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					                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

				
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