Non-Compliant with the oral form of the injection OR  History of claims for the same injectable agent in the past 90 days. o History defined as: o 3 claims - Abilify Maintena, Invega Sustenna, Zyprexa Relprevv o 6 claims - Risperdal Consta ANTIVIRALS (Oral) – ANTIHERPETIC AGENTS acyclovir famciclovir valacyclovir FAMVIR (famciclovir) SITAVIG (acyclovir)NR 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

ATOPIC DERMATITIS SmartPA ELIDEL (pimecrolimus) PROTOPIC (tacrolimus) SmartPA Criteria:  Minimum age requirements 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o Elidel – 2 years o Protopic 0.03% - 2 years o Protopic 0.1% - 6 years

Non Preferred Criteria  One claim for a different preferred agent in the past 6 months OR  90 days of completed therapy with the same agent in the past 105 day BETA BLOCKERS SmartPA acebutolol BETAPACE (sotalol) SmartPA Criteria: atenolol betaxolol Bystolic bisoprolol CORGARD (nadolol)  90 days completed therapy with the Step Edit NR same agent in the past 105 days OR BYSTOLIC (nebivolol) HEMANSEOL (propranolol) INDERAL LA (propranolol)  30 days of therapy with 1 different metoprolol INNOPRAN XL (propranolol) preferred agent in the past 6 months metoprolol XL LEVATOL (penbutolol) nadolol LOPRESSOR (metoprolol) Sotalol pindolol SECTRAL (acebutolol)  Documented diagnosis found in the propranolol sotalol past 2 years medical claims for atrial timolol TENORMIN (atenolol) fibrillation OR TOPROL XL (metoprolol) ZEBETA (bisoprolol)  30 days of therapy with 2 different preferred Beta Blocker, Beta and Alpha Blocker or Beta Blocker Combo agents

in the past 6 months OR

 90 days completed therapy with the same agent in the past 105 days

Non Preferred Agents  30 days of therapy with 2 different preferred Beta Blocker, Beta and Alpha Blocker or Beta Blocker Combo agents in the past 6 months OR  90 days completed therapy with the same agent in the past 105 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS BETA- AND ALPHA-BLOCKERS carvedilol COREG (carvedilol) Coreg CR labetalol COREG CR (carvedilol)  Documented diagnosis found in the TRANDATE (labetalol) past 2 years medical claims for hypertension AND  30 days of therapy with carvedilol AND a different preferred Beta Blocker, Beta and Alpha Blocker or Beta Blocker Combo agent in the past 6 months OR 90 days completed therapy with the same agent in the past 105 days BETA BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone CORZIDE (nadolol/bendroflumethiazide) Non Preferred Agents bisoprolol/HCTZ DUTOPROL (metoprolol/HCTZ)  30 days of therapy with 2 different metoprolol/HCTZ LOPRESSOR HCT (metoprolol/HCTZ) preferred Beta Blocker, Beta and Alpha TENORETIC (atenolol/chlorthalidone) nadolol/bendroflumethiazide Blocker or Beta Blocker Combo agents ZIAC (bisoprolol/HCTZ) in the past 6 months OR propranolol/HCTZ 90 days completed therapy with the timolol/HCTZ same agent in the past 105 days BILE SALTS ursodiol ACTIGALL (ursodiol) CHENODAL (chenodiol) URSO (ursodiol) URSO FORTE (ursodiol)

BLADDER RELAXANT PREPARATIONS SmartPA oxybutynin IR DETROL (tolterodine) Smart PA Criteria: TOVIAZ (fesoterodine fumarate) DETROL LA (tolterodine)  30 days of therapy with 2 different DITROPAN XL (oxybutynin) preferred agents in the past 6 months ENABLEX (darifenacin) OR  90 days completed therapy with the GELNIQUE (oxybutynin) same agent in the past 105 days MYRBETRIQ (mirabegron) oxybutynin ER OXYTROL (oxybutynin) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SANCTURA (trospium) SANCTURA XR (trospium) tolterodine tolterodine ER trospium VESICARE (solifenacin) BONE RESORPTION SUPPRESSION AND RELATED AGENTS SmartPA BISPHOSPHONATES ACTONEL (risedronate) alendronate solution SmartPA Criteria: alendronate ATELVIA (risedronate)  Documented diagnosis found in the BINOSTO (alendronate) BONIVA (ibandronate) past 2 years medical claims for FOSAMAX PLUS D (alendronate/vitamin D) DIDRONEL (etidronate) osteoporosis or osteopenia AND  One claim for 2 different preferred FOSAMAX (alendronate) agents in the past 6 months OR ibandronate PROLIA (denosumab)  90 days completed therapy with the same agent in the past 105 days

OTHERS FORTICAL (calcitonin) calcitonin salmon EVISTA (raloxifene) FORTEO (teriparatide) MIACALCIN (calcitonin) raloxifene BPH AGENTS SmartPA ALPHA BLOCKERS doxazosin alfuzosin SmartPA Criteria: FLOMAX (tamsulosin) CARDURA (doxazosin)  Male patient AND terazosin CARDURA XL (doxazosin)  30 days of therapy with 2 different UROXATRAL (alfuzosin) JALYN (dutasteride/tamsulosin) preferred agent in the past 6 months OR RAPAFLO (silodosin)  90 days completed therapy with the tamsulosin same agent in the past 105 days

 Female Patient AND 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o Alfuzosin, doxazosin IR, finasteride, tamsulosin, and terazosin AND . Documented diagnosis found in the past 2 years medical claims based on a state accepted diagnosis 5-ALPHA-REDUCTASE (5AR) INHIBITORS AVODART (dutasteride) PROSCAR (finasteride) finasteride PDE5 INHIBITORS

CIALIS (tadalafil) Cialis: (Requires a Manual PA)  Limited to Male Patients AND  Documented diagnosis found in the past 2 years medical claims for Benign Prostatic Hypertrophy AND  NO documented diagnosis of Erectile Dysfunction found in the past 2 years medical claims AND  Prescriber signed waiver stating treatment is NOT for Erectile Dysfunction AND  30 days therapy with 2 different preferred agents in the past 6 months BRONCHODILATORS & COPD AGENTS ANTICHOLINERGICS & COPD AGENTS ATROVENT HFA (ipratropium) DALIRESP (roflumilast) ipratropium TUDORZA PRESSAIR (aclidinium) SPIRIVA (tiotropium)

ANTICHOLINERGIC-BETA AGONIST COMBINATIONS albuterol/ipratropium ANORO ELLIPTA (umeclidinium/vilanterol) COMBIVENT RESPIMAT (albuterol/ipratropium)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS BRONCHODILATORS, BETA AGONIST INHALERS, SHORT-ACTING PROVENTIL HFA (albuterol) PROAIR HFA (albuterol) SmartPA Criteria: VENTOLIN HFA (albuterol) Xopenex HFA XOPENEX HFA (levalbuterol) SmartPA  Age requirements – 4 years AND  One claim for a short acting albuterol inhaler in the past 30 days

Non Preferred Criteria o One claim for a short acting albuterol inhaler in the past 6 months SmartPA INHALERS, LONG ACTING FORADIL (formoterol) ARCAPTA (indacaterol) SmartPA Criteria: SEREVENT (salmeterol) Arcapta  Documented diagnosis found in the past 2 years medical claims for COPD AND  Age requirements – 18 years AND  30 days of therapy with a preferred long acting agent in the past 6 months OR 90 days completed therapy

Foradil  Age requirements – 5 years

Serevent  Age requirements – 4 years AND  30 days of therapy with a preferred long acting agent in the past 6 months OR  90 days completed therapy with the same agent in the past 105 days

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SmartPA INHALATION SOLUTION albuterol ACCUNEB (albuterol) SmartPA Criteria: BROVANA (arformoterol) Brovana or Perforomist levalbuterol  Age requirements – 18 years AND metaproterenol  One claim for 1 different preferred PERFOROMIST (formoterol) Inhalation Solution in the past 6 months XOPENEX (levalbuterol) OR  3 claims for the same agent in the past 105 days

Xopenex Inhalation Solution  Age requirements – 6 years AND  One claim for an albuterol solution in the past 30 days

Non Preferred Agents  One claim for 1 different preferred Inhalation Solution in the past 6 months OR  3 claims for the same agent in the past 105 days ORAL albuterol VOSPIRE ER (albuterol) metaproterenol terbutaline CALCIUM CHANNEL BLOCKERS SmartPA SHORT-ACTING diltiazem CALAN (verapamil) SmartPA Criteria: nicardipine CARDIZEM (diltiazem)  nimodipine nifedipine isradipine o documented diagnosis found in the verapamil nimodipine past 45 days for subarachnoid PROCARDIA (nifedipine) hemorrhage AND o quantity < to 21 days maximum therapy (252 capsules/2520mL) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS  Short Acting CCB o 30 days of therapy with 2 different preferred Short Acting CCB agents in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

LONG-ACTING amlodipine ADALAT CC (nifedipine)  Long Acting CCB diltiazem ER CALAN SR (verapamil) o 30 days of therapy with 2 different felodipine ER CARDENE SR (nicardipine) preferred Long Acting CCB agents nifedipine ER CARDIZEM CD (diltiazem) in the past 6 months OR o 90 days completed therapy with the verapamil ER CARDIZEM LA (diltiazem) DILACOR XR (diltiazem) same agent in the past 105 days

nisoldipine NORVASC (amlodipine) PROCARDIA XL (nifedipine) SULAR (nisoldipine) TIAZAC (diltiazem) verapamil ER PM VERELAN/VERELAN PM (verapamil) CALORIC AGENTS BOOST (includes all Boost) COMPLEAT BRIGHT BEGINNINGS EO28 SPLASH CARNATION INSTANT BREAKFAST FIBERSOURCE DUOCAL ISOSOURCE ENSURE JEVITY JUVEN KINDERCAL GLUCERNA PEPTAMEN NUTREN (includes all Nutren) PROMOTE OSMOLITE SIMPLY THICK PEDIASURE TOLEREX POLYCOSE VITAL PROMOD VIVONEX

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS RESOURCE SCANDISHAKE TWOCAL HN CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS amoxicillin/clavulanate amoxicillin/clavulanate XR AUGMENTIN 125 and 250 (amoxicillin/clavulanate) AUGMENTIN (amoxicillin/clavulanate) Tablets Suspension MOXATAG (amoxicillin) AUGMENTIN XR (amoxicillin/clavulanate) SmartPA CEPHALOSPORINS – First Generation cefadroxil KEFLEX (cephalexin) SmartPA Criteria: cephalexin Cephalosporins (all generations)  One claim for 2 different preferred agents in the past 6 months SmartPA CEPHALOSPORINS – Second Generation cefaclor cefuroxime suspension cefprozil CEFTIN (cefuroxime) cefuroxime tablets

SmartPA CEPHALOSPORINS – Third Generation cefdinir suspension (for patients <18 yr only) CEDAX (ceftibuten) Cefdinir suspension cefdinir capsules cefditoren  Maximum age requirement – 18 years SUPRAX (cefixime) cefpodoxime OR ceftibuten o One claim for 2 different preferred agents in the past 6 months SPECTRACEF (cefditoren)

CYSTIC FIBROSIS AGENTS BETHKIS (tobramycin) CAYSTON (aztreonam)** SmartPA Criteria COLY-MYCIN M (colistimethate sodium)**  Documented diagnosis found in the KALYDECO (ivacaftor) past 2 years medical claims Cystic PULMOZYME (dornase alfa)** Fibrosis TOBI (tobramycin) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS TOBI PODHALER (tobramycin) Cayston, Coly-Mycin, and tobramycin Pulmozyme:  One claim in the past 105 days

Kalydeco:  Documented diagnosis found in the past 2 years medical claims Cystic Fibrosis AND  One claim for Kalydeco in the past 105 days

Tobramycin Nebulizer Solution:  Must use the preferred agent - Bethkis

Manual PA:  Kalydeco – new starts after 7.1.2013  TOBI Podhaler COLONY STIMULATING FACTORS LEUKINE (sargramostim) GRANIX (tbo-filgrastim) SmartPA Criteria: NEUPOGEN Vial (filgrastim) NEULASTA (pegfilgrastim) Neulasta NEUPOGEN Syringe (filgrastim)  One claim in the past 105 days

Manual PA: Neupogen Syringes Valid reason why the preferred vial cannot be used.

CYTOKINE & CAM ANTAGONISTS ENBREL (etanercept) ACTEMRA (tocilizumab)NR Amevive, Orencia, Remicade and HUMIRA (adalimumab) CIMZIA (certolizumab) Stelara are for administration in hospital methotrexate ILARIS (canakinumab) or clinic setting. PA will not be issued at Point of Sale without justification. SIMPONI (golimumab) KINERET (anakinra) ORENCIA (abatacept) OTEZLA (apremilast)NR OTREXUP (methotrexate) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS REMICADE (infliximab) RHEUMATREX (methotrexate) STELARA (ustekinumab) TREXALL (methotrexate) XELJANZ (tofacitinib)

ERYTHROPOIESIS STIMULATING PROTEINS SmartPA ARANESP (darbepoetin) EPOGEN (rHuEPO) SmartPA Criteria: PROCRIT (rHuEPO) Omontys  Minimum age requirement – 18 years AND  Documented diagnosis found in the past 2 years medical claims for chronic renal failure AND  Documented procedure code found in the past 180 days medical claims for dialysis

Non Preferred Agents  Documented diagnosis found in the past 2 years medical claims for cancer or chronic renal failure OR Antineoplastic therapy in the past 6 months AND Procrit history in the past 6 months claims FIBROMYALGIA AGENTS LYRICA (pregabalin) CYMBALTA (duloxetine) SmartPA+ SmartPA Criteria SAVELLA (milnacipran) duloxetine Cymbalta  Documented diagnosis of fibromyalgia found in past 2 years medical claims AND o 30 days of therapy with BOTH Lyrica and Savella in the past 6 months OR 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o 90 days completed therapy with the same agent in the past 105 days  Documented diagnosis of depression found in past 2 years medical claims AND o 30 days of therapy with 2 different preferred antidepressants, other products in the past 6 months OR o 30 days of therapy with BOTH preferred SSRI and antidepressant other in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

 Documented diagnosis of anxiety found in past 2 years medical claims AND o 30 days of therapy with 2 of the following: sertraline , paroxetine IR, or any venlafaxine agent in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

 Documented diagnosis of Diabetic Peripheral Neuropathy found in past 2 years medical claims AND o 30 days of therapy with Lyrica in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days FLUOROQUINOLONES (Oral) SmartPA AVELOX (moxifloxacin) ciprofloxacin ER SmartPA Criteria: ciprofloxacin tablets CIPRO (ciprofloxacin) Non Preferred Oral Tablets CIPRO XR (ciprofloxacin)  One claim for 1 preferred agent in the FACTIVE (gemifloxacin) past 30 days

LEVAQUIN (levofloxacin) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS levofloxacin  Ciprofloxacin suspension moxifloxacin o Age < 12 years AND NOROXIN (norfloxacin) . Documented diagnosis found in ofloxacin the past 3 months medical claims for anthrax infection or exposure OR . Documented diagnosis found in the past 2 years for cystic fibrosis OR . Documented diagnosis found in the past 3 months claims for pneumonic plague or tularemia AND history of doxycycline found in claims in the past 3 months OR . 7 days of therapy with a preferred agent from 2 of the preferred classes below in the past 3 months  Penicillin, 2nd or 3rd generation cephalosporin, or macrolide OR o Age >12 years AND o One claim for 1 preferred agent in the past 30 days

Levaquin Tablets  One claim for ciprofloxacin, moxifloxacin, or SMX/TMP in the past 14 days OR  One claim for 1 preferred agent in the past 30 days

 Levofloxacin solution o Age < 12 years AND . Documented diagnosis found in the past 3 months medical claims 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS for anthrax infection or exposure OR . 7 days of therapy with a preferred agent from 2 of the preferred classes below in the past 3 months  Penicillin, 2nd or 3rd generation cephalosporin, or macrolide AND  Ciprofloxacin suspension in the past 3 months claims OR o Age >12 years AND o One claim for ciprofloxacin, moxifloxacin, or SMX/TMP in the past 14 days OR o One claim for 1 preferred agent in the past 30 days GENITAL WARTS & RELATED AGENTS ALDARA (imiquimod) Age Edit Imiquimod Age Edit  Minimum age requirements apply to CONDYLOX (podofilox) Age Edit PICATO (ingenol) Age Edit all drug formulations below podofilox Age Edit o imiquimod –12 years VEREGEN (sinecatechins) Age Edit o ingenol – 18 years ZYCLARA (imiquimod) Age Edit o podofilox – 18 years o sinecatechins – 18 years

GLUCOCORTICOIDS (Inhaled) SmartPA GLUCOCORTICOIDS SmartPA AEROSPAN (flunisolide) ALVESCO (ciclesonide) SmartPA Criteria: ASMANEX (mometasone) budesonide  Pulmicort Flexhaler FLOVENT Diskus (fluticasone) PULMICORT (budesonide) Respules, 1mg o Minimum age requirement - 6 years FLOVENT HFA (fluticasone) Non Preferred Agents QVAR (beclomethasone)  30 days of therapy with 2 different PULMICORT (budesonide) Flexhaler preferred agents in the past 6 months PULMICORT (budesonide) Respules, 0.25mg & OR 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 0.5mg 90 days completed therapy with the same agent in the past 105 days

NOTE: Institutional sized products are Non Preferred GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR Diskus (fluticasone/salmeterol) BREO ELLIPTA (fluticasone/vilanterol) ADVAIR HFA (fluticasone/salmeterol) DULERA (mometasone/formoterol) SYMBICORT (budesonide/formoterol)

GI ULCER THERAPIES H2 RECEPTOR ANTAGONISTS cimetidine AXID (nizatidine) famotidine tablet famotidine suspension ranitidine syrup nizatidine PEPCID (famotidine) ranitidine tablet ranitidine capsule ZANTAC (ranitidine)

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

OTHER CARAFATE SUSPENSION (sucralfate) CARAFATE TABLET (sucralfate) misoprostol CYTOTEC (misoprostol) sucralfate tablet sucralfate suspension 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS GROWTH HORMONE SmartPA GENOTROPIN (somatropin) HUMATROPE (somatropin) SmartPA Criteria: NORDITROPIN (somatropin) OMNITROPE (somatropin) Age >18 NUTROPIN AQ (somatropin) SAIZEN (somatropin)  Documented diagnosis found in the SEROSTIM (somatropin) past 2 years medical claims for craniopharyngioma, Prader-Willi TEV-TROPIN (somatropin) Syndrome, or Turner Syndrome OR  Documented procedure found in the past 2 years medical claims for cranial irradiation

Non Preferred Agents  28 days of therapy with 1 preferred agent in the past 6 months OR  84 days of completed therapy with the same agent in the past 105 days

H. PYLORI COMBINATION TREATMENTS HELIDAC (bismuth subsalicylate, metronidazole, PYLERA (bismuth subcitrate potassium, Limited to 1 treatment course per year tetracycline) metronidazole, tetracycline) PREVPAC (lansoprazole, amoxicillin, OMECLAMOX (omeprazole, clarithromycin, clarithromycin) amoxicillin) HEPATITIS C TREATMENTS SmartPA INCIVEK (telaprevir) INFERGEN (interferon alfacon-1) Incivek, Olysio, Sovaldi & Victrelis PEGASYS (peginterferon alfa-2a) OLYSIO (simeprevir) require manual PA PEG-INTRON (peginterferon alfa-2b) ribavirin SmartPA Criteria: RIBAPAK DOSEPACK (ribavirin) REBETOL (ribavirin) Non Preferred Interferon Agents SOVALDI (sofosbuvir) RIBASPHERE (ribavirin)  One claim for a preferred peginterferon VICTRELIS (boceprevir) agent in the past 6 months OR  One claim with the same agent in the past 12 months

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS HYPERURICEMIA & GOUT SmartPA allopurinol ULORIC (febuxostat) SmartPA Criteria: COLCRYS (colchicine) ZYLOPRIM (allopurinol)  30 days of therapy with 2 different probenecid preferred agents in the past 6 months probenecid/colchicine OR o 90 days completed therapy with the

same agent in the past 105 days HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS BYETTA (exenatide) BYDUREON (exenatide) Tradjenta SmartPA Criteria: JANUMET (sitagliptin/metformin) JANUMET XR (sitagliptin/metformin)  90 days completed therapy with the JANUVIA (sitagliptin) JENTADUETO (linagliptin/metformin) same agent in the past 105 days KOMBIGLYZE XR (saxagliptin/metformin) KAZANO (alogliptin/metformin)

ONGLYZA (saxagliptin) NESINA (alogliptin) OSENI (alogliptin/pioglitazone) SYMLIN (pramlintide) TANZEUM (albiglutide)NR TRADJENTA (linagliptin) VICTOZA (liraglutide)

HYPOGLYCEMICS, INSULINS AND RELATED AGENTS SmartPA HUMALOG VIAL (insulin lispro) APIDRA (insulin glulisine) SmartPA Criteria: HUMALOG MIX VIAL (insulin lispro/ lispro HUMALOG KWIKPEN (insulin lispro)  Documented diagnosis found in the protamine) HUMALOG MIX KWIKPEN (insulin lispro/ lispro past 2 years medical claims for HUMULIN VIAL (insulin) protamine) Diabetes Mellitus AND LANTUS SOLOSTAR & VIAL (insulin glargine) HUMULIN KWIKPEN (insulin)  30 days of therapy with 1 preferred * product in the past 6 months OR LEVEMIR FLEXPEN & VIAL (insulin detemir) NOVOLIN FLEXPEN (insulin) 90 days completed therapy with the NOVOLIN VIAL (insulin) same agent in the past 105 days NOVOLOG FLEXPEN & VIAL (insulin aspart) NOVOLOG MIX FLEXPEN & VIAL (insulin aspart/ aspart protamine)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS HYPOGLYCEMICS, MEGLITINIDES PRANDIN (repaglinide) nateglinide PRANDIMET (repaglinide/metformin) repaglinide STARLIX (nateglinide)

HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITORS HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITORS FARXIGA (dapaglifozin) INVOKANA (canagliflozin)

HYPOGLYCEMICS, SODIUM GLUCOSE COTRANSPORTER-2 INHIBITOR COMBINATIONS NR XIGDUO (dapaglifozin/metformin) HYPOGLYCEMICS, TZDS THIAZOLIDINEDIONES pioglitazone ACTOS (pioglitazone) AVANDIA (rosiglitazone)

TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) ACTOPLUSMET XR (pioglitazone/metformin) DUETACT (pioglitazone/glimepiride) AVANDARYL (rosiglitazone/glipizide) pioglitazone/metformin AVANDAMET (rosiglitazone/metformin)

IMMNOSUPPRESSIVE (ORAL) SmartPA AZASAN (azathioprine) ASTAGRAF XL (tacrolimus)NR SmartPA Criteria: azathioprine HECORIA (tacrolimus)NR CELLCEPT (mycophenolate)  Azasan cyclosporine o Documented diagnosis found in the past 2 years medical claims for kidney cyclosporine modified transplant, RA or a state accepted GENGRAF (cyclosporine) diagnosis mycophenolate mofetil 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MYFORTIC (mycophenolic acid) NEORAL (cyclosporine)  Cyclosporine & Cyclosporine, PROGRAF (tacrolimus) modified RAPAMUNE (sirolimus) o Documented diagnosis found in the SANDIMMUNE (cyclosporine) past 2 years medical claims for heart transplant, kidney transplant, liver tacrolimus transplant, psoriasis, RA or a state ZORTRESS (everolimus) accepted diagnosis OR o A manual PA review for a diagnosis of Kimura’s disease or multifocal motor neuropathy

 Everolimus o Minimum age requirement – 18 years AND o Documented diagnosis found in the past 2 years medical claims for kidney transplant

 Myfortic (mycophenolate sodium) o Documented diagnosis found in the past 2 years medical claims for kidney transplant or psoriasis

 Sirolimus o Minimum age requirement – 13 years AND o Documented diagnosis found in the past 2 years medical claims for kidney transplant

 Tacrolimus & CellCept o Documented diagnosis found in the past 2 years medical claims for heart transplant, kidney transplant, liver transplant or a state accepted diagnosis 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS INTRANASAL RHINITIS AGENTS ANTICHOLINERGICS ipratropium ATROVENT (ipratropium)

ANTIHISTAMINES ASTELIN (azelastine) ASTEPRO (azelastine) PATANASE (olopatadine) azelastine ANTIHISTAMINE/CORTICOSTEROID COMBINATION SmartPA DYMISTA (azelastine/fluticasone) SmartPA CORTICOSTEROIDS FLONASE (fluticasone) BECONASE AQ (beclomethasone) SmartPA Criteria: NASAREL (flunisolide) budesonide  Documented diagnosis found in the NASONEX (mometasone) flunisolide past 2 years medical claims for allergic QNASL (beclomethasone) fluticasone rhinitis AND  One claim for 2 different preferred ZETONNA (ciclesonide) OMNARIS (ciclesonide) agents in the past 6 months OR RHINOCORT AQUA (budesonide)  90 days completed therapy with the triamcinolone same agent in the past 105 days VERAMYST (fluticasone)

IRRITABLE BOWEL SYNDROME/SHORT BOWEL SYNDROME AGENTS/SELECTED GI AGENTS IRRITABLE BOWL SYNDROME/SHORT BOWEL SYNDROME AGENTS dicyclomine AMITIZA (lubiprostone) SmartPA Criteria: hyoscyamine BENTYL (dicyclomine)  Amitiza, Linzess, Lotronex, or GATTEX (teduglutide) Zorbtive users will be grandfathered LEVSIN (hyoscyamine) o 1 claim with the same agent in the LEVSIN-SL (hyoscyamine) past 105 days LINZESS (linaclotide) Other Non Preferred Agents – require LOTRONEX (alosetron) Manual PA NUTRESTORE POWDER PACK (glutamine) ZORBTIVE (somatropin)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SELECTED GI AGENTS FULYZAQ (crofelemer)

LEUKOTRIENE MODIFIERS SmartPA ACCOLATE (zafirlukast) montelukast SmartPA Criteria: SINGULAIR (montelukast) ZYFLO CR (zileuton)  Zyflo or Zyflo CR zafirlukast o Minimum age requirement - 12 years

Non Preferred Agents  30 days of therapy with 2 different preferred agents in the past 6 months OR  90 days completed therapy with the same agent in the past 105 days

LIPOTROPICS, OTHER (Non-statins) SmartPA BILE ACID SEQUESTRANTS cholestyramine COLESTID (colestipol) SmartPA Criteria colestipol QUESTRAN (cholestyramine) Criteria for all drugs: WELCHOL (colesevelam)  90 days completed therapy with the same agent in the past 105 days OR  30 days completed therapy with a statin or statin combination agent in the past 1 year OR  One of the following exceptions: o A female patient with a documented diagnosis of pregnancy found in medical claims in the past 280 days OR o Documented diagnosis found in the past 2 years medical claims for liver disease OR o Documented diagnosis found in the past 2 years medical claims for hypertriglyceridemia OR 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS o Clinical justification provided for the reason the patient is unable to take a statin or statin combination product AND Welchol  Documented diagnosis found in the past 2 years medical claims for diabetes AND  30 days of therapy with a preferred oral antidiabetic agent in the past 180 days

OR  30 days therapy with 2 different preferred bile acid sequestrants OR  A female patient with a documented diagnosis of pregnancy in the past 280 days OMEGA-3 FATTY ACIDS LOVAZA (omega-3-acid ethyl esters) VASCEPA (icosapent ethyl) Non Preferred Agents 30 days of therapy with 2 different preferred non-statin lipotropics in the past 6 months CHOLESTEROL ABSORPTION INHIBITORS ZETIA (ezetimibe)

FIBRIC ACID DERIVATIVES ANTARA (fenofibrate, micronized) fenofibrate, micronized Fibric Acid Derivative gemfibrozil fenofibrate nanocrystallized 145mg 30 days of therapy with 2 different fibric TRICOR (fenofibrate nanocrystallized) fenofibric acid acid derivatives in the past 6 months TRILIPIX (fenofibric acid) FIBRICOR (fenofibric acid) LIPOFEN (fenofibrate) LOFIBRA (fenofibrate) LOPID (gemfibrozil) TRIGLIDE (fenofibrate)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MTP INHIBITOR JUXTAPID (lomitapide) APOLIPOPROTEIN B-100 SYNTHESIS INHIBITOR KYNAMRO (mipomersen)

NIACIN NIACOR (niacin) NIASPAN (niacin)

LIPOTROPICS, STATINS SmartPA STATINS atorvastatin ALTOPREV (lovastatin) SmartPA Criteria: CRESTOR (rosuvastatin) LIVALO (pitavastatin)  30 days of therapy with 2 different LESCOL (fluvastatin) MEVACOR (lovastatin) preferred agents in the past 6 months LESCOL XL (fluvastatin) PRAVACHOL (pravastatin) OR  90 days completed therapy with the LIPITOR (atorvastatin) ZOCOR (simvastatin) same agent in the past 105 days lovastatin pravastatin Simvastatin 80mg: simvastatin  12 months of therapy with simvastatin 80mg in the past 18 months AND  NO documented myopathies found in medical claims in the past 12 months

STATIN COMBINATIONS atorvastatin/amlodipine ADVICOR (lovastatin/niacin) Manual Criteria: Prior to SIMCOR (simvastatin/niacin) CADUET (atorvastatin/amlodipine) consideration of a non-preferred VYTORIN (simvastatin/ezetimibe) LIPTRUZET (atorvastatin/ezetimibe) statin combination, the patient must first have an unsuccessful trial with the preferred statin combination plus an unsuccessful trial with a preferred statin and calcium channel blocker (single agents) used together.

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS MACROLIDES/KETOLIDES (Oral) KETOLIDES KETEK (telithromycin)

MACROLIDES

Azithromycin BIAXIN (clarithromycin) clarithromycin ER BIAXIN XL (clarithromycin) E.E.S. (erythromycin ethylsuccinate) clarithromycin IR E-MYCIN (erythromycin) E.E.S. Suspension (erythromycin ethylsuccinate) ERYC (erythromycin) ERYPED Suspension (erythromycin ERY-TAB (erythromycin) ethylsuccinate) ERYTHROCIN (erythromycin stearate) erythromycin erythromycin estolate PCE (erythromycin) ZITHROMAX (azithromycin) ZMAX (azithromycin) MISCELLANEOUS BRAND/GENERIC CLONIDINE CATAPRES-TTS (clonidine) clonidine patches clonidine tablets CATAPRES (clonidine)

EPINEPHRINE EPIPEN (epinephrine) ADRENACLICK (epinephrine) EPIPEN JR (epinephrine) AUVI-Q (epinephrine)

MISCELLANEOUS SmartPA alprazolam alprazolam ER Suboxone References can be found at: hydroxyzine hcl syrup hydroxyzine hcl tablets http://www.medicaid.ms.gov/Document hydroxyzine pamoate KORLYM (mifepristone) s/Pharmacy/Suboxone%20Resources.p df. megestrol suspension 625mg/5mL MEGACE ES (megestrol) SmartPA Criteria SUBOXONE (buprenorphine/naloxone)SmartPA VISTARIL (hydroxyzine pamoate) ZUBSOLV (buprenorphine/naloxone)  Alprazolam ER: Applicable CUMULATIVE quantity limit in 31 rolling days

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS . 31 tablets . Exception: previous beneficiaries with a paid claim for 2 tablets per day in the past 90 days are allowed to remain on cumulative of 62 tablets. SUBLINGUAL NITROGLYCERIN nitroglycerin lingual 12gm nitroglycerin lingual 4.9gm nitroglycerin sublingual NITROLINGUAL (nitroglycerin) 4.9gm NITROLINGUAL PUMPSPRAY (nitroglycerin) NITROMIST (nitroglycerin) 12gm NITROSTAT SUBLINGUAL (nitroglycerin) MULTIPLE SCLEROSIS AGENTS SmartPA AVONEX (interferon beta-1a) AMPYRA (dalfampridine) SmartPA Criteria: COPAXONE 20mg (glatiramer) AUBAGIO (teriflunomide)  Documented diagnosis found in the REBIF (interferon beta-1a) BETASERON (interferon beta-1b) past 2 years medical claims for multiple COPAXONE 40mg (glatiramer) sclerosis AND

EXTAVIA (interferon beta-1b) Non Preferred Agents: GILENYA (fingolimod)  One claim for 2 different preferred TECFIDERA (dimethyl fumarate) agents in the past 6 months OR  3 claims with the same agent in the past 105 days

*Ampyra – Requires Manual PA: 1. For patients that have a gait disorder associated with MS; and 2. Initial authorizations will be approved for 12 weeks with a baseline Timed 25- foot Walk (T25FW) assessment; and 3. Additional prior authorizations will be considered at 6 month intervals after assessing the benefit to the patient as measured by a 20% improvement in the T25FW from baseline. Renewal will not be approved if the 20% improvement is 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS not maintained; and 4. Prior authorizations will not be considered for patients with a seizure diagnosis or in patients will moderate to severe renal impairment. 5. Max dose of 20 mg daily; and #60 units in 30 days; approved for ages 18 and above NSAIDS NON-SELECTIVE diclofenac EC ADVIL (ibuprofen) SmartPA Criteria: etodolac tab ANAPROX (naproxen)  Non-Selective agents: flurbiprofen CAMBIA (diclofenac) 30 days therapy with 2 different CATAFLAM (diclofenac) ibuprofen preferred agents in the past 6 months DAYPRO (oxaprozin) indomethacin diclofenac SR ketorolac etodolac cap naproxen etodolac tab SR sulindac FELDENE (piroxicam) fenoprofen INDOCIN (indomethacin) indomethacin cap ER ketoprofen ketoprofen ER meclofenamate mefenamic acid nabumetone NALFON (fenoprofen) NAPRELAN (naproxen) NAPROSYN (naproxen) NUPRIN (ibuprofen) oxaprozin piroxicam PONSTEL (mefenamic acid)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS SPRIX NASAL SPRAY (ketorolac) tolmetin VOLTAREN XR (diclofenac) ZIPSOR (diclofenac) ZORVOLEX (diclofenac) NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) diclofenac/misoprostol DUEXIS (ibuprofen/famotidine) VIMOVO (naproxen/esomeprazole)

SmartPA COX II SELECTIVE meloxicam CELEBREX (celecoxib) SmartPA Criteria MOBIC (meloxicam)  COX II Selective Agents: o Documented diagnosis found in the past 2 years medical claims for Osteoarthritis, Rheumatoid Arthritis, Familial Adenomatous Polyposis, or Ankylosing Spondylitis AND . 30 days of therapy with 1 preferred COX-II Selective agent OR . 90 days completed therapy with the same agent in the past 105 days OR . 30 days of therapy with 1 preferred COX-II Selective agent AND . 30 days of therapy with 1 preferred Non-Selective Agent OR . 30 days of therapy with 1 preferred COX-II Selective agent AND

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS . Documented diagnosis found in the past 2 years medical claims for GI Bleed, GERD, PUD, GI Perforation, or Coagulation Disorder

OPHTHALMIC ANTIBIOTICS bacitracin AZASITE (azithromycin) bacitracin/neomycin/gramicidin BESIVANCE (besifloxacin) bacitracin/polymyxin BLEPH-10 (sulfacetamide) erythromycin CILOXAN (ciprofloxacin) gentamicin ciprofloxacin MOXEZA (moxifloxacin) GARAMYCIN (gentamicin) neomycin/bacitracin/polymyxin b levofloxacin polymyxin/trimethoprim NATACYN (natamycin) sulfacetamide NEO-POLYCIN (neomy/baci/polymyxin b) tobramycin NEOSPORIN (bacitracin/neomycin/gramicidin) VIGAMOX (moxifloxacin) (oxy-tcn/polymyx sul) TOBREX (tobramycin) oint OCUFLOX (ofloxacin) ofloxacin POLYTRIM (polymyxin/trimethoprim) ZYMAR (gatifloxacin) ZYMAXID (gatifloxacin) ANTIBIOTIC STEROID COMBINATIONS neomycin/bacitracin/polymyxin/hc BLEPHAMIDE (sulfacetamide/prednisolone) neomycin//polymyxin/dexamethasone MAXITROL(neomycin/polymyxin/dexamethasone) PRED-G (gentamicin/prednisolone) sulfacetamide/prednisolone TOBRADEX OINTMENT (tobramycin/dexamethasone) tobramycin/dexamethasone ZYLET (loteprednol/tobramycin)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OPHTHALMIC ANTI-INFLAMMATORIES SmartPA dexamethasone ACULAR LS (ketorolac) SmartPA Criteria: diclofenac ACUVAIL (ketorolac)  One claim for 2 different preferred FLAREX (fluorometholone) BROMDAY (bromfenac) agents in the past 6 months flurbiprofen bromfenac FML FORTE (fluorometholone) DUREZOL (difluprednate) FML SOP (fluorometholone) LOTEMAX (loteprednol) ILEVRO (nepafenac) OCUFEN (flurbiprofen) MAXIDEX (dexamethasone) PROLENSA (bromfenac) NEVANAC (nepafenac) PRED MILD (prednisolone) prednisolone acetate PRED FORTE (prednisolone) prednisolone NA phosphate VOLTAREN (diclofenac) VEXOL (rimexolone) OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS SmartPA cromolyn ALAMAST (pemirolast) SmartPA Criteria: ketotifen OTC ALOCRIL (nedocromil)  30 days of therapy with 2 different OPTIVAR (azelastine) ALOMIDE (lodoxamide) preferred agents in the past 6 months PATADAY (olopatadine) ALREX (loteprednol) OR 90 days completed therapy with the PATANOL (olopatadine) azelastine same agent in the past 105 days BEPREVE (bepotastine) ELESTAT (epinastine) EMADINE (emedastine) epinastine LASTACAFT (alcaftadine) OPHTHALMICS, GLAUCOMA AGENTS SmartPA BETA BLOCKERS betaxolol BETAGAN (levobunolol) SmartPA Criteria: BETIMOL (timolol) BETOPTIC S (betaxolol)  Documented diagnosis found in the carteolol OPTIPRANOLOL (metipranolol) past 2 years medical claims for ISTALOL (timolol) timolol gel glaucoma AND  30 days of therapy with 2 different levobunolol TIMOPTIC (timolol) preferred agents in the past 6 months metipranolol 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS timolol solution OR 90 days completed therapy with the same agent in the past 105 days CARBONIC ANHYDRASE INHIBITORS AZOPT (brinzolamide) dorzolamide TRUSOPT (dorzolamide) COMBINATION AGENTS COMBIGAN (brimonidine/timolol) COSOPT PF(dorzolamide/timolol) COSOPT (dorzolamide/timolol) 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 LUMIGAN (bimatoprost) TRAVATAN Z (travoprost) RESCULA (unoprostone)NR travoprost XALATAN (latanoprost) ZIOPTAN (tafluprost) SYMPATHOMIMETICS ALPHAGAN P 0.1% (brimonidine) dipivefrin ALPHAGAN P 0.15% (brimonidine) PROPINE (dipivefrin) brimonidine

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS OTIC ANTIBIOTICS CIPRO HC (ciprofloxacin/hydrocortisone) ciprofloxacin  Maximum age requirements CIPRODEX (ciprofloxacin/dexamethasone) DERMOTIC (fluocinolone) o Cipro HC –8 years COLY-MYCIN S (colistin/neomycin/ ofloxacin o Ciprodex – 14 years hydrocortisone) CORTISPORIN-TC (colistin/neomycin/ hydrocortisone) neomycin/polymyxin/hydrocortisone

PANCREATIC ENZYMES SmartPA CREON (pancreatin) PANCREAZE (pancrelipase) SmartPA Criteria: ZENPEP (pancrelipase) PANCRELIPASE  30 days of therapy with 2 different PERTZYE preferred agents in the past 6 months ULTRESA OR  90 days completed therapy with the VIOKACE same agent in the past 105 days

PARATHYROID AGENTS calcitriol doxercalciferol ergocalciferol DRISDOL (ergocalciferol) ZEMPLAR (paricalcitol) HECTOROL (doxercalciferol) paricalcitol ROCALTROL (calcitriol) SENSIPAR (cinacalcet)

PHOSPHATE BINDERS ELIPHOS (calcium acetate) calcium acetate RENAGEL (sevelamer HCl) FOSRENOL (lanthanum) PHOSLYRA (calcium acetate) PHOSLO (calcium acetate) RENVELA (sevelamer carbonate) sevelamer carbonate VELPHORO (sucroferric oxyhydronxide)

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PLATELET AGGREGATION INHIBITORS SmartPA AGGRENOX (dipyridamole/aspirin) BRILINTA (ticagrelor) SmartPA Criteria: dipyridamole cilostazol Brilinta PLAVIX (clopidogrel) clopidogrel  Documented diagnosis found in the EFFIENT (prasugrel) past 2 years medical claims for Acute Coronary Syndrome or Percutaneous PERSANTINE (dipyridamole) Coronary Intervention OR PLETAL (cilostazol)  30 days of therapy with Brilinta in the ticlopidine NR past 60 days ZONTIVITY (vorapaxar) Effient  Documented diagnosis found in the past 2 years medical claims for Acute Coronary Syndrome or Percutaneous Coronary Intervention

Pletal  Documented diagnosis found in the past 2 years medical claims for an approvable indication OR  90 days completed therapy with the same agent in the past 105 days

Non Preferred Agents  Documented diagnosis found in the past 2 years medical claims for an approvable indication AND  30 days of therapy with 2 different preferred agents in the past 6 months OR  90 days completed therapy with the same 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.

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PAIRE OB PLUS DHA COMBO PACK CITRANATAL 90 DHA PACK PRENATAL PLUS Tablet CITRANATAL ASSURE COMBO PACK PREQUE 10 TABLET CITRANATAL B-CALM PACK SE-NATAL CHEWABLE Tablet CITRANATAL DHA PACK TARON-C DHA Capsule CITRANATAL HARMONY Capsule TRICARE PRENATAL Tablet CITRANATAL HARMONY Capsule VOL-PLUS Tablet CITRANATAL RX Tablet COMPLETE NATAL DHA COMPLETENATE Tablet CHEW CONCEPT OB Capsule CORENATE-DHA COMBO PACK 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 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 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS 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 PREQUE 10 Tablet RELNATE DHA PRENATAL SOFTGEL ROVIN-NV DHA Capsule ROVIN-NV Tablet SE-CARE CHEWABLE Tablet SELECT-OB + DHA PACK SELECT-OB CAPLET SE-NATAL 19 CHEWABLE Tablet SE-NATAL 19 Tablet SE-TAN DHA Capsule TARON-BC Tablet TARON-PREX PRENATAL DHA CAP PSEUDOBULBAR AFFECT AGENTS NUEDEXTA (dextromethorphan/quinidine)** SmartPA Criteria  90 days completed therapy with the same agent in the past 105 days OR  Documented diagnosis found in the past 2 years medical claims for Pseudobulbar Affect, Multiple Sclerosis, or Amytrophic Lateral Sclerosis

PULMONARY ANTIHYPERTENSIVES – ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS (ambrisentan) OPSUMIT (macitentan) SmartPA Criteria: TRACLEER (bosentan)  Documented diagnosis found in the

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS past 2 years medical claims for pulmonary hypertension

PULMONARY ANTIHYPERTENSIVES – PDE5s SmartPA ADCIRCA (tadalafil) REVATIO (sildenafil) SmartPA Criteria: sildenafil  Documented diagnosis found in the past 2 years medical claims for pulmonary hypertension

Revatio  Age <1 year AND o Documented diagnosis found in the past 1 year medical claims for Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation OR  Age > 18 years AND o 30 days of therapy with 1 preferred PAH agent in the past 6 months OR o 90 days completed therapy with the same agent in the past 105 days

Sildenafil  Minimum age requirement of 12 years AND  Documented diagnosis found in the past 2 years medical claims for Pulmonary Hypertension, Patent Ductus Arteriosus, or Persistent Fetal Circulation OR  Documented diagnosis found in the past 2 years medical claims for Heart Transplant

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS PULMONARY ANTIHYPERTENSIVES – PROSTACYCLINS TYVASO (treprostinil) SmartPA Criteria: ORENITRAM ER (treprostinil)NR  Documented diagnosis found in the VENTAVIS (iloprost) past 2 years medical claims for pulmonary hypertension

Non Preferred Agents  30 days of therapy with 1 preferred PAH agent in the past 6 months OR  90 days completed therapy with the same agent in the past 105 days

PULMONARY ANTIHYPERTENSIVES – SOLUABLE GUANYLATE CYCLASE STIMULATORS ADEMPAS (riociguat) SmartPA Criteria:  Documented diagnosis found in the past 2 years medical claims for pulmonary hypertension

Non Preferred Agents  30 days of therapy with 1 preferred PAH agent in the past 6 months OR  90 days completed therapy with the same agent in the past 105 days

Manual PA  Adempas will be approved for patients that meet the criteria for WHO Group 4 Pulmonary Arterial Hypertension.

SEDATIVE HYPNOTICS BENZODIAZEPINES estazolam DALMANE (flurazepam) Single source benzodiazepines and flurazepam DORAL (quazepam) barbiturates are NOT covered; PAs will temazepam (15mg and 30mg) HALCION (triazolam) not be issued for these drugs. 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS triazolam RESTORIL (temazepam) temazepam (7.5mg and 22.5mg) Sedative/Hypnotics are limited to 31 cumulative units of all/any strengths per month. Any quantity required above these limits requires a PA. SmartPA OTHERS zaleplon AMBIEN (zolpidem) SmartPA Criteria: zolpidem AMBIEN CR (zolpidem) Applicable CUMULATIVE quantity limit EDLUAR (zolpidem) in 31 rolling days HETLIOZ (tasimelteon)NR  31 tablets in 31 days  1 Canister (Zolpimist ) INTERMEZZO (zolpidem) Female - 62 days LUNESTA (eszopiclone) Male – 31 days ROZEREM (ramelteon) SILENOR (doxepin) Applicable dosage and gender SONATA (zaleplon) limitations for zolpidem products: zolpidem ER  Female – zolpidem 5mg, ZOLPIMIST (zolpidem) 6.25mg, and 1.75 mg  Male – all zolpidem strengths

 One claim for 2 different preferred agents in the past 6 months

Hetlioz  Documented diagnosis found in medical claims in the past 2 years for circadian rhythm sleep disorder AND  Documented diagnosis found in medical claims in the past 2 years indicating total blindness of the patient SELECT CONTRACEPTIVE PRODUCTS INJECTABLE CONTRACEPTIVES medroxyprogesterone acetate IM DEPO-PROVERA IM (medroxyprogesterone Depo Provera Injection acetate) 90 days completed therapy with the DEPO-SUBQ PROVERA 104 same agent in the past 105 days 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS (medroxyprogesterone acetate)

ORAL CONTACEPTIVES ALL CONTRACEPTIVES ARE PREFERRED AMETHIA (levonorgestrel/ethinyl estradiol) SmartPA Criteria EXCEPT FOR THOSE SPECIFICALLY AMETHYST (levonorgestrel/ethinyl estradiol) Oral Contraceptive Products INDICATED AS NON-PREFERRED BEYAZ (ethinyl  One claim in 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) QUASENSE (levonorgestrel/ethinyl estradiol) SAFYRAL (ethinyl estradiol/drospirenone/levomefolate) SYEDA (ethinyl estradiol/drospirenone) TILIA FE (norethindrone/ethinyl estradiol/fe) TRI-LEGEST FE (norethindrone/ethinyl estradiol/fe) VESTURA (ethinyl estradiol/drospirenone) WYMZYA FE (norethindrone/ethinyl estradiol/fe) ZARAH (ethinyl estradiol/drospirenone) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS ZENCHENT FE (norethindrone/ethinyl estradiol/fe) ZEOSA (norethindrone/ethinyl estradiol/fe) SKELETAL MUSCLE RELAXANTS SmartPA baclofen AMRIX (cyclobenzaprine ER) SmartPA Criteria: chlorzoxazone carisoprodol Carisoprodol cyclobenzaprine 5mg, 10mg carisoprodol compound  Documented diagnosis found in medical methocarbamol cyclobenzaprine 7.5mg, 15mg claims in the past 3 months for an acute musculoskeletal condition AND tizanidine tablets cyclobenzaprine ER  NO history of meprobamate therapy in dantrolene the past 90 days AND FEXMID (cyclobenzaprine)  One claim for cyclobenzaprine in the LORZONE (chlorzoxazone) past 21 days OR a documented metaxalone intolerance to cyclobenzaprine AND orphenadrine  Quantity limits of 84 tablets total in the orphenadrine compound past 6 months OR PARAFON FORTE DSC (chlorzoxazone)  One claim for 18 tablets of carisoprodol ROBAXIN (methocarbamol) to taper off SKELAXIN (metaxalone) SOMA (carisoprodol) Non Preferred Agents tizanidine capsules  Documented diagnosis found in the ZANAFLEX (tizanidine) past 2 years medical claims for an approvable indication AND

 One claim for 2 different preferred agents in the past 6 months OR  Documented diagnosis found in the past 2 years medical claims for a chronic musculoskeletal disorder AND  90 days completed therapy with the same agent in the past 105 days STEROIDS (Topical) SmartPA LOW POTENCY CAPEX (fluocinolone) alclometasone SmartPA Criteria: DESOWEN (desonide) lotion DERMA-SMOOTHE-FS (fluocinolone)  Low Potency Agents o One claim for 2 different preferred 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS desonide cr, oint. DESONATE (desonide) low potency agents in the past 6 hydrocortisone cr, oint, soln. desonide lotion months OR DESOWEN (desonide) o 90 days completed therapy with the fluocinolone oil same agent in the past 105 days

hydrocortisone lotion PEDIACARE HC (hydrocortisone) PEDIADERM (hydrocortisone) VERDESO (desonide) MEDIUM POTENCY fluocinolone CLODERM (clocortolone) SmartPA Criteria: hydrocortisone CUTIVATE (fluticasone)  Medium Potency Agents mometasone cr, oint. DERMATOP (prednicarbate) o One claim for 2 different preferred prednicarbate cr ELOCON (mometasone) medium potency agents in the past 6 months OR PANDEL (hydrocortisone probutate) fluticasone o 90 days completed therapy with the LUXIQ (betamethasone) same agent in the past 105 days mometasone solution MOMEXIN (mometasone) prednicarbate oint SYNALAR (fluocinolone) HIGH POTENCY amcinonide cr, lot amcinonide oint SmartPA Criteria betamethasone dipropionate cr, gel, lotion betameth diprop/prop gly cr, lot, oint  High Potency Agents betamethasone valerate cr, lotion, oint. betamethasone dipropionate oint. o One claim for 2 different preferred CAPEX (fluocinolone) BETA-VAL (betamethasone valerate) high potency agents in the past 6 months OR fluocinolone desoximetasone o 90 days completed therapy with the fluocinonide diflorasone same agent in the past 105 days triamcinolone DIPROLENE AF (betamethasone diprop/prop gly) ELOCON (mometasone) HALOG (halcinonide) KENALOG (triamcinolone) PEDIADERM TA (triamcinolone) TOPICORT (desoximetasone) TRIANEX (triamcinolone) 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS VANOS (fluocinonide) VERY HIGH POTENCY clobetasol emollient clobetasol propionate foam SmartPA Criteria clobetasol propionate cr, gel, oint, sol CLOBEX (clobetasol)  Very High Potency Agents halobetasol DIPROLENE (betamethasone diprop/prop gly) o One claim for 2 different preferred HALONATE very high potency agents in the past (halobetasol/ammonium lactate) 6 months OR o 90 days completed therapy with the HALAC (halobetasol/ammoium lac) same agent in the past 105 days TEMOVATE (clobetasol propionate) OLUX (clobetasol) OLUX-E (clobetasol) ULTRAVATE (halobetasol)

STIMULANTS AND RELATED AGENTS SmartPA SHORT-ACTING amphetamine salt combination ADDERALL (amphetamine salt combination) Applicable quantity limit in 31 rolling dexmethylphenidate IR DESOXYN (methamphetamine) days dextroamphetamine IR methamphetamine  62 tablets in 31 days – FOCALIN (dexmethylphenidate) methylphenidate solution Adderall IR, Concerta 36mg, NR Desoxyn, dextroamphetamine METHYLIN chewable tablets (methylphenidate) ZENZEDI (dextroamphetamine) IR, Focalin IR, Focalin XR 15

METHYLIN solution (methylphenidate) & 20mg, methylphenidate IR, methylphenidate IR Nuvigil 50mg, methylphenidate PROCENTRA (dextroamphetamine) IR  31 tablets in 31 days – Adderall XR, Concerta 18, 27, & 54 mg, Daytrana, Dexedrine Spansule, Focalin XR 5 & 10mg, Intuniv ER, Metadate CD, Methylin ER, Nuvigil 150 & 200 mg, Provigil 200mg, Ritalin LA & SR, Strattera, and Vyvanse  46.5 tablets in 31 days – 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS Provigil 100 mg  155 mL in 31 days – methylphenidate solution, dextroamphetamine solution  124 tablets in 31 days – Kapvay 0.1mg  372 mL in 31 days – methylphenidate ER solution

SmartPA Criteria: Short Acting Agents  Minimum age requirements apply to all drug formulations below o Amphetamine salts – 3 years o Dexmethylphenidate IR – 6 years o Dextroamphetamine IR – 3 years o Methylphenidate – 6 years o Methamphetamine – 6 years

 30 days therapy with 2 different preferred Short Acting agents OR  1 claim for a 30 day supply in the past 180 days LONG-ACTING ADDERALL XR (amphetamine salt combination) amphetamine salt combination ER Long Acting Agents DAYTRANA (methylphenidate) CONCERTA (methylphenidate)  Minimum age requirements apply to all FOCALIN XR (dexmethylphenidate) DEXEDRINE (dextroamphetamine) drug formulations below METADATE CD (methylphenidate) dexmethylphenidate XR o Armodafinil – 17 years o Modafinil – 16 years methylphenidate ER (generic Concerta) dextroamphetamine ER o All other long acting agents – 6 QUILLIVANT XR (methylphenidate) methylphenidate CD (generic Metadate CD) years VYVANSE (lisdexamfetamine) NUVIGIL (armodafinil) PROVIGIL (modafinil) Non Preferred Agents RITALIN LA (methylphenidate)  30 days therapy with 2 different preferred Long Acting agents in the past 6 months OR 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS  1 claim for a 30 day supply in the past 180 days

Nuvigil or Provigil  Documented diagnosis found in the past 2 years medical claims for Narcolepsy, Obstructive Sleep Apnea, or Shift Work Disorder AND  30 days therapy with 2 different preferred Short Acting or Long Acting agents in the past 6 months OR  1 claim for a 30 day supply with the same agent in the past 180 days NON-STIMULANTS STRATTERA (atomoxetine) clonidine ER Kapvay/Intuniv INTUNIV (guanfacine ER)  1 claim for a 30 day supply in the past KAPVAY (clonidine extended-release) 180 days OR  Age requirement – 6 to 17 years AND  Documented diagnosis found in the past 2 years medical claims for ADD or ADHD AND  30 days of therapy with a Short Acting or Long Acting agent in the past 6 months OR  30 days therapy with Strattera in the past 6 months OR  30 days therapy with short acting product (Intuniv - guanfacine or Kapvay - clonidine)

TETRACYCLINES SmartPA doxycycline hyclate caps/tabs ADOXA (doxycycline monohydrate) SmartPA Criteria: doxycycline monohydrate caps (50mg & 100mg) demeclocycline  Demeclocycline - a documented minocycline caps IR doxycycline monohydrate caps (75mg & 150mg) diagnosis found in the past 2 years tetracycline doxycycline monohydrate tabs medical claims for Diabetes Insipidus or SIADH 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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F MISSISSIPPI DIVISION OF MEDICAID EFFECTIVE 07/01/2014 PREFERRED DRUG LIST Version 2014.9d Updated: 7-9-2014

THERAPEUTIC PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA DRUG CLASS DYNACIN (minocycline) minocycline ER Non Preferred Agents minocycline tabs One claims for 2 different preferred ORACEA (doxycycline) agents in the past 6 months SOLODYN (minocycline) VIBRAMYCIN cap/susp/syrup ULCERATIVE COLITIS AGENTS ORAL APRISO (mesalamine) ASACOL HD (mesalamine) SmartPA Criteria ASACOL (mesalamine) AZULFIDINE (sulfasalazine) Giazo balsalazide AZULFIDINE ER (sulfasalazine)  Limited to Male Patients AND DIPENTUM (olsalazine) COLAZAL (balsalazide)  Non Preferred Criteria

PENTASA 250mg (mesalamine) DELZICOL (mesalamine)  Documented diagnosis found in the sulfasalazine GIAZO (balsalazide) past 2 years medical claims for LIALDA (mesalamine) Ulcerative Colitis AND PENTASA 500mg (mesalamine)  30 days therapy with 2 different NR UCERIS (budesonide) preferred agents in the past 6 months OR  90 days completed therapy with the same agent in the past 105 days RECTAL CANASA (mesalamine) SFROWASA (mesalamine) mesalamine

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. *All other new, non-preferred products will not be approved unless two preferred agents have been tried; stable therapy check will not apply until 10-1-2014. **Users of these products as of 6-30-14 will be grandfathered To search the PDL, press CTRL + F