Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free 1-866-250-2518 or Local 501-526-4200. This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFFERED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. 6/24/2010 For the most up-to-date Preferred Drug List visit www.medicaid.state.ar.us CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS AGENTS FOR MIGRAINE ANTIDEPRESSANTS ANTIDEPRESSANTS Serotonin 5-HT1 Receptor Agonist SSRIs, SSNRIs, SNRIs SSRIs, SSNRIs, SNRIs ORIGINAL POSTED PREFERRED STATUS: 12/8/2005 ORIGINAL POSTED PREFERRED STATUS: 2/7/2007 ORIGINAL POSTED PREFERRED STATUS: 2/7/2007 ORIGINAL EDIT EFFECTIVE DATE: 2/7/2006 ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007 ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007 REVISED POSTED PREFERRED STATUS: 7/25/2007 RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009 RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009 REVISED EDIT EFFECTIVE DATE: 10/1/2007 REVISED EDIT EFFECTIVE DATE: 1/1/2010 REVISED EDIT EFFECTIVE DATE: 1/1/2010 RE-REVIEW POSTED PREFERRED STATUS: 4/26/2010 REVISED EDIT EFFECTIVE DATE: 7/1/2010 PREFERRED NON-PREFERRED -- BUPROPION EXTENDED RELEASE (WELLBUTRIN XL)* INCLUDE BUT NOT LIMITED TO PREFERRED BUPROPION REGULAR RELEASE (WELLBUTRIN)* BUPROPION HBR ER TABLET (APLENZIN)* RIZATRIPTAN (MAXALT)* Effective 7/1/2010 BUPROPION SUSTAINED RELEASE (WELLBUTRIN SR)* BUPROPION HCL SR TABLET (WELLBUTRIN SR)* Eff 11/1/2009 RIZATRIPTAN DISINTEGRATING (MAXALT MLT)* Eff 7/1/2010 Eff 11/1/2009 DESVENLAFAXINE (PRISTIQ)* SUMATRIPTAN 4MG/0.5ML KIT REFILL (IMITREX)* CITALOPRAM (CELEXA)* DULOXETINE (CYMBALTA)* SUMATRIPTAN 5MG NASAL SPRAY (IMITREX)* ESCITALOPRAM 5MG TABLET, 5MG/5ML SOL'N (LEXAPRO)* ESCITALOPRAM 5MG TABLET; 5MG/5ML SOL'N (LEXAPRO)* SUMATRIPTAN 6MG/0.5ML KIT REFILL (IMITREX)* Eff 11/1/2009 Eff 11/1/2009 SUMATRIPTAN 6MG/0.5ML KIT SYRINGE (IMITREX)* ESCITALOPRAM 10MG, 20MG TABLET (LEXAPRO)* FLUOXETINE 10MG, 15MG, 20MG TABLET, 40MG CAPSULE, SUMATRIPTAN 6MG/0.5ML VIAL (IMITREX)* FLUOXETINE 10MG, 20MG CAPSULE, AND 20MG/5ML AND 90MG DELAYED RELEASE (PROZAC)* SUMATRIPTAN 20MG NASAL SPRAY (IMITREX)* SOLUTION (PROZAC)* FLUVOXAMINE (LUVOX)* Eff 11/1/2009 SUMATRIPTAN 25MG TABLET (IMITREX)* FLUVOXAMINE EXTENDED RELEASE (LUVOX CR)* MILNACIPRAN (SAVELLA)* SUMATRIPTAN 100MG TABLET (IMITREX)* FLUVOXAMINE (LUVOX)* Eff 11/1/2009 MIRTAZAPINE 7.5MG TABLET AND RPD TABLET (REMERON)* SUMATRIPTAN/NAPROXEN (TREXIMET)* Effective 7/1/2010 MIRTAZAPINE 15MG, 30MG, 45MG TABLET (REMERON)* NEFAZODONE (SERZONE)* PAROXETINE HCL TABLET (PAXIL)* PAROXETINE CR TABLET; SUSPENSION (PAXIL)* NON-PREFERRED -- PAROXETINE MESYLATE (PEXEVA)* Eff 1/1/2010 PAROXETINE MESYLATE (PEXEVA)* Eff 1/1/2010 INCLUDE BUT NOT LIMITED TO SERTRALINE (ZOLOFT)* VENLAFAXINE ER CAPSULES (EFFEXOR)* AMLOTRIPTAN (AXERT) VENLAFAXINE REGULAR RELEASE TABLET (EFFEXOR)* VENLAFAXINE ER TABLETS* ELETRIPTAN (RELPAX) FROVATRIPTAN (FROVA) NON-PREFERRED -- NARATRIPTAN (AMERGE) Non-preferred agents listed in next column RIZATRIPTAN (MAXALT) Effective 7/1/2010 RIZATRIPTAN DISINTEGRATING (MAXALT MLT)* Eff 7/1/2010 SUMATRIPTAN 4MG/0.5ML VIAL (IMITREX) SUMATRIPTAN 6MG/0.5ML INJECTION (SUMAVEL DOSEPRO) SUMATRIPTAN/NAPROXEN (TREXIMET) Effective 7/1/2010 ZOLMITRIPTAN (ZOMIG) *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free 1-866-250-2518 or Local 501-526-4200. This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFFERED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. 6/24/2010 For the most up-to-date Preferred Drug List visit www.medicaid.state.ar.us CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT DISORDER/HYPERACTIVITY DISORDER NEUROPATHIC PAIN AGENTS NON-BENZODIAZEPINE SEDATIVE Amphetamine Salts, Amphetamine-Like Drugs, and HYPNOTICS Norepinephrine Reuptake Inhibitor ORIGINAL POSTED PREFERRED STATUS: 4/3/2008 ORIGINAL EDIT EFFECTIVE DATE: 6/5/2008 ORIGINAL POSTED PREFERRED STATUS: 3/7/2006 ORIGINAL POSTED PREFERRED STATUS: 5/7/2007 ORIGINAL EDIT EFFECTIVE DATE: 5/9/2006 ORIGINAL EDIT EFFECTIVE DATE: 7/10/2007 PREFERRED REVISED EDIT EFFECTIVE DATE: 10/17/2007 RE-REVIEW POSTED PREFERRED STATUS: 5/11/2009 AMITRIPTYLINE (ELAVIL) RE-REVIEW POSTED PREFERRED STATUS: 12/15/2008 REVISED EDIT EFFECTIVE DATE: 7/21/2009 CARBAMAZEPINE CHEWABLE TABLET (TEGRETOL TABLET REVISED EDIT EFFECTIVE DATE: 3/1/2009 CHEWABLE) PREFERRED CARBAMAZEPINE IMMEDIATE RELEASE TABLET (TEGRETOL) PREFERRED AMPHETAMINE SALTS ER CAPSULE (ADDERALL XR)* GABAPENTIN CAPSULE (NEURONTIN) RAMELTEON (ROZEREM)* AMPHETAMINE SALTS TABLET (ADDERALL)* GABAPENTIN 600MG, 800MG TABLET (NEURONTIN) ZALEPLON (SONATA)* ATOMOXETINE (STRATTERA)* Effective 7/21/2009 NORTRIPTYLINE (PAMELOR) ZOLPIDEM TABLET (AMBIEN)* DEXMETHYLPHENIDATE ER CAPSULE (FOCALIN XR)* PREGABALIN (LYRICA)* ZOLPIDEM CR TABLET (AMBIEN CR) Effective 3/1/2009 DEXMETHYLPHENIDATE TABLET (FOCALIN)* VENLAFAXINE REGULAR RELEASE TABLET (EFFEXOR)* DEXTROAMPHETAMINE TABLET* Effective 7/21/2009 NON-PREFERRED -- LISDEXAMFETAMINE (VYVANSE)* Effective 7/21/2009 NON-PREFERRED -- INCLUDE BUT NOT LIMITED TO METHLYPHENIDATE ER PATCH (DAYTRANA)* INCLUDE BUT NOT LIMITED TO ESZOPICLONE (LUNESTA) METHYLPHENIDATE ER TABLET (CONCERTA)* CARBAMAZEPINE EXTENDED RELEASE CAPSULE ZOLPIDEM CR TABLET (AMBIEN CR) Effective 3/1/2009 METHYLPHENIDATE SWALLOW TABLET (RITALIN)* (CARBATROL SA)* ZOLPIDEM SL TABLET (EDULAR) CARBAMAZEPINE EXTENDED RELEASE TABLET NON-PREFERRED -- (TEGRETOL XR)* INCLUDE BUT NOT LIMITED TO CARBAMAZEPINE SUSPENSION (TEGRETOL)* ATOMOXETINE (STRATTERA)* Effective 7/21/2009 DIVALPROEX SODIUM (DEPAKOTE)* DEXTROAMPHETAMINE CAPSULE (DEXEDRINE SPANSULE) DULOXETINE (CYMBALTA)* DEXTROAMPHETAMINE SOLUTION (PROCENTRA) GABAPENTIN 250MG/5ML SOLUTION (NEURONTIN)* DEXTROAMPHETAMINE TABLETS* Effective 7/21/2009 GABAPENTIN 100MG, 300MG, 400MG TABLET* GUANFACINE ER TABLET (INTUNIV ER) LACOSAMIDE (VIMPAT)* LISDEXAMFETAMINE (VYVANSE)* Effective 7/21/2009 LAMOTRIGINE (LAMICTAL)* METHAMPHETAMINE TABLET (DESOXYN) LIDOCAINE PATCH (LIDODERM)* METHYLPHENIDATE CHEWABLE TABLET (METHYLIN) OXCARBAZEPINE (TRILEPTAL)* METHYLPHENIDATE SOLUTION (METHYLIN) TOPIRAMATE (TOPAMAX)* METHYLPHENIDATE ER CAPSULE (METADATE CD, RITALIN LA) VALPROIC ACID (DEPAKENE, STAVZOR)* METHYLPHENIDATE ER TABLET (METADATE ER,RITALIN SR) VENLAFAXINE ER CAPSULE (EFFEXOR XR)* ***SEE DISCLAIMER ON LAST PAGE*** *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free 1-866-250-2518 or Local 501-526-4200. This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFFERED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. 6/24/2010 For the most up-to-date Preferred Drug List visit www.medicaid.state.ar.us DISCLAIMER NEUROPATHIC PAIN AGENTS ORIGINAL POSTED PREFERRED STATUS: 4/3/2008 ORIGINAL EDIT EFFECTIVE DATE: 6/5/2008 The non-preferred antiepileptic medications will be considered non- preferred for treating neuropathic pain only. Medications listed as either preferred or non-preferred status in this category may or may not include an FDA approved indication for neuropathic pain. Use of these medications for neuropathic pain and neuralgias has been reviewed through the evidence-based review process. Medications listed in this category as either preferred or non-preferred status are not to be construed as endorsements for marketing of off-label use by the manufacturer or by Medicaid. .