Preferred Drug List Medicaid

Preferred Drug List



 Medicaid



21NVMDCD11268

Medicaid Preferred Drug List

Table of Contents





Introduction .............................................................. i



Drug Benefit Guide .................................................. 1

Section 1 Anti-Infectives

Section 2 Cancer and Transplant

Section 3 Cardiovascular

Section 4 Central Nervous System

Section 5 Dermatologicals

Section 6 Endocrine and Hormones

Section 7 Gastrointestinals

Section 8 Genitourinary

Section 9 Musculoskeletal and Pain

Section 10 Vitamins and Hematologicals

Section 11 Eye, Ear, and Throat

Section 12 Respiratory

Section 13 Self-Injectable/Specialty





Preferred Alternatives............................................... 29



Alphabetical Index ................................................... 32

Medicaid Preferred Drug List

Introduction



As a member of Health Plan of Nevada (HPN), you have access to a wide range of effective and

affordable medications. HPN utilizes a Preferred Drug List (PDL) as a tool to guide providers to

prescribe clinically sound yet cost-effective drugs. This list was established to give you access to

the prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost is lower

when you use preferred medications. Please refer to your plan documents for specific pharmacy

benefit information.



The PDL is a list of FDA-approved generic and brand name medications recommended for use by

HPN. The list is developed and maintained by a Pharmacy and Therapeutics (P&T) Committee

comprised of actively practicing primary care and specialty physicians, pharmacists and other

healthcare professionals. Patient needs, scientific data, drug effectiveness, availability of drug

alternatives currently on the PDL and cost are all considerations in selecting "preferred"

medications. Due to the number of drugs on the market and the continuous introduction of new

drugs, the PDL is a dynamic and routinely updated document screened regularly to ensure that it

remains a clinically sound tool for our providers.



Reading the Preferred Drug List



For your convenience, medications are grouped together based on their therapeutic category (i.e.,

Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e., Antidepressants,

Contraceptives, etc.). Each drug class has a designated section number (i.e., 1-A, 1-B, etc.) and is

the reference point noted in the index.



The generic or chemical name is listed to the left of the brand or trade name for each drug. Drugs

with a generic equivalent available are identified by an asterisk (*) before the common brand name

of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicates that

PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy). Drugs

that are not available generically have the brand-name listed in BOLD print (for example, the

listing for atorvastatin.....LIPITOR, indicates that there is no generic for LIPITOR and the brand

name product will be dispensed).



Other abbreviations used throughout the PDL are:

• AL = age limitations

• M = mail-order/maintenance drug

• NTI = narrow therapeutic index (generic not required)

• PA = prior authorization

• QL = quantity limitations

• SIO = self-injectable/orphan drug

• ST = step therapy



The amount of your copayment for a preferred prescription drug will vary, depending upon whether

you select a generic drug, a brand name drug or a brand name when a generic is available.







i

Certain medications may have quantity, age or therapeutic supply limitations based on FDA

approved dosages, literature documentation or P&T Committee decisions. See your plan

documents for a complete list of covered benefits, limitations and exclusions.





Mandatory Generic Substitution Policy



Most of our prescription drug plans include a mandatory generic requirement, therefore, if a

preferred brand name drug is dispensed when a preferred generic equivalent is available, you will

be required to pay the difference between the contracted cost of the generic and brand name drug in

addition to the preferred generic (tier 1) copayment. Please note that not all dosage forms or

strengths may be available in a generic form. The asterisk (*) indicates that at least one form or

strength of the drug is available as a generic at the time of printing. Check with your pharmacist

for more information.



Pharmacy Exceptions



The Medical Necessity/Exceptions Policy allows members and practitioners to request, on the basis

of medical necessity, that Health Plan of Nevada cover a certain pharmaceutical not on the current

Preferred Drug List. This Policy is applicable to members with a closed or 2-tier prescription drug

benefit where no coverage for non-preferred drugs is available. It is anticipated that such

exceptions will be rare and that preferred medications will be appropriate to treat the vast majority

of medical conditions.



Requests for medical necessity or exceptions may be submitted by members, pharmacists or

providers; however, the prescribing practitioner must provide the appropriate information to support

the request on the basis of medical necessity. Pharmacy Services uses pharmacists, practitioners of

appropriate specialists and/or medical guidelines to review exception requests. Each request is

evaluated on an individual basis to determine if the patient meets criteria based on current medical

literature, drug information, opinion or medical professionals and patient specific information.

Exception requests are processed within 24 hours of receipt of all necessary clinical information,

with exception of weekend and holidays. The member and the prescribing practitioner are notified

of the decision by fax, phone or letter. If the exception request is denied, the practitioner or the

member may choose to appeal through the HPN appeal process.



To request an exception, members should contact Member Services at (702) 242-7300 or (800) 777-

1840.



Since this list is to be used in the decision-making process and does not represent standards of care

for an individual, we encourage you to take this reference to all doctor appointments and verify that

the drug he/she prescribes is included on this list. You and your provider should discuss the best

possible treatment plan and medications to meet your needs. Because a drug is included on our

Preferred Drug List does not guarantee that the provider will prescribe that medication.



If you have any questions regarding HPN’s Preferred Drug List, please contact our Member

Services Department at (702) 242-7300 or (800) 777-1840. We are proud to be your healthcare

provider of choice. Working together, we can achieve our common goal – to keep you healthy!





ii

This summary is not an offer of coverage. If there are any differences between the information

contained within this document and a specific plan document, the plan documents will govern.

Participating pharmacies in our retail and/or mail-order network are independent contractors and

are neither employees nor agents of Health Plan of Nevada or its affiliates. This is not meant to

replace the advice of a healthcare provider. This is a proprietary document and may not be copied

or distributed without the express permission of Health Plan of Nevada.









iii

MEDICAID Preferred Drug List



This Preferred Drug List is applicable to HPN

members with a Medicaid prescription drug program.







ANTI-INFECTIVES (drugs to treat infections)

1-A Penicillins

Generic Name Brand Name Notes

amoxicillin *AMOXIL

amoxicillin AMOXIL (400mg chewable)

amoxicillin-clavulanate *AUGMENTIN

ampicillin *PRINCIPEN

ampicillin PRINCIPEN (suspension)

aztreonam CAYSTON QL (84 mls/42 days) PA

dicloxacillin *DYNAPEN

penicillin V potassium *VEETIDS

1-B Cephalosporins

Generic Name Brand Name Notes

cefaclor ER CECLOR CD

cefaclor *CECLOR

cefadroxil *DURICEF

cefdinir *OMNICEF (suspension) 125mg/5ml QL (24 ml/day)

cefdinir *OMNICEF (suspension) 250mg/5ml QL (12 ml/day)

cefpodoxime *VANTIN 200mg QL (28 tablets/month)

cefprozil *CEFZIL 250mg QL (28 tablets/month)

cefprozil *CEFZIL 500mg QL (28 tablets/month)

cefprozil *CEFZIL 125mg/ml QL (140 mls/month)

cefprozil *CEFZIL 250mg/ml QL (140 mls/month)

cefuroxime *CEFTIN (tablets) QL (28 tablets/month)

cephalexin *KEFLEX

cephradine *VELOSEF

1-C Macrolides

Generic Name Brand Name Notes

azithromycin *ZITHROMAX 250mg QL (6 tablets/fill)

azithromycin *ZITHROMAX 500mg QL (4 tablets/fill)

azithromycin *ZITHROMAX 600mg QL (8 tablets/fill)

azithromycin *ZITHROMAX 100mg/ml QL (30 mls/fill)

azithromycin *ZITHROMAX 200mg/ml QL (30 mls/fill)

clarithromycin *BIAXIN QL (28 tablets/month)

clarithromycin SR *BIAXIN XL QL (28 tablets/month)

clindamycin *CLEOCIN

erythromycin EC ERY-TAB

erythromycin estolate *ILOSONE

erythromycin ethylsuccinate *EES

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 1 Medicaid Drug Benefit Guide 10/01/11

erythromycin ethylsuccinate *ERYPED

erythromycin stearate ERYTHROCIN

ERYTHROMYCIN BASE

1-D Tetracyclines

Generic Name Brand Name Notes

doxycycline *VIBRAMYCIN

doxycycline hyclate *PERIOSTAT QL (60 tablets/month)

doxycycline monohyclate *VIBRATABS QL (60 tablets/month)

minocycline *MINOCIN QL (60 tablets/month)

tetracycline *SUMYCIN

1-E Fluoroquinolones

Generic Name Brand Name Notes

ciprofloxacin *CIPRO QL (60 tablets/month)

ciprofloxacin SR *CIPRO XR QL (14 tablets/month)

levofloxacin *LEVAQUIN QL (14 tablets/month)

ofloxacin *FLOXIN

1-F Antimycobacterial Agents

Generic Name Brand Name Notes

ethambutol *MYAMBUTOL

isoniazid

pyrazinamide

rifampin *RIFADIN

1-G Antifungals

Generic Name Brand Name Notes

fluconazole *DIFLUCAN 50mg QL (30 tablets/month)

fluconazole *DIFLUCAN 100mg QL (30 tablets/month)

fluconazole *DIFLUCAN 150mg QL (1 tablet/fill)

fluconazole *DIFLUCAN 200mg QL (30 tablets/month)

griseofulvin microsize *GRIFULVIN V

griseofulvin ultramicrosize GRIS-PEG

itraconazole *SPORANOX QL (14 capsules/month)

ketoconazole *NIZORAL

nystatin BIO-STATIN

nystatin *MYCOSTATIN susp

terbinafine HCL *LAMISIL QL (90 tablets/year)

voriconazole VFEND 50mg QL (180 tablets/month)

voriconazole VFEND 200mg QL (60 tablets/month)

1-H Miscelleanous Antivirals

Generic Name Brand Name Notes

acyclovir *ZOVIRAX

famciclovir *FAMVIR 125mg QL (60 tablets/month)

famciclovir *FAMVIR 250mg QL (60 tablets/month)

famciclovir *FAMVIR 500mg QL (21 tablets/month)

ganciclovir *CYTOVENE

ribavirin *REBETOL capsules/tablets QL (180 capsules/tabletsmonth) PA

rimantadine *FLUMADINE QL (14 pills/fill)

1-I Antiretrovirals

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 2 Medicaid Drug Benefit Guide 10/01/11

Generic Name Brand Name Notes

abacavir sulfate ZIAGEN M

amprenavir AGENERASE M

didanosine M

didanosine *VIDEX EC M

emtricitabine EMTRIVA QL (30 capsules/month) M

enfuvirtide FUZEON

indinavir sulfate CRIXIVAN M

lamivudine-zidovudine COMBIVIR M

lopinavir-ritonavir KALETRA M

nevirapine VIRAMUNE M

nevirapine XR VIRAMUNE XR

stavudine *ZERIT M

tenofovir VIREAD M

zalcitabine HIVID M

zidovudine *RETROVIR M

1-J Antimalarials

Generic Name Brand Name Notes

chloroquine *ARALEN

hydroxychloroquine *PLAQUENIL

mefloquine *LARIAM

primaquine *PRIMAQUINE

pyrimethamine DARAPRIM

quinine sulfate

1-K Anthelmintics

Generic Name Brand Name Notes

mebendazole VERMOX

1-L Misc Anti-Infectives

Generic Name Brand Name Notes

dapsone DAPSONE

dornase alfa PULMOZYME

EES-sulfisoxazole *PEDIAZOLE

iodoquinol *YODOXIN

metronidazole *FLAGYL tablets

metronidazole *FLAGYL capsule

neomycin *MYCIFRADIN

SMZ-TMP *BACTRIM

SMZ-TMP *SEPTRA

sulfadiazine

sulfamethoxazole *GANTANOL

sulfisoxazole *GANTRISIN

tobramycin TOBI PA

trimethoprim *TRIMPEX

CANCER and TRANSPLANT (drugs to treat cancers and prevent organ rejection)

2-A Antineoplastics (cancer drugs)

Generic Name Brand Name Notes



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 3 Medicaid Drug Benefit Guide 10/01/11

altretamine HEXALEN

anastrozole *ARIMIDEX QL (30 tablets/month) M

bicalutamide *CASODEX

busulfan MYLERAN

chlorambucil LEUKERAN

cyclophosphamide CYTOXAN

estramustine EMCYT

etoposide *VEPESID

exemestane *AROMASIN QL (30 tablets/month)

flutamide *EULEXIN

hydroxyurea *HYDREA

letrozole *FEMARA QL (30 tablets/month) M

leucovorin calcium *WELLCOVORIN

lomustine CEENU

megestrol *MEGACE

melphalan ALKERAN

mercaptopurine *PURINETHOL

mesna MESNEX

methotrexate

mitotane LYSODREN

procarbazine HCL MATULANE

tamoxifen *NOLVADEX M

testolactone TESLAC

thioguanine THIOGUANINE

tretinoin *VESANOID

2-B Immunosuppressives

Generic Name Brand Name Notes

azathioprine *IMURAN

cyclosporine *SANDIMMUNE (NTI)

cyclosporine modified *GENGRAF

cyclosporine modified *NEORAL (NTI)

mycophenolate mofetil *CELLCEPT

sirolimus RAPAMUNE

tacrolimus *PROGRAF

CARDIOVASCULAR (drugs to treat heart conditions)

3-A Cardiotonics

Generic Name Brand Name Notes

digoxin *LANOXIN (NTI) M

3-B Antianginals

Generic Name Brand Name Notes

isosorbide dinitrate *ISORDIL M

isosorbide mononitrate *IMDUR M

nitroglycerin ointment *NITROBID M

nitroglycerin patch *MINITRAN M

nitroglycerin patch *NITRO-DUR M

nitroglycerin spray *NITROLINGUAL PUMPSPRAY M



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 4 Medicaid Drug Benefit Guide 10/01/11

nitroquick *NITROSTAT M

3-C Beta Blockers

Generic Name Brand Name Notes

acebutolol *SECTRAL M

atenolol *TENORMIN M

betaxolol *KERLONE M

bisoprolol *ZEBETA M

carvedilol *COREG 3.125mg QL (60 tablets/month) M

carvedilol *COREG 6.25mg QL (60 tablets/month) M

carvedilol *COREG 12.5mg QL (60 tablets/month) M

carvedilol *COREG 25mg QL (120 tablets/month) M

labetalol *NORMODYNE M

labetalol *TRANDATE M

metoprolol *LOPRESSOR M

metoprolol succinate SR *TOPROL XL QL (45 tablets/month) M

nadolol *CORGARD 20mg QL (90 tablets/month) M

nadolol *CORGARD 40mg QL (60 tablets/month) M

nadolol *CORGARD 80mg QL (90 tablets/month) M

nadolol *CORGARD 120mg QL (60 tablets/month) M

nebivolol BYSTOLIC 2.5mg QL (30 tablets/month) M

nebivolol BYSTOLIC 5mg QL (30 tablets/month) M

nebivolol BYSTOLIC 10mg QL (120 tablets/month) M

nebivolol BYSTOLIC 20mg QL (60 tablets/month) M

pindolol *VISKEN M

propranolol *INDERAL M

propranolol HCL CR *INDERAL LA M

sotalol *BETAPACE M

sotalol AF *BETAPACE AF M

timolol maleate *BLOCADREN M

3-D Calcium Channel Blockers

Generic Name Brand Name Notes

amlodipine *NORVASC M

cartia XT QL (60 capsules/month) M

diltiazem *CARDIZEM M

diltiazem SR *TIAZAC M

diltiazem SR 12HR *CARDIZEM SR M

felodipine *PLENDIL QL (60 tablets/month) M

isradipine *DYNACIRC QL (60 tablets/month) M

nicardipine *CARDENE M

nifedipine CR *ADALAT CC M

nifedipine CR *PROCARDIA XL M

nifedipine IR *ADALAT CC M

nifedipine IR *PROCARDIA M

verapamil *CALAN M

verapamil SR *CALAN SR M

verapamil SR *VERELAN PM M

3-E Antiarrhythmics

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 5 Medicaid Drug Benefit Guide 10/01/11

Generic Name Brand Name Notes

amiodarone *CORDARONE M

disopyramide *NORPACE M

flecainide *TAMBOCOR M

mexiletine *MEXITIL M

moricizine ETHMOZINE M

procainamide *PRONESTYL M

procainamide SR PROCANBID M

propafenone *RYTHMOL M

quinidine gluconate M

quinidine sulfate M

tocainide TONOCARD

3-F Angiotensin Converting Enzyme (ACE) Inhibitors

Generic Name Brand Name Notes

benazepril *LOTENSIN QL (60 tablets/month) M

captopril *CAPOTEN M

enalapril *VASOTEC QL (60 tablets/month) M

fosinopril *MONOPRIL QL (60 tablets/month) M

lisinopril *PRINIVIL QL (60 tablets/month) M

lisinopril *ZESTRIL QL (60 tablets/month) M

moexipril *UNIVASC QL (60 tablets/month) M

quinapril *ACCUPRIL QL (60 tablets/month) M

ramipril *ALTACE QL (60 capsules/month) M

trandolapril *MAVIK QL (60 tablets/month) M

3-G Angiotensin II Receptor Blockers (ARB's)

Generic Name Brand Name Notes

losartan *COZAAR 25mg QL (60 tablets/month)

losartan *COZAAR 50mg QL (60 tablets/month)

losartan *COZAAR 100mg QL (30 tablets/month)

3-H Miscellaneous Antihypertensives

Generic Name Brand Name Notes

bosentan TRACLEER QL (60 tablets/month) PA M

clonidine *CATAPRES M

clonidine patch *CATAPRES-TTS QL (8 patches/month)

doxazosin *CARDURA QL (60 tablets/month) M

guanfacine *TENEX M

hydralazine *APRESOLINE M

methyldopa *ALDOMET M

minoxidil *LONITEN M

prazosin *MINIPRESS M

terazosin *HYTRIN QL (60 capsules/month) M

3-I Antihypertensive Combinations

Generic Name Brand Name Notes

amlodipine-benazepril *LOTREL QL (30 capsules/month) M

atenolol-chlorthalidone *TENORETIC M

benazepril-HCTZ *LOTENSIN HCT QL (60 tablets/month) M

bisoprolol-HCTZ *ZIAC M

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 6 Medicaid Drug Benefit Guide 10/01/11

captopril-HCTZ *CAPOZIDE M

enalapril-HCTZ *VASERETIC M

fosinopril-HCTZ *MONOPRIL HCT QL (60 tablets/month) M

lisinopril-HCTZ *PRINZIDE M

lisinopril-HCTZ *ZESTORETIC M

losartan-HCTZ *HYZAAR QL (30 tablets/month)

methyldopa-HCTZ *ALDORIL M

moexipril-HCTZ *UNIRETIC QL (60 tablets/month) M

nadolol-bendroflumethiazide *CORZIDE QL (60 tablets/month) M

propranolol-HCTZ *INDERIDE M

quinapril-HCTZ *ACCURETIC QL (60 tablets/month) M

3-J Diuretics

Generic Name Brand Name Notes

acetazolamide *DIAMOX M

amiloride M

amiloride-HCTZ *MODURETIC M

bumetanide *BUMEX M

chlorothiazide *DIURIL M

chlorthalidone *HYGROTON M

furosemide *LASIX M

hydrochlorothiazide *HYDRODIURIL M

hydrochlorothiazide *MICROZIDE M

indapamide *LOZOL M

methazolamide *NEPTAZANE M

methyclothiazide *AQUATENSEN M

metolazone *ZAROXOLYN M

spironolactone *ALDACTONE M

spironolactone-HCTZ *ALDACTAZIDE M

torsemide *DEMADEX M

triamterene-HCTZ *DYAZIDE M

triamterene-HCTZ *MAXZIDE M

3-K Pressors

Generic Name Brand Name Notes

epinephrine inj EPIPEN

epinephrine inj EPIPEN JR

epinephrine inj TWINJECT

midodrine *PROAMATINE

3-L Antihyperlipidemics

Generic Name Brand Name Notes

atorvastatin LIPITOR QL (30 tablets/month) M

cholestyramine *QUESTRAN M

colestipol *COLESTID M

fenofibrate *LOFIBRA QL (30 capsules/month) M

fenofibrate TRICOR 48mg QL (60 tablets/month) M

fenofibrate TRICOR 54mg QL (60 tablets/month) M

fenofibrate TRICOR 145mg QL (30 tablets/month) M

fenofibrate TRICOR 160mg QL (30 tablets/month) M

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 7 Medicaid Drug Benefit Guide 10/01/11

gemfibrozil *LOPID M

lovastatin *MEVACOR 10mg QL (30 tablets/month) M

lovastatin *MEVACOR 20mg QL (30 tablets/month) M

lovastatin *MEVACOR 40mg QL (60 tablets/month) M

pravastatin *PRAVACHOL QL (30 tablets/month) M

simvastatin *ZOCOR QL (30 tablets/month) M

3-M Miscellaneous Cardiovascular

Generic Name Brand Name Notes

ranolazine RANEXA QL (60 tablets/month)

CENTRAL NERVOUS SYSTEM (drugs that affect the brain)

4-A Antianxiety Agents

Generic Name Brand Name Notes

alprazolam *XANAX

alprazolam SR *XANAX XR 0.5mg QL (30 tablets/month)

alprazolam SR *XANAX XR 1mg QL (30 tablets/month)

alprazolam SR *XANAX XR 2mg QL (30 tablets/month)

alprazolam SR *XANAX XR 3mg QL (60 tablets/month)

buspirone BUSPAR (7.5mg)

buspirone *BUSPAR 10mg QL (60 tablets/month) M

buspirone *BUSPAR 15mg QL (120 tablets/month) M

chlordiazepoxide *LIBRIUM

clorazepate *TRANXENE

diazepam *VALIUM

hydroxyzine HCL *ATARAX

hydroxyzine pamoate *VISTARIL

lorazepam *ATIVAN

meprobamate

oxazepam *SERAX

4-B Antidepressants

Generic Name Brand Name Notes

amitriptyline *ELAVIL M

amoxapine *ASENDIN M

bupropion *WELLBUTRIN 75mg QL (180 tablets/month) M

bupropion *WELLBUTRIN 100mg QL (120 tablets/month) M

bupropion SR *WELLBUTRIN SR 100mg QL (60 tablets/month) M

bupropion SR *WELLBUTRIN SR 150mg QL (60 tablets/month) M

bupropion SR *WELLBUTRIN SR 200mg QL (60 tablets/month) M

bupropion XL *WELLBUTRIN XL QL (30 tablets/month) M

citalopram *CELEXA QL (45 tablets/month) M

clomipramine *ANAFRANIL M

desipramine *NORPRAMIN M

doxepin *SINEQUAN M

fluoxetine *PROZAC 10mg QL (30 capsules/month) M

fluoxetine *PROZAC 20mg QL (120 capsules/month) M

fluoxetine *PROZAC 40mg QL (60 capsules/month) M

fluvoxamine *LUVOX QL (90 tablets/month) M



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 8 Medicaid Drug Benefit Guide 10/01/11

imipramine *TOFRANIL M

maprotiline *LUDIOMIL M

mirtazapine *REMERON QL (30 tablets/month) M

mirtazapine soltabs *REMERON SOLTABS

nefazodone HCL *SERZONE M

nortriptyline *PAMELOR M

paroxetine HCL *PAXIL 10mg QL (30 tablets/month) M

paroxetine HCL *PAXIL 20mg QL (30 tablets/month) M

paroxetine HCL *PAXIL 30mg QL (60 tablets/month) M

paroxetine HCL *PAXIL 40mg QL (45 tablets/month) M

phenelzine sulfate *NARDIL M

protriptyline *VIVACTIL M

sertraline HCL *ZOLOFT 25mg QL (45 tablets/month) M

sertraline HCL *ZOLOFT 50mg QL (45 tablets/month) M

sertraline HCL *ZOLOFT 100mg QL (60 tablets/month) M

trazodone *DESYREL M

venlafaxine *EFFEXOR QL (90 tablets/month) M

4-C Hypnotics (Sleep Aids)

Generic Name Brand Name Notes

chloral hydrate SOMNOTE

estazolam *PROSOM

flurazepam *DALMANE

mephobarbital *MEBARAL

phenobarbital

temazepam *RESTORIL QL (30 capsules/month)

triazolam *HALCION QL (15 tablets/fill; 2 fills/month)

zaleplon *SONATA 5mg QL (30 capsules/month)

zaleplon *SONATA 10mg QL (60 capsules/month)

zolpidem *AMBIEN QL (30 tablets/month)

4-D Antipsychotics

Generic Name Brand Name Notes

chlorpromazine *THORAZINE M

clozapine *CLOZARIL (NTI) ST M

Clozaril ST = requires failure/contraindication to Risperidone and Seroquel AND supported diagnosis in

the past 2 years

fluphenazine *PROLIXIN M

haloperidol *HALDOL M

lithium carbonate *ESKALITH M

lithium carbonate CR *ESKALITH CR M

lithium carbonate CR *LITHOBID M

loxapine *LOXITANE M

paliperidone palmitate INVEGA SUSTENNA QL (1 syringe/month)

perphenazine *TRILAFONE M

prochlorperazine *COMPAZINE

quetiapine fumarate SEROQUEL 25mg QL (90 tablets/month) M

quetiapine fumarate SEROQUEL 100mg QL (90 tablets/month) M

quetiapine fumarate SEROQUEL 200mg QL (120 tablets/month) M

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 9 Medicaid Drug Benefit Guide 10/01/11

quetiapine fumarate SEROQUEL 300mg QL (90 tablets/month) M

quetiapine fumarate SEROQUEL XR 200mg QL (30 tablets/month) M

quetiapine fumarate SEROQUEL XR 300mg QL (60 tablets/month) M

quetiapine fumarate SEROQUEL XR 400mg QL (60 tablets/month) M

risperidone *RISPERDAL M

risperidone *RISPERDAL M M

thioridazine M

thiothixene *NAVANE M

trifluoperazine *STELAZINE M

4-E Stimulants

Generic Name Brand Name Notes

amphetamine-d-amphetamine *ADDERALL

amphetamine-d-amphetamine SR ADDERALL XR 5mg QL (30 capsules/month)

amphetamine-d-amphetamine SR ADDERALL XR 10mg QL (30 capsules/month)

amphetamine-d-amphetamine SR ADDERALL XR 15mg QL (30 capsules/month)

amphetamine-d-amphetamine SR ADDERALL XR 20mg QL (60 capsules/month)

amphetamine-d-amphetamine SR ADDERALL XR 25mg QL (30 capsules/month)

amphetamine-d-amphetamine SR ADDERALL XR 30mg QL (30 capsules/month)

atomoxetine STRATTERA QL (30 capsules/month) ST

Strattera ST = requires failure of at least one stimulant ADHD medication in the last 2 years

dexmethylphenidate *FOCALIN QL (60 tablets/month)

dextroamphetamine *DEXEDRINE

dextroamphetamine *DEXEDRINE SPANSULES

lisdexamfetamine dimesylate VYVANSE QL (30 capsules/month)

methamphetamine *DESOXYN QL (150 tablets/month)

methylphenidate *METHYLIN (tablets) 5mg QL (180 tablets/month)

methylphenidate *METHYLIN (tablets) 10mg QL (180 tablets/month)

methylphenidate *METHYLIN (tablets) 20mg QL (60 tablets/month)

methylphenidate *METHYLIN ER QL (90 tablets/month)

methylphenidate *RITALIN 5mg QL (180 tablets/month)

methylphenidate *RITALIN 10mg QL (180 tablets/month)

methylphenidate *RITALIN 20mg QL (90 tablets/month)

methylphenidate CR *RITALIN SR QL (90 tablets/month)

sodium oxybate XYREM PA

4-F Misc Psychotherapeutic and Neurological Agents

Generic Name Brand Name Notes

amitriptyline-chlordiazepoxide LIMBITROL

disulfiram *ANTABUSE

donepezil ARICEPT 23mg QL (30 tablets/month) ST

Aricept 23mg ST = requires 3 fills of donepezil 10mg within the last 120 days

donepezil *ARICEPT QL (30 tablets/month) M

ergoloid mesylates *HYDERGINE

galantamine *RAZADYNE QL (60 tablets/month) M

galantamine *RAZADYNE ER QL (30 capsules/month) M

guanfacine INTUNIV QL (30 tablets/month) ST

Intuniv ST = requires failure of at least one stimulant ADHD medication in the last 2 years

pemoline *CYLERT

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 10 Medicaid Drug Benefit Guide 10/01/11

perphenazine-amitriptyline *ETRAFON M

rivastigmine *EXELON QL (60 capsules/month) M

4-G Anticonvulsants

Generic Name Brand Name Notes

carbamazepine *TEGRETOL (NTI) M

carbamazepine SR *CARBATROL

carbamazepine SR *TEGRETOL XR M

clonazepam *KLONOPIN

divalproex sodium EC *DEPAKOTE M

ethosuximide *ZARONTIN M

gabapentin *GABARONE M

gabapentin *NEURONTIN 100mg QL (240 capsules/month) M

gabapentin *NEURONTIN 300mg QL (360 capsules/month) M

gabapentin *NEURONTIN 400mg QL (270 capsules/month) M

gabapentin *NEURONTIN 600mg QL (180 tablets/month) M

gabapentin *NEURONTIN 800mg QL (120 tablets/month) M

lamotrigine *LAMICTAL M

lamotrigine *LAMICTAL STARTER KIT QL (1 kit/month)

levetiracetam *KEPPRA M

oxcarbazepine *TRILEPTAL 100mg QL (60 tablets/month)M

oxcarbazepine *TRILEPTAL 300mg QL (90 tablets/month)M

oxcarbazepine *TRILEPTAL 600mg QL (120 tablets/month)M

phenytoin *DILANTIN (NTI) M

primidone *MYSOLINE M

topiramate *TOPAMAX QL (90 tablets/month)

topiramate *TOPAMAX SPRINKLES QL (120 capsules/month)

valproic acid *DEPAKENE M

zonisamide *ZONEGRAN 25mg QL (120 capsules/month)

zonisamide *ZONEGRAN 50mg QL (120 capsules/month)

zonisamide *ZONEGRAN 100mg QL (180 capsules/month)

4-H Antiparkinsonian Agents

Generic Name Brand Name Notes

AMANTADINE (Symmetrel) M

apomorphine APOKYN

benztropine *COGENTIN M

bromocriptine (tablets) *PARLODEL M

carbidopa-levodopa *SINEMET M

carbidopa-levodopa *PARCOPA

carbidopa-levodopa CR *SINEMET CR M

entacapone COMTAN QL (240 tablets/month) M

pergolide *PERMAX M

pramipexole *MIRAPEX QL (90 tablets/month)

ropinirole *REQUIP QL (90 tablets/month) M

trihexyphenidyl *ARTANE M

*SELEGILINE M

DERMATOLOGICALS (drugs to treat skin disorders or conditions)

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 11 Medicaid Drug Benefit Guide 10/01/11

5-A Anorectal

Generic Name Brand Name Notes

hydrocortisone rectal *ANUSOL-HC

hydrocortisone-pramoxine rectal *ANALPRAM-HC

hydrocortisone-pramoxine rectal PROCTOFOAM-HC

5-B Acne Products

Generic Name Brand Name Notes

benzoyl peroxide *BREVOXYL

benzoyl peroxide-erythromycin gel *BENZAMYCIN QL (60 gm/month)

clindamycin topical *CLEOCIN-T

erythromycin topical *ERYGEL

metronidazole cream *METROCREAM QL (60 gm/month)

metronidazole cream NORITATE** QL (60 gm/month)

metronidazole lotion *METROLOTION

sulfacetamide lotion (acne) *KLARON

sulfacetamide-sulfur emulsion *PLEXION

tretinoin *RETIN-A ** AL

tretinoin RETIN-A MICRO ** AL

** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply

5-C Topical Antibiotics

Generic Name Brand Name Notes

bac-polymy-neomycin HC oint CORTISPORIN OINTMENT

gentamicin topical *GARAMYCIN

mupirocin *BACTROBAN

mupirocin BACTROBAN CREAM

mupirocin BACTROBAN NASAL OINTMENT

neomycin-polymyxin-HC cream CORTISPORIN CREAM

silver sulfadiazine *SILVADENE

5-D Topical Antifungals

Generic Name Brand Name Notes

ciclopirox *LOPROX

ciclopirox solution *PENLAC QL (7 ml/month)

clotrimazole *LOTRIMIN

clotrimazole-betamethasone *LOTRISONE QL (30 ml/month)

econazole *SPECTAZOLE

ketoconazole shampoo *NIZORAL SHAMPOO

ketoconazole topical

nystatin topical *MYCOSTATIN topical

nystatin-triamcinolone *MYCOLOG II

5-E Topical Antivirals

Generic Name Brand Name Notes

acyclovir topical ZOVIRAX topical

5-F Antipsoriatics

Generic Name Brand Name Notes

anthralin *PSORIATEC

calcipotriene DOVONEX QL (1 tube/month)

calcitriol ointment VECTICAL QL (100 gm/month)

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 12 Medicaid Drug Benefit Guide 10/01/11

** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply

5-G Scabicides and Pediculicides

Generic Name Brand Name Notes

lindane shampoo *KWELL

permethrin *ELIMITE

5-H Topical Corticosteroids

Generic Name Brand Name Notes

alclometasone *ACLOVATE

augmented betamethasone *DIPROLENE

augmented betamethasone *DIPROLENE AF

betamethasone dipropionate *DIPROSONE

betamethasone valerate *VALISONE

clobetasol foam *OLUX

clobetasol propionate *TEMOVATE

desonide *DESOWEN

desoximetasone *TOPICORT

diflorasone diacetate PSORCON QL (60 gm/month)

fluocinolone acetonide *SYNALAR

fluocinonide *LIDEX

fluticasone *CUTIVATE **

halobetasol *ULTRAVATE

hydrocortisone butyrate *LOCOID QL (45 gm/month)

hydrocortisone topical *HYTONE

hydrocortisone valerate *WESTCORT

mometasone *ELOCON

pramoxine-HC cream *PRAMOSONE

pramoxine-HC foam EPIFOAM

prednicarbate *DERMATOP

sodium hyaluronate *HYLIRA

triamcinolone acetonide *KENALOG

** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply

5-I Miscellaneous Topicals

Generic Name Brand Name Notes

aluminum chloride *DRYSOL

fluorouracil *EFUDEX

imiquimod *ALDARA QL (12 packets/month)

lactic acid *LAC-HYDRIN

lidocaine (topical) *XYLOCAINE M

lidocaine/hydrocortisone *ANAMANTLE

lidocaine-prilocaine *EMLA cream QL (30 gm/month)

papain-urea *ACCUZYME

papain-urea-chlorophyllin foam PAPFYLL

pimecrolimus ELIDEL QL (1 tube/month)

podofilox *CONDYLOX

podophyllum resin PODOCON

selenium sulfide shampoo *SELSUN

sulfacetamide-urea lotion *CARMOL SCALP

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 13 Medicaid Drug Benefit Guide 10/01/11

trypsin-castor oil-peruvian balsam *XENADERM

urea *KERALAC

urea *VANAMIDE

urea (carbamide) *CARMOL 40

ENDOCRINE AND HORMONES (drugs to treat metabolic or hormone conditions, ie diabetes)

6-A Corticosteroids

Generic Name Brand Name Notes

cortisone acetate *CORTONE M

dexamethasone *DECADRON M

fludrocortisone *FLORINEF M

hydrocortisone acetate *CORTEF M

methylprednisolone *MEDROL M

prednisolone *PRELONE M

prednisolone PREDNISOLONE 5MG M

prednisolone sodium *ORAPRED M

prednisolone sodium *PEDIAPRED M

prednisone M

6-B Androgens

Generic Name Brand Name Notes

danazol *DANOCRINE

6-C Estrogens

Generic Name Brand Name Notes

esterified estrogens

esterified estrogens MENEST M

estradiol *ESTRACE M

estradiol patch *CLIMARA QL (4 patches/month) M

estradiol patch VIVELLE QL (8 patches/month) M

estradiol patch VIVELLE DOT QL (8 patches/month) M

estradiol TD gel DIVIGEL QL (1 tube/month) M

estradiol-norgestimate ORTHO-PREFEST M

estrogen-medroxyprogesterone PREMPHASE QL (1 dialpak/month) M

estrogen-medroxyprogesterone PREMPRO QL (1 dialpak/month) M

estrogens (conjugated synthetic) CENESTIN QL (30 tablets/month)

estrogens (conjugated synthetic) ENJUVIA

estrogens-methyltestosterone *ESTRATEST M

estrogens-methyltestosterone *ESTRATEST HS M

estropipate *OGEN M

6-D Contraceptives

Generic Name Brand Name Notes

Apri, Solia, Reclipsen *ORTHO CEPT QL (28 tablets/21 days) M

Aviane, Lessina, Lutera, Sroynx *LEVLITE QL (28 tablets/21 days) M

drospirenone-ethyinal YAZ QL (28 tablets/21 days) M

Enpresse, Trivora *TRI-LEVLEN QL (28 tablets/21 days) M

Errin, Camila, Nora-Be, Jolivette *ORTHO MICRONOR QL (28 tablets/month) M

June1, Microgestin *LOESTRIN QL (28 tablets/21 days) M

Junel FE, Microgestin FE *LOESTRIN FE QL (28 tablets/month) M



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 14 Medicaid Drug Benefit Guide 10/01/11

Kariva *MIRCETTE QL (28 tablets/month) M

Levora, Portia *LEVLEN QL (28 tablets/21 days) M

Low-Ogestrel QL (28 tablets/21 days) M

Necon 10/11 *ORTHO NOVUM 10/11 QL (28 tablets/21 days) M

Nortrel 7/7/7, Necon 7/7/7 *ORTHO NOVUM 7/7/7 QL (28 tablets/21 days) M

Nortrel, Necon *MODICON QL (28 tablets/21 days) M

Nortrel, Necon *ORTHO NOVUM 1/35 QL (28 tablets/21 days) M

Nortrel, Necon *ORTHO NOVUM 1/50 QL (28 tablets/21 days) M

Ogestrel QL (28 tablets/month) M

Sprintec, Mononessa, Previfem *ORTHO CYCLEN QL (28 tablets/21 days) M

Tilia FE, Tri-Legest FE *ESTROSTEP FE QL (28 tablets/month) M

Tri-sprintec, Trinessa, Tri-Previfem *ORTHO TRI-CYCLEN QL (28 tablets/21 days) M

NUVARING QL (1 ring/month)

ORTHO TRI-CYCLEN LO QL (28 tablets/21 days) M

YASMIN QL (28 tablets/21 days) M

6-E Progestins

Generic Name Brand Name Notes

medroxyprogesterone *PROVERA M

norethindrone *AYGESTIN M

6-F Oral Antidiabetics (diabetes)

Generic Name Brand Name Notes

acarbose *PRECOSE QL (90 tablets/month) M

chlorpropamide *DIABINESE M

glimepiride *AMARYL QL (60 tablets/month) M

glipizide *GLUCOTROL 5mg QL (90 tablets/month) M

glipizide *GLUCOTROL 10mg QL (60 tablets/month) M

glipizide CR *GLUCOTROL XL 2.5mg QL (90 tablets/month) M

glipizide CR *GLUCOTROL XL 5mg QL (60 tablets/month) M

glipizide CR *GLUCOTROL XL 10mg QL (60 tablets/month) M

glipizide-metformin *METAGLIP QL (120 tablets/month) M

glyburide *DIABETA M

glyburide micronized *GLYNASE QL (60 tablets/month) M

glyburide-metformin *GLUCOVANCE QL (120 tablets/month) M

metformin *GLUCOPHAGE 500mg QL (150 tablets/month) M

metformin *GLUCOPHAGE 850mg QL (90 tablets/month) M

metformin *GLUCOPHAGE 1000mg QL (75 tablets/month) M

metformin SR *GLUCOPHAGE XR 500mg QL (120 tablets/month) M

metformin SR *GLUCOPHAGE XR 750mg QL (90 tablets/month) M

nateglinide *STARLIX QL (90 tablets/month)

piolitazone ACTOS QL (30 tablets/month) M

piolitazone-glimepiride DUETACT QL (30 tablets/month) M

piolitazone-metformin ACTOPLUS MET QL (90 tablets/month) M

repaglinide PRANDIN QL (120 tablets/month) M

repaglinide-metformin PRANDIMET M

tolazamide *TOLINASE M

tolbutamide *TOLBUTAMIDE

6-G Insulins

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 15 Medicaid Drug Benefit Guide 10/01/11

Generic Name Brand Name Notes

insulin (human) NOVOLIN

insulin (human) HUMULIN

insulin (human) HUMULIN PEN

insulin aspart NOVOLOG

insulin aspart mix NOVOLOG MIX

insulin detemir LEVEMIR M

insulin glargine LANTUS M

insulin lispro HUMALOG

insulin lispro HUMALOG PEN

insulin lispro mix HUMALOG MIX

insulin lispro mix HUMALOG MIX PEN

6-H Glucagon

Generic Name Brand Name Notes

GLUCAGON QL (2 kits/month

6-I Thyroid Agents

Generic Name Brand Name Notes

levothroid QL (60 tablets/month) M

levothyroxine QL (60 tablets/month) M

levothyroxine TIROSINT QL (60 tablets/month)

levothyroxine *SYNTHROID (NTI) QL (60 tablets/month) M

levoxyl QL (60 tablets/month) M

liothyronine *CYTOMEL M

methimazole *TAPAZOLE QL (90 tablets/month) M

methimazole NORTHYX QL (90 tablets/month) M

propylthiouracil *PTU M

thyroid ARMOUR THYROID M

thyroid NATURE-THROID M

unithroid QL (60 tablets/month) M

6-J Miscellaneous Endocrine

Generic Name Brand Name Notes

alendronate * FOSAMAX 5mg QL (30 tablets/month) M

alendronate * FOSAMAX 10mg QL (30 tablets/month) M

alendronate * FOSAMAX 35mg QL (4 tablets/month) M

alendronate * FOSAMAX 40mg QL (4 tablets/month) M

alendronate * FOSAMAX 70mg QL (4 tablets/month) M

caberoline *DOSTINEX

calcitonin MIACALCIN QL (2 bottles/month) M

calcitonin (salmon) nasal *FORTICAL QL (2 bottles/month) M

desmopressin (nasal) *DDAVP QL (1 bottle/month)

desmopressin (oral) *DDAVP 0.1mg QL (30 tablets/month)

desmopressin (oral) *DDAVP 0.2mg QL (90 tablets/month)

etidronate *DIDRONEL

exenatide BYETTA M

levocarnitine *CARNITOR

pramlintide SYMLIN AMYLIN ANALOG ST

Symlin ST = requires concurrent mealtime insulin therapy (rapid or fast acting)

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 16 Medicaid Drug Benefit Guide 10/01/11

raloxifene EVISTA QL (30 tablets/month) M

6-K Diabetic Supplies

Generic Name Brand Name Notes

ACCU-CHEK ACTIVE CARE KIT

ACCU-CHEK ACTIVE TEST STRIPS

ACCU-CHEK ADVANTAGE CARE KIT

ACCU-CHEK AVIVA CARE KIT

ACCU-CHEK AVIVA TEST STRIPS

ACCU-CHEK COMFORT CURVE TEST STRIPS

ACCU-CHEK COMPACT CARE KIT

ACCU-CHEK COMPACT TEST STRIPS



GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)

7-A Laxatives

Generic Name Brand Name Notes

lactulose

PEG electrolyte *COLYTE

PEG electrolyte GOLYTELY

peg(high)-electrolyte *NULYTELY

7-B Antidiarrheals

Generic Name Brand Name Notes

diphenoxylate-atropine *LOMOTIL

7-C Miscelleanous Ulcer Drugs

Generic Name Brand Name Notes

dicyclomine *BENTYL

glycopyrrolate *ROBINUL

glycopyrrolate *ROBINUL FORTE

hyoscyamine *LEVSIN

hyoscyamine *LEVBID

hyoscyamine *NULEV

hyoscyamine SR *LEVSINEX

misoprostol *CYTOTEC QL (120 tablets/month)

phenobarbital-belladonna *DONNATAL

propantheline PRO-BANTHINE

sucralfate CARAFATE

7-D H2 Blockers

Generic Name Brand Name Notes

cimetidine *TAGAMET M

famotidine *PEPCID M

nizatadine *AXID M

ranitidine *ZANTAC M

7-E Proton Pump Inhibitors (PPI)

Generic Name Brand Name Notes

omeprazole *PRILOSEC 20mg capsules QL (60 capsules/month)

omeprazole *PRILOSEC 20mg tablets QL (30 tablets/month)

omeprazole *PRILOSEC 40mg QL (30 capsules/month)

omeprazole-sodium bicarb ZEGERID (brand) QL (30 capsules/month)



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 17 Medicaid Drug Benefit Guide 10/01/11

pantoprazole *PROTONIX QL (30 tablets/month)

7-F Antiemetics

Generic Name Brand Name Notes

meclizine *ANTIVERT

granisetron *KYTRIL QL (2 tablets/fill; 2 fills/month)

ondansetron *ZOFRAN 4mg QL (30 tablets/fill; 2 fills/month)

ondansetron *ZOFRAN 8mg QL (30 tablets/fill; 2 fills/month)

ondansetron *ZOFRAN 24mg QL (15 tablets/fill; 2 fills/month)

ondansetron *ZOFRAN ODT 4mg QL (30 tablets/fill; 2 fills/month)

ondansetron *ZOFRAN ODT 8mg QL (30 tablets/fill; 2 fills/month)

ondansetron *ZOFRAN ODT 24mg QL (15 tablets/fill; 2 fills/month)

scopolamine oral SCOPACE

trimethobenzamide *TIGAN

trimethobenzamide-benzocaine *TEBAMIDE

7-G Digestive Aids

Generic Name Brand Name Notes

amylase-lipase-protease PANCREASE MT M

amylase-lipase-protease PANCRECARB M

amylase-lipase-protease CREON M

amylase-lipase-protease VIOKASE M

amy-lip-prot dr ULTRASE M

amy-lip-prot dr ULTRASE MT

miglustat ZAVESCA

pancrelipase COTAZYM M

pancrelipase ZENPEP

pegademase ADAGEN

sacrosidase SUCRAID

sodium phenylbutyrate BUPHENYL

7-H Miscelleanous Gastrointestinal

Generic Name Brand Name Notes

balsalazide *COLAZAL QL (270 capsules/month)

budesonide SR *ENTOCORT EC QL (90 capsules/month)

calcium acetate (phosphate binder) *PHOSLO

calcium acetate (phosphate binder) ELIPHOS

lamivudine (hepatitis) EPIVIR HBV QL (30 tablets/month) M

lanthanum FOSRENOL 250mg QL (150 tablets/month)

lanthanum FOSRENOL 500mg QL (150 tablets/month)

lanthanum FOSRENOL 750mg QL (150 tablets/month)

lanthanum FOSRENOL 1000mg QL (120 tablets/month)

lubiprostone AMITIZA QL M

mesalamine CANASA

mesalamine CR APRISO

mesalamine EC ASACOL

mesalamine EC ASACOL HD

mesalamine enema *ROWASA

metoclopramide *REGLAN

sulfasalazine *AZULFIDINE

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 18 Medicaid Drug Benefit Guide 10/01/11

sulfasalazine EC *AZULFIDINE EN

ursodiol *ACTIGALL

GENITOURINARY (drugs to treat genital and bladder or kidney conditions)

8-A Urinary Anti-Infectives

Generic Name Brand Name Notes

methenamine-NA biphosphate *UROQID

nitrofurantoin macro *MACROBID

nitrofurantoin macrocrystals *MACRODANTIN

nitrofurantoin susp FURADANTIN

8-B Urinary Antispasmodics

Generic Name Brand Name Notes

bethanechol *URECHOLINE

darifenacin ENABLEX QL (30 tablets/month)

flavoxate *URISPAS QL (240 tablets/month) M

oxybutynin *DITROPAN QL (240 tablets/month) M

oxybutynin CR *DITROPAN XL 5mg QL (30 tablets/month) M

oxybutynin CR *DITROPAN XL 10mg QL (60 tablets/month) M

oxybutynin CR *DITROPAN XL 15mg QL (60 tablets/month) M

solifenacin VESICARE QL (30 tablets/month)

8-C Vaginal Products

Generic Name Brand Name Notes

buconazole vaginal GYNAZOLE-1 QL (1 applicator/fill)

clindamycin vaginal *CLEOCIN vaginal cream

estradiol vaginal ESTRACE vaginal M

estrogens (conjugated) vaginal PREMARIN vaginal

estropipate vaginal OGEN vaginal

metronidazole vaginal *METROGEL vaginal

metronidazole vaginal *VANDAZOLE

nystatin vaginal

sulfanilamide vaginal AVC vaginal

terconazole vaginal TERAZOL

triple sulfas vaginal

8-D Miscelleanous Genitourinary Agents

Generic Name Brand Name Notes

citric acid-sodium citrate *BICITRA

finasteride *PROSCAR QL (30 tablets/month)

pentosan polysulfate sodium ELMIRON QL (90 capsules/month)

phenazopyridine *PYRIDIUM

potassium citrate CR *UROCIT-K

potassium phosphate K-PHOS

POTASSIUM CHLORIDE

tamsulosin *FLOMAX QL (60 capsules/month)

MUSCULOSKELETAL AND PAIN (drugs to treat pain and muscle conditions)

9-A Analgesics-Non-Narcotic

Generic Name Brand Name Notes



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 19 Medicaid Drug Benefit Guide 10/01/11

APAP-butalbital *PHRENILIN QL (360 tablets/month)

DIFLUNISAL

APAP-caffeine-butalbital *ESGIC PLUS QL (360 tablets/month)

APAP-caffeine-butalbital *FIORICET QL (360 tablets/month)

ASA-caffeine-butalbital *FIORINAL

choline-mag salicylates *TRILISATE

salsalate *DISALCID

9-B Analgesics-Narcotic

Generic Name Brand Name Notes

CODEINE PHOSPHATE

CODEINE SULFATE

METHADONE

APAP-codeine *TYLENOL w/CODEINE QL (390 tablets/month)

APAP-hydrocodone *LORCET 10/650mg QL (180 tablets/month)

APAP-hydrocodone *LORTAB QL (240 tablets/month)

APAP-hydrocodone *MAXIDONE QL (150 tablets/month)

APAP-hydrocodone *NORCO QL (360 tablets/month)

APAP-hydrocodone *VICODIN QL (240 tablets/month)

APAP-hydrocodone *VICODIN ES QL (150 tablets/month)

APAP-hydrocodone *VICODIN HP QL (180 tablets/month)

APAP-hydrocodone ZYDONE QL (300 mls/month)

ASA-caffeine-but-codeine *FIORINAL w/CODEINE

ASA-codeine *EMPIRIN w/CODEINE

buprenorphine naloxone SUBOXONE FILM TAB PA

butorphanol *STADOL NS QL (1 bottle/month)

fentanyl patch *DURAGESIC QL (10 patches/month) ST

Duragesic ST = requires 30 day trial fill of MSSR in past 2 years

hydromorphone *DILAUDID 2mg QL (360 tablets/month)

hydromorphone *DILAUDID 4mg QL (360 tablets/month)

hydromorphone *DILAUDID 8mg QL (360 tablets/month)

ibuprofen-hydrocodone *VICOPROFEN QL (480 tablets/month)

meperidine *DEMEROL QL (360 tablets/month)

morphine sulfate *ROXANOL

morphine sulfate SR *MS CONTIN

naltrexone *REVIA

oxycodone *OXYIR

oxycodone *ROXICODONE QL (360 tablets/month)

oxycodone-APAP *PERCOCET 2.5-325mg QL (360 tablets/month)

oxycodone-APAP *PERCOCET 5-325mg QL (360 tablets/month)

oxycodone-APAP *PERCOCET 7.5-325mg QL (360 tablets/month)

oxycodone-APAP *PERCOCET 10-325mg QL (360 tablets/month)

oxycodone-APAP *PERCOCET 7.5-500mg QL (240 tablets/month)

oxycodone-APAP *PERCOCET 10-650mg QL (180 tablets/month)

oxycodone-ASA *PERCODAN QL (360 tablets/month)

oxymorphone ER OPANA ER 5mg QL (60 tablets/month)

oxymorphone ER OPANA ER 7.5mg QL (60 tablets/month)

oxymorphone ER OPANA ER 10mg QL (60 tablets/month)

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 20 Medicaid Drug Benefit Guide 10/01/11

oxymorphone ER OPANA ER 15mg QL (60 tablets/month)

oxymorphone ER OPANA ER 20mg QL (60 tablets/month)

oxymorphone ER OPANA ER 30mg QL (60 tablets/month)

Opana ER ST = requires 30 day trial fill of MSSR in past 2 years

pentazocine-naloxone *TALWIN NX

propoxyphene *DARVON QL (180 capsules/month)

propoxyphene-APAP *DARVOCET N 50 QL (360 tablets/month)

propoxyphene-APAP *DARVOCET N 100 QL (180 tablets/month)

propoxyphene nap-APAP *TRYCET QL (180 tablets/month)

tramadol *ULTRAM QL (240 tablets/month)

tramadol-APAP ULTRACET QL (240 tablets/month)

9-C Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

Generic Name Brand Name Notes

diclofenac *VOLTAREN 25mg QL (240 tablets/month)

diclofenac *VOLTAREN 50mg QL (120 tablets/month)

diclofenac *VOLTAREN 75mg QL (90 tablets/month)

diclofenac potassium *CATAFLAM QL (120 tablets/month)

diclofenac SR *VOLTAREN XR

etodolac *LODINE 200mg QL (90 capsules/month)

etodolac *LODINE 300mg QL (90 capsules/month)

etodolac *LODINE 400mg QL (90 tablets/month)

etodolac *LODINE 500mg QL (90 tablets/month)

etodolac SR *LODINE XL 600mg QL (60 tablets/month)

fenoprofen *NALFON

flurbiprofen *ANSAID

ibuprofen *MOTRIN

indomethacin *INDOCIN

indomethacin CR *INDOCIN SR

ketoprofen ORUDIS QL (60 capsules/month)

ketorolac *TORADOL QL (20 tablets/month)

meloxicam *MOBIC 7.5mg QL (60 tablets/month)

meloxicam *MOBIC 15mg QL (30 tablets/month)

nabumetone *RELAFEN

naproxen *NAPROSYN

naproxen sodium *ANAPROX

oxaprozin *DAYPRO QL (90 tablets/month)

piroxicam *FELDENE

sulindac *CLINORIL

tolmetin sodium *TOLECTIN

9-D Anti-Rheumatic Agents

Generic Name Brand Name Notes

auranofin RIDAURA

deferasirox EXJADE PA

leflunomide *ARAVA QL (30 tablets/month)

methotrexate

penicillamine CUPRIMINE

penicillamine DEPEN

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 21 Medicaid Drug Benefit Guide 10/01/11

9-E Migraine Products

Generic Name Brand Name Notes

APAP-isometh-dichlor hydrate *MIDRIN

divalproex sodium (migraine) *DEPAKOTE ER M

eletriptan RELPAX ST QL (6 tablets/fill; 2 fills/month)

RELPAX ST = requires failure of sumatriptan within the last 120 days

ergotamine-caffeine *CAFERGOT QL (40 tablets/month)

ergotamine-phenobarb-belladona

sumatriptan *IMITREX QL (9 tablets/fill; 2 fills/month)

sumatriptan *IMITREX NASAL QL (6 vials/month)

sumatriptan SUMATRIPTAN INJ QL (2 kits/fill, 2 fills/month)

9-F Gout

Generic Name Brand Name Notes

allopurinol *ZYLOPRIM M

colchicine-probenecid *COLBENEMID M

probenecid *BENEMID M

sulfinpyrazone SULFINPYRAZONE

9-G Musculoskeletal Therapy Agents

Generic Name Brand Name Notes

baclofen *LIORESAL

carisoprodol *SOMA QL (120 tablets/month)

carisoprodol-ASA *SOMA COMPOUND QL (120 tablets/month)

carisoprodol-ASA-codeine *SOMA CPD w/CODEINE QL (120 tablets/month)

chlorzoxazone *PARAFON FORTE

cyclobenzaprine *AMRIX QL (30 capsules/month)

cyclobenzaprine *FLEXERIL 5mg QL (90 tablets/month)

cyclobenzaprine *FLEXERIL 10mg

dantrolene *DANTRIUM

methocarbamol *ROBAXIN

methocarbamol-ASA *ROBAXISAL

orphenadrine citrate *NORFLEX

tizanidine *ZANAFLEX

9-H Miscelleanous Neuromuscular Agents

Generic Name Brand Name Notes

pyridostigmine *MESTINON

VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood disorders)

10-A Vitamins

Generic Name Brand Name Notes

calcitriol *ROCALTROL

ergocalciferol [vitamin D] *CALCIFEROL

paricalcitol [vitamin D] ZEMPLAR QL (30 capsules/month)

phytonadione MEPHYTON

potassium aminobenzoate POTABA M

10-B Multivitamins

Generic Name Brand Name Notes

B complex-vit C-FA *NEPHROCAPS



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 22 Medicaid Drug Benefit Guide 10/01/11

ped multi vitamin-fluoride *POLY-VI-FLOR

ped multi vitamin-fluoride-FE *POLY-VI-FLOR-FE

ped vitamins ACD-fluoride *TRI-VI-FLOR

ped vitamins ACD-fluoride-FE *TRI-VI-FLOR-FE

prenatal FE-CBN-DSS-Methylfol-FA *PRENATE ELITE M

prenatal vitamin-FE-bisglycinate-FA *NATELLE C QL (30 tablets/month) M

prenatal vitamins-fe- bis-fe prot succ-fa-ca- *DUET DHA EC QL (30 tablets/month) M

prenatal vitamins-FE-FA *NATALCARE M

prenatal vitamins-FE-FA *STUARTNATAL

prenatal vitamins-FE-FA *PRIMACARE M

prenatal vitamins-FE-FA *PRECARE M

prenatal vitamins-FE-FA-CA-omega *DUET DHA QL (60 tablets/month) M

prenatal vitamins-iron carbonyl-FA *NESTABS M

prenate vitamin FE-Fum-Lmethylfol-FA-CA *PRENATE DHA QL (30 tablets/month) M

10-C Minerals

Generic Name Brand Name Notes

cyanocobalamin inj

FA-vit B6-vit B12 *FOLBEE QL (30 tablets/month)

FA-vit B6-vit B12 *FOLGARD RX QL (30 tablets/month)

FA-vit B6-vit B12 *FOLTX QL (60 tablets/month)

folic acid

L-methylfolate B12 B6 *METANX QL (60 tablets/month)

10-D Anticoagulants

Generic Name Brand Name Notes

warfarin *COUMADIN (NTI) M

10-E Miscelleanous Hematologicals

Generic Name Brand Name Notes

aminocaproic acid *AMICAR

anagrelide *AGRYLIN

cilostazol *PLETAL QL (60 tablets/month) M

clopidogrel PLAVIX M

dipyridamole *PERSANTINE M

pentoxifylline *TRENTAL QL (90 tablets/month) M

sodium polystyrene sulfonate *KAYEXALATE

ticlopidine *TICLID QL (60 tablets/month) M

tranexamic acid LYSTEDA QL (5 days therapy/28 days)

EYE, EAR AND THROAT (drugs to treat eye, ear and throat conditions)

11-A Ophthalmic Anti-infectives

Generic Name Brand Name Notes

bacitracin ophth

bacitracin-polymyxin B ophth *POLYSPORIN ophth

ciprofloxacin ophth *CILOXAN

gentamycin sulfate ophth *GENTAMICIN OINT 3%

neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth

ofloxacin ophth *OCUFLOX QL (10 ml/month)

sulfacetamide sodium ophth *BLEPH-10



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 23 Medicaid Drug Benefit Guide 10/01/11

tobramycin ophth *TOBREX

trifluridine ophth *VIROPTIC

trimethoprim-polymy B ophth *POLYTRIM ophth

11-B Ophthalmics Beta-Blocker

Generic Name Brand Name Notes

brimonidine timolol ophth COMBIGAN 5ml QL (5 ml/month)

brimonidine timolol ophth COMBIGAN 10ml QL (10 ml/month)

carteolol ophth *OCUPRESS M

dorzolamide-timolol ophth *COSOPT M

levobunolol ophth *BETAGAN M

metipranolol ophth *OPTIPRANOLOL M

timolol ophth BETIMOL M

timolol maleate ophth *TIMOPTIC M

timolol maleate ophth *TIMOPTIC XE M

11-C Ophthalmic Steroids

Generic Name Brand Name Notes

dexamethasone phosphate ophth *DECADRON ophth

fluorometholone ophth FML FORTE

fluorometholone ophth *FML LIQUIFILM

fluorometholone ophth FML SOP

loteprednol etb-tobramycin ophth ZYLET QL (5 ml/month)

loteprednol ophth ALREX QL (10 ml/month)

loteprednol ophth LOTEMAX QL (5 ml/month)

neomycin-polymyxin-HC ophth *CORTISPORIN OPHTH

prednisolone ophth *PRED FORTE

rimexolone ophth VEXOL

sulfacetamide-prednisolone ophth *BLEPHAMIDE

tobramycin-dexamethasone ophth *TOBRADEX QL (5 ml/month)

11-D Ophthalmic Prostaglandin

Generic Name Brand Name Notes

bimatoprost ophth LUMIGAN QL (3 ml/month) M

travaprost ophth TRAVATAN 2.5ml QL (3 ml/month) M

travaprost ophth TRAVATAN 5ml QL (10 ml/month) M

11-E Ophthalmic Cycloplegics

Generic Name Brand Name Notes

atropine ophth *ISOPTO ATROPINE M

cyclopentolate ophth *CYCLOGYL M

homatropine ophth *ISOPTO HOMATROPINE M

tropicamide ophth *MYDRIACYL M

11-F Ophthalmics Miotics

Generic Name Brand Name Notes

pilocarpine ophth *ISOPTO CARPINE M

pilocarpine ophth PILOPINE HS M

pilocarpine ophth *PILOPTIC-1/2

pilocarpine ophth *PILOPTIC-3

11-G Ophthalmics Adrenergic Agents

Generic Name Brand Name Notes

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 24 Medicaid Drug Benefit Guide 10/01/11

brimonidine ophth *ALPHAGAN P 0.1% M

brimonidine ophth *ALPHAGAN P 0.2% M

brimonidine ophth *ALPHAGAN P 0.15% M

dipivefrin ophth PROPINE M

11-H Ophthalmics Miscelleanous

Generic Name Brand Name Notes

cromolyn sodium ophth *CROLOM ophth

dorzolamide ophth *TRUSOPT M

epinastine ELESTAT

flurbiprofen ophth *OCUFEN

ketorolac ophth *ACULAR

ketorolac ophth *ACULAR LS

ketotifen *ZADITOR

nepafenac ophth NEVANAC

11-I Otic (Ear) Medications

Generic Name Brand Name Notes

benzocaine-antipyrine otic *AURALGAN

hydrocortisone-acetic acid otic *VOSOL-HC

neomycin-polymyxin-HC otic *CORTISPORIN otic

ofloxacin otic *FLOXIN OTIC QL (10 ml/month)

11-J Mouth and Throat

Generic Name Brand Name Notes

chlorhexidine *PERIDEX

clotrimazole troche *MYCELEX TROCHE

lidocaine *VISCOUS LIDOCAINE

pilocarpine *SALAGEN 5mg QL (180 tablets/month)

pilocarpine *SALAGEN 7.5mg QL (120 tablets/month)

sodium fluoride *KARIGEL

sodium fluoride *KARIGEL-N

triamcinolone/orabase *KENALOG-ORABASE

RESPIRATORY (drugs to treat breathing conditions, ie asthma and allergies)

12-A Antihistamines

Generic Name Brand Name Notes

clemastine *TAVIST

cyproheptadine *PERIACTIN

fexofenadine *ALLEGRA

promethazine *PHENERGAN

12-B Topical Nasal Products

Generic Name Brand Name Notes

azelastine nasal *ASTELIN QL (1 inhaler/month)

azelastine nasal ASTEPRO QL (1 inhaler/month)

flunisolide nasal *NASALIDE QL (3 inhalers/month)

flunisolide nasal *NASAREL QL (3 inhalers/month)

fluticasone nasal *FLONASE

ipratropium nasal *ATROVENT 0.03% NASAL QL (1 inhaler/month) M

ipratropium nasal *ATROVENT 0.06% NASAL QL (2 inhalers/month) M



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 25 Medicaid Drug Benefit Guide 10/01/11

12-C Cough/Cold/Allergy

Generic Name Brand Name Notes

acetylcysteine *MUCOMYST

azatadine-pseudoephedrine CR TRINALIN

benzonatate *TESSALON

carbinoxamine-PSE *PEDIATEX D

carbinoxamine-PSE *RONDEC

carbinoxamine-PSE-DM *PEDIATEX DM

cardec DM *RONDEC DM

chlorpheniramine *ED CHLORPED

chlorpheniramine-PSE *DECONAMINE

chlorphen-pyrilamine-PE *RYNATAN-S

guaifenesin-codeine *TUSSI-ORGANIDIN

hydrocodone-guaifenesin *ENTUSS

hydrocodone-homatropine *HYCODAN

PE-pyrilamine-hydrocodone *CODIMAL DH

promethazine VC PHENERGAN VC

promethazine-codeine *PHENERGAN w/CODEINE

PSE-guaifenesin-codeine *NOVAHISTINE

PSE-methscopolamine *ALLERX-D

pyrilamine-phenyleph *RYNA-12

12-D Asthma/COPD

Generic Name Brand Name Notes

albuterol nebulizer *PROVENTIL (nebulizer) M

albuterol tablets *PROVENTIL (tablets) M

albuterol CR tablets PROVENTIL REPETABS M

albuterol HFA inhaler VENTOLIN HFA

albuterol SR tablets *VOSPIRE ER 4mg QL (60 tablets/month) M

albuterol SR tablets *VOSPIRE ER 8mg QL (120 tablets/month) M

albuterol-ipratropium nebulizer *DUONEB QL (540 mls/month)

aminophylline M

budesonide formoterol inhaler SYMBICORT QL (1 inhaler/month) M

cromolyn sodium nebulizer *INTAL (nebulizer) QL (120 vials/month) M

cromolyn sodium inhaler INTAL INHALER QL (2 inhalers/month) M

formoterol inhaler FORADIL QL (60 capsules/month) M

ipratropium nebulizer *ATROVENT (nebulizer) QL (450 mls/month) M

ipratropium HFA inhaler ATROVENT HFA QL (2 inhalers/month) M

ipratropium inhaler ATROVENT INHALER QL (2 inhalers/month) M

metaproterenol nebulizer *ALUPENT (nebulizer) QL (120 vials/month (300 ml/month) M

metaproterenol tablets *ALUPENT (tablets) M

metaproterenol inhaler ALUPENT INHALER QL (2 inhalers/month) M

montelukast SINGULAIR 4mg ST QL (30 tablets/month) M

Singulair ST = (for 13 years of older) requires failure of LABA, SABA, ICS, ICS/LABA or a

non-sedating antihistamine in the last 120 days

montelukast SINGULAIR 5mg ST QL (30 tablets/month) M

Singulair ST = (for 13 years of older) requires failure of LABA, SABA, ICS, ICS/LABA or a

non-sedating antihistamine in the last 120 days

QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 26 Medicaid Drug Benefit Guide 10/01/11

montelukast SINGULAIR 10mg ST QL (30 tablets/month)

Singulair ST = (for 13 years of older) requires failure of LABA, SABA, ICS, ICS/LABA or a

non-sedating antihistamine in the last 120 days

nedocromil inhaler TILADE QL (1 inhaler/month) M

sodium chloride soln nebu 7% HYPER-SAL NEBULIZER

terbutaline *BRETHINE QL (30 tablets/month) M

theophylline M

theophylline AEROLATE

theophylline SLO-PHYLLIN

theophylline THEOLAIR

theophylline CR *UNIPHYL M

theophylline SR THEO-24 M

tiotropium inhaler SPIRIVA QL (1 inhaler/month) M

zafirlukast *ACCOLATE QL (60 tablets/month)

12-E Steroid Inhalers

Generic Name Brand Name Notes

beclomethasone HFA inhaler QVAR 40mcg QL (1 inhaler/month) M

beclomethasone HFA inhaler QVAR 80mcg QL (2 inhaler/month) M

mometasone inhaler ASMANEX QL (1 inhaler/month) M

SELF-INJECTABLE/SPECIALTY (injectable drugs)

13-A Anticoagulants

Generic Name Brand Name Notes

dalteparin sodium FRAGMIN PA (covered up to 14 days without prior authorization)

13-B Growth Hormones

Generic Name Brand Name Notes

somatropin TEV-TROPIN PA

somatropin SEROSTIM PA

13-C Hematopoietic Agents

Generic Name Brand Name Notes

darbepoetin alpha ARANESP PA

filgrastim NEUPOGEN PA

pegfilgrastim NEULASTA PA

13-D Hepatitis C Agents

Generic Name Brand Name Notes

peginterferon alfa-2A PEGASYS PA

13-E Multiple Sclerosis Agents

Generic Name Brand Name Notes

glatiramer acetate COPAXONE PA

interferon beta-1A REBIF PA

interferon beta-1A AVONEX PA

13-F Osteoporosis Agents

Generic Name Brand Name Notes

teriparatide (recombinant) FORTEO PA

13-G Somatostatin Analogs

Generic Name Brand Name Notes

lanreotide acetate SOMATULINE PA



QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 27 Medicaid Drug Benefit Guide 10/01/11

nafarelin SYNAREL PA

octreotide acetate *OCTREOTIDE PA

octreotide acetate release SANDOSTATIN LAR PA

pegvisomant SOMAVERT PA

13-H TNF-Inhibitors

Generic Name Brand Name Notes

adalimumab HUMIRA PA

certolizumab pegol CIMZIA PA

etanercept for subcutaneous ENBREL PA

golimumab SIMPONI QL (1 unit/month) PA

13-I Miscellaneous Specialty

Generic Name Brand Name Notes

corticotropin ACTHAR HP PA

interferon gamma-1B ACTIMMUNE PA

nitisinone ORFADIN PA

oprelvekin NEUMEGA PA

oxandralone OXANDRALONE PA

oxymetholone ANADROL-50 PA

palonosetron ALOXI (tablets) PA

rilonacept ARCALYST PA









QL - Quantity Limits AL - Age Limits

PA - Prior Authorization Required

ST - Step Therapy Required M - Mail-order/Maintenance drug 28 Medicaid Drug Benefit Guide 10/01/11

Preferred Alternatives

The following table identifies the preferred alternatives for some commonly prescribed non-preferred drugs.

Copayments are lower when preferred drugs are prescribed.





Non-Preferred Drug Preferred Alternative(s)



ACEON benazepril, fosinopril, lisinopril, quinapril, trandolapril UNIVASC

ACIPHEX omeprazole, pantoprazole

ACTIVELLA ORTHO-PREFEST, PREMPRO, PREMPHASE

ADVAIR SYMBICORT (see section 12-D)

AEROBID ASMANEX, QVAR

AEROBID-M ASMANEX, QVAR

AGGRENOX dipyridamole and aspirin

ALESSE LEVLITE (see section 6-D)

ALORA VIVELLE, VIVELLE DOT

ALTOCOR simvastatin, lovastatin, LIPITOR

AMERGE sumatriptan

ATACAND losartan

ATACAND HCT losartan-HCTZ

AVALIDE losartan-HCTZ

AVAPRO losartan

AXERT sumatriptan

AZMACORT ASMANEX, QVAR

AZOPT TRUSOPT

BECONASE AQ

BETAPACE AF sotalol (BETAPACE)

BREVICON MODICON

CELEBREX ibuprofen, naproxen, others (see section 9-C)

CLIMARA VIVELLE, VIVELLE DOT

COGNEX donepezil, galantamine

CONCERTA methylphenidate, dextroamphetamine, ADDERALL XR

COREG CR carvedilol, metoprolol succinate SR

COVERA HS verapamil

CYCLESSA another oral contraceptive (see section 6-D)

DEMULEN another oral contraceptive (see section 6-D)

DESOGEN ORTHO-CEPT (see section 6-D)

DESOXYN methylphenidate, dextroamphetamine, ADDERALL XR

DETROL oxybutynin, URECHOLINE, URISPAS

DETROL LA oxybutynin XL, URECHOLINE, URISPAS

DIOVAN losartan

DIOVAN HCT losartan-HCTZ

DYNACIRC nifedipine XR





29 Medicaid Drug Benefit Guide 10/01/11

Preferred Alternatives

ESCLIM estradiol patch, VIVELLE, VIVELLE DOT

ESTRADERM estradiol patch, VIVELLE, VIVELLE DOT

FAMVIR acyclovir

FEMHRT ORTHO-PREFEST, PREMPRO, PREMPHASE

FLOVENT QVAR

FOCALIN methylphenidate, dextroamphetamine, ADDERALL XR

FROVA sumatriptan

GEODON RISPERDAL, SEROQUEL

GLYSET PRECOSE

LEXXEL enalapril

LIDODERM lidocaine (topical)

LO-OVRAL another oral contraceptive (see section 6-D)

MAXAIR VENTOLIN HFA

MAXALT sumatriptan

MAXALT MLT sumatriptan

MIRCETTE another oral contraceptive (see section 6-D)

NASACORT fluticasone

NASACORT AQ fluticasone

NASAREL fluticasone

NASCOBAL cyanocobalamin injection

NEXIUM omeprazole, pantoprazole

NORDETTE LEVLEN (see section 6-D)

NORINYL ORTHO-NOVUM (see section 6-D)

NOR-QD MICRONOR (see section 6-D)

NULEV generic Levsin, Levbid

ONE TOUCH TEST STRIPS ACCU-CHECK DIABETIC STRIPS

ORAMORPH morphine sulfate (MS CONTIN)

OVCON another oral contraceptive (see section 6-D)

OVRAL another oral contraceptive (see section 6-D)

OVRETTE another oral contraceptive (see section 6-D)

OXYCONTIN morphine sulfate SR (MS CONTIN)

PATANOL flurbiprofen, ZADITOR

PAXIL CR paroxetine

PENTASA APRISO, ASACOL, ASACOL HD

PERIOSTAT doxycycline

PLETAL pentoxifylline

PREVACID omeprazole, pantoprazole

PROTOPIC ELIDEL

PROZAC WEEKLY fluoxetine

PULMICORT ASMANEX, QVAR

RELION insulins NOVOLIN insulins

RELPAX sumatriptan



30 Medicaid Drug Benefit Guide 10/01/11

Preferred Alternatives

RESCULA LUMIGAN, TRAVATAN

RITALIN LA dextroamphetamine, methylphenidate, ADDERALL XR

SAIZEN TEVTROPIN

SARAFEM fluoxetine

SKELAXIN baclofen, carisoprodol, methocarbamol

TARKA benzepril-hctz , lisinopril-hctz, quinapril-hctz, enalapril-hctz

TEVETEN losartan

Ticlopidine (TICLID) PLAVIX

TOFRANIL PM imipramine

TOLBUTAMIDE glipizide, glyburide, AMARYL

TRI-NASAL fluticasone

TRI-NORINYL another oral contraceptive (see section 6-D)

TRIPHASIL TRI-LEVLEN (see section 6-D)

VALCYTE CYTOVENE

VALTREX acyclovir

VERELAN PM verapamil

XALATAN LUMIGAN, TRAVATAN

XOPENEX albuterol nebs

ZEGERID (generic) omeprazole, pantoprazole

ZYPREXA RISPERDAL, SEROQUEL









31 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



abacavir sulfate 1-I albuterol tablets 12-D

acarbose 6-F albuterol-ipratropium nebulizer 12-D

ACCOLATE 12-D alclometasone 5-H

ACCU-CHEK ACTIVE CARE KIT 6-K ALDACTAZIDE 3-J

ACCU-CHEK ACTIVE TEST STRIPS 6-K ALDACTONE 3-J

ACCU-CHEK ADVANTAGE CARE KIT 6-K ALDARA 5-I

ACCU-CHEK AVIVA CARE KIT 6-K ALDOMET 3-H

ACCU-CHEK AVIVA TEST STRIPS 6-K ALDORIL 3-I

ACCU-CHEK COMFORT CURVE TEST STRIPS 6-K alendronate 6-J

ACCU-CHEK COMPACT CARE KIT 6-K ALKERAN 2-A

ACCU-CHEK COMPACT TEST STRIPS 6-K ALLEGRA 12-A

ACCUPRIL 3-F ALLERX-D 12-C

ACCURETIC 3-I allopurinol 9-F

ACCUZYME 5-I ALOXI (tablets) 13-I

acebutolol 3-C ALPHAGAN P 11-G

acetazolamide 3-J alprazolam 4-A

acetylcysteine 12-C alprazolam SR 4-A

ACLOVATE 5-H ALREX 11-C

ACTHAR HP 13-I ALTACE 3-F

ACTIGALL 7-H altretamine 2-A

ACTIMMUNE 13-I aluminum chloride 5-I

ACTOPLUS MET 6-F ALUPENT (nebulizer) 12-D

ACTOS 6-F ALUPENT (tablets) 12-D

ACULAR 11-H ALUPENT INHALER 12-D

ACULAR LS 11-H AMANTADINE (Symmetrel) 4-H

acyclovir 1-H AMARYL 6-F

acyclovir topical 5-E AMBIEN 4-C

ADAGEN 7-G AMICAR 10-F

ADALAT 3-D amiloride 3-J

ADALAT CC 3-D amiloride-HCTZ 3-J

adalimumab 13-H aminocaproic acid 10-F

ADDERALL 4-E aminophylline 12-D

ADDERALL XR 4-E amiodarone 3-E

AEROLATE 12-D AMITIZA 7-H

AGENERASE 1-I amitriptyline 4-B

AGRYLIN 10-F amitriptyline-chlordiazepoxide 4-F

albuterol CR tablets 12-D amlodipine 3-D

albuterol HFA inhaler 12-D amlodipine-benazepril 3-I

albuterol nebulizer 12-D amoxapine 4-B

albuterol SR tablets 12-D amoxicillin 1-A



32 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



amoxicillin-clavulanate 1-A ARTANE 4-H

AMOXIL 1-A ASA-caffeine-butalbital 9-A

amphetamine-d-amphetamine 4-E ASA-caffeine-but-codeine 9-B

amphetamine-d-amphetamine SR 4-E ASA-codeine 9-B

ampicillin 1-A ASACOL 7-H

amprenavir 1-I ASACOL HD 7-H

AMRIX 9-G ASENDIN 4-B

amylase-lipase-protease 7-G ASMANEX 12-E

amy-lip-prot dr 7-G ASTELIN 12-B

ANADROL-50 13-I ASTEPRO 12-B

ANAFRANIL 4-B ATARAX 4-A

anagrelide 10-F atenolol 3-C

ANALPRAM-HC 5-A atenolol-chlorthalidone 3-I

ANAMANTLE 5-I ATIVAN 4-A

ANAPROX 9-C atomoxetine 4-E

anastrozole 2-A atorvastatin 3-L

ANSAID 9-C atropine ophth 11-E

ANTABUSE 4-F ATROVENT (nebulizer) 12-D

anthralin 5-F ATROVENT HFA 12-D

ANTIVERT 7-F ATROVENT INHALER 12-D

ANUSOL-HC 5-A ATROVENT NASAL 12-B

APAP-butalbital 9-A augmented betamethasone 5-H

APAP-caffeine-butalbital 9-A AUGMENTIN 1-A

APAP-codeine 9-B AURALGAN 11-I

APAP-hydrocodone 9-B auranofin 9-D

APAP-isometh-dichlor hydrate 9-E AVC vaginal 8-C

APOKYN 4-H AVIANE 6-D

apomorphine 4-H AVONEX 13-E

APRESOLINE 3-H AXID 7-D

APRI 6-D AYGESTIN 6-E

APRISO 7-H azatadine-pseudoephedrine CR 12-C

AQUATENSEN 3-J azathioprine 2-B

ARALEN 1-J azelastine nasal 12-B

ARANESP 13-C azithromycin 1-C

ARAVA 9-D aztreonam 1-A

ARCALYST 13-I AZULFIDINE 7-H

ARICEPT 4-F AZULFIDINE EN 7-H

ARIMIDEX 2-A B complex-vit C-FA 10-B

ARMOUR THYROID 6-I bacitracin ophth 11-A

AROMASIN 2-A bacitracin-polymyxin B ophth 11-A



33 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



baclofen 9-G brimonidine ophth 11-G

bac-polymy-neomycin HC oint 5-C brimonidine timolol ophth 11-B

BACTRIM 1-L bromocriptine (tablets) 4-H

BACTROBAN 5-C buconazole vaginal 8-C

BACTROBAN CREAM 5-C budesonide formoterol inhaler 12-D

BACTROBAN NASAL OINTMENT 5-C budesonide SR 7-H

balsalazide 7-H bumetanide 3-J

beclomethasone HFA inhaler 12-E BUMEX 3-J

benazepril 3-F BUPHENYL 7-G

benazepril-HCTZ 3-I buprenorphine naloxone 9-B

BENEMID 9-F bupropion 4-B

BENTYL 7-C bupropion SR 4-B

BENZAMYCIN 5-B bupropion XL 4-B

benzocaine-antipyrine otic 11-I BUSPAR 4-A

benzonatate 12-C buspirone 4-A

benzoyl peroxide 5-B busulfan 2-A

benzoyl peroxide-erythromycin gel 5-B butorphanol 9-B

benztropine 4-H BYETTA 6-J

BETAGAN 11-B BYSTOLIC 3-C

betamethasone dipropionate 5-H caberoline 6-J

betamethasone valerate 5-H CAFERGOT 9-E

BETAPACE 3-C CALAN 3-D

BETAPACE AF 3-C CALAN SR 3-D

betaxolol 3-C CALCIFEROL 10-A

bethanechol 8-B calcipotriene 5-F

BETIMOL 11-B calcitonin 6-J

BIAXIN 1-C calcitonin (salmon) nasal 6-J

BIAXIN XL 1-C calcitriol 10-A

bicalutamide 2-A calcitriol ointment 5-F

BICITRA 8-D calcium acetate (phosphate binder) 7-H

bimatoprost ophth 11-D CAMILA 6-D

BIO-STATIN 1-G CANASA 7-H

bisoprolol 3-C CAPOTEN 3-F

bisoprolol-HCTZ 3-I CAPOZIDE 3-I

BLEPH-10 11-A captopril 3-F

BLEPHAMIDE 11-C captopril-HCTZ 3-I

BLOCADREN 3-C CARAFATE 7-C

bosentan 3-H carbamazepine 4-G

BRETHINE 12-D carbamazepine SR 4-G

BREVOXYL 5-B CARBATROL 4-G



34 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



carbidopa-levodopa 4-H certolizumab pegol 13-H

carbidopa-levodopa CR 4-H chloral hydrate 4-C

carbinoxamine-PSE 12-C chlorambucil 2-A

carbinoxamine-PSE-DM 12-C chlordiazepoxide 4-A

cardec DM 12-C chlorhexidine 11-J

CARDENE 3-D chloroquine 1-J

CARDIZEM 3-D chlorothiazide 3-J

CARDIZEM SR 3-D chlorpheniramine 12-C

CARDURA 3-H chlorpheniramine-PSE 12-C

carisoprodol 9-G chlorphen-pyrilamine-PE 12-C

carisoprodol-ASA 9-G chlorpromazine 4-D

carisoprodol-ASA-codeine 9-G chlorpropamide 6-F

CARMOL 40 5-I chlorthalidone 3-J

CARMOL SCALP 5-I chlorzoxazone 9-G

CARNITOR 6-J cholestyramine 3-L

carteolol ophth 11-B choline-mag salicylates 9-A

cartia XT 3-D ciclopirox 5-D

carvedilol 3-C ciclopirox solution 5-D

CASODEX 2-A cilostazol 10-F

CATAFLAM 9-C CILOXAN 11-A

CATAPRES 3-H cimetidine 7-D

CATAPRES-TTS 3-H CIMZIA 13-H

CAYSTON 1-A CIPRO 1-E

CECLOR 1-B CIPRO XR 1-E

CECLOR CD 1-B ciprofloxacin 1-E

CEENU 2-A ciprofloxacin ophth 11-A

cefaclor 1-B ciprofloxacin SR 1-E

cefaclor ER 1-B citalopram 4-B

cefadroxil 1-B citric acid-sodium citrate 8-D

cefdinir 1-B clarithromycin 1-C

cefpodoxime 1-B clarithromycin SR 1-C

cefprozil 1-B clemastine 12-A

CEFTIN 1-B CLEOCIN 1-C

cefuroxime 1-B CLEOCIN vaginal cream 8-C

CEFZIL 1-B CLEOCIN-T 5-B

CELEXA 4-B CLIMARA 6-C

CELLCEPT 2-B clindamycin 1-C

CENESTIN 6-C clindamycin topical 5-B

cephalexin 1-B clindamycin vaginal 8-C

cephradine 1-B CLINORIL 9-C



35 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



clobetasol foam 5-H CORZIDE 3-I

clobetasol propionate 5-H COSOPT 11-B

clomipramine 4-B COTAZYM 7-G

clonazepam 4-G COUMADIN 10-F

clonidine 3-H COZAAR 3-G

clonidine patch 3-H CREON 7-G

clopidogrel 10-F CRIXIVAN 1-I

clorazepate 4-A CROLOM ophth 11-H

clotrimazole 5-D cromolyn sodium inhaler 12-D

clotrimazole troche 11-J cromolyn sodium nebulizer 12-D

clotrimazole-betamethasone 5-D cromolyn sodium ophth 11-H

clozapine 4-D CUPRIMINE 9-D

CLOZARIL 4-D CUTIVATE 5-H

CODEINE PHOSPHATE 9-B cyanocobalamin inj 10-C

CODEINE SULFATE 9-B cyclobenzaprine 9-G

CODIMAL DH 12-C CYCLOGYL 11-E

COGENTIN 4-H cyclopentolate ophth 11-E

COLAZAL 7-H cyclophosphamide 2-A

COLBENEMID 9-F cyclosporine 2-B

colchicine-probenecid 9-F cyclosporine modified 2-B

COLESTID 3-L CYLERT 4-F

colestipol 3-L cyproheptadine 12-A

COLYTE 7-A CYTOMEL 6-I

COMBIGAN 11-B CYTOTEC 7-C

COMBIVIR 1-I CYTOVENE 1-H

COMPAZINE 4-D CYTOXAN 2-A

COMTAN 4-H DALMANE 4-C

CONDYLOX 5-I dalteparin sodium 13-A

COPAXONE 13-E danazol 6-B

CORDARONE 3-E DANOCRINE 6-B

COREG 3-C DANTRIUM 9-G

CORGARD 3-C dantrolene 9-G

CORTEF 6-A dapsone 1-L

corticotropin 13-I DAPSONE 1-L

cortisone acetate 6-A DARAPRIM 1-J

CORTISPORIN CREAM 5-C darbepoetin alpha 13-C

CORTISPORIN OINTMENT 5-C darifenacin 8-B

CORTISPORIN OPHTH 11-C DARVOCET N 100 9-B

CORTISPORIN otic 11-I DARVOCET N 50 9-B

CORTONE 6-A DARVON 9-B



36 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



DAYPRO 9-C DIFLUNISAL 9-A

DDAVP 6-J digoxin 3-A

DECADRON 6-A DILANTIN 4-G

DECADRON ophth 11-C DILAUDID 9-B

DECONAMINE 12-C diltiazem 3-D

deferasirox 9-D diltiazem SR 3-D

DEMADEX 3-J diltiazem SR 12HR 3-D

DEMEROL 9-B diphenoxylate-atropine 7-B

DEPAKENE 4-G dipivefrin ophth 11-G

DEPAKOTE 4-G DIPROLENE 5-H

DEPAKOTE ER 9-E DIPROLENE AF 5-H

DEPEN 9-D DIPROSONE 5-H

DERMATOP 5-H dipyridamole 10-F

desipramine 4-B DISALCID 9-A

desmopressin (nasal) 6-J disopyramide 3-E

desmopressin (oral) 6-J disulfiram 4-F

desonide 5-H DITROPAN 8-B

DESOWEN 5-H DITROPAN XL 8-B

desoximetasone 5-H DIURIL 3-J

DESOXYN 4-E divalproex sodium (migraine) 9-E

DESYREL 4-B divalproex sodium EC 4-G

dexamethasone 6-A DIVIGEL 6-C

dexamethasone phosphate ophth 11-C donepezil 4-F

DEXEDRINE 4-E DONNATAL 7-C

DEXEDRINE SPANSULES 4-E dornase alfa 1-L

dexmethylphenidate 4-E dorzolamide ophth 11-H

dextroamphetamine 4-E dorzolamide-timolol ophth 11-B

DIABETA 6-F DOSTINEX 6-J

DIABINESE 6-F DOVONEX 5-F

DIAMOX 3-J doxazosin 3-H

diazepam 4-A doxepin 4-B

diclofenac 9-C doxycycline 1-D

diclofenac potassium 9-C doxycycline hyclate 1-D

diclofenac SR 9-C doxycycline monohyclate 1-D

dicloxacillin 1-A drospirenone-ethyinyl 6-D

dicyclomine 7-C DRYSOL 5-I

didanosine 1-I DUET DHA 10-B

DIDRONEL 6-J DUET DHA EC 10-B

diflorasone diacetate 5-H DUETACT 6-F

DIFLUCAN 1-G DUONEB 12-D



37 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



DURAGESIC 9-B ergocalciferol [vitamin D] 10-A

DURICEF 1-B ergoloid mesylates 4-F

DYAZIDE 3-J ergotamine-caffeine 9-E

DYNACIRC 3-D ergotamine-phenobarb-belladona 9-E

DYNAPEN 1-A ERRIN 6-D

econazole 5-D ERYGEL 5-B

ED CHLORPED 12-C ERYPED 1-C

EES 1-C ERY-TAB 1-C

EES-sulfisoxazole 1-L ERYTHROCIN 1-C

EFFEXOR 4-B ERYTHROMYCIN BASE 1-C

EFUDEX 5-I erythromycin EC 1-C

ELAVIL 4-B erythromycin estolate 1-C

ELESTAT 11-H erythromycin ethylsuccinate 1-C

eletriptan 9-E erythromycin stearate 1-C

ELIDEL 5-I erythromycin topical 5-B

ELIMITE 5-G ESGIC PLUS 9-A

ELIPHOS 7-H ESKALITH 4-D

ELMIRON 8-D ESKALITH CR 4-D

ELOCON 5-H estazolam 4-C

EMCYT 2-A esterified estrogens 6-C

EMLA cream 5-I ESTRACE 6-C

EMPIRIN w/CODEINE 9-B ESTRACE vaginal 8-C

emtricitabine 1-I estradiol 6-C

EMTRIVA 1-I estradiol patch 6-C

ENABLEX 8-B estradiol TD gel 6-C

enalapril 3-F estradiol vaginal 8-C

enalapril-HCTZ 3-I estradiol-norgestimate 6-C

ENBREL 13-H estramustine 2-A

enfuvirtide 1-I ESTRATEST 6-C

ENJUVIA 6-C ESTRATEST HS 6-C

ENPRESSE 6-D estrogen-medroxyprogesterone 6-C

entacapone 4-H estrogens (conjugated synthetic) 6-C

ENTOCORT EC 7-H estrogens (conjugated) vaginal 8-C

ENTUSS 12-C estrogens-methyltestosterone 6-C

EPIFOAM 5-H estropipate 6-C

epinastine 11-H estropipate vaginal 8-C

epinephrine inj 3-K ESTROSTEP FE 6-D

EPIPEN 3-K etanercept for subcutaneous 13-H

EPIPEN JR 3-K ethambutol 1-F

EPIVIR HBV 7-H ETHMOZINE 3-E



38 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



ethosuximide 4-G flunisolide nasal 12-B

etidronate 6-J fluocinolone acetonide 5-H

etodolac 9-C fluocinonide 5-H

etodolac SR 9-C fluorometholone ophth 11-C

etoposide 2-A fluorouracil 5-I

ETRAFON 4-F fluoxetine 4-B

EULEXIN 2-A fluphenazine 4-D

EVISTA 6-J flurazepam 4-C

EXELON 4-F flurbiprofen 9-C

exemestane 2-A flurbiprofen ophth 11-H

exenatide 6-J flutamide 2-A

EXJADE 9-D fluticasone 5-H

famciclovir 1-H fluticasone nasal 12-B

famotidine 7-D fluvoxamine 4-B

FAMVIR 1-H FML FORTE 11-C

FA-vit B6-vit B12 10-C FML LIQUIFILM 11-C

FELDENE 9-C FML SOP 11-C

felodipine 3-D FOCALIN 4-E

FEMARA 2-A FOLBEE 10-C

fenofibrate 3-L FOLGARD RX 10-C

fenoprofen 9-C folic acid 10-C

fentanyl patch 9-B FOLTX 10-C

fexofenadine 12-A FORADIL 12-D

filgrastim 13-C formoterol inhaler 12-D

finasteride 8-D FORTEO 13-F

FIORICET 9-A FORTICAL 6-J

FIORINAL 9-A FOSAMAX 6-J

FIORINAL w/CODEINE 9-B fosinopril 3-F

FLAGYL 1-L fosinopril-HCTZ 3-I

flavoxate 8-B FOSRENOL 7-H

flecainide 3-E FRAGMIN 13-A

FLEXERIL 9-G FURADANTIN 8-A

FLOMAX 8-D furosemide 3-J

FLONASE 12-B FUZEON 1-I

FLORINEF 6-A gabapentin 4-G

FLOXIN 1-E GABARONE 4-G

FLOXIN OTIC 11-I galantamine 4-F

fluconazole 1-G ganciclovir 1-H

fludrocortisone 6-A GANTANOL 1-L

FLUMADINE 1-H GANTRISIN 1-L



39 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



GARAMYCIN 5-C HUMALOG MIX PEN 6-G

gemfibrozil 3-L HUMALOG PEN 6-G

GENGRAF 2-B HUMIRA 13-H

GENTAMICIN OINT 3% 11-A HUMULIN 6-G

gentamicin topical 5-C HUMULIN PEN 6-G

gentamycin sulfate ophth 11-A HYCODAN 12-C

glatiramer acetate 13-E HYDERGINE 4-F

glimepiride 6-F hydralazine 3-H

glipizide 6-F HYDREA 2-A

glipizide CR 6-F hydrochlorothiazide 3-J

glipizide-metformin 6-F hydrocodone-guaifenesin 12-C

GLUCAGON 6-H hydrocodone-homatropine 12-C

GLUCOPHAGE XR 6-F hydrocortisone acetate 6-A

GLUCOTROL 6-F hydrocortisone butyrate 5-H

GLUCOTROL XL 6-F hydrocortisone rectal 5-A

GLUCOVANCE 6-F hydrocortisone topical 5-H

glyburide 6-F hydrocortisone valerate 5-H

glyburide-metformin 6-F hydrocortisone-acetic acid otic 11-I

glycopyrrolate 7-C hydrocortisone-pramoxine rectal 5-A

GLYNASE 6-F HYDRODIURIL 3-J

golimumab 13-H hydromorphone 9-B

GOLYTELY 7-A hydroxychloroquine 1-J

granisetron 7-F hydroxyurea 2-A

GRIFULVIN V 1-G hydroxyzine HCL 4-A

griseofulvin microsize 1-G hydroxyzine pamoate 4-A

griseofulvin ultramicrosize 1-G HYGROTON 3-J

GRIS-PEG 1-G HYLIRA 5-H

guaifenesin-codeine 12-C hyoscyamine 7-C

guanfacine 3-H hyoscyamine SR 7-C

guanfacine 4-F HYPER-SAL NEBULIZER 12-D

GYNAZOLE-1 8-C HYTONE 5-H

HALCION 4-C HYTRIN 3-H

HALDOL 4-D HYZAAR 3-I

halobetasol 5-H ibuprofen 9-C

haloperidol 4-D ibuprofen-hydrocodone 9-B

HEXALEN 2-A ILOSONE 1-C

HIVID 1-I IMDUR 3-B

homatropine ophth 11-E imipramine 4-B

HUMALOG 6-G imiquimod 5-I

HUMALOG MIX 6-G IMITREX 9-E



40 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



IMITREX NASAL 9-E JUNEL FE 6-D

IMURAN 2-B KALETRA 1-I

indapamide 3-J KARIGEL 11-J

INDERAL 3-C KARIGEL-N 11-J

INDERAL LA 3-C KARIVA 6-D

INDERIDE 3-I KAYEXALATE 10-F

indinavir sulfate 1-I KEFLEX 1-B

INDOCIN 9-C KENALOG 5-H

INDOCIN SR 9-C KENALOG-ORABASE 11-J

indomethacin 9-C KEPPRA 4-G

indomethacin CR 9-C KERALAC 5-I

insulin (human) 6-G KERLONE 3-C

insulin aspart 6-G ketoconazole 1-G

insulin aspart mix 6-G ketoconazole shampoo 5-D

insulin detemir 6-G ketoconazole topical 5-D

insulin glargine 6-G ketoprofen 9-C

insulin lispro 6-G ketorolac 9-C

insulin lispro mix 6-G ketorolac ophth 11-H

INTAL (nebulizer) 12-D ketotifen 11-H

INTAL INHALER 12-D KLARON 5-B

interferon beta-1A 13-E KLONOPIN 4-G

interferon gamma-1B 13-I K-PHOS 8-D

INTUNIV 4-F KWELL 5-G

INVEGA SUSTENNA 4-D KYTRIL 7-F

iodoquinol 1-L labetalol 3-C

ipratropium HFA inhaler 12-D LAC-HYDRIN 5-I

ipratropium inhaler 12-D lactic acid 5-I

ipratropium nasal 12-B lactulose 7-A

ipratropium nebulizer 12-D LAMICTAL 4-G

isoniazid 1-F LAMICTAL STARTER KIT 4-G

ISOPTO ATROPINE 11-E LAMISIL 1-G

ISOPTO CARPINE 11-F lamivudine (hepatitis) 7-H

ISOPTO HOMATROPINE 11-E lamivudine-zidovudine 1-I

ISORDIL 3-B lamotrigine 4-G

isosorbide dinitrate 3-B LANOXIN 3-A

isosorbide mononitrate 3-B lanreotide acetate 13-G

isradipine 3-D lanthanum 7-H

itraconazole 1-G LANTUS 6-G

JOLIVETTE 6-D LARIAM 1-J

JUNEL 6-D LASIX 3-J



41 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



leflunomide 9-D LODINE XL 9-C

LESSINA 6-D LOESTRIN 6-D

letrozole 2-A LOESTRIN FE 6-D

leucovorin calcium 2-A LOFIBRA 3-L

LEUKERAN 2-A LOMOTIL 7-B

LEVAQUIN 1-E lomustine 2-A

LEVBID 7-C LONITEN 3-H

LEVEMIR 6-G LOPID 3-L

levetiracetam 4-G lopinavir-ritonavir 1-I

LEVLEN 6-D LOPRESSOR 3-C

LEVLITE 6-D LOPROX 5-D

levobunolol ophth 11-B lorazepam 4-A

levocarnitine 6-J LORCET 9-B

levofloxacin 1-E LORTAB 9-B

LEVORA 6-D losartan 3-G

levothroid 6-I losartan-HCTZ 3-I

levothyroxine 6-I LOTEMAX 11-C

levoxyl 6-I LOTENSIN 3-F

LEVSIN 7-C LOTENSIN HCT 3-I

LEVSINEX 7-C loteprednol etb-tobramycin ophth 11-C

LIBRIUM 4-A loteprednol ophth 11-C

LIDEX 5-H LOTREL 3-I

lidocaine 11-J LOTRIMIN 5-D

lidocaine (topical) 5-I LOTRISONE 5-D

lidocaine/hydrocortisone 5-I lovastatin 3-L

lidocaine-prilocaine 5-I LOW-OGESTREL 6-D

LIMBITROL 4-F loxapine 4-D

lindane shampoo 5-G LOXITANE 4-D

LIORESAL 9-G LOZOL 3-J

liothyronine 6-I lubiprostone 7-H

LIPITOR 3-L LUDIOMIL 4-B

lisdexamfetamine dimesylate 4-E LUMIGAN 11-D

lisinopril 3-F LUTERA 6-D

lisinopril-HCTZ 3-I LUVOX 4-B

lithium carbonate 4-D LYSODREN 2-A

lithium carbonate CR 4-D LYSTEDA 10-F

LITHOBID 4-D MACROBID 8-A

L-methylfolate B12 B6 10-C MACRODANTIN 8-A

LOCOID 5-H maprotiline 4-B

LODINE 9-C MATULANE 2-A



42 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



MAVIK 3-F methotrexate 2-A

MAXIDONE 9-B methotrexate 9-D

MAXZIDE 3-J methyclothiazide 3-J

MEBARAL 4-C methyldopa 3-H

mebendazole 1-K methyldopa-HCTZ 3-I

meclizine 7-F METHYLIN 4-E

MEDROL 6-A METHYLIN ER 4-E

medroxyprogesterone 6-E methylphenidate 4-E

mefloquine 1-J methylphenidate CR 4-E

MEGACE 2-A methylprednisolone 6-A

megestrol 2-A metipranolol ophth 11-B

meloxicam 9-C metoclopramide 7-H

melphalan 2-A metolazone 3-J

MENEST 6-C metoprolol 3-C

meperidine 9-B metoprolol succinate SR 3-C

mephobarbital 4-C METROCREAM 5-B

MEPHYTON 10-A METROGEL vaginal 8-C

meprobamate 4-A METROLOTION 5-B

mercaptopurine 2-A metronidazole 1-L

mesalamine 7-H metronidazole cream 5-B

mesalamine CR 7-H metronidazole lotion 5-B

mesalamine EC 7-H metronidazole vaginal 8-C

mesalamine enema 7-H MEVACOR 3-L

mesna 2-A mexiletine 3-E

MESNEX 2-A MEXITIL 3-E

MESTINON 9-H MIACALCIN 6-J

METAGLIP 6-F MICROGESTIN 6-D

METANX 10-C MICROGESTIN FE 6-D

metaproterenol inhaler 12-D MICROZIDE 3-J

metaproterenol nebulizer 12-D midodrine 3-K

metaproterenol tablets 12-D MIDRIN 9-E

metformin 6-F miglustat 7-G

metformin SR 6-F MINIPRESS 3-H

METHADONE 9-B MINITRAN 3-B

methamphetamine 4-E MINOCIN 1-D

methazolamide 3-J minocycline 1-D

methenamine-NA biphosphate 8-A minoxidil 3-H

methimazole 6-I MIRAPEX 4-H

methocarbamol 9-G MIRCETTE 6-D

methocarbamol-ASA 9-G mirtazapine 4-B



43 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



mirtazapine soltabs 4-B NARDIL 4-B

misoprostol 7-C NASALIDE 12-B

mitotane 2-A NASAREL 12-B

MOBIC 9-C NATALCARE 10-B

MODICON 6-D nateglinide 6-F

MODURETIC 3-J NATELLE C 10-B

moexipril 3-F NATURE-THROID 6-I

moexipril-HCTZ 3-I NAVANE 4-D

mometasone 5-H nebivolol 3-C

mometasone inhaler 12-E NECON 6-D

MONONESSA 6-D NECON 10/11 6-D

MONOPRIL 3-F NECON 7/7/7 6-D

MONOPRIL HCT 3-I nedocromil inhaler 12-D

montelukast 12-D nefazodone HCL 4-B

moricizine 3-E neomycin 1-L

morphine sulfate 9-B neomycin-polymyxin B-gramacidin ophth 11-A

morphine sulfate SR 9-B neomycin-polymyxin-HC cream 5-C

MOTRIN 9-C neomycin-polymyxin-HC ophth 11-C

MS CONTIN 9-B neomycin-polymyxin-HC otic 11-I

MUCOMYST 12-C NEORAL 2-B

mupirocin 5-C NEOSPORIN ophth 11-A

MYAMBUTOL 1-F nepafenac ophth 11-H

MYCELEX TROCHE 11-J NEPHROCAPS 10-B

MYCIFRADIN 1-L NEPTAZANE 3-J

MYCOLOG II 5-D NESTABS 10-B

mycophenolate mofetil 2-B NEULASTA 13-C

MYCOSTATIN susp 1-G NEUMEGA 13-I

MYCOSTATIN topical 5-D NEUPOGEN 13-C

MYDRIACYL 11-E NEURONTIN 4-G

MYLERAN 2-A NEVANAC 11-H

MYSOLINE 4-G nevirapine 1-I

nabumetone 9-C nevirapine XR 1-I

nadolol 3-C nicardipine 3-D

nadolol-bendroflumethiazide 3-I nifedipine CR 3-D

nafarelin 13-G nifedipine IR 3-D

NALFON 9-C nitisinone 13-I

naltrexone 9-B NITROBID 3-B

NAPROSYN 9-C NITRO-DUR 3-B

naproxen 9-C nitrofurantoin macro 8-A

naproxen sodium 9-C nitrofurantoin macrocrystals 8-A



44 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



nitrofurantoin susp 8-A OCUPRESS 11-B

nitroglycerin ointment 3-B ofloxacin 1-E

nitroglycerin patch 3-B ofloxacin ophth 11-A

nitroglycerin spray 3-B ofloxacin otic 11-I

NITROLINGUAL PUMPSPRAY 3-B OGEN 6-C

nitroquick 3-B OGEN vaginal 8-C

NITROSTAT 3-B OGESTREL 6-D

nizatadine 7-D OLUX 5-H

NIZORAL 1-G omeprazole 7-E

NIZORAL SHAMPOO 5-D omeprazole-sodium bicarb 7-E

NOLVADEX 2-A OMNICEF 1-B

NORA-BE 6-D ondansetron 7-F

NORCO 9-B OPANA ER 9-B

norethindrone 6-E oprelvekin 13-I

NORFLEX 9-G OPTIPRANOLOL 11-B

NORITATE 5-B ORAPRED 6-A

NORMODYNE 3-C ORFADIN 13-I

NORPACE 3-E orphenadrine citrate 9-G

NORPRAMIN 4-B ORTHO CEPT 6-D

NORTHYX 6-I ORTHO CYCLEN 6-D

NORTREL 6-D ORTHO MICRONOR 6-D

NORTREL 7/7/7 6-D ORTHO NOVUM 1/35 6-D

nortriptyline 4-B ORTHO NOVUM 1/50 6-D

NORVASC 3-D ORTHO NOVUM 10/11 6-D

NOVAHISTINE 12-C ORTHO NOVUM 7/7/7 6-D

NOVOLIN 6-G ORTHO TRI-CYCLEN 6-D

NOVOLOG 6-G ORTHO TRI-CYCLEN LO 6-D

NOVOLOG MIX 6-G ORTHO-PREFEST 6-C

NULEV 7-C ORUDIS 9-C

NULYTELY 7-A oxandralone 13-I

NUVARING 6-D OXANDRALONE 13-I

nystatin 1-G oxaprozin 9-C

nystatin topical 5-D oxazepam 4-A

nystatin vaginal 8-C oxcarbazepine 4-G

nystatin-triamcinolone 5-D oxybutynin 8-B

OCTREOTIDE 13-G oxybutynin CR 8-B

octreotide acetate 13-G oxycodone 9-B

octreotide acetate release 13-G oxycodone-APAP 9-B

OCUFEN 11-H oxycodone-ASA 9-B

OCUFLOX 11-A OXYIR 9-B



45 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



oxymetholone 13-I PEPCID 7-D

oxymorphone ER 9-B PE-pyrilamine-hydrocodone 12-C

paliperidone palmitate 4-D PERCOCET 9-B

palonosetron 13-I PERCODAN 9-B

PAMELOR 4-B pergolide 4-H

PANCREASE MT 7-G PERIACTIN 12-A

PANCRECARB 7-G PERIDEX 11-J

pancrelipase 7-G PERIOSTAT 1-D

pantoprazole 7-E PERMAX 4-H

papain-urea 5-I permethrin 5-G

papain-urea-chlorophyllin foam 5-I perphenazine 4-D

PAPFYLL 5-I perphenazine-amitriptyline 4-F

PARAFON FORTE 9-G PERSANTINE 10-F

PARCOPA 4-H phenazopyridine 8-D

paricalcitol [vitamin D] 10-A phenelzine sulfate 4-B

PARLODEL 4-H PHENERGAN 12-A

paroxetine HCL 4-B PHENERGAN VC 12-C

PAXIL 4-B PHENERGAN w/CODEINE 12-C

ped multi vitamin-fluoride 10-B phenobarbital 4-C

ped multi vitamin-fluoride-FE 10-B phenobarbital-belladonna 7-C

ped vitamins ACD-fluoride 10-B phenytoin 4-G

ped vitamins ACD-fluoride-FE 10-B PHOSLO 7-H

PEDIAPRED 6-A PHRENILIN 9-A

PEDIATEX D 12-C phytonadione 10-A

PEDIATEX DM 12-C pilocarpine 11-J

PEDIAZOLE 1-L pilocarpine ophth 11-F

PEG electrolyte 7-A PILOPINE HS 11-F

peg(high)-electrolyte 7-A PILOPTIC-1/2 11-F

pegademase 7-G PILOPTIC-3 11-F

PEGASYS 13-D pimecrolimus 5-I

pegfilgrastim 13-C pindolol 3-C

peginterferon alfa-2A 13-D piolitazone 6-F

pegvisomant 13-G piolitazone-glimepiride 6-F

pemoline 4-F piolitazone-metformin 6-F

penicillamine 9-D piroxicam 9-C

penicillin V potassium 1-A PLAQUENIL 1-J

PENLAC 5-D PLAVIX 10-F

pentazocine-naloxone 9-B PLENDIL 3-D

pentosan polysulfate sodium 8-D PLETAL 10-F

pentoxifylline 10-F PLEXION 5-B



46 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



PODOCON 5-I prenatal vitamins-FE-FA-CA-omega 10-B

podofilox 5-I prenatal vitamins-iron carbonyl-FA 10-B

podophyllum resin 5-I PRENATE DHA 10-B

POLYSPORIN ophth 11-A PRENATE ELITE 10-B

POLYTRIM ophth 11-A prenate vitamin FE-Fum-Lmethylfol-FA-CA 10-B

POLY-VI-FLOR 10-B PREVIFEM 6-D

POLY-VI-FLOR-FE 10-B PRILOSEC 7-E

PORTIA 6-D PRIMACARE 10-B

POTABA 10-A primaquine 1-J

potassium aminobenzoate 10-A PRIMAQUINE 1-J

POTASSIUM CHLORIDE 8-D primidone 4-G

potassium citrate CR 8-D PRINCIPEN 1-A

potassium phosphate 8-D PRINIVIL 3-F

pramipexole 4-H PRINZIDE 3-I

pramlintide 6-J PROAMATINE 3-K

PRAMOSONE 5-H PRO-BANTHINE 7-C

pramoxine-HC cream 5-H probenecid 9-F

pramoxine-HC foam 5-H procainamide 3-E

PRANDIMET 6-F procainamide SR 3-E

PRANDIN 6-F PROCANBID 3-E

PRAVACHOL 3-L procarbazine HCL 2-A

pravastatin 3-L PROCARDIA 3-D

prazosin 3-H PROCARDIA XL 3-D

PRECARE 10-B prochlorperazine 4-D

PRECOSE 6-F PROCTOFOAM-HC 5-A

PRED FORTE 11-C PROGRAF 2-B

prednicarbate 5-H PROLIXIN 4-D

prednisolone 6-A promethazine 12-A

PREDNISOLONE 6-A promethazine VC 12-C

prednisolone ophth 11-C promethazine-codeine 12-C

prednisolone sodium 6-A PRONESTYL 3-E

prednisone 6-A propafenone 3-E

PRELONE 6-A propantheline 7-C

PREMARIN vaginal 8-C PROPINE 11-G

PREMPHASE 6-C propoxyphene 9-B

PREMPRO 6-C propoxyphene nap-APAP 9-B

prenatal FE-CBN-DSS-Methylfol-FA 10-B propoxyphene-APAP 9-B

prenatal vitamin-FE-bisglycinate-FA 10-B propranolol 3-C

prenatal vitamins-fe- bis-fe prot succ-fa-ca- 10-B propranolol HCL CR 3-C

prenatal vitamins-FE-FA 10-B propranolol-HCTZquinapril-HCTZ 3-I



47 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



propylthiouracil 6-I RELAFEN 9-C

PROSCAR 8-D RELPAX 9-E

PROSOM 4-C REMERON 4-B

PROTONIX 7-E REMERON SOLTABS 4-B

PROVENTIL (nebulizer) 12-D repaglinide 6-F

PROVENTIL (tablets) 12-D repaglinide-metformin 6-F

PROVENTIL REPETABS 12-D REQUIP 4-H

PROVERA 6-E RESTORIL 4-C

PROZAC 4-B RETIN-A 5-B

PSE-guaifenesin-codeine 12-C RETIN-A MICRO 5-B

PSE-methscopolamine 12-C RETROVIR 1-I

PSORCON 5-H REVIA 9-B

PSORIATEC 5-F ribavirin 1-H

PTU 6-I RIDAURA 9-D

PULMOZYME 1-L RIFADIN 1-F

PURINETHOL 2-A rifampin 1-F

pyrazinamide 1-F rilonacept 13-I

PYRIDIUM 8-D rimantadine 1-H

pyridostigmine 9-H rimexolone ophth 11-C

pyrilamine-phenyleph 12-C RISPERDAL 4-D

pyrimethamine 1-J RISPERDAL M 4-D

QUESTRAN 3-L risperidone 4-D

quetiapine fumarate 4-D RITALIN 4-E

quinapril 3-F RITALIN SR 4-E

quinidine gluconate 3-E rivastigmine 4-F

quinidine sulfate 3-E ROBAXIN 9-G

quinine sulfate 1-J ROBAXISAL 9-G

QVAR 12-E ROBINUL 7-C

raloxifene 6-J ROBINUL FORTE 7-C

ramipril 3-F ROCALTROL 10-A

RANEXA 3-M RONDEC 12-C

ranitidine 7-D RONDEC DM 12-C

ranolazine 3-M ropinirole 4-H

RAPAMUNE 2-B ROWASA 7-H

RAZADYNE 4-F ROXANOL 9-B

RAZADYNE ER 4-F ROXICODONE 9-B

REBETOL capsules/tablets 1-H RYNA-12 12-C

REBIF 13-E RYNATAN-S 12-C

RECLIPSEN 6-D RYTHMOL 3-E

REGLAN 7-H sacrosidase 7-G



48 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



SALAGEN 11-J SOMATULINE 13-G

salsalate 9-A SOMAVERT 13-G

SANDIMMUNE 2-B SOMNOTE 4-C

SANDOSTATIN LAR 13-G SONATA 4-C

SCOPACE 7-F sotalol 3-C

scopolamine oral 7-F sotalol AF 3-C

SECTRAL 3-C SPECTAZOLE 5-D

SELEGILINE 4-H SPIRIVA 12-D

selenium sulfide shampoo 5-I spironolactone 3-J

SELSUN 5-I spironolactone-HCTZ 3-J

SEPTRA 1-L SPORANOX 1-G

SERAX 4-A SPRINTEC 6-D

SEROQUEL 4-D SROYNX 6-D

SEROQUEL XR 4-D STADOL NS 9-B

SEROSTIM 13-B STARLIX 6-F

sertraline HCL 4-B stavudine 1-I

SERZONE 4-B STELAZINE 4-D

SILVADENE 5-C STRATTERA 4-E

silver sulfadiazine 5-C STUARTNATAL 10-B

SIMPONI 13-H SUBOXONE FILM TAB 9-B

simvastatin 3-L SUCRAID 7-G

SINEMET 4-H sucralfate 7-C

SINEMET CR 4-H sulfacetamide lotion (acne) 5-B

SINEQUAN 4-B sulfacetamide sodium ophth 11-A

SINGULAIR 12-D sulfacetamide-prednisolone ophth 11-C

sirolimus 2-B sulfacetamide-sulfur emulsion 5-B

SLO-PHYLLIN 12-D sulfacetamide-urea lotion 5-I

SMZ-TMP 1-L sulfadiazine 1-L

sodium chloride soln nebu 7% 12-D sulfamethoxazole 1-L

sodium fluoride 11-J sulfanilamide vaginal 8-C

sodium hyaluronate 5-H sulfasalazine 7-H

sodium oxybate 4-E sulfasalazine EC 7-H

sodium phenylbutyrate 7-G sulfinpyrazone 9-F

sodium polystyrene sulfonate 10-F SULFINPYRAZONE 9-F

SOLIA 6-D sulfisoxazole 1-L

solifenacin 8-B sulindac 9-C

SOMA 9-G sumatriptan 9-E

SOMA COMPOUND 9-G SUMATRIPTAN INJ 9-E

SOMA CPD w/CODEINE 9-G SUMYCIN 1-D

somatropin 13-B SYMBICORT 12-D



49 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



SYMLIN AMYLIN ANALOG 6-J thioridazine 4-D

SYNALAR 5-H thiothixene 4-D

SYNAREL 13-G THORAZINE 4-D

SYNTHROID 6-I thyroid 6-I

tacrolimus 2-B TIAZAC 3-D

TAGAMET 7-D TICLID 10-F

TALWIN NX 9-B ticlopidine 10-F

TAMBOCOR 3-E TIGAN 7-F

tamoxifen 2-A TILADE 12-D

tamsulosin 8-D TILIA FE 6-D

TAPAZOLE 6-I timolol maleate 3-C

TAVIST 12-A timolol maleate ophth 11-B

TEBAMIDE 7-F timolol ophth 11-B

TEGRETOL 4-G TIMOPTIC 11-B

TEGRETOL XR 4-G TIMOPTIC XE 11-B

temazepam 4-C tiotropium inhaler 12-D

TEMOVATE 5-H TIROSINT 6-I

TENEX 3-H tizanidine 9-G

tenofovir 1-I TOBI 1-L

TENORETIC 3-I TOBRADEX 11-C

TENORMIN 3-C tobramycin 1-L

TERAZOL 8-C tobramycin ophth 11-A

terazosin 3-H tobramycin-dexamethasone ophth 11-C

terbinafine HCL 1-G TOBREX 11-A

terbutaline 12-D tocainide 3-E

terconazole vaginal 8-C TOFRANIL 4-B

teriparatide (recombinant) 13-F tolazamide 6-F

TESLAC 2-A tolbutamide 6-F

TESSALON 12-C TOLBUTAMIDE 6-F

testolactone 2-A TOLECTIN 9-C

testolactone 2-A TOLINASE 6-F

tetracycline 1-D tolmetin sodium 9-C

TEV-TROPIN 13-B TONOCARD 3-E

THEO-24 12-D TOPAMAX 4-G

THEOLAIR 12-D TOPAMAX SPRINKLES 4-G

theophylline 12-D TOPICORT 5-H

theophylline CR 12-D topiramate 4-G

theophylline SR 12-D TOPROL XL 3-C

thioguanine 2-A TORADOL 9-C

THIOGUANINE 2-A torsemide 3-J



50 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



TRACLEER 3-H TRUSOPT 11-H

tramadol 9-B TRYCET 9-B

tramadol-APAP 9-B trypsin-castor oil-peruvian balsam 5-I

TRANDATE 3-C TUSSI-ORGANIDIN 12-C

trandolapril 3-F TWINJECT 3-K

tranexamic acid 10-F TYLENOL w/CODEINE 9-B

TRANXENE 4-A ULTRACET 9-B

travaprost ophth 11-D ULTRAM 9-B

TRAVATAN 11-D ULTRASE 7-G

trazodone 4-B ULTRASE MT 7-G

TRENTAL 10-F ULTRAVATE 5-H

tretinoin 2-A UNIPHYL 12-D

tretinoin 5-B UNIRETIC 3-I

triamcinolone acetonide 5-H unithroid 6-I

triamcinolone/orabase 11-J UNIVASC 3-F

triamterene-HCTZ 3-J urea 5-I

triazolam 4-C urea (carbamide) 5-I

TRICOR 3-L URECHOLINE 8-B

trifluoperazine 4-D URISPAS 8-B

trifluridine ophth 11-A UROCIT-K 8-D

trihexyphenidyl 4-H UROQID 8-A

TRILAFONE 4-D ursodiol 7-H

TRI-LEGEST FE 6-D VALISONE 5-H

TRILEPTAL 4-G VALIUM 4-A

TRI-LEVLEN 6-D valproic acid 4-G

TRILISATE 9-A VANAMIDE 5-I

trimethobenzamide 7-F VANDAZOLE 8-C

trimethobenzamide-benzocaine 7-F VANTIN 1-B

trimethoprim 1-L VASERETIC 3-I

trimethoprim-polymy B ophth 11-A VASOTEC 3-F

TRIMPEX 1-L VECTICAL 5-F

TRINALIN 12-C VEETIDS 1-A

TRINESSA 6-D VELOSEF 1-B

triple sulfas vaginal 8-C venlafaxine 4-B

TRI-PREVIFEM 6-D VENTOLIN HFA 12-D

TRI-SPRINTEC 6-D VEPESID 2-A

TRI-VI-FLOR 10-B verapamil 3-D

TRI-VI-FLOR-FE 10-B verapamil SR 3-D

TRIVORA 6-D VERELAN PM 3-D

tropicamide ophth 11-E VERMOX 1-K



51 Medicaid Drug Benefit Guide 10/01/11

Alphabetical Index

Drug Name PDL Section Drug Name PDL Section



VESANOID 2-A XYLOCAINE 5-I

VESICARE 8-B XYREM 4-E

VEXOL 11-C YASMIN 6-D

VFEND 1-G YAZ 6-D

VIBRAMYCIN 1-D YODOXIN 1-L

VIBRATABS 1-D ZADITOR 11-H

VICODIN 9-B zafirlukast 12-D

VICODIN ES 9-B zalcitabine 1-I

VICODIN HP 9-B zaleplon 4-C

VICOPROFEN 9-B ZANAFLEX 9-G

VIDEX EC 1-I ZANTAC 7-D

VIOKASE 7-G ZARONTIN 4-G

VIRAMUNE 1-I ZAROXOLYN 3-J

VIRAMUNE XR 1-I ZAVESCA 7-G

VIREAD 1-I ZEBETA 3-C

VIROPTIC 11-A ZEGERID 7-E

VISCOUS LIDOCAINE 11-J ZEMPLAR 10-A

VISKEN 3-C ZENPEP 7-G

VISTARIL 4-A ZERIT 1-I

VIVACTIL 4-B ZESTORETIC 3-I

VIVELLE 6-C ZESTRIL 3-F

VIVELLE DOT 6-C ZIAC 3-I

VOLTAREN 9-C ZIAGEN 1-I

VOLTAREN XR 9-C zidovudine 1-I

voriconazole 1-G ZITHROMAX 1-C

VOSOL-HC 11-I ZOCOR 3-L

VOSPIRE ER 12-D ZOFRAN 7-F

VYVANSE 4-E ZOFRAN ODT 7-F

warfarin 10-F ZOLOFT 4-B

WELLBUTRIN 4-B zolpidem 4-C

WELLBUTRIN SR 4-B ZONEGRAN 4-G

WELLBUTRIN XL 4-B zonisamide 4-G

WELLCOVORIN 2-A ZOVIRAX 1-H

WESTCORT 5-H ZOVIRAX topical 5-E

XANAX 4-A ZYDONE 9-B

XANAX XR 4-A ZYLET 11-C

XENADERM 5-I ZYLOPRIM 9-F









52 Medicaid Drug Benefit Guide 10/01/11