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with criteria - MaineCare PDL - Excel

VIEWS: 63 PAGES: 51

									                                            MAINECARE PREFERRED DRUG LIST (with criteria)*
                                                            -- INDEX --
                    DRUG CATEGORY                           Page #                            DRUG CATEGORY                               Page #
ACE AND THIAZIDE COMBO'S                                        11   ARTHRITIS - MISC.                                                        25
ACE INHIBITORS                                                  10   ARTIFICIAL SALIVA/STIMULANTS                                             36
ACE INHIBITORS AND CA CHANNEL BLOCKERS                          11   BETA BLOCKERS - ALPHA / BETA                                              9
ALCOHOL DETERRENTS                                              22   BETA BLOCKERS - CARDIO SELECTIVE                                          9
ALS DRUG                                                        27   BETA BLOCKERS - NON SELECTIVE                                             9
ALTERNATIVE MEDICINES                                           36   BETA BLOCKERS AND DIURETIC COMBO'S                                       11
ALZHEIMER - Cholinomimetics/Others                              21   BETA-LACTAMS / CLAVULANATE COMBO'S                                        1
AMINO GLYCOSIDES                                                 2   BPH                                                                      17
ANALGESICS - MISC.                                              22   CALCIMIMETIC AGENTS                                                       8
ANDROGENS / ANABOLICS                                            5   CALCIUM CHANNEL BLOCKERS--Amlodipines, Bepridil, Diltiazems,              9
                                                                     Felodipines, Isradipines, Nifedipines, Nisoldipine, and Verapamils
ANESTHETICS - MISC.                                             25   CANCER THERAPIES                                                         37
ANGIOTENSIN RECEPTOR BLOCKER                                    10   CARBAPENEMS                                                               2
ANORECTAL - MISC.                                               36   CARDIAC GLYCOSIDES                                                        9
ANTHELMINTICS                                                    2   CCB / LIPID                                                              11
ANTI INFECTIVE COMBO'S - MISC.                                   2   CEPHALOSPORINS                                                            1
ANTIANGINALS--Isosorbide Di-nitrate                              9   CHELATING AGENTS                                                         36
ANTIARRHYTHMICS                                                 10   CHOLESTEROL - BILE SEQUESTRANTS                                          11
ANTIASTHMATIC - ANTICHOLINERGICS INHALER                        13   CHOLESTEROL - FIBRIC ACID DERIVATIVES                                    11
ANTIASTHMATIC - ANTICHOLINERGICS NEBULIZER                      13   CHOLESTEROL - HGM COA + ABSORB INHIBITORS                                11
ANTIASTHMATIC - 5-Lipoxygenase Inhibitors                       14   CHOLINERGIC                                                               9
ANTIASTHMATIC - ADRENERGIC ANTICHOLINERGIC                      13   CONTRACEPTIVES - BI-PHASIC COMBINATIONS                                   6
ANTIASTHMATIC - ADRENERGIC COMBOS                               13   CONTRACEPTIVES - EMERGENCY CONTRACEPTIVE                                  5
ANTIASTHMATIC - ALPHA-PROTEINASE INHIBITOR                      14   CONTRACEPTIVES - INJECTABLE                                               5
ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS                         13   CONTRACEPTIVES - PROGESTIN ONLY                                           5
ANTIASTHMATIC - BETA - ADRENERGICS                              13   CONTRACEPTIVES - TRI-PHASIC COMBINATIONS                                  6
ANTIASTHMATIC - HYDRO-LYTIC ENZYMES                             14   CONTRACEPTIVES -MONOPHASIC COMBINATION O/C'S                              6
ANTIASTHMATIC - MUCOLYTIC                                       14   CONTRACEPTIVES -PATCHES/ VAGINAL PRODUCTS                                 5
ANTIASTHMATIC - NASAL MISC.                                     13   COUGH/COLD                                                               14
ANTIASTHMATIC - NASAL STEROIDS                                  13   COX 2 INHIBITORS - SELECTIVE/ HIGHLY SELECTIVE                           24
ANTIASTHMATIC - STEROID INHALANTS                               14   CYTO-MEGALOVIRUS AGENTS                                                   4
ANTIASTHMATIC - XANTHINES                                       14   DENTAL PRODUCTS                                                          36
ANTIASTHMATIC -LEUKOTRIENE RECEPTOR ANTAGONISTS                 14   DIABETIC - DPP- 4 ENZYME INHIBITOR                                        7
ANTIBIOTICS - MISC.                                              2   DIABETIC - DPP- 4 ENZYME INHIBITOR - COMBO                                7
ANTICOAGULANTS                                                  30   DIABETIC - / THIAZOL                                                      8
ANTICONVULSANTS                                                 26   DIABETIC - INSULIN                                                        6
ANTIDEPRESSANTS - MAO INHIBITORS                                17   DIABETIC - ALPHAGLUCOSIDASE                                               8
ANTIDEPRESSANTS - SELECTED SSRI's                               17   DIABETIC - MEGLITINIDES                                                   8
ANTIDEPRESSANTS - TRI-CYCLICS                                   18   DIABETIC - ORAL SULFONYLUREAS                                             7
ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ SUBSTANCE P            12   DIABETIC - OTHER                                                          7
NEUROKININ
ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC                          DIABETIC - PENFILLS
                                                                12                                                                             6
ANTIFUNGALS - ASSORTED                                           3   DIABETIC - SULFONYLUREA / BIGUANIDE                                       8
ANTIHEMOPHILIC AGENTS                                           30   DIABETIC - THIAZOL / BIGUANIDE COMBO                                      7
ANTIHISTAMINES                                                  12   DIABETIC -ORAL BIGUANIDES                                                 7
ANTIHISTAMINES - NON-SEDATING                                   12   DIRECT RENIN INHIBITOR                                                   10
ANTIHYPERTENSIVES - CENTRAL                                     10   DIURETICS                                                                11
ANTILEPROTIC                                                    36   EAR                                                                      35
ANTIMALARIAL AGENTS                                              2   ELECTROLYTES/ NUTRITIONALS                                               29
ANTIMYCOBACTERIALS / ANTITUBERCULOSIS                            2   ERYTHROPOEITINS                                                          29
ANTINEOPLASTIC AGENTS- LHRH ANALOGS                             36   ESTROGEN COMBO'S                                                          5
ANTIPSYCHOTICS - ATYPICALS                                      18   ESTROGENS - PATCHES                                                       5
ANTIPSYCHOTICS - SPECIAL ATYPICALS                              19   ESTROGENS - TABS                                                          5
ANTIPSYCHOTICS - TYPICAL                                        19   FLUOROQUINOLONES                                                          2
ANTIRETROVIRALS                                                  3   GH ANTAGONISTS                                                            8
ANTISPASMODICS                                                   8   GI - ANTI - FLATULENTS / GI STIMULANTS                                   15
ANTISPASMODICS - LONG ACTING                                     9   GI - ANTIDIARRHEAL / ANTACID - MISC.                                     14
ANTITHYROID THERAPIES                                            8   GI - ANTIPERISTALTIC AGENTS                                              14
ANXIOLYTICS - BENZODIAZEPINES                                   17   GI - DIGESTIVE ENZYMES                                                   15
ANXIOLYTICS - LONG ACTING                                       17   GI - H2-ANTAGONISTS                                                      15
ANXIOLYTICS - MISC.                                             17   GI - INFLAMMATORY BOWEL AGENTS                                           15
ARB'S AND DIURETICS                                             11   GI - IRRITABLE BOWEL SYNDROME AGENTS                                     16
GI - MISC.                                                   16   OSTEOPOROSIS                                                         8
GI - PROSTAGLANDINS                                          15   PARKINSONS - DOPAMINERGICS/CARBII/ LEVO                             26
GI - PROTON PUMP INHIBITOR                                   15   PARKINSONS - ANTICHOLINERGICS                                       26
GI - ULCER ANT-INFECTIVE                                     15   PARKINSONS - COMBO.                                                 26
GLUCOCORTICOIDS/ MINERALOCORTICOIDS                           4   PARKINSONS - COMT INHIBITORS                                        26
GOUT                                                         26   PARKINSONS - SELECTED DOPAMIN AGONISTS                              26
GRANULOCYTE CSF                                              30   PHOSPHATE BINDERS                                                   16
GROWTH HORMONE                                                8   PLATELET AGGR. INHIBITORS / COMBO'S - MISC.                         30
HEMOSTATIC                                                   31   PLATELET AGGREGATION INHIBITORS                                     30
HEPATITIS B ONLY                                              4   PROGESTINS                                                           5
HEPATITIS C AGENTS                                            4   PSORIASIS BIOLOGICALS                                               35
HEPATITS AGENTS - MISC.                                       4   PSYCHOTHERAPEUTIC AGENS MISC.                                       21
HERED. TYROSINEMIA                                            9   PSYCHOTHERAPEUTIC COMBINATION                                       19
HERPES AGENTS                                                 4   PULMONARY ANTI-HYPERTENSIVES                                        12
IMMUNOSUPPRESSANTS                                           37   PURINE ANALOG                                                       36
IMPOTENCE AGENTS                                             12   RHEUMATOID ARTHRITIS                                                25
INCRETIN MIMETIC                                              7   RSV PROPHYLAXIS                                                      4
INFLUENZA AGENTS                                              4   SEDATIVE/HYPNOTICS - BARBITURATE                                    18
K REMOVING RESINS                                            37   SEDATIVE/HYPNOTICS - BENZODIAZEPINES                                18
LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS                  2   SEDATIVE/HYPNOTICS - Non-Benzodiazepines                            18
LITHIUM                                                      19   SOMATOSTATIC AGENTS                                                  8
LONG ACTING AMPHETAMINES                                     20   STIMULANT - AMPHETAMINES - LONG ACTING                              20
MACROLIDES / ERYTHROMYCIN'S                                   1   STIMULANT - AMPHETAMINES -SHORT ACTING                              19
MIGRAINE - CARBOXYLIC ACID DERIVATIVES                       25   STIMULANT - METHYLPHENIDATE                                         20
MIGRAINE - ERGOTAMINE DERIVATIVES                            25   STIMULANT - METHYLPHENIDATE - LONG ACTING                           21
MIGRAINE - MISC.                                             25   STIMULANT - STIMULANT LIKE                                          21
MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)--Injectables   25   TETRACYCLINES                                                        2
MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)--Tabs          26   THYROID HORMONES                                                     8
MINERALS                                                     28   TOPICAL - ANTIFUNGALS                                               33
MOUTH ANTI-INFECTIVES                                        36   TOPICAL - CORTICOSTEROIDS                                           33
MOUTH ANTISEPTICS                                            36   TOPICAL - ACNE PREPARATIONS                                         32
MULTIPLE SCLEROSIS AGENTS                                     4   TOPICAL - ANTIBIOTIC                                                33
MUSCLE RELAXANT -COMBINATIONS                                27   TOPICAL - ANTIPRURITICS                                             33
MUSCLE RELAXANTS                                             27   TOPICAL - ANTIPSORIATICS                                            33
NARCOTIC - ANTAGONISTS                                       24   TOPICAL - ANTISEBORRHEICS                                           33
NARCOTICS - MICS.                                            23   TOPICAL - ANTISEPTICS / DISINFECTANTS                               35
NARCOTICS - SELECTED                                         23   TOPICAL - ANTIVIRALS                                                33
NARCOTICS-LONG ACTING                                        22   TOPICAL - ANTNEOPLASTICS                                            33
NEUROLOGICS - MISC.                                           4   TOPICAL - ASTRINGENTS / PROTECTANTS                                 34
NICOTINE PATCHES / TABLETS                                   22   TOPICAL - BURN PRODUCTS                                             33
NICOTINE REPLACEMENT - OTHER                                 22   TOPICAL - DEPIGMENTING AGENTS                                       34
NITRO - OINTMENT/CAP/CR                                       9   TOPICAL - EMOLLIENTS                                                34
NITRO - PATCHES                                               9   TOPICAL - ENZYMES / KERATOLYTICS / UREA                             34
NITRO - SUBLINGUAL/ SPRAY                                     9   TOPICAL - GENITAL WARTS                                             34
NSAID PPI                                                    24   TOPICAL - IMMUNOMODULATORS                                          35
NSAIDS                                                       24   TOPICAL - LOCAL ANESTHETICS                                         35
OP. - ADRENERGIC AGENTS                                      31   TOPICAL - SCABICIDES AND PEDICULICIDES                              35
OP. - ANTIALLERGICS                                          32   TOPICAL - STEROID COMBINATIONS                                      34
OP. - ANTI-ALLERGICS-MASTCELL STABLIZER CLASS                32   TOPICAL - STEROID LOCAL ANESTHETICS                                 34
OP. - ANTIBIOTICS                                            30   TOPICAL - WOUND / DECUBITUS CARE                                    35
OP. - ANTIINFLAMMATORY / STEROIDS OPHTH.                     31   UROLOGICAL - MISC.                                                  16
OP. - ARTIFICIAL TEARS AND LUBRICANTS                        31   VAGINAL - ESTROGENS                                                 17
OP. - BETA - BLOCKERS                                        31   VAGINAL - ANTI FUNGALS                                              17
OP. - CARBONIC ANHYDRASE INHIBITORS/COMBO                    32   VAGINAL - ANTIBACTERIALS                                            17
OP. - CYCLOPLEGICS                                           31   VAGINAL - CONTRACEPTIVES                                            17
OP. - MIOTICS - DIRECT ACTING                                31   VAGINAL - OTHER                                                     17
OP. - NSAID'S                                                32   VASOPRESSINS                                                         8
OP. - OF INTEREST                                            32   VITAMINS                                                            27
OP. - PROSTAGLANDINS                                         31   VITAMINS - MISC.                                                    27
OP. - QUINOLONES                                             31   WEIGHT LOSS                                                         21
OP. - QUINOLONES 4TH GENERATION                              31                                                 *As of January 2009
OP. - SELECTIVE ALPHA ADRENERGIC AGONISTS                    32   Due to formatting page numbers may be off
OPIOID DEPENDENCE TREATMENTS                                 24
                                                                                                                                                   PDL Effective: January 1, 2010              Physicians' Summarized PDL

                                 Coverage                                                                    Coverage      Step        NON-PREFERRED DRUGS                            PA
          CATEGORY                         Step Order                   PREFERRED DRUGS                                                                                                              Comments                                                                                                     Criteria
                                 Indicator                                                                   Indicator     Order                      Required

* PLEASE NOTE: All cost effective generics applicable to DEL are considered PREFERRED Drugs. "BASIC" Covered Drugs are bolded with the Coverage Indicator of "MC / DEL".
General Criteria for all PDL categories- For more information or help using the PDL, providers may call 1-888-445-0497; members should call 1-866-796-2463. To access PDL and PA materials via the internet: www.mainecarepdl.org
A: Preferred Drugs- Unless otherwise specified, preferred drugs are available without prior authorization. Step order may apply for preferred drugs in some drug categories as indicated on the PDL. (See item "D" below for explanation of step order.)

B: Requests for Non-preferred Drugs- Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
between another drug and the preferred drug(s) exists.

C: Adequate Drug Trials- 1. The minimum trial period for each preferred and step order drug is two weeks, unless otherwise stated within specific PDL drug categories; trials with less than a two week duration will be reviewed on a case-by-case basis; 2. A trial will not be considered valid if preferred or non-preferred products were readily available (by override, individual
purchase, samples, etc.); 3. Certain drug trials, such as with controlled substances, may require evidence that the preferred drugs were actually tried (example: with random pill counts and with random urine drug tests, using the methods of GC/MS with no lower threshold); 4. Adequate trials require documentation of attempts to titrate dose of preferred agents toward desired
clinical response. 5. Adequate trials include prevention/treatment of common adverse effects associated with preferred agents (example: antinausea, antipruritics, etc.)

D: Step Order- When numbers appear in the "step order" column, it means drugs in this category must be used in the order specified, with the lower numbers having preference over the higher numbers. Chart notes should be provided to confirm drug trials that do not appear in the member's MaineCare drug profile.

E. The Department will institute strategies to ensure cost effectiveness through the use of an enhanced Drug Benefit Preferred brand drugs will no longer be preferred in any PDL drug category where preferred generic drugs are also available. It is expected that preferred generics will be used prior to any preferred brands. This will be operated as a form of step care. Preferred
brands in these categories will require prior authorization for these high utilization / high cost members.


F: Brand Name Medication Requests- (Must be submitted on the Brand Name PA request form)- According to MaineCare Benefits Manual Chapter II (80.07-5), when medically necessary covered brand-name drugs have an A-rated generic equivalent available, the most cost effective medically necessary version will be approved and reimbursed, since the brand-name and A-rated
generic drugs have been determined by the FDA to be chemically and therapeutically equivalent. The Bureau does not make determinations as to whether or not a generic drug is clinically inferior or inequivalent to its brand version. This is the proper role of the FDA. Physicians should submit their reports of generic inequivalence directly to the FDA via the MEDWATCH.


G: PA requests for non- FDA Approved Indications- Decisions will be made on a case-by-case basis until the DUR committee is able to review the evidence and make a recommendation. Interim approvals and DUR recommendations for approval of a drug for a non- FDA approved indication will require a minimum of two published, peer reviewed, non contradicted, double- blind,
placebo-controlled randomized clinical studies establishing both safety and efficacy.

H: Dose Consolidation Requirements- Some drugs may also be affected by dose consolidation requirements. Please see Dose Consolidation List and/or Splitting Tables provided in the PDL.

I. Trials from Multiple Drug Classes - Trial/failure/intolerance to preferred agents from multiple classes within the same category or other catagories of drugs may be required prior to the approval of non-preferred agents (e.g., Cymbalta, Zofran, Elidel and others).

J. Drug-specific PA Forms- Drug-specific PA forms contain medical necessity documentation requirements and/or criteria that may not be repeated in the PDL. Drug-specific PA forms may be obtained on the web at www.mainecarepdl.org .

K. PA Exemptions for Prescribers- According to MaineCare Benefits Manual Chapter II (80.07-4), providers may receive a three (3) month exemption from prior authorization requirement for certain categories of drugs when they demonstrate high compliance with the Department's PDL. The Department will notify providers in writing which drug categories are included and what
dates apply to the exemption. If a provider loses his/ her exemption, members who previously were not required to obtain a PA while the prescriber was exempt will be required to do so, and criteria for approval of that medication will need to be met.

L: Drug-Drug Interactions (DDI)- The DUR Committee has implemented new drug-drug interation edits requiring prior authorization. Several drug-drug combinations and PDL drug catagories are affected by new PA requirements. These will be indicated in the PDL with DDI notation. Please see the DDI document provided in the PDL.

                                                                                            ASSORTED ANTIBIOTICS
BETA-LACTAMS /                    MC/DEL                  AMOXICILLIN                                         MC/DEL                AMOXIL 500MG TABS                                        1. Amoxil 500mg tabs are Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
CLAVULANATE COMBO'S               MC/DEL                  AMOXICILLIN/POTASSIUM CLA CHEW                      MC/DEL                AUGMENTIN ES-600 SUSR                                    non-preferred. All other    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                  MC/DEL                                                                      MC/DEL                                                                         Amoxil products are         drug and the preferred drug(s) exists.
                                                          AMOXICILLIN/POTASSIUM CLA SUSR                                            AUGMENTIN3
                                                                                                                                                                                             preferred.      2.Principen
                                  MC/DEL                  AMOXICILLIN/POTASSIUM CLA TABS                      MC/DEL                AUGMENTIN XR TB124                                       250 mg is available without
                                  MC/DEL                  AMOXIL1                                               MC                  PRINCIPEN CAPS2                                          PA.
                                  MC/DEL                  AMPICILLIN                                            MC                  PRINCIPEN SUSR                                                                       DDI: Ampicillin will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, Protonix, Prilosec, or any currently non
                                     MC                   BEEPEN                                                                                                                             3. Chewable 125mg &         preferred PPI.
                                     MC                   BICILLIN L-A SUSP                                                                                                                  250mg and Solution
                                                                                                                                                                                             125mg/5ml and 250mg/5ml
                                  MC/DEL                  DICLOXACILLIN SODIUM CAPS
                                                                                                                                                                                             available without PA.
                                     MC                   DYNAPEN SUSR
                                     MC                   GEOCILLIN TABS
                                     MC                   OXACILLIN SODIUM SOLR                                                                                                               4. Use preferred generic
                                  MC/DEL                  PENICILLIN V POTASSIUM                                                                                                             amoxicillin/clavulanate
                                                                                                                                                                                             potassium alternatives.
                                     MC                   TICAR SOLR
                                     MC                   TIMENTIN SOLR                                                                                                                      Use PA Form# 20420
                                     MC                   TRIMOX
                                     MC                   UNASYN SOLR
                                     MC                   VEETIDS
                                  MC/DEL                  ZOSYN
CEPHALOSPORINS                    MC/DEL                  CEFADROXIL HEMIHYDRATE                                MC                  CECLOR1                                                  1. Both brand and generic Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                  MC/DEL                  CEFAZOLIN SODIUM SOLR                                 MC                  CEDAX                                                    are clinically non-preferred. offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                                                                                           drug and the preferred drug(s) exists.
                                  MC/DEL                  CEFDINIR                                            MC/DEL                CEFACLOR1
                                  MC/DEL                  CEFPODOXIME SUSP                                    MC/DEL                CEFADROXIL MONOHYDRATE TABS
                                  MC/DEL                  CEFPODOXIME 100MG                                   MC/DEL                CEFTIN
                                  MC/DEL                  CEFPODOXIME 200MG                                     MC                  CEFZIL
                                  MC/DEL                  CEFPROZIL                                           MC/DEL                DURICEF TABS
                                     MC                   CEFTAZIDIME 6MG                                     MC/DEL                FORTAZ
                                  MC/DEL                  CEFTIN SUSP                                         MC/DEL                FORTAZ SOLN
                                  MC/DEL                  CEFTRIAXONE                                           MC                  KEFLEX CAPS
                                  MC/DEL                  CEFUROXIME AXETIL TABS                                MC                  OMNICEF
                                  MC/DEL                  CEPHALEXIN MONOHYDRATE                              MC/DEL                ROCEPHIN
                                  MC/DEL                  DURICEF SUSR                                        MC/DEL                SUPRAX                                                   Use PA Form# 20420
                                  MC/DEL                  FORTAZ SOLR                                           MC                  TAZICEF SOLR                                                                          DDI: Vantin will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, Protonix, Prilosec, or any currently non
                                     MC                   KEFZOL SOLR                                         MC/DEL                TAZIDIME SOLN                                                                         preferred PPI.
                                     MC                   MAXIPIME SOLR                                       MC/DEL                VANTIN 200MG
                                     MC                   TAZICEF 6GM



                                                                                                                                                                                           Page 3 of 51
                           MC/DEL    TAZIDIME
                           MC/DEL    VANTIN 100MG
                           MC/DEL    VANTIN SUSP
MACROLIDES /                 MC      BIAXIN XL1                     MC/DEL   AZITHROMYCIN POWDER           1. 7- Day supply per month Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ERYTHROMYCIN'S             MC/DEL    AZITHROMYCIN TABS                       BIAXIN                        without PA.                offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                      MC
                                                                                                                                      drug and the preferred drug(s) exists.
                           MC/DEL    AZITHROMYCIN SUSP              MC/DEL   CLARITHROMYCIN SUSP
                           MC/DEL    CLARITHROMYCIN TABS            MC/DEL   DYNABAC D5-PAK TBEC
                             MC      E.E.S.                          MC      ERYPED CHEW                                                 DDI: Preferred erythromycin will now be non-preferred and require prior authorization if it is currently being used in combination with either Enablex 15mg or Vesicare 10mg. Any
                             MC      E-MYCIN TBEC                    MC      PCE TBEC                                                    non preferred formulation of erythromycin will require prior authorization and the member's drug profile will also be monitored for concurrent use with either Enablex 15mg or
                             MC                                     MC/DEL                                                               Vesicare 10mg.
                                     ERYPED 200 SUSR                         ZITHROMAX TABS                Use PA Form# 20420
                             MC      ERYPED 400 SUSR                MC/DEL   ZITHROMAX 1GM PAK
                             MC      ERY-TAB TBEC                   MC/DEL   ZITHROMAX TRI-PAK                                           DDI: Preferred clarithromycin formulations (clarithromycin tablets and Biaxin XL tablets) will now be non-preferred and require prior authorization if they are currently being used in
                             MC      ERYTHROCIN STEARATE TABS       MC/DEL                                                               combination with either Enablex 15mg or Vesicare 10mg. Any non preferred formulation of clarithromycin will require prior authorization and the member's drug profile will also be
                                                                             ZITHROMAX SUSP
                                                                                                                                         monitored for concurrent use with either Enablex 15mg or Vesicare 10mg.
                           MC/DEL    ERYTHROMYCIN                   MC/DEL   ZMAX
TETRACYCLINES              MC/DEL    DOXYCYCLINE HYCLATE             MC      DECLOMYCIN TABS               Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                           MC/DEL    MINOCYCLINE HCL CAPS           MC/DEL   DORYX CPEP                                                  unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of
                             MC      SUMYCIN                        MC/DEL   DOXYCYCLINE MONO CAPS                                       the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
                           MC/DEL    TETRACYCLINE HCL CAPS          MC/DEL   DYNACIN CAPS
                           MC/DEL    VIBRAMYCIN SYRP                 MC      MONODOX CAPS
                                                                     MC      ORACEA
                                                                    MC/DEL   PERIOSTAT
                                                                    MC/DEL   SOLODYN ER
FLUOROQUINOLONES             MC      AVELOX SOLN                     MC      CIPRO                         1. QL 3/script/month          Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC      AVELOX TABS                     MC                                                                  offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                             CIPRO XR1                     Use PA Form# 20420
                                                                                                                                         drug and the preferred drug(s) exists.
                             MC      AVELOX ABC PACK TABS            MC      FLOXIN TABS
                           MC/DEL    CIPROFLOXACIN                   MC      FACTIVE
                           MC/DEL    LEVAQUIN TABS                  MC/DEL   LEVAQUIN TABS SOLN/INJ                                      DDI: All preferred fluoroquinolones will require clinical PA for patients over 60 that are currently on immunosuppressants or steroid therapy.
                           MC/DEL    OFLOXACIN                       MC      NOROXIN TABS
                                                                     MC      PROQUIN XR
                                                                     MC      TEQUIN
AMINO GLYCOSIDES             MC      GENTAMICIN                                                                                          Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                           MC/DEL    NEOMYCIN SULFATE TABS                                                                               offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC                                                                                                          drug and the preferred drug(s) exists.
                                     TOBI NEBU
                           MC/DEL    TOBRAMYCIN SULFATE SOLN
ANTI-MYCOBACTERIALS / ANTI- MC/DEL   ETHAMBUTOL HCL TABS             MC      RIMACTANE CAPS                Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
TUBERCULOSIS                MC/DEL   MYAMBUTOL TABS                                                                                      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                           MC/DEL                                                                                                        drug and the preferred drug(s) exists.
                                     MYCOBUTIN CAPS
                           MC/DEL    RIFAMPIN
ANTIMALARIAL AGENTS        MC/DEL    CHLOROQUINE PHOSPHATE TABS      MC      ARALEN TABS                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                           MC/DEL    DARAPRIM TABS                   MC      ISONARIF1                                                   offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                           MC/DEL    HYDROXYCHLOROQUINE TABS        MC/DEL                                                               drug and the preferred drug(s) exists.
                                                                             MALARONE TABS                 1. Ingredients available as
                           MC/DEL    LARIAM TABS                    MC/DEL   PLAQUENIL TABS                preferred without PA.
                           MC/DEL    MEFLOQUINE HCL TABS             MC      QUALAQUIN
                             MC      QUINACRINE HCL POWD
                           MC/DEL    QUININE SULFATE
ANTHELMINTICS              MC/DEL    ALBENZA TABS                    MC      VERMOX CHEW                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC      BILTRICIDE TABS                                                                                     offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                           MC/DEL                                                                                                        drug and the preferred drug(s) exists.
                                     MEBENDAZOLE CHEW
                           MC/DEL    STROMECTOL TABS
ANTIBIOTICS - MISC.          MC      AZACTAM SOLR                    MC      COLY-MYCIN-M SOLR             1. Need to fail other anti-   Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC      COLISTIMETHATE SODIUM SOLR     MC/DEL   FLAGYL CAPS                   protozoals                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC                                     MC/DEL                                                               drug and the preferred drug(s) exists.
                                     FUROXONE TABS                           FLAGYL TABS                   2. 375mg caps and 750mg
                           MC/DEL    METRONIDAZOLE2                 MC/DEL   FLAGYL ER TBCR                tabs are non-preferred.   1. For macrolide resistant infections when quinolones inappropriate
                             MC                                     MC/DEL                                 Please use available
                                     PENTAMIDINE ISETHIONATE SOLR            KETEK
                                                                                                           preferred strengths(250mg
                             MC      PRIMSOL SOLN                   MC/DEL   LORABID                       & 500mg tabs) to obtain   DDI: Ketek is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with either Enablex 15mg or Vesicare
                           MC/DEL    TRIMETHOPRIM TABS              MC/DEL   METRONIDAZOLE 375MG CAPS2     required dose without PA. 10mg.
                             MC      VANCOCIN HCL                   MC/DEL   METRONIDAZOLE 750MG TABS2
                           MC/DEL    VANCOMYCIN 5GM INJ.             MC      NEBUPENT SOLR
                                                                    MC/DEL   PROLOPRIM TABS
                                                                     MC      TINDAMAX1                     3. Please use multiple 5gm
                                                                    MC/DEL   VANCOMYCIN 10GM INJ.3         which are preferred to
                                                                     MC                                    obtain dose without PA.
                                                                             XIFAXAN


                                                                                                           Use PA Form# 20420
CARBAPENEMS                                                          MC      INVANZ SOLR                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                     MC      MERREM SOLR                                                 offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                    MC/DEL                                                               drug and the preferred drug(s) exists.
                                                                             PRIMAXIN


LINCOSAMIDES /             MC/DEL    CLEOCIN SOLN                   MC/DEL   CLEOCIN CAPS                  1. Use multiple 150's for     Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
OXAZOLIDINONES /           MC/DEL    CLEOCIN SUSR                   MC/DEL                                 Clindamycin instead of        offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                             CLINDAMYCIN HCL 300CAPS1
LEPROSTATICS                                                                                               300's.                        drug and the preferred drug(s) exists. For Zyvox, please see the criteria listed in the Zyvox PA form.



                                                                                                         Page 4 of 51
OXAZOLIDINONES /                                                                                                                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
LEPROSTATICS                                                                                                                                               drug and the preferred drug(s) exists. For Zyvox, please see the criteria listed in the Zyvox PA form.

                           MC/DEL   CLINDAMYCIN HCL 150CAPS                     MC/DEL        ZYVOX SUSR                   Zyvox: use PA Form #
                                                                                                                           30820

                            MC      DAPSONE TABS                                MC/DEL        ZYVOX TABS                   Others: use PA Form #
                                                                                                                           20420
ANTI INFECTIVE COMBO'S -   MC/DEL   ERYTHROMYCIN/SULF SUSR                        MC          BACTRIM DS TABS              Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
MISC.                      MC/DEL   SEPTRA/DS TABS                                                                                                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                           MC/DEL                                                                                                                          drug and the preferred drug(s) exists.
                                    SULFAMETHOXAZOLE/TRIMETH
                           MC/DEL   TRIMETHOPRIM/SULFAMETHOXA
ANTIPROTOZOALS                                                                    MC          ALINIA1
                                                                                                                           1. Alina is preferred for
                                                                                                                           children less than 12 years
                                                                                                                           of age.
                                                                                                                           Use PA Form# 20420

                                                                    ANTI - FUNGALS
ANTIFUNGALS - ASSORTED      MC      ANCOBON CAPS                             MC/DEL       5   LAMISIL TABS4                1. QL--1/every 7-day period     Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                           MC/DEL                  1                              MC                                       (150mg only).
                                    FLUCONAZOLE                                           6   SPORANOX SOLN2
                                                                                                                           2. Sporanox QL
                           MC/DEL   GRIFULVIN V TABS10                            MC      6   SPORANOX PULSEPAK CAPS3      300cc/month with PA. See        unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of
                            MC      GRISEOFULVIN SUSP10                           MC      7   SPORANOX CAPS3               quantity limit table.           the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. The other criteria are listed
                            MC                                                  MC/DEL                                     3. Sporanox QL 30/month         on the Antifungal PA form including the required proof of a non-cosmetic fungal infection.
                                    GRISEOFULVIN ULTRAMICROSI TABS 10                     8   ERAXIS INJ6
                                                                                                                           with PA. See quantity limit
                            MC      GRIS-PEG TABS10                             MC/DEL    8   DIFLUCAN                     table. Non-preferred
                           MC/DEL   KETOCONAZOLE TABS8                            MC      8   GRIFULVIN SUSP               products must be used in
                                                                                                                           specified step order.           DDI: Preferred ketoconazole will now be non-preferred and require prior authorization if it is currently being used in combination with either Enablex 15mg or Vesicare 10mg.
                           MC/DEL   NYSTATIN                                      MC      8   NIZORAL TABS                 Continue to use Anti-Fungal
                                                                                                                           PA form for non-preferred
                           MC/DEL   TERBINAFINE TABS4                           MC/DEL    8   NOXAFIL5                                                     DDI: Any Griseofulvin will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, Protonix, Prilosec, or any currently
                                                                                                                           products.
                                                                                                                                                           non preferred PPI.


                           MC/DEL   VFEND TABS                                                                             4. Quantity limit of one        DDI: Sporanox is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for current use with Enablex 15mg, Vesicare 10mg,
                                                                                                                           tablet daily. Please see        Prandin, Prevacid, Protonix, Prilosec, or any currently non preferred PPI, due to a significant drug-drug interaction.
                                                                                                                           dosage consolidation list.

                                                                                                                                                     DDI: Fluconazole (except 150mg strength) will now be non-preferred and require prior authorization if it is currently being used with glimepiride (Amaryl), Enablex 15mg, or
                                                                                                                           5. Approved if immuno
                                                                                                                                                     Vesicare 10mg. Diflucan is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with either glimepiride
                                                                                                                           suppressed/ HIV or if the
                                                                                                                                                     (Amaryl), Enablex 15mg, or Vesicare 10mg.
                                                                                                                           member has failed a 7 day
                                                                                                                           trial of a preferred
                                                                                                                           antifungal therapy.

                                                                                                                           6. Eraxis will be approved if
                                                                                                                           submitting with
                                                                                                                           documentation that it was
                                                                                                                           initiated during a
                                                                                                                           hospitalization and this
                                                                                                                           request is to finish the
                                                                                                                           hospital course.


                                                                                                                           8. Quantity limits allowing
                                                                                                                           30 day supply without PA.
                                                                                                                           PA will be required if using
                                                                                                                           > 30 days.




                                                                                                                           10. For children < 18,
                                                                                                                           quantity limits allows 8
                                                                                                                           weeks supply without PA.
                                                                                                                           PA will be required if using
                                                                                                                           > than 8 weeks. If 18 and
                                                                                                                           older PA will be required for
                                                                                                                           any quantity. Not approving
                                                                                                                           for Onychomycosis
                                                                                                                           indication.
                                                                                                                           Please use PA form
                                                                                                                           #20420 for Noxafil.

                                                                        ANTI - VIRALS
ANTIRETROVIRALS            MC/DEL   AGENERASE CAPS                               MC/DEL       DIDANOSINE                   Fuzeon use PA Form #            Please refer to the criteria listed on the Fuzeon PA form.
                           MC/DEL   APTIVUS                                     MC/DEL        FUZEON3                      10620
                             MC     ATRIPLA 1                                   MC/DEL        INTELENCE   3

                           MC/DEL   COMBIVIR TABS                               MC/DEL        ISENTRESS3
                           MC/DEL   CRIXIVAN CAPS                               MC/DEL        RETROVIR                     1. Quantity limit of one per DDI: Reyataz will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, Protonix, Prilosec, or any currently non
                            MC      EMTRIVA                                     MC/DEL        SELZENTRY3                   day                          preferred PPI .
                           MC/DEL   EPIVIR / HBV                                  MC          ZERIT                        2. Only preferred if Norvir
                           MC/DEL   EPZICOM                                                                                script is in member's profile DDI: Preferred Norvir will now be non-preferred and require prior authorization if it is currently being used in combination with either Enablex 15mg or Vesicare 10mg.
                           MC/DEL                                                                                          within the past 30 days of
                                    FORTOVASE CAPS
                                                                                                                           filling Prezista
                            MC      HIVID TABS
                           MC/DEL   INVIRASE CAPS                                                                         3. Prescribers with >= 10   DDI: Preferred Crixivan caps will now be non-preferred and require prior authorization if it is currently being used in combination with either Enablex 15mg or Vesicare 10mg.
                            MC      KALETRA                                                                               ART scripts per quarter and
                                                                                                                          75% ART PDL compliance
                                                                                                                          will be exempt from PA for
                                                                                                                          these of 51
                                                                                                                        Page 5products.
                                                                                                         3. Prescribers with >= 10
                                                                                                         ART scripts per quarter and
                            MC/DEL                                                                       75% ART PDL compliance
                                     LEXIVA
                                                                                                         will be exempt from PA for
                             MC      NORVIR
                                                                                                         these products.
                             MC      PREZISTA2
                            MC/DEL   RESCRIPTOR TABS
                             MC      REYATAZ
                             MC      STAVUDINE
                             MC      SUSTIVA
                            MC/DEL   TRIZIVIR TABS
                             MC      TRUVADA
                             MC      VIDEX / EC
                            MC/DEL   VIRACEPT TABS
                            MC/DEL   VIRAMUNE TABS
                             MC      VIREAD TABS
                            MC/DEL   ZIAGEN TABS
                            MC/DEL   ZIDOVUDINE
CYTO-MEGALOVIRUS AGENTS      MC      FOSCARNET SODIUM                   MC           CYTOVENE CAPS       Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC      VALCYTE TABS                      MC/DEL        FOSCAVIR                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                       MC/DEL                                                           drug and the preferred drug(s) exists.
                                                                                     GANCICLOVIR


HERPES AGENTS               MC/DEL   ACYCLOVIR                         MC/DEL        FAMVIR TABS         Must fail Acyclovir and        Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
                            MC/DEL   VALTREX TABS                      MC/DEL        ZOVIRAX             Valtrex before non-            exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                         preferred products.            another drug and the preferred drug(s) exists.

                                                                                                         Use PA Form# 20420
INFLUENZA AGENTS            MC/DEL   AMANTADINE                        MC/DEL        FLUMADINE TABS      1. Tamiflu 10 caps or          Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
                                                                                                         60cc's per month.              exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                             MC      RELENZA DISKHALER AEPB             MC           FLUMIST2            Will be audited for presence another drug and the preferred drug(s) exists.
                                                                                                         of positive influenza tests in
                            MC/DEL   RIMANTADINE HCL TABS
                                                                                                         patient or family member.
                            MC/DEL   TAMIFLU1


                                                                                                         2. For Flumist requests
                                                                                                         use Form # 10610
                                                                                                         Others Use PA Form #
                                                                                                         20420

                                                              IMMUNE SERUMS
IMMUNE SERUMS                        HYPERRHO INJ
                                                              HEPATITIS AGENTS
HEPATITIS C AGENTS          MC/DEL   PEGASYS KIT1                       MC/DEL       COPEGUS TABS        1. Dosing limits apply,        Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
                            MC/DEL   PEGASYS SOLN                      MC/DEL        PEG-INTRON KIT2     please see dosage              exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                         consolidation list.            another drug and the preferred drug(s) exists.
                            MC/DEL   REBETRON KIT                      MC/DEL        REBETOL CAPS
                             MC      RIBAVIRIN                                                           2. Current users are
                                                                                                         grandfathered.
                                                                                                         Use PA Form# 20420


HEPATITIS AGENTS - MISC.                                                MC           ACTIMMUNE           Use PA Form# 20420             Approved for chronic granulomatous disease, osteopetrosis and idiopathic pulmonary fibrosis.
HEPATITIS B ONLY             MC      HEPSERA TABS                       MC           BARACLUDE
                                                                        MC           TYZEKA
                                                              RSV PROPHYLAXIS
RSV PROPHYLAXIS                                                         MC           SYNAGIS1            Use PA Form # 30120            Please see the criteria listed on the Synagis PA form.
                                                                                                         1. MaineCare will approve
                                                                                                         Synagis PA's for start date
                                                                                                         of November 23rd for
                                                                                                         infants who meet the
                                                                                                         guidelines. PA will be
                                                                                                         approved for max of 5
                                                                                                         doses. Maximum 1 dose/30
                                                                                                         days.




                                                              MS TREATMENTS
MULTIPLE SCLEROSIS -         MC      AVONEX KIT1                                                         1.Clinical PA is required to   Non-Preferred drugs must be tried in step-order and failed due to lack of efficacy or intolerable side effects before lower ranked non-preferred drugs will be approved , unless an
INTERFERONS                                                                                              establish diagnosis and        acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
                            MC/DEL   BETASERON SOLR1
                                                                                                         medical necessity.             interaction between another drug and the preferred drug(s) exists.
                             MC      REBIF SOLN1


MULTIPLE SCLEROSIS - NON-   MC/DEL   COPAXONE2                         MC/DEL    8   TYSABRI1            1. Providers must be
INTERFERONS                                                                                              enrolled in the TOUCH
                                                                                                         Prescribing program, a
                                                                                                         restricted distribution
                                                                                                         program. Clinical PA is
                                                                                                         required to establish
                                                                                                         diagnosis and medical
                                                                                                         necessity.




                                                                                                       Page 6 of 51
                                                                                                                    2. Clinical PA is required to
                                                                                                                    establish diagnosis and
                                                                                                                    medical necessity.

                                                                                                                    Use PA Form # 20430
                                                           ASSORTED NEUROLOGICS
NEUROLOGICS - MISC.      MC      MESTINON                               MC            BOTOX                         1. Myobloc approval will be Failed/did not tolerate therapeutic trials fo muscle relaxants, unless contraindicated, including but not limited to baclofen, cyclobenzaprine, orphenadrine, Skelaxin, and tizanidine.
                        MC/DEL   ORAP TABS                             MC/DEL         MYOBLOC1                      limited to Cervical Dystonia.


                         MC      PROSTIGMIN TABS                                                                    Use PA Form #10210
                                                                  STEROIDS
GLUCOCORTICOIDS/         MC      CELESTONE SUSP                         MC            CORTEF 10 and 20 TABS         Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
MINERALOCORTICOIDS      MC/DEL   CORTEF 5                               MC            DECADRON TABS                                                 offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                        MC/DEL                                         MC/DEL                                                                       drug and the preferred drug(s) exists.
                                 CORTISONE ACETATE TABS                               FLORINEF TABS
                        MC/DEL   DELTASONE TABS                        MC/DEL         MEDROL TABS
                        MC/DEL   DEPO-MEDROL SUSP                       MC            MEDROL DOSEPAK TABS
                        MC/DEL   DEXAMETHASONE                          MC            ORAPRED SOLN
                        MC/DEL   ENTOCORT EC CP24                       MC            PEDIAPRED LIQD
                        MC/DEL   FLUDROCORTISONE ACETATE TABS           MC            PREDNISONE INTENSOL CONC
                        MC/DEL   HYDROCORTISONE                         MC            PRELONE SYRP
                         MC      KENALOG                                MC            STERAPRED TABS                                                DDI: All preferred steroids will require clinical PA for patients over 60 that are currently on fluoroquinolone therapy.
                        MC/DEL   METHYLPREDNISOLONE TABS
                        MC/DEL   PREDNISOLONE
                        MC/DEL   PREDNISONE
                        MC/DEL   SOLU-CORTEF SOLR
                        MC/DEL   SOLU-MEDROL SOLR
                                                     HORMONE REPLACEMENT THERAPIES
ANDROGENS / ANABOLICS   MC/DEL   ANDRODERM PT24                      MC           ANDRO LA 200 OIL                  Use PA Form# 20420         Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                 ANDROGEL                               MC            DELATESTRYL OIL                                          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                        MC/DEL
                                                                                                                                               drug and the preferred drug(s) exists. Additionally, laboratory evidence of a testosterone deficiency must be supplied. One of each dosage form should be tried (tablet, injection,
                        MC/DEL   ANDROID CAPS                           MC            HALOTESTIN TABS               1. Non-preferred effective
                                                                                                                                               and topical)
                        MC/DEL   DANAZOL CAPS                          MC/DEL         METHITEST TABS                12.01.05.
                        MC/DEL   DEPO-TESTOSTERONE OIL                 MC/DEL         OXANDRIN TABS1                Use the Oxandrin PA Form
                        MC/DEL   FLUOXYMESTERONE TABS                  MC/DEL         TESTIM                        #20600
                        MC/DEL   TESTOSTERONE PROPIONATE
                         MC      TESTRED CAPS
                         MC      WINSTROL TABS
ESTROGENS - PATCHES /   MC/DEL   ESTRADERM PTTW1                       MC/DEL     5   ESTRADIOL PTWK                1. Both preferred drugs      Approved for failures on multiple oral estrogen agents after 90 day trials or if unable to swallow any oral medication.
TOPICAL                 MC/DEL   VIVELLE-DOT PTTW1                                8   ALORA PTTW                    must be tried. 2. Step order
                                                                       MC/DEL
                                                                                                                    drugs must be used in
                                                                       MC/DEL     8   CLIMARA PTWK
                                                                                                                    specified step order.
                                                                       MC/DEL     8   DIVIGEL
                                                                       MC/DEL     8   ELESTRIN
                                                                                  8   EVAMIST                       Use PA Form# 20420
ESTROGENS - TABS        MC/DEL   CENESTIN TABS                         MC/DEL         ENJUVIA                       Must fail preferred products Preferred drugs must be tried for at least 90 days and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
                        MC/DEL   ESTRADIOL                             MC/DEL         ESTRACE TABS                  before non-preferred         clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
                                                                                                                    products.                    between another drug and the preferred drug(s) exists.
                        MC/DEL   ESTROPIPATE TABS                       MC            ESTRATAB TABS
                        MC/DEL   MENEST TABS                           MC/DEL         OGEN TABS
                        MC/DEL   PREMARIN TABS                          MC            ORTHO-EST TABS                Use PA Form# 20420
ESTROGEN COMBO'S        MC/DEL   PREMPHASE TABS                        MC/DEL         ACTIVELLA TABS                Must fail Premphase and         Preferred drugs must be tried for at least 90 days and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
                        MC/DEL   PREMPRO TABS                          MC/DEL         COMBIPATCH PTTW               Prempro products before         clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
                                                                                      FEMHRT 1/5 TABS               non preferred products.         between another drug and the preferred drug(s) exists.
                                                                       MC/DEL
                                                                       MC/DEL         ORTHO-PREFEST TABS            Use PA Form# 20420
                                                                       MC/DEL         SYNTEST H.S. TABS
PROGESTINS              MC/DEL   MEDROXYPROGESTERONE ACETA 2           MC/DEL         AYGESTIN TABS                 1. PA approvals will require Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                        MC/DEL   NORETHINDRONE ACETATE TABS2            MC            CYCRIN TABS                   two 100 mg caps instead of offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC                                            MC/DEL                                       one 200mg.                   drug and the preferred drug(s) exists.
                                 PROGESTERONE POWD                                    PROMETRIUM 100MG CAPS   1

                                                                       MC/DEL         PROMETRIUM 200MG1             2. Must fail
                                                                       MC/DEL         PROVERA TABS                  Medroxyprogesterone and
                                                                                                                    Norethidrone products
                                                                                                                    before non-preferred
                                                                                                                    products.

                                                                                                                    Use PA Form# 20420
                                                               CONTRACEPTIVES
CONTRACEPTIVES -         MC      ORTHO MICRONOR TABS                   MC/DEL         CAMILA TABS                   If member experienced       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
PROGESTIN ONLY                                                                        ERRIN                         adverse reactions, consider offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                       MC/DEL
                                                                                                                    using Oral Contraceptives drug and the preferred drug(s) exists.
                                                                       MC/DEL         JOLIVETTE
                                                                                                                    from other groups.
                                                                       MC/DEL         NORA-BE TABS
                                                                       MC/DEL         NOR-QD TABS
                                                                       MC/DEL         OVRETTE 28 TABS               Use PA Form# 20420
CONTRACEPTIVES -        MC/DEL   MEDROXYPROGESTERONE ACETATE 150mg     MC/DEL         DEPO-PROVERA 150 mg SUSP      Use PA Form# 20420              The preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
INJECTABLE                       IM                                    MC/DEL         LUNELLE SUSP                                                  offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                    drug and the preferred drug(s) exists.



                                                                                                                  Page 7 of 51
CONTRACEPTIVES -                                                                                                                                    The preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
INJECTABLE                                                                                                                                          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                    drug and the preferred drug(s) exists.


CONTRACEPTIVE -              MC/DEL   NEXT CHOICE1                           MC/DEL     PLAN - B                     1. Allowed 4 tablets per 30
EMERGENCY                                                                                                            days without PA
                                                                                                                     Use PA Form# 20420




CONTRACEPTIVES - PATCHES/    MC/DEL   NUVARING RING3                                                                 1.No PA required for users Approved if adequate clinical reason given why patient unable to comply with other preferred agents including long acting injectable.
VAGINAL PRODUCTS              MC                                                                                     less than 21 years of age.
                                      ORTHO EVRA PTWK1,2,4
                                                                                                                     2. The FDA has issued a
                                                                                                                     public health warning of the
                                                                                                                     potentials for increased
                                                                                                                     exposure to estrogen with
                                                                                                                     Ortho Eva use, possibly up
                                                                                                                     to 60% estrogen
                                                                                                                     exposoure.


                                                                                                                     3. Quantity limit allowing 1
                                                                                                                     every 28 days with out PA.




                                                                                                                     4. Dose limits apply
                                                                                                                     allowing 3 patches per 28
                                                                                                                     days supply. Please refer to
                                                                                                                     Dose Consolidation Chart.
CONTRACEPTIVES -             MC/DEL   APRI TABS                              MC/DEL     AVIANE TABS                  Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
MONOPHASIC COMBINATION                                                       MC/DEL     BREVICON-28 TABS                                            offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC/DEL   BALZIVA
O/C'S                                                                                                                                               drug and the preferred drug(s) exists.
                             MC/DEL   CRYSELLE-28 TABS                        MC        DEMULEN 1/35-21 TABS
                             MC/DEL   DESOGEN TABS                           MC/DEL     KARIVA TABS                   If member experienced
                                                                             MC/DEL     LESSINA-28 TABS              adverse reactions, consider
                                      DESOGESTREL/ ETHINYL ESTRADIOL
                                                                                                                     using Oral Contraceptives
                             MC/DEL   LOW-OGESTREL TABS                      MC/DEL     LEVORA
                                                                                                                     from other groups.
                              MC      MODICON TABS                            MC        LOESTRIN TABS
                             MC/DEL   MONONESSA                              MC/DEL     LOESTRIN FE TABS
                              MC      ORTHO-CEPT-28 TABS                     MC/DEL     LOESTRIN FE 1/20 TABS
                               MC     ORTHO-CYCLEN-28 TABS                   MC/DEL     LOESTRIN 1.5/30-21 TABS
                               MC     ORTHO-NOVUM 1/35-28 TABS               MC/DEL     LOESTRIN 1/20-21 TABS
                               MC     ORTHO-NOVUM 1/50-28 TABS                MC        LO/OVRAL 21 TABS
                             MC/DEL   OVCON-50 28 TABS                       MC/DEL     LO/OVRAL 28 TABS
                             MC/DEL   PREVIFEM                               MC/DEL     MICROGESTIN FE TABS
                             MC/DEL   RECLIPSEN                              MC/DEL     MIRCETTE TABS
                             MC/DEL   SOLIA                                  MC/DEL     NECON
                             MC/DEL   SPRINTEC 28 TABS                       MC/DEL     NORDETTE-28 TABS
                             MC/DEL   YASMIN 28 TABS                         MC/DEL     NORINYL
                             MC/DEL   ZENCHENT                               MC/DEL     NORTREL
                             MC/DEL   SEASONIQUE                             MC/DEL     OCELLA
                             MC/DEL   LOSEASONIQUE                           MC/DEL     OGESTREL TABS
                                                                             MC/DEL     OVCON-35/28 TABS
                                                                             MC/DEL     OVRAL
                                                                             MC/DEL     PORTIA-28 TABS
                                                                             MC/DEL     SEASONALE
                                                                             MC/DEL     YAZ
                                                                             MC/DEL     ZOVIA
CONTRACEPTIVES - BI-PHASIC     MC     ORTHO-NOVUM 10/11-28 TABS              MC/DEL     NECON 10/11-28 TABS           If member experienced      Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
COMBINATIONS                          NORETHINDRONE-ETH ESTRADIOL TAB 0.5-                                           adverse reactions, consider offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                      35/1-35                                                                        using Oral Contraceptives drug and the preferred drug(s) exists.
                                                                                                                     from other groups.


                                                                                                                     Use PA Form# 20420
CONTRACEPTIVES - TRI-        MC/DEL   ENPRESSE                               MC/DEL     CYCLESSA TABS                If member experienced       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
PHASIC COMBINATIONS          MC/DEL   NECON 7/7/7                            MC/DEL     ESTROSTEP FE TABS            adverse reactions, consider offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                     using Oral Contraceptives drug and the preferred drug(s) exists.
                              MC      ORTHO-NOVUM 7/7/7-28 TABS              MC/DEL     NORTREL 7/7/7
                                                                                                                     from other groups.
                             MC/DEL   TRI-PREVIFEM                            MC        ORTHO TRI-CYCLEN TABS
                             MC/DEL   TRIPHASIL 28 TABS                       MC        ORTHO TRI-CYCLEN LO TABS
                             MC/DEL   TRI-SPRINTEC                           MC/DEL     TRI-NORINYL 28 TABS
                               MC     TRINESSA                                                                       Use PA Form# 20420
                             MC/DEL   TRIVORA-28 TABS
                                                                   DIABETES THERAPIES
DIABETIC - INSULIN             MC     HUMALOG INJ 100/ML                     MC/DEL     APIDRA                       Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                               MC     HUMALOG MIX 75/25                       MC        HUMALOG MIX 50/50                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                              MC                                                                    drug and the preferred drug(s) exists.
                               MC     HUMULIN N INJ U-100                               HUMULIN INJ 50/50
                               MC     HUMULIN INJ 70/30                       MC        HUMULIN R INJ U-500


                                                                                                                   Page 8 of 51
                             MC     HUMULIN R U-100                    MC   RELION
                           MC/DEL   LANTUS SOLN
                           MC/DEL   LEVEMIR
                           MC/DEL   NOVOLIN
                           MC/DEL   NOVOLOG
                           MC/DEL   NOVOLOG MIX
DIABETIC - PENFILLS        MC/DEL   LANTUS OPTICLIK PEN 1              MC   APIDRA OPTICLIK PEN           1. Clinical PA will be
                           MC/DEL   LANTUS SOLOSTAR1                                                      required to establish
                                                                                                          significant visual or
                           MC/DEL   LEVEMIR FLEXPEN 1                  MC   HUMALOG KWIK INJ 100/ML
                                                                                                          neurological impairment.
                           MC/DEL   NOVOLIN PENFILL1                   MC   HUMALOG MIX INJ 75/25 KWP
                           MC/DEL   NOVOLIN 70/30   1                  MC   HUMALOG MIX INJ 50/50 KWP
                           MC/DEL   NOVOLOG MIX PENFILL1               MC   HUMALOG PEN SOLN
                           MC/DEL   NOVOLOG PENFILL SOLN1              MC   HUMULIN PEN                   Use PA Form# 20420
                           MC/DEL   NOVOLOG MIX FLEXPEN1               MC   HUMULIN N PN INJ U-100
                           MC/DEL   NOVOLOG FLEXPEN1                   MC   HUMULIN PEN INJ 70/30
DIABETIC - DPP- 4 ENZYME   MC/DEL   JANUVIA1                           MC   ONGLYZA                       1. Preferred if therapeutic
INHIBITOR                                                                                                 doses of metformin are
                                                                                                          seen in members drug
                                                                                                          profile for at least 60 days
                                                                                                          within the past 18 months
                                                                                                          or if phosphate binder is
                                                                                                          currently seen in the
                                                                                                          members drug profile.
                                                                                                          Dosing limits apply. Please
                                                                                                          refer to Dose consolidation
                                                                                                          list.




DIABETIC - DPP- 4 ENZYME   MC/DEL   JANUMET1                                                              1. Preferred if therapeutic
INHIBITOR-COMBO                                                                                           doses of metformin are
                                                                                                          seen in members drug
                                                                                                          profile for at least 60 days
                                                                                                          within the past 18 months
                                                                                                          or if phosphate binder is
                                                                                                          currently seen in the
                                                                                                          members drug profile.
                                                                                                          Dosing limits apply. Please
                                                                                                          refer to Dose consolidation
                                                                                                          list.




DIABETIC - LANCET-LANCET            ONE TOUCH LANCETS                                                     Use PA Form# 20420
DEVICE                              FREESTYLE LANCETS
                                    UNILET LANCETS
                                    UNISTIK LANCING DEVICE
                                    AUTOLOT LANCING DEVICE
DIABETIC - SYRINGES-                BD MICRO-FINE                                                         Use PA Form# 20420
NEEDLES                             BD ULTRA-FINE
                                    BD ULTRA-FINE PEN NEEDLES
                                    UNIFINE PEN NEEDLES
DIABETIC - OTHER                                                       MC   SYMLIN                        Use PA Form #301501               Please see the criteria listed in the Symlin PA form.
DIABETIC MONITOR            MC      FREESTYLE LITE SYSTEM KIT          MC   ACCUCHECK                     Effective October 25th
                            MC                                         MC                                 2007, approvals for all non
                                    FREESTYLE FLASH SYSTEM KIT              ASCENSIA
                                                                                                          preferred meters/ test strips
                            MC      FREESTYLE FREEDOM SYSTEM KIT       MC   ASSURE                        will require medical
                            MC      FREESTYLE FREEDOM LITE KIT         MC   EXACTECH                      necessity documenting
                                                                                                          clinically significant features
                            MC      ONE TOUCH ULTRA 2 KIT              MC   PRODIGY
                                                                                                          that are not available on
                            MC      ONE TOUCH ULTRA MINI KIT                                              any of the preferred meters.
                            MC      ONE TOUCH ULTRA SMART KIT


                            MC      PRECISION XTRA METER                                                  Use PA Form# 20420
DIABETIC TEST STRIPS        MC      FREESTYLE1                         MC   ACCUCHECK                     Effective October 25th
                            MC                                         MC                                 2007, approvals for all non
                                    FREESTYLE LITE1                         ASCENSIA
                                                                                                          preferred meters/ test strips
                            MC      ONE TOUCH BASIC1                   MC   ASSURE                        will require medical
                            MC      ONE TOUCH SURESTEP1                MC   EXACTECH                      necessity documenting
                                                                                                          clinically significant features
                            MC      ONE TOUCH FAST TAKE1               MC   PRODIGY
                                                                                                          that are not available on
                            MC      ONE TOUCH ULTRA1                                                      any of the preferred meters.
                            MC      PRECISION XTRA1
                            MC      PRECISION XTRA BETA KETONE 10 CT
                                                                                                          1. Only 50 ct & 100 ct
                                                                                                          package size.




                                                                                                        Page 9 of 51
                                                                                                                       Use PA Form# 20420
INCRETIN MIMETIC                                                         MC             BYETTA1                        1. If patient is not
                                                                                                                       responding to oral agents
                                                                                                                       (single or multiple) please
                                                                                                                       look to insulin therapy.
                                                                                                                       Dosing limits apply. Please
                                                                                                                       refer to Dose Consolidation
                                                                                                                       List.


                                                                                                                       Use PA Form# 10230
DIABETIC - ORAL             MC/DEL   CHLORPROPAMIDE TABS                MC/DEL          AMARYL TABS                    Use PA Form# 20420             Preferred drugs must be tried for at least 3 months at full therapeutic doses and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
SULFONYLUREAS                                                                                                                                         unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant
                                                                                                                                                      potential drug interaction between another drug and the preferred drug(s) exists.

                            MC/DEL   GLIMEPIRIDE                        MC/DEL          DIABETA TABS
                            MC/DEL   GLIPIZIDE TABS                      MC             GLUCOTROL TABS                                                DDI: All sulfonylureas (except glyburide) will now be non-preferred and require prior authorization if it is currently being used with either ranitidine or cimetidine.
                            MC/DEL   GLIPIZIDE ER TABS                  MC/DEL          GLUCOTROL XL TBCR
                            MC/DEL   GLYBURIDE TABS                     MC/DEL          GLYNASE TABS
                            MC/DEL   GLYBURIDE MICRONIZED TABS          MC/DEL          MICRONASE TABS                                                DDI: Glimepiride will now be non-preferred and require prior authorization if it is currently being used with either fluconazole (except 150mg strength) or fluvoxamine. Amaryl is non-
                            MC/DEL   TOLAZAMIDE TABS                                                                                                  preferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with either fluconazole or fluvoxamine.
                            MC/DEL   TOLBUTAMIDE TABS
DIABETIC -ORAL BIGUANIDES   MC/DEL   METFORMIN HCL TABS                  MC             GLUCOPHAGE TABS                Use PA Form# 20420             Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   METFORMIN ER                        MC             GLUCOPHAGE XR TB24                                            offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                        MC/DEL                                                                        drug and the preferred drug(s) exists.
                                                                                        FORTAMET



DIABETIC - THIAZOL /                                                    MC/DEL          ACTOPLUS MET1                  Use PA Form# 20420             DDI: Actos, Avandia, or any combination product with Actos or Avandia will now be non-preferred and require prior authorization if it is currently being used with gemfibrozil.
BIGUANIDE COMBO                                                         MC/DEL                                         1. Requires use of Actos,
                                                                                        AVANDARYL1
                                                                        MC/DEL          AVANDAMET TABS1                Metformin, or other
                                                                                                                       preferred anti-diabetics.


DIABETIC - / THIAZOL        MC/DEL   ACTOS 15MG TABS1                   MC/DEL          ACTOS 30MG AND 45MG TABS2      1. Actos is preferred if       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                        MC/DEL                                         therapeutic doses of           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                        AVANDIA TABS3
                                                                                                                       metformin therapy are seen     drug and the preferred drug(s) exists.
                                                                                                                       in members drug profile for
                                                                                                                       at least 60 days prior to      DDI: Actos, Avandia, or any combination product with Actos or Avandia will now be non-preferred and require prior authorization if it is currently being used with gemfibrozil.
                                                                                                                       initial Actos therapy. Actos
                                                                                                                       is non-preferred as
                                                                                                                       monotherapy.




                                                                                                                       2. Actos 30mg or 45mg -
                                                                                                                       please use multiple 15mg
                                                                                                                       tabs.

                                                                                                                       3. Current users of Avandia
                                                                                                                       who have tried Actos will be
                                                                                                                       able to continue use of
                                                                                                                       Avandia.

                                                                                                                       Use PA Form# 20420


DIABETIC -                  MC/DEL   GLYSET TABS                         MC             PRECOSE TABS                   Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ALPHAGLUCOSIDASE                                                                                                                                      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                      drug and the preferred drug(s) exists.

DIABETIC - SULFONYLUREA /   MC/DEL   GLYBURIDE/METFORMIN                 MC             GLUCOVANCE TABS                Use individual ingredients.    Approved for patients failing to achieve good diabetic control with maximal doses of individual components.
BIGUANIDE                                                                MC             METAGLIP TABS
                                                                        MC/DEL          DUETACT   1                    1. Use Actos 15mgs with
                                                                                                                       generic glimepiride.
                                                                                                                       Use PA Form# 20420
DIABETIC - MEGLITINIDES     MC/DEL   STARLIX TABS                       MC/DEL          PRANDIN TABS                   Use PA Form# 20420             Preferred drugs from other diabetic sub-categories must be tried and failed due to lack of inadequate diabetic control or intolerable side effects before non-preferred drug will be
                                                                         MC             NATEGLINIDE                                                   approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
                                                                                                                                                      significant potential drug interaction between another drug and the preferred drug(s) exists.


                                                                                                                                                      DDI: Prandin is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for current use with both Sporanox and gemfibrozil, due to
                                                                                                                                                      a significant drug-drug interaction.

                                                             GLUCOSE ELEVATING AGENTS
GLUCOSE ELEVATING           MC/DEL   GLUCAGEN INJ. HYPOKIT              MC/DEL          GLUCAGON DIAGNOSTIC KIT        Use PA Form# 20420
AGENTS                                                                  MC/DEL          GLUCAGEN DIAGNOSTIC KIT
                                                                   THYROID
THYROID HORMONES            MC/DEL   ARMOUR THYROID TABS                 MC             LEVOTHYROXINE SODIUM SOLR      Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   CYTOMEL TABS                       MC/DEL          LIOTHYRONINE                                                  offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL   LEVOTHROID TABS                    MC/DEL                                                                        drug and the preferred drug(s) exists.
                                                                                        SYNTHROID TABS
                            MC/DEL   LEVOTHYROXINE SODIUM TABS
                            MC/DEL   LEVOXYL TABS


                                                                                                                    Page 10 of 51
                               MC/DEL   THYROID TABS
                               MC/DEL   THYROLAR
                               MC/DEL   UNITHROID TABS
ANTITHYROID THERAPIES          MC/DEL   METHIMAZOLE TABS                       MC/DEL          TAPAZOLE TABS                   Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                               MC/DEL   PROPYLTHIOURACIL TABS                                                                                                 offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                              drug and the preferred drug(s) exists.

                                                                       OSTEOPOROSIS
OSTEOPOROSIS                   MC/DEL   ALENDRONATE                           MC/DEL           ACTONEL TABS                    Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                               MC/DEL   BONIVA TABS   2                        MC/DEL          BONIVA INJECTION KIT            1. Approval only requires      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                               failure of Alendronate or      drug and the preferred drug(s) exists.
                               MC/DEL   FORTICAL                                MC             AREDIA SOLR
                                                                                                                               Boniva.
                               MC/DEL   FOSAMAX SOLN2                          MC/DEL          DIDRONEL TABS
                               MC/DEL   MIACALCIN SOLN2                         MC             EVISTA TABS1                    2. Quantity limits apply,
                                                                                               FORTEO                          please see dosage
                                                                                 MC
                                                                                                                               consolidation list.
                                                                               MC/DEL          FOSAMAX TABS AND PLUS D3
                                                                                                                               3. Please use Alendronate
                                                                                                                               and Vitamin D.


                                                                    CALCIMIMETIC AGENTS
CALCIMIMETIC AGENTS                                                             MC             SENSIPAR                        Use PA Form # 30115            Baseline PTH, Ca, and phosphorous levels are required and initial approvals will be limited to 3 months. Subsequent approvals will require additional levels being done to assess
                                                                                                                                                              changes. Will not approve if baseline Ca is less than 8.4.
                                                                      GROWTH HORMONE
GROWTH HORMONE                 MC/DEL   GENOTROPIN1                            MC/DEL      5   NORDITROPIN CARTRIDGE SOLN      Use PA Form # 10710            See Growth Hormone PA form for criteria. Step-order will still apply unless clinical contraindication supplied.
                               MC/DEL   NUTROPIN1                              MC/DEL      5   TEV-TROPIN                      1.Clinical PA is required to
                                                                                                                               establish diagnosis and
                               MC/DEL   NUTROPIN AQ1                            MC         8   HUMATROPE SOLR2
                                                                                                                               medical necessity.
                                MC      OMNITROPE1                              MC         8   INCRELEX2
                                                                                MC         8   IPLEX2                          2. Products must be used in
                                                                                                                               specified step order. All
                                                                                MC         8   SAIZEN SOLR2
                                                                                                                               step 5's must be tried prior
                                                                                                                               to moving to step 8's.



SOMATOSTATIC AGENTS            MC/DEL   SANDOSTATIN                                            SOMATULINE                      Use PA Form # 10710



                                                            GROWTH HORMONE ANTAGONISTS
GH ANTAGONISTS                                                             MC          SOMAVERT                                Use PA Form # 10710            Approved for acromegaly patients failing surgery/radiation/drug therapy including bromocriptine and sandostatin.


                                                                    URINARY INCONTINENCE
VASOPRESSINS                            DESMOPRESSIN TABS                      MC/DEL      5   DDAVP TABS                      Products must be used in Approved for central diabetes insipidus and for nocturnal enuresis. For nocturnal enuresis- must be over 6 years old, must fail an adequate trial of alarm training (higher success
                                                                                           6   DDAVP SOLN                      specified step order.       rate, lower relapse rate) and must periodically attempt weaning (at 6 month intervals).
                                                                               MC/DEL
                                                                                                                               Nocturnal enuresis patients
                                                                                MC         6   DESMOPRESSIN SPRAY                                          * Patients with a diagnosis of hemophilia or Von Willebrands disease will be exempt from prior authorization.
                                                                                                                               will be encouraged to
                                                                               MC/DEL      8   DESMOPRESSIN ACETATE SOLN       periodically attempt
                                                                               MC/DEL      8   STIMATE SOLN*                   stopping DDAVP.



                                                                                                                               Use PA Form# 20420




ANTISPASMODICS                 MC/DEL   OXYBUTYNIN                             MC/DEL          CYSTOSPAZ TABS                  Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                                MC      URISPAS TABS                           MC/DEL          DETROL TABS                                                    unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of
                                                                               MC/DEL          DITROPAN                                                       the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
ANTISPASMODICS - LONG          MC/DEL   DETROL LA CP24                          MC             DITROPAN XL TBCR                Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ACTING                         MC/DEL                                          MC/DEL          OXYTROL                                                        offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                        ENABLEX1
                                                                                                                                                              drug and the preferred drug(s) exists.
                                MC      SANCTURA
                                MC      SANCTURA XR                                                                                                           1. Vesicare 5mg and Enablex 7.5mg maximum doses if given with drugs known to be significant CYP3A4 inhibitors.(Ketoconazole, Sporanox, Erythromycin, Biaxin, Nefazodone,
                               MC/DEL   TOVIAZ                                                                                                                Nelfinavir, and Ritonavir)
                                MC      VESICARE1                                                                                                             DDI: Enablex 15mg and Vesicare 10mg will now be non-preferred and require prior authorization if they are currently being used in combination with any of the following
                                                                                                                                                              medications: clarithromycin, erythromycin, Ketek, Crixivan, Norvir, ketoconazole, fluconazole, Sporanox. nefazodone, or diltiazem.

CHOLINERGIC                    MC/DEL   URECHOLINE
                                                                     METABOLIC MODIFIER
HERED. TYROSINEMIA                                                              MC             ORFADIN                         Use PA Form# 20420             Approved for Type 1 hereditary tyrosinemia patients. Must include laboratory evidence of dx at first PA.
                                                                ANTIHYPERTENSIVES / CARDIAC
CARDIAC GLYCOSIDES             MC/DEL   DIGITEK TABS
                               MC/DEL   DIGOXIN
                               MC/DEL   LANOXICAPS
                               MC/DEL   LANOXIN
ANTIANGINALS--Isosorbide Di-   MC/DEL   ISOSORBIDE MONONITRATE TABS             MC             DILATRATE SR CPCR               Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
nitrate/ Mono-Nitrates         MC/DEL   ISOSORBIDE MONONITRATE ER               MC             ISORDIL TABS                                                   offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                               MC/DEL          ISORDIL TITRADOSE TABS                                         drug and the preferred drug(s) exists.



                                                                                                                            Page 11 of 51
                                                                                                                                                           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                                                                                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                           drug and the preferred drug(s) exists.

                                                                             MC          ISOSORBIDE DINITRATE SUBL
                                                                            MC/DEL       ISOSORBIDE DINITRATE TABS
                                                                            MC/DEL       ISOSORBIDE DINITRATE CR TBCR
                                                                            MC/DEL       ISOSORBIDE DINITRATE ER TBCR
                                                                            MC/DEL       ISOSORBIDE DINITRATE TD TBCR
                                                                            MC/DEL       IMDUR TB24
                                                                            MC/DEL       ISMO TABS
                                                                             MC          MONOKET TABS
NITRO - OINTMENT/CAP/CR          MC          NITROBID OINT
                                MC/DEL       NITROGLYCERIN CPCR
                                 MC          NITROL OINT
                                 MC          NITRO-TIME CPCR
NITRO - PATCHES                 MC/DEL   1   NITROGLYCERIN PT24              MC          NITRODISC PT24                    At least 2 step 1's and step Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                MC/DEL   1   NITREK PT24                    MC/DEL       NITRO-DUR PT24                    3 of the preferred products offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                MC/DEL       NITRO-DUR PT 24 0.8MG                                                         must be used in specified drug and the preferred drug(s) exists.
                                         1
                                                                                                                           order or PA will be required.
                                MC/DEL   3   MINITRAN PT24


                                                                                                                           Use PA Form# 20420
NITRO - SUBLINGUAL/ SPRAY        MC          NITROLINGUAL AERS               MC          NITROLINGUAL SOLN                 Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                MC/DEL       NITROSTAT SUBL                 MC/DEL       NITROQUICK SUBL                                                   offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                MC/DEL       NITROTAB SUBL                                                                                                 drug and the preferred drug(s) exists.

BETA BLOCKERS - NON              MC          CARVEDILOL                     MC/DEL       BETAPACE TABS                     1. Recommend using BID Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
SELECTIVE                        MC          LEVATOL TABS                                BETAPACE AF TABS                  since its effects do not last offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                              MC
                                                                                                                           24 hours.                     drug and the preferred drug(s) exists.
                                MC/DEL       NADOLOL TABS                   MC/DEL       COREG CR3
                                MC/DEL       PINDOLOL TABS                  MC/DEL       COREG TABS                        2. Please use other
                                MC/DEL                                      MC/DEL       CORGARD TABS                      strengths in combination to
                                             PROPRANOLOL HCL SOLN1
                                                                                                                           obtain this dose.
                                MC/DEL       PROPRANOLOL HCL TABS1          MC/DEL       INDERAL TABS
                                MC/DEL       PROPRANOLOL LA CAPS            MC/DEL       INDERAL LA CPCR                   3. Dosing limits still apply.
                                MC/DEL       SOTALOL HCL TABS                MC          INNOPRAN XL                       Please see dose
                                                                                                                           consolidation list
                                MC/DEL       TIMOLOL MALEATE TABS           MC/DEL       PROPRANOLOL HCL 60MG TABS2
                                                                             MC          RANEXA                            Use PA Form# 20420
BETA BLOCKERS - CARDIO          MC/DEL       ACEBUTOLOL HCL CAPS            MC/DEL       BYSTOLIC                          1. Recommend using           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
SELECTIVE                       MC/DEL       ATENOLOL TABS    1              MC          KERLONE TABS                      Atenolol (and metoprolol) offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                 MC                                         MC/DEL       LOPRESSOR TABS                    BID since its effects do not drug and the preferred drug(s) exists.
                                             BETAXOLOL HCL TABS
                                                                                                                           last 24 hours.
                                MC/DEL       BISOPROLOL FUMARATE TABS       MC/DEL       METOPROLOL ER
                                MC/DEL       METOPROLOL TARTRATE TABS   1    MC          SECTRAL CAPS                      Use PA Form# 20420
                                MC/DEL       TOPROL XL TB24                 MC/DEL       TENORMIN TABS
                                                                            MC/DEL       ZEBETA TABS
BETA BLOCKERS - ALPHA /         MC/DEL       LABETALOL HCL TABS              MC          TRANDATE TABS                     Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
BETA                                                                                                                                                       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                           drug and the preferred drug(s) exists.

CALCIUM CHANNEL                 MC/DEL       AMLODIPINE1                    MC/DEL       NORVASC TABS1                     1. Dosing limits apply,
BLOCKERS--Amlodipines,                                                                                                     please see dose
Bepridil, Diltiazems,                                                                                                      consolidation list.
Felodipines, Isradipines,
Nifedipines, Nisoldipine, and    MC      1   DILTIA XT CP24                  MC      5   DILACOR XR CP24                   Products must be used in        Preferred drugs must be tried and failed (in step-order) due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
Verapamils                      MC/DEL   1   DILTIAZEM HCL ER CP24           MC      6   TAZTIA                            specified order or PA will be   exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                                           required. Just write            another drug and the preferred drug(s) exists.
                                MC/DEL   1   DILTIAZEM HCL XR CP24          MC/DEL   7   TIAZAC CP24
                                                                                                                           "Diltiazem 24-hour"and the
                                MC/DEL   1   DILTIAZEM CD 300MG CP24        MC/DEL   8   CARDIZEM TABS                     pharmacy will use a
                                MC/DEL   1   DILTIAZEM CD 360MG CP24        MC/DEL   8   CARDIZEM CD CP24                  preferred long acting           DDI: All preferred diltiazems will now be non-preferred and require prior authorization if they are currently being used in combination with either Enablex 15mg or Vesicare 10mg.
                                 MC      4   CARTIA XT CP24                  MC      8   CARDIZEM LA TB24                  diltiazem that does not         All non-preferred diltiazems require prior authorization, but with any prior authorization request, the member's drug profile will also be monitored for current use with Enablex 15mg
                                                                                                                           require PA.                     or Vesicare 10mg.
                                MC/DEL   4   DILTIAZEM CD CP24               MC      8   CARDIZEM SR CP12
                                MC/DEL   4   DILTIAZEM HCL ER CP24          MC/DEL   8   DILTIAZEM HCL TABS
                                MC/DEL   4   DILTIAZEM XR CP24              MC/DEL   8   DILTIAZEM HCL ER CP12             Use PA Form# 20420

                                                                            MC/DEL       PLENDIL TB24                      Use PA Form# 20420              Other Preferred calcium channel blockers must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an
                                                                                                                                                           acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
                                                                                                                                                           interaction between another drug and the preferred drug(s) exists.

                                                                             MC          DYNACIRC CAPS                     Use PA Form# 20420           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                             MC          DYNACIRC CR TBCR1                 1. Established users will be offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                           grandfathered                drug and the preferred drug(s) exists.

                                                                            MC/DEL       CARDENE CAPS                      Use PA Form# 20420              Other Preferred calcium channel blockers must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an
                                                                            MC/DEL       CARDENE SR CPCR                                                   acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
                                                                            MC/DEL       NICARDIPINE HCL CAPS                                              interaction between another drug and the preferred drug(s) exists.

                                MC/DEL       AFEDITAB CR                     MC          ADALAT CC TBCR                    Established users of Adalat Preferred drug must be tried and failed in step order due to lack of efficacy or intolerable side effects before non-preferred drugs in step order will be approved, unless an
                                MC/DEL       NIFEDIAC CC                    MC/DEL       NIFEDIPINE CAPS                   CC are grandfathered.       acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
                                                                                                                                                       interaction between another drug and the preferred drug(s) exists.
                                MC/DEL       NIFEDICAL XL TBCR               MC          PROCARDIA CAPS
                                MC/DEL       NIFEDIPINE TBCR                MC/DEL       PROCARDIA XL TBCR                 Use PA Form# 20420
                                MC/DEL       NIFEDIPINE ER TBCR




                                                                                                                        Page 12 of 51
                                                                       MC          SULAR TB24                  Established users of 10MG
                                                                                                               and 20MG strengths are
                                                                                                               grandfathered.


                           MC/DEL   1   VERAPAMIL HCL CR TBCR         MC/DEL       CALAN TABS                  Products must be used in Preferred drugs must be tried and failed (in step-order) due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
                           MC/DEL   1   VERAPAMIL HCL ER TBCR         MC/DEL       CALAN SR TBCR               specified order or PA will be exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                           MC/DEL       VERAPAMIL HCL SR TBCR         MC/DEL       COVERA-HS TBCR              required. Just write          another drug and the preferred drug(s) exists.
                                    1
                                                                                                               "Verapamil 24-hour" and
                                                                       MC          ISOPTIN-SR
                                                                                                               the pharmacy will use a
                                                                      MC/DEL       VERAPAMIL HCL ER CP24       preferred long acting
                                                                       MC          VERAPAMIL HCL SR CP24       generic that does not
                                                                       MC          VERAPAMIL HCL TABS          require PA.
                                                                       MC          VERELAN CP24
                                                                       MC          VERELAN PM CP24             Use PA Form# 20420
ANTIARRHYTHMICS            MC/DEL       AMIODARONE                    MC/DEL       CORDARONE                   1. Prescription must be       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                           MC/DEL       FLECAINIDE                    MC/DEL       DISOPYRAMIDE                written by Cardiologist.      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                        MEXILETINE                    MC/DEL       MEXITIL                                                   drug and the preferred drug(s) exists.
                           MC/DEL
                           MC/DEL       NORPACE                       MC/DEL       PACERONE
                           MC/DEL       PROCAINAMIDE                   MC          QUINIDEX                    Use PA Form# 20420
                           MC/DEL       PROCANBID CR                  MC/DEL       TAMBOCOR                                                  DDI: Amiodarone will now be non-preferred and require prior authorization if it is currently being used in combination with either Lovastatin (doses greater than 40mg/day) or Lipitor
                           MC/DEL       PROPAFENONE                   MC/DEL       TIKOSYN   1                                               (doses greater than 20mg/day).
                            MC          QUINAGLUTE
                           MC/DEL       QUINIDINE GLUCONATE
                           MC/DEL       QUINIDINE SULFATE
                            MC          RYTHMOL
ACE INHIBITORS             MC/DEL       BENAZEPRIL HCL                 MC      5   MAVIK TABS                  Non-preferred products        Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
                           MC/DEL       CAPTOPRIL TABS                MC/DEL   5   ACCUPRIL TABS               must be used in specified     exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                        ENALAPRIL MALEATE TABS        MC/DEL       ACEON TABS                  order.                        another drug and the preferred drug(s) exists. Non-preferred products are subject to step-order requirements unless clinical circumstances warrant exception.
                           MC/DEL                                              8
                           MC/DEL       FOSINOPRIL SODIUM             MC/DEL   8   ALTACE CAPS                 Use PA Form# 20420
                           MC/DEL       LISINOPRIL TABS                MC      8   CAPOTEN TABS
                           MC/DEL       RAMIPRIL                      MC/DEL   8   LOTENSIN TABS
                           MC/DEL       QUINAPRIL                     MC/DEL   8   MOEXIPRIL
                                                                       MC      8   MONOPRIL HCT TABS
                                                                      MC/DEL   8   PRINIVIL TABS
                                                                      MC/DEL   8   UNIVASC
                                                                       MC      8   VASOTEC TABS
                                                                      MC/DEL   8   ZESTRIL TABS
ANGIOTENSIN RECEPTOR        MC          AVAPRO                        MC/DEL       ATACAND TABS                Use PA Form# 20420            The initial criteria to use any ARB is that the member must have failed ACE inhibitors (such as due to coughing) in the past or must currently be actively treated for diabetes and
BLOCKER                    MC/DEL       BENICAR TABS                  MC/DEL       COZAAR 50MG & 100MG1        Preferred products only       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                           MC/DEL                                      MC                                      available without PA if       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                        COZAAR TABS 25MG    2                      TEVETEN TABS
                                                                                                               patient on diabetic therapy   drug and the preferred drug(s) exists.
                           MC/DEL       DIOVAN
                                                                                                               or prior ACE therapy.
                           MC/DEL       MICARDIS TABS


                                                                                                               1. Please use multiple
                                                                                                               preferred 25mg tabs.
                                                                                                               2.Dosing limits apply.
                                                                                                               Please see dose
                                                                                                               consolidation list.

DIRECT RENIN INHIBITOR                                                MC/DEL       TEKTURNA1                   1. Must show failure of
                                                                                                               single and combination
                                                                                                               therapy from all preferred
                                                                                                               antihypertensive
                                                                                                               categories.
                                                                                                               Use PA Form# 20420


ANTIHYPERTENSIVES -        MC/DEL       CATAPRES-TTS                  MC/DEL       CATAPRES TABS               Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
CENTRAL                    MC/DEL       CLONIDINE HCL TABS             MC          GUANABENZ ACETATE TABS                                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                           MC/DEL       GUANFACINE HCL TABS            MC                                                                    drug and the preferred drug(s) exists.
                                                                                   ISMELIN TABS
                           MC/DEL       HYDRALAZINE HCL TABS           MC          MINIPRESS CAPS
                            MC          HYLOREL TABS                  MC/DEL       TENEX TABS
                           MC/DEL       METHYLDOPA TABS
                           MC/DEL       MINOXIDIL TABS
                           MC/DEL       PRAZOSIN HCL CAPS
                           MC/DEL       RESERPINE TABS
ACE INHIBITORS AND CA                                                 MC/DEL       LEXXEL TBCR                 Use individual preferred      `
CHANNEL BLOCKERS                                                      MC/DEL                                   generic medications.
                                                                                   LOTREL CAPS
                                                                       MC          TARKA TBCR                  Use PA Form# 20420
ACE AND THIAZIDE COMBO'S   MC/DEL       BENAZEPRIL HCL/HYDROCHLOR     MC/DEL       ACCURETIC TABS              Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                           MC/DEL                                                  CAPOZIDE TABS                                             offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                        CAPTOPRIL/HYDROCHLOROTHIA       MC
                                                                                                                                             drug and the preferred drug(s) exists.
                           MC/DEL       ENALAPRIL MALEATE/HCTZ TABS   MC/DEL       LOTENSIN HCT TABS
                           MC/DEL       LISINOPRIL-HCTZ TABS           MC          MONOPRIL HCT TABS
                                                                      MC/DEL       PRINZIDE TABS



                                                                                                            Page 13 of 51
                                                                       MC/DEL   UNIRETIC TABS
                                                                         MC     VASERETIC TABS
                                                                       MC/DEL   ZESTORETIC TABS
BETA BLOCKERS AND           MC/DEL   ATENOLOL/CHLORTHALIDONE            MC      CORZIDE TABS              Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
DIURETIC COMBO'S            MC/DEL   BISOPROLOL FUMARATE/HCTZ          MC/DEL   INDERIDE 40/25 TABS                                      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL   PROPRANOLOL/HCTZ                  MC/DEL   LOPRESSOR HCT TABS                                       drug and the preferred drug(s) exists.

                                                                         MC     TENORETIC
                                                                         MC     TIMOLIDE 10/25 TABS
                                                                       MC/DEL   ZIAC TABS
ARB'S AND CA CHANNEL        MC/DEL   AZOR
BLOCKERS                    MC/DEL   EXFORGE
                            MC/DEL   EXFORGE HCT
ARB'S AND DIURETICS          MC      AVALIDE TABS                      MC/DEL   ATACAND HCT TABS          Preferred products only     Same initial criteria as the ARB class and Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                            MC/DEL   BENICAR HCT                        MC      TEVETEN HCT TABS          available without PA if     unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant
                            MC/DEL   DIOVAN HCT TABS                                                      patient on diabetic therapy potential drug interaction between another drug and the preferred drug(s) exists.
                                                                                                          or prior ACE therapy.
                            MC/DEL   HYZAAR TABS


                            MC/DEL   MICARDIS HCT TABS                                                    Use PA Form# 20420
DIURETICS                   MC/DEL   ACETAZOLAMIDE TABS                MC/DEL   ALDACTAZIDE TABS          1. Multiples of            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   BUMETANIDE                        MC/DEL   ALDACTONE TABS            Spironolactone 25 mg are offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL   CHLOROTHIAZIDE TABS                MC                                cheaper than 50 mg         drug and the preferred drug(s) exists.
                                                                                AMILORIDE HCL
                                                                                                          strength. Inspra will be
                            MC/DEL   CHLORTHALIDONE TABS               MC/DEL   BUMEX TABS
                                                                                                          approved for severe breast
                             MC      EDECRIN TABS                      MC/DEL   DEMADEX TABS              tenderness and male
                            MC/DEL   FUROSEMIDE                        MC/DEL   DIAMOX                    gynecomastia.
                            MC/DEL   HYDROCHLOROTHIAZIDE               MC/DEL   DIURIL
                            MC/DEL   INDAPAMIDE TABS                   MC/DEL   DYAZIDE CAPS
                            MC/DEL   METHAZOLAMIDE TABS                 MC      ENDURON TABS              Use PA Form# 20420
                            MC/DEL   METHYCLOTHIAZIDE TABS              MC      INSPRA
                            MC/DEL   SPIRONOLACTONE 25MG TABS          MC/DEL   LASIX TABS
                            MC/DEL   SPIRONOLACTONE/HYDRO               MC      LOZOL TABS
                            MC/DEL   TORSEMIDE TABS                    MC/DEL   MAXZIDE
                            MC/DEL   TRIAMTERENE/HCTZ                   MC      MICROZIDE CAPS
                             MC      ZAROXOLYN TABS                    MC/DEL   MIDAMOR TABS
                                                                        MC      MODURETIC 5-50 TABS
                                                                        MC      NAQUA TABS
                                                                         MC     NATURETIN TABS
                                                                       MC/DEL   SPIRONOLACTONE 50MG1
CCB / LIPID                 MC/DEL   CADUET
                                                                LIPID DRUGS
CHOLESTEROL - BILE          MC/DEL   CHOLESTYRAMINE                    MC/DEL   PREVALITE                 Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
SEQUESTRANTS                MC/DEL   COLESTID                           MC      QUESTRAN                                                 offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                       MC/DEL   WELCHOL TABS                                             drug and the preferred drug(s) exists.

CHOLESTEROL - FIBRIC ACID   MC/DEL   GEMFIBROZIL TABS                   MC      ANTARA                    Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
DERIVATIVES                 MC/DEL   NIASPAN                            MC      LOPID                                                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC                                         MC                                                               drug and the preferred drug(s) exists.
                                     TRICOR                                     LOFIBRA
                             MC      TRILIPIX                          MC/DEL   FENOFIBRATE                                              DDI: Gemfibrozil will now be non-preferred and require prior authorization if it is currently being used with any of the following medications: Prandin, Actos, Avandia, any
                                                                        MC      TRIGLIDE                                                 Avandia/Actos combination product, or any HMG-COA Reductase Inhibitors (statins).

CHOLESTEROL - HGM COA +     MC/DEL   LIPITOR                           MC/DEL   CRESTOR                   1. Dosing limits apply,        Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ABSORB INHIBITORS MORE      MC/DEL                                              VYTORIN                   please see dosage              offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                     SIMVASTATIN1                        MC
POTENT                                                                                                    consolidation list.            drug and the preferred drug(s) exists.
                                                                       MC/DEL   ZOCOR
DRUGS/COMBINATIONS
                                                                                                          Use PA Form# 20420             DDI: Lipitor (doses greater than 20mg/day) will now be non-preferred and require prior authorization if they are currently being used in combination cyclosporine.
                                                                                                                                         DDI: Lipitor (doses greater than 20mg/day) will now be non-preferred and require prior authorization if it is currently being used in combination with Amiodarone.
                                                                                                                                         DDI: All preferred statins will now be non-preferred and require prior authorization if it is currently being used in combination with Gemfibrozil.




CHOLESTEROL - HGM COA +     MC/DEL   LESCOL CAPS                       MC/DEL   ALTOPREV TB 24            1. Zetia available w/out PA    Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ABSORB INHIBITORS LESS      MC/DEL   LESCOL XL TB 24                   MC/DEL   MEVACOR TABS              as addition to Lipitor 80mg.   offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
POTENT                                                                                                    Zetia will also be approved    drug and the preferred drug(s) exists. Zetia will be approved for patients unable to tolerate all other therapies or unable to achieve cholesterol goal with maximally tolerated dose of
                            MC/DEL   LOVASTATIN TABS2                   MC      PRAVACHOL TABS
DRUGS/COMBINATIONS                                                                                        with a PA as add on for        most potent statins.
                            MC/DEL   PRAVASTATIN2                      MC/DEL   PRAVIGARD                 patients at maximally
                                                                        MC      ZETIA TABS1,              tolerated doses of statins.
                                                                                                                                         DDI: Lescol will now be non-preferred and require prior authorization if it is currently being used in combination with diclofenac.
                                                                                                                                         DDI: Lovastatin (doses greater than 40mg/day) will now be non-preferred and require prior authorization if it is currently being used in combination with Amiodarone.
                                                                                                                                         DDI: Lovastatin (doses greater than 20mg per day) will now be non-preferred and require prior authorization if it is currently being used in combination cyclosporine.
                                                                                                          2. Dosing limits apply,
                                                                                                          please see dosage
                                                                                                          consolidation list.



                                                                                                          Use PA Form# 20420             DDI: All preferred statins will now be non-preferred and require prior authorization if it is currently being used in combination with Gemfibrozil.



                                                                                                       Page 14 of 51
CHOLESTEROL - HGM COA +     MC/DEL   SIMCOR
ABSORB INHIBITORS STATIN/   MC/DEL   ADVICOR TBCR
NIACIN COMBO



                                                                 PULMONARY ANTI-HYPERTENSIVES
PULMONARY ANTI-             MC/DEL   REVATIO1                             MC/DEL        FLOLAN                      3. There will be dosing      Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
HYPERTENSIVES                MC                 2                           MC                                      limits of one 20ml multidose offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significat potential drug interation between another drug
                                     VENTAVIS                                           REMODULIN3
                            MC/DEL                      5                                                           vial/ 30 days supply without and the preferred drug(s) exists.
                                     EPOPROSTENOL INJ
                                                                                                                    pa.

                                                                                                                    4. Viagra would be         1. Revatio approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 2,3, or 4.
                                                                                                                    approved after a diagnosis 2. Ventavis approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 3 or 4.
                                                                                                                    of pulmonary hypertension
                                                                                                                    is confirmed.


                                                                                                                    5. PA is required to
                                                                                                                    establish and conferm who
                                                                                                                    group 1 diagnosis of
                                                                                                                    primary PAH (Primary
                                                                                                                    Pulmonary Hypertension)
                                                                                                                    and NYHA functional class
                                                                                                                    3&4



                                                                                                                    Use PA Form# 20420
ERA / ENDOTHELIN RECEPTOR    MC      TRACLEER                                                                       1. Providers must be             Tracleer approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 3 or 4.
ANTAGONIST                   MC                                                                                     registered with LEAP
                                     LETAIRIS1, 2
                                                                                                                    Prescribing program, a
                                                                                                                    restricted distribution
                                                                                                                    program.

                                                                                                                    2. Clinical PA is required to Letairis approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and functional class 2 or 3 symptoms.
                                                                                                                    establish diagnosis and
                                                                                                                    medical necessity.


                                                                 IMPOTENCE AGENTS
IMPOTENCE AGENTS                                                                                                    As of January 1, 2006, per
                                                                                                                    CMS (federal govt.),
                                                                                                                    impotence agents are no
                                                                                                                    longer covered.



                                                                 ANTI-EMETOGENICS
ANTIEMETIC -                MC/DEL   MECLIZINE HCL TABS                     MC          ANTIVERT TABS               Use PA Form# 20420               Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
ANTICHOLINERGIC /           MC/DEL   PHENERGAN SUPP                       MC/DEL        PHENERGAN SOLN                                               unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant
DOPAMINERGIC                                                                                                                                         potential drug interaction between another drug and the preferred drug(s) exists.
                            MC/DEL   PHENERGAN FORTIS SYRP                MC/DEL        PHENERGAN TABS
                            MC/DEL   PROMETHAZINE SUPP                    MC/DEL        PROMETHAZINE 50MG SUPP
                            MC/DEL   PROMETHAZINE                         MC/DEL        PROMETHEGAN SUPP
                             MC      TRANSDERM-SCOP PT72                    MC          TORECAN TABS
ANTIEMETIC - 5-HT3          MC/DEL   MARINOL CAPS                         MC/DEL    5   GRANISETRON                 *See quantity limit table.       Preferred drugs and step therapy must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
RECEPTOR ANTAGONISTS/                                                       MC          ALOXI                       1. Approvals will require        clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
                             MC      ONDANSETRON TABS* 2                            8
SUBSTANCE P NEUROKININ                                                                                              diagnosis of chemo-induced       between another drug and the preferred drug(s) exists. * Ondansetron limits still apply as listed on the Ondansetron PA form for covered indications including chemotherapy,
                             MC      ONDANSETRON ODT TBDP* 2                MC      8   ANZEMET TABS
                                                                                                                    nausea/vomiting and failed       radiotherapy, post operative nausea & vomiting and hyperemesis gravidarum. Other medical indications will be approved or denied on a case by case basis. Hyperemesis and
                             MC      ONDANSETRON INJ*                       MC      8   CESAMET1                                                     other medical indications approved are still subject to failure of multiple preferred antiemesis drugs.
                                                                                                                    trials of all preferred anti-
                                                                            MC      8   EMEND3                      emetics, including 5-HT3
                                                                          MC/DEL    8   KYTRIL                      class (Ondansetron) and
                                                                           MC       8   SANCUSO                     Marinol.
                                                                          MC/DEL    8   ZOFRAN ODT TBDP*

                                                                          MC/DEL    8   ZOFRAN TABS*                2. Ondansetron will be
                                                                          MC/DEL    8   ZOFRAN INJ*                 preferred with CA diag and
                                                                                                                    dosing limits still apply.


                                                                                                                    3. Clinical PA is required for
                                                                                                                    members on highly emetic
                                                                                                                    anti-neoplastic agents.


                                                                                                                    Ondansetron: use PA Form
                                                                                                                    # 20610
                                                                                                                    Others: use PA Form #
                                                                                                                    20420

                                                    NON-SEDATING ANTIHISTAMINES / DECONGESTANTS
ANTIHISTIMINES - NON-        MC      ALAVERT TABS                         MC/DEL    5   CLARINEX TABS1              1. Must fail preferred drugs, Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
SEDATING                    MC/DEL                                                                                  OTC loratidine and            exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                     CETIRIZINE TABS                      MC/DEL    5   CLARINEX SYR1,2
                                                                                                                    cetirizine before moving to another drug and the preferred drug(s) exists. No combination product with decongestant will be approved since pseudoephedrine available without PA.
                             MC      CLARITIN (OTC)                       MC/DEL    5   FEXOFENADINE1               non-preferred step order
                                                                                                                    drugs.

                                                                                                                 Page 15 of 51
SEDATING                                                                                                                  OTC loratidine and               exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                                          cetirizine before moving to      another drug and the preferred drug(s) exists. No combination product with decongestant will be approved since pseudoephedrine available without PA.
                                                                                                                          non-preferred step order
                            MC      CLARITIN SYRP (OTC)                  MC/DEL   5     ZYRTEC1                           drugs.

                          MC/DEL    LORATADINE                           MC/DEL   5     ZYRTEC SYR1,2
                          MC/DEL    TAVIST ND (OTC)                      MC/DEL   8     ALLEGRA3                          2. Clarinex and Zyrtec
                                                                                                                          syrup <6 yr w/o PA.
                                                                         MC/DEL   8     CLARITIN3
                                                                         MC/DEL   8     LORATADINE ODT4                   3. Must fail all step 5 drugs
                                                                                                                          (Clarinex, Fexofenadine
                                                                         MC/DEL   8     XYZAL3
                                                                                                                          and Zyrtec) before moving
                                                                                                                          to next step product.



                                                                                                                          4. All OTC versions of
                                                                                                                          loratadine ODT are now
                                                                                                                          non-preferred.
                                                                                                                          Pseudoephedrine is
                                                                                                                          available with prescription.


                                                                                                                          Use PA Form # 20530
ANTIHISTIMINES - OTHER    MC/DEL    CLEMASTINE
                          MC/DEL    CHLORPHENIRAMINE
                          MC/DEL    DIPHENHYDRAMINE
                                                           ALLERGY / ASTHMA THERAPIES
ANTIASTHMATIC -            MC/DEL   ATROVENT AERS                                                                         1. Quantity limit of 1
ANTICHOLINERGICS - INHALER  MC      ATROVENT HFA                                                                          inhalation daily (1 capsule
                          MC/DEL                                                                                          for inhalation daily) Spiriva
                                    SPIRIVA1 2
                                                                                                                          will require PA if Combivent
                                                                                                                          or Atrovent
                                                                                                                          inhaler/nebulizer solution is
                                                                                                                          in member's current drug
                                                                                                                          profile.



                                                                                                                           2. We ask physicians to
                                                                                                                          write "asthma" on the
                                                                                                                          prescription whenever
                                                                                                                          Sprivia is primarily being
                                                                                                                          used for that condition.

ANTIASTHMATIC -           MC/DEL    IPRATROPIUM BROMIDE SOLN              MC            ATROVENT SOLN                     Use PA Form# 20420               Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ANTICHOLINERGICS -                                                                                                                                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
NEBULIZER                                                                                                                                                  drug and the preferred drug(s) exists.

ANTIASTHMATIC -           MC/DEL    CROMOLYN SODIUM NEBU                 MC/DEL         XOLAIR1                           1. Need max inhaled              Xolair approval will require suboptimal response to maximal doses of inhaled steroid as evidenced by asthmatic ER/Hospital admissions and Allergy/Pulmonary specialist
ANTIINFLAMMATORY AGENTS   MC/DEL    INTAL AERS                                                                            steroids and written by          management.
                          MC/DEL                                                                                          pulmonary or allergy
                                    TILADE AERS
                                                                                                                          specialist.
                                                                                                                          Use PA Form# 20420
ANTIASTHMATIC - NASAL       MC      FLUTICASONE SPR                      MC/DEL   5     BECONASE AQ INHA1                 Use PA Form# 20420           Preferred drugs and step therapy must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
STEROIDS                  MC/DEL    NASONEX SUSP                         MC/DEL                                           Dosing limits apply to whole clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
                                                                                  5     NASACORT AQ AERS1
                                                                                                                          category, please see         between another drug and the preferred drug(s) exists.
                                                                          MC      5     NASAREL SOLN1
                                                                                                                          dosage consolidation list.
                                                                         MC/DEL   8     FLONASE SUSP2

                                                                         MC/DEL   8     FLUNISOLIDE SOLN2                 1. All preferred drugs must
                                                                          MC                                              be tried before moving to
                                                                                  8     NASACORT AERS2
                                                                                                                          non preferred steps.
                                                                         MC/DEL   8     OMNARIS SPR
                                                                          MC      8     RHINOCORT AERO2
                                                                         MC/DEL   8     RHINOCORT AQUA SUSP2              2. All step 5 medications
                                                                                                                          need to be tried before
                                                                          MC      8     TRI-NASAL SOLN2
                                                                                                                          moving to step 8's.
                                                                          MC      8     VANCENASE POCKETHALER AERS 2
                                                                         MC/DEL   8     VERAMYST2
ANTIASTHMATIC - NASAL     MC/DEL    CROMOLYN NASAL 4%                     MC      7     ATROVENT NASAL SOL                Use PA Form# 20420               Approved if patient fails on nonsedating antihistamines and steroid nasal sprays.
MISC.                                                                                                                     1. Ipratropium will be           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                          MC/DEL    NASALCROM                             MC      7     IPRATROPIUM NASAL SOL1
                                                                                                                          approved if submitted with       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                          MC/DEL    OCEAN 0.65%                          MC/DEL   7     ASTELIN
                                                                                                                          documentation supporting         drug and the preferred drug(s) exists.
                          MC/DEL    SALINE NASAL SPRAY 0.65%             MC/DEL   8     ASTEPRO2                          use of CPAP machine.



                                                                                                                          2. Utilize Multiple preferred,
                                                                                                                          as well as step therapy
                                                                                                                          Astelin.

ANTIASTHMATIC - BETA -    MC/DEL    ALBUTEROL NEB                        MC/DEL         ACCUNEB NEBU                      1. Xopenex users w/ prior Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ADRENERGICS               MC/DEL    MAXAIR                               MC/DEL         ALBUTEROL AER                     asthma hospitalization due offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                          MC/DEL    METAPROTERENOL                       MC/DEL         ALBUTEROL HFA                     to albuterol nebulizer failure drug and the preferred drug(s) exists.
                                                                                                                          will be grandfathered.
                            MC      PROAIR HFA3                          MC/DEL         ALBUTEROL 0.63mg/3ml
                                                                                                                          2. Quantity Limit: 12
                          MC/DEL    PROVENTIL HFA AERS3                  MC/DEL         ALUPENT AERP                      cc/day.
                          MC/DEL    SEREVENT                             MC/DEL         BRETHINE



                                                                                                                       Page 16 of 51
                                                                                                                                                   2. Quantity Limit: 12
                                                                                                                                                   cc/day.

                            MC/DEL   TERBUTALINE SULFATE TABS               MC/DEL        FORADIL AEROLIZER CAPS
                            MC/DEL   VENTOLIN HFA AERS3                     MC/DEL        PROVENTIL                                                3. Dosing limits apply,
                                                                            MC/DEL        VENTOLIN AERS                                            please see dosage
                                                                                                                                                   consolidation list.
                                                                              MC          VOLMAX TBCR
                                                                              MC          VOSPIRE ER TB12
                                                                            MC/DEL        XOPENEX HFA3
                                                                             MC/DEL       XOPENEX NEBU1,2                                          Use PA Form# 20420
ANTIASTHMATIC -             MC/DEL   ADVAIR DISKUS/HFA1                                                                                            We ask physicians to write
ADRENERGIC COMBINATIONS     MC/DEL                                                                                                                 "asthma" on the
                                     SYMBICORT1
                                                                                                                                                   prescription whenever
                                                                                                                                                   Advair is primarily being
                                                                                                                                                   used for that condition.

                                                                                                                                                   1. Dosing limits apply,
                                                                                                                                                   please see dosage
                                                                                                                                                   consolidation list.

                                                                                                                                                   Use PA Form# 20420
ANTIASTHMATIC -             MC/DEL   ALBUTEROL/IPRATROPIUM NEB. SOLN        MC/DEL        DUONEB SOLN1                                             1. Please use preferred        Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ADRENERGIC                                                                                                                                         individual ingredients         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
ANTICHOLINERGIC                                                                                                                                    Albuterol and Ipratropium.     drug and the preferred drug(s) exists. Duoneb components are available separately without PA.

                            MC/DEL   COMBIVENT AERO2                                                                                               2. We ask physicians to
                                                                                                                                                   write "asthma" on the
                                                                                                                                                   prescription whenever
                                                                                                                                                   Combivent is primarily
                                                                                                                                                   being used for that
                                                                                                                                                   condition.

                                                                                                                                                   Use PA Form# 20420
ANTIASTHMATIC - XANTHINES   MC/DEL   AMINOPHYLLINE TABS                       MC          QUIBRON CAPS                                             Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   THEOCHRON TB12                           MC          QUIBRON-T TABS                                                                          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL                                            MC                                                                                                  drug and the preferred drug(s) exists.
                                     THEOLAIR-SR TB12                                     QUIBRON-T/SR TB12
                            MC/DEL   THEOPHYLLINE CR TB12                   MC/DEL        THEO-24 CP24
                            MC/DEL   THEOPHYLLINE ELIX                        MC          THEOLAIR TABS
                            MC/DEL   THEOPHYLLINE SOLN                      MC/DEL        UNIPHYL TBCR
                            MC/DEL   THEOPHYLLINE ER CP12
                            MC/DEL   THEOPHYLLINE ER TB12
ANTIASTHMATIC - STEROID     MC/DEL   ASMANEX                                MC/DEL    5   AEROBID AERS2                                            Dosing limits apply to whole Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
INHALANTS                   MC/DEL   AZMACORT AERS                            MC                                                                   category, please see         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                      5   BECLOVENT AERS2
                            MC/DEL   FLOVENT DISKUS                           MC                                                                   dosage consolidation list. drug and the preferred drug(s) exists.
                                                                                      5   VANCERIL AERS2
                            MC/DEL   FLOVENT HFA                            MC/DEL    8   AEROBID-M AERS3
                            MC/DEL   PULMICORT SUSP1                        MC/DEL    8   ALVESCO                                                  1. No PA for Pulmicort
                             MC                                               MC                                                                   susp if under 8 years old.
                                     QVAR AERS                                        8   VANCERIL DOUBLE STRENGTH AERS 3

                                                                            MC/DEL    8   PULMICORT FLEXHALER                                      2. All preferreds must be
                                                                                                                                                   tried before moving to non
                                                                                                                                                   preferred steps.

                                                                                                                                                   3. All step 5 medications
                                                                                                                                                   need to be tried before
                                                                                                                                                   moving to step 8's.

                                                                                                                                                   Use PA Form# 20420
ANTIASTHMATIC - 5-                                                            MC          ZYFLO CR TABS                                            Use PA Form# 20420             Other Preferred asthma controller drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
Lipoxygenase Inhibitors                                                                                                                                                           clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
                                                                                                                                                                                  between another drug and the preferred drug(s) exists.

ANTIASTHMATIC -             MC/DEL   SINGULAIR1                             MC/DEL        ACCOLATE TABS                                             1. We ask physicians to       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
LEUKOTRIENE RECEPTOR                                                                                                                               write "asthma" on the          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
ANTAGONISTS                                                                                                                                        prescription whenever          drug and the preferred drug(s) exists.
                                                                                                                                                   Singulair is primarily being
                                                                                                                                                   used for that condition.
                                                                                                                                                   Use PA Form # 20420


ANTIASTHMATIC - ALPHA-                                                        MC          PROLASTIN SUSR                                           Use PA Form# 20420             Prolastin and Azemaira will be approved for members with A1AT deficiency and clinically demonstrable panacinar emphysema.
PROTEINASE INHIBITOR                                                                      ZEMAIRA
                                                                              MC
ANTIASTHMATIC - HYDRO-                                                       MC/DEL       PULMOZYME SOLN                                           Use PA Form# 20420             Will be approved for cystic fibrosis patients.
LYTIC ENZYMES
ANTIASTHMATIC -             MC/DEL   ACETYLCYSTEINE1                          MC          MUCOMYST                                                 1. Acetylcysteine is
MUCOLYTICS                                                                                                                                         covered with diagnosis of
                                                                                                                                                   CF.

                                                                                                                                                   Use PA Form# 20420
                                                                       COUGH/COLD
COUGH/COLD                           DEXTRO-GUAIF SYRP                                    All others are a non-covered service (this includes      All of cough cold              All non-preferred products are not covered as permitted by Federal Medicaid regulations and MaineCare Policy.
                                                                                          antihistamines-decongestive combinations).               preparations are not
                            MC/DEL   GUAIFENESIN SYRP
                                                                                                                                                   covered except these
                            MC/DEL   PSEUDOEPHEDRINE
                                                                                                                                                   preferred products.
                             MC      ROBITUSSIN DM SYRP



                                                                                                                                                Page 17 of 51
                              MC                ROBITUSSIN SUGAR FREE SYRP                                                                          Use PA Form# 20420

                                                                         DIGESTIVE AIDS / ASSORTED GI
                                      **Preferred drugs that used to require diag codes still require diag codes unless indicated otherwise.**
GI - ANTIPERISTALTIC         MC/DEL             DIPHENOXYLATE                              MC/DEL            LOFENE TABS                            Use PA Form# 20420           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
AGENTS                       MC/DEL             DIPHENOXYLATE/ATROPINE                       MC              LONOX TABS                                                          unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage
                             MC/DEL             LOPERAMIDE HCL CAPS/LIQ                    MC/DEL            MOTOFEN TABS                                                        of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
                             MC/DEL             OPIUM TINCTURE TINC                                                                                                              As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
                              MC                PAREGORIC TINC
GI - ANTI-DIARRHEAL/         MC/DEL             ATROPINE SULFATE SOLN                        MC              B & O 15-A SUPPRETTE SUPP              Use PA Form# 20420           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ANTACID - MISC.              MC/DEL             BENTYL SYRP                                  MC              B & O 16-A SUPPRETTE SUPP                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC/DEL                                                          MC                                                                                  drug and the preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
                                                BISMATROL                                                    BELLADONNA ALKALOIDS & OP
                             MC/DEL             BISMUTH SUBSALICYLATE                      MC/DEL            BENTYL TABS
                             MC/DEL             CALCIUM CARBONATE (ANTACID) CHEW           MC/DEL            GLYCOPYRROLATE INJ
                             MC/DEL             DICYCLOMINE HCL                            MC/DEL            HYOSCYAMINE SL
                             MC/DEL             GLYCOPYRROLATE TABS                        MC/DEL            LEVBID TB12
                              MC                HAPONAL TABS                                 MC              LEVSIN ELIX
                             MC/DEL             HYOSCYAMINE CAPS & TABS                    MC/DEL            LEVSIN TABS
                             MC/DEL             HYOSCYAMINE SULFATE                        MC/DEL            LEVSIN/SL SUBL
                             MC/DEL             KAOPECTATE                                 MC/DEL            NULEV TBDP
                             MC/DEL             MAGNESIUM OXIDE TABS                         MC              ROBINUL INJ
                              MC                MAG-OX 400 TABS                              MC              ROBINUL TABS
                             MC/DEL             PAMINE TABS
                             MC/DEL             PROPANTHELINE BROMIDE TABS
                             MC/DEL             SAL-TROPINE TABS
                              MC                SCOPOLAMINE HYDROBROMIDE
                             MC/DEL             SODIUM BICARBONATE TABS
                             MC/DEL             TUMS
GI - H2-ANTAGONISTS          MC/DEL             CIMETIDINE                                   MC              AXID CAPS                              Use PA Form# 20420           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC/DEL             FAMOTIDINE                                   MC              AXID AR TABS                                                        offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC/DEL                                                        MC/DEL                                                                                drug and the preferred drug(s) exists.
                                                RANITIDINE                                                   NIZATIDINE CAPS
                             MC/DEL             RANITIDINE SYRUP                           MC/DEL            PEPCID
                              MC                ACID REDUCER TABS                            MC              PEPCID AC                                                           DDI: Ranitidine and cimetidine will now be non-preferred and require prior authorization if it is currently being used with any sulfonylurea (except for glyburide).
                                                                                           MC/DEL            TAGAMET TABS
                                                                                           MC/DEL            ZANTAC SYRUP
                                                                                           MC/DEL            ZANTAC TABS
GI - PROTON PUMP INHIBITOR   MC/DEL             KAPIDEX2                                     MC         6    PRILOSEC OTC4                          1. Prevacid Solutabs         All preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable
                                                                                                                                                    available without PA for     clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
                             MC/DEL             OMEPRAZOLE 10MG/20MG2                        MC         7    ACIPHEX TBEC4
                                                                                                                                                    children less than 9 years   between another drug and the preferred drug(s) exists.
                             MC/DEL             PROTONIX2                                  MC/DEL       8    PREVACID CPDR4, 5                      old.
                                                                                           MC/DEL       8    PREVACID SOLUTABS1                                                  Patients obtaining refills as of 7/10/09 will begin to require prior authorizations if they have been on any PPI longer than 60 days in the past year.
                                                                                           MC/DEL       8    NEXIUM CPDR4                                                        The 12-month period is patient specific and begins 12 months before the requested date of prior authorization. Payment for usage beyond these limits will be authorized for cases
                                                                                                                                                                                 in which there is a diagnosis of:
                                                                                           MC/DEL       8    PRILOSEC CPDR                          2. Dosing limits apply,
                                                                                                                                                                                 1. Barrett’s esophagus.
                                                                                                        8    PROTONIX INJ                           please see dosage
                                                                                           MC/DEL                                                                                2. Erosive esophagitis
                                                                                                                                                    consolidation list.
                                                                                             MC         9    OMEPRAZOLE 40MG3                                                    3. Hypersecretory conditions (Zollinger-Ellison syndrome, systemic mastocytosis,
                                                                                                                                                    3. Please use multiple          multiple endocrine adenomas). Recurrent peptic ulcer disease after documentation of
                                                                                                                                                    20mg Capsules to obtain         previous trials and therapy failure with at least one histamine H2-receptor antagonist at
                                                                                                                                                    required dose.                  full therapeutic doses and with documentation of either failure of Helicobacter pylori
                                                                                                                                                                                    treatment or anegative Helicobacter pylori test result.
                                                                                                                                                    4. All preferreds and step   4. Symptomatic gastroesophageal reflux after documentation of previous trials and therapy
                                                                                                                                                    therapy must be tried and       failure with at least onehistamine H2-receptor antagonist at full therapeutic doses.
                                                                                                                                                    failed.

                                                                                                                                                    5.Established users prior to
                                                                                                                                                    10/1/09 may continue to
                                                                                                                                                    obtain Prevacid until
                                                                                                                                                    12/31/09.                    DDI: Prevacid, Omeprazole and Protonix will now be non-preferred and require prior authorization if they are currently being used in combination with any of the following
                                                                                                                                                                                 medications: Ampicillin, B-12, Fe salts, Griseofulvin, Sporanox, Ketoconazole, Reyataz, or Vantin.


                                                                                                                                                    Use PA Form # 20720          DDI: All non-preferred PPIs require prior authorization, but with any prior authorization request, the member's drug profile will also be monitored for current use with ampicillin, B-
                                                                                                                                                                                 12, Fe salts, griseofulvin, itraconazole, ketoconazole, Reyataz or Vantin due to a significant drug-drug interaction.


GI - ULCER ANTI-INFECTIVE                                                                    MC              HELIDAC                                1. Please use individual
                                                                                             MC              PREVPAC1                               ingredients.

GI - PROSTAGLANDINS           MC                MISOPROSTOL TABS                           MC/DEL            CYTOTEC TABS                           Use PA Form# 20420           Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drug will be approved, unless an acceptable clinical exception is
                                                                                                                                                                                 offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                                                 drug and the preferred drug(s) exists.

GI - DIGESTIVE ENZYMES       MC/DEL             CREON                                      MC/DEL            LACTRASE CAPS                          Use PA Form# 20420           Non -Preferred drugs must be tried and failed in step-order due to lack of efficacy or intolerable side effects before other non-preferred drugs will be approved, unless an
                             MC/DEL             LACTASE CHEW                               MC/DEL            LIPRAM                                                              acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
                                                                                                                                                                                 interaction between another drug and the preferred drug(s) exists. In all cases except cystic fibrosis patients, objective evidence of pancreatic insufficiency (fat malabsorption test
                             MC/DEL             LACTASE TAB                                MC/DEL            LIPRAM CR
                                                                                                                                                                                 etc...) must be supplied.
                              MC                ULTRASE CPEP                                 MC              KUTRASE CAPS
                              MC                ULTRASE MT                                 MC/DEL            KU-ZYME CAPS
                              MC                VIOKASE                                      MC              PANCREASE



                                                                                                                                                 Page 18 of 51
                                                                                              MC                  PANCREASE MT
                                                                                            MC/DEL                PANCRECARB MS-8 CPEP
                                                                                            MC/DEL                PANCRELIPASE
                                                                                            MC/DEL                PANGESTYME
                                                                                               MC                 PANOKASE TABS
GI - ANTI - FLATULENTS / GI    MC        CALULOSE SYRP                                      MC/DEL                AMITIZA1                            Diag codes no longer          Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
STIMULANTS                    MC/DEL     CONSTULOSE SYRP                                       MC                 CEPHULAC SYRP                       necessary for preferred       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                              MC/DEL                                                        MC/DEL                                                    products. Lactulose has       drug and the preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
                                         ENULOSE SYRP                                                             INFANTS GAS RELIEF SUSP
                                                                                                                                                      60cc/day QL
                               MC        GASTROCROM CONC                                    MC/DEL                REGLAN TABS
                              MC/DEL     GENERLAC SYRP                                                                                                Use PA Form# 20420
                              MC/DEL     LACTULOSE SYRP                                                                                               1. Prior failed trials of
                              MC/DEL     METOCLOPRAMIDE HCL                                                                                           multiple other preferred GI
                              MC/DEL                                                                                                                  agents must occur first,
                                         SIMETHICONE
                                                                                                                                                      Such as OTC senna,
                                                                                                                                                      docusate, lactulose,
                                                                                                                                                      polyethylene glycol.

GI - INFLAMMATORY BOWEL       MC/DEL     ASACOL TBEC                                        MC/DEL                ASACOL 800MG HD                     Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
AGENTS                         MC        APRISO                                             MC/DEL                AZULFIDINE EN-TABS TBEC                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                               MC                                                           MC/DEL                                                                                  drug and the preferred drug(s) exists.
                                         AZULFIDINE TABS                                                          PENTASA 500MG2                      1. Current users
                               MC        CANASA SUPP                                        MC/DEL                LIALDA TABS1                        grandfathered.
                               MC        COLAZAL CAPS                                                                                                 2. Use multiple Pentasa
                               MC        DIPENTUM CAPS                                                                                                250mg.
                              MC/DEL     PENTASA CPCR 250MG
                              MC/DEL     ROWASA ENEM
                              MC/DEL     SULFAZINE EC TBEC
                              MC/DEL     SULFASALAZINE TABS
GI - IRRITABLE BOWEL                                                                        MC/DEL                LOTRONEX TABS                       Use PA Form# 20420            Lotronex will be approved for females with IBS and predominant diarrhea. Prior failed trials of multiple preferred GI agents must occur first. IBS dx must be thoroughly documented.
SYNDROME AGENTS

                                                                              MISCELLANEOUS GI
                                       **Preferred drugs that used to require diag codes still require diag codes unless indicated otherwise.**
GI - MISC.                    MC/DEL     BISAC-EVAC SUPP                                    MC/DEL                ACTIGALL CAPS                       1. Must show evidence of Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                              MC/DEL     BISACODYL                                             MC                 BENEFIBER                           trials of preferred agents   offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                               MC                                                           MC/DEL                                                    that do not require PA, such drug and the preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
                                         BISCOLAX SUPP                                                            CARAFATE
                                                                                                                                                      as OTC senna, docusate,
                               MC        CINOBAC CAPS                                       MC/DEL                COLACE CAPS
                                                                                                                                                      mineral oil and prescription
                              MC/DEL     CITRATE OF MAGNESIA SOLN                           MC/DEL                COLYTE                              lactulose.
                              MC/DEL     CITRUCEL                                              MC                 DIOCTO-C SYRP
                              MC/DEL     DIOCTO SYRP                                           MC                 DOC SOD /CAS CAP
                               MC        DOCUSATE CALCIUM CAPS                                 MC                 DOC-Q-LAX CAPS
                              MC/DEL     DOCUSATE SODIUM                                    MC/DEL                DOCUSATE SODIUM/CAS CAPS
                              MC/DEL     FIBER LAXATIVE TABS                                MC/DEL                DOK PLUS
                               MC        FLEET                                              MC/DEL                DULCOLAX SUPP                       Use PA Form# 20420
                              MC/DEL     GENFIBER POWD                                         MC                 FIBER CON TABS
                              MC/DEL     GLYCERIN                                           MC/DEL                FIBER-LAX TABS
                               MC        HIPREX TABS                                           MC                 GOLYTELY SOLR
                              MC/DEL     KRISTALOSE PACK                                       MC                 MALTSUPEX
                               MC        MAALOX                                                MC                 MIRALAX PACK (OTC versions)
                               MC        METAMUCIL                                             MC                 MIRALAX POWD (OTC versions)
                              MC/DEL     MILK OF MAGNESIA SUSP                                 MC                 PEG 3350/ELECTROLYTES SOLR
                               MC        MINERAL OIL OIL                                    MC/DEL                SENEXON TABS
                              MC/DEL     NULYTELY SOLR                                      MC/DEL                SENOKOT TABS
                              MC/DEL     SENNA                                                 MC                 SENOKOT S TABS
                              MC/DEL     SENOKOT GRAN                                          MC                 STOOL SOFTENER PLUS CAPS
                              MC/DEL     SENOKOT SYRP                                       MC/DEL                UNI-CENNA TABS
                              MC/DEL     SENOKOT CHILDRENS SYRP                                MC                 UNI-EASE PLUS CAPS
                               MC        SENOKOT XTRA TABS                                     MC                 V-R NATURAL SENNA LAXATIV TABS
                              MC/DEL     SORBITOL                                              MC                 URSO 250
                              MC/DEL     STOOL SOFTENER CAPS
                              MC/DEL     SUCRALFATE TABS
                               MC        UNI-EASE CAPS
                               MC        UNIFIBER POWD
                               MC        URSO FORTE
                              MC/DEL     URSODIOL
                                                                              MISC. UROLOGICAL
UROLOGICAL - MISC.             MC        ACETIC ACID 0.25% SOLN                                MC                 CITRIC ACID/SODIUM CITRAT SOLN      1. Elmiron requires           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                         CYTRA-K SOLN                                       MC/DEL                CYTRA-2 SOLN                        adequate proof of Dx with     offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                               MC
                                                                                                                                                      supportive testing.           drug and the preferred drug(s) exists.
                               MC        FURADANTIN SUSP                                       MC                 ELMIRON CAPS1
                               MC        K-PHOS MF TABS                                     MC/DEL                MACROBID CAPS                       Use PA Form# 20420
                              MC/DEL     METHENAMINE MANDELATE TABS                         MC/DEL                MANDELAMINE TABS
                              MC/DEL     MONUROL PACK                                       MC/DEL                MACRODANTIN CAPS
                              MC/DEL     NEOSPORIN GU IRRIGANT SOLN                          MC                   POTASSIUM CITRATE/CITRIC SOLN



                                                                                                                                                   Page 19 of 51
                           MC/DEL       NITROFURANTOIN MACR CAPS                MC/DEL         PYRIDIUM PLUS TABS
                           MC/DEL       PHENAZOPYRIDINE HCL TABS                 MC            PYRIDIUM TABS
                           MC/DEL       PHENAZOPYRIDINE PLUS                    MC/DEL         RENACIDIN SOLN
                           MC/DEL       PROSED/DS TABS
                            MC          TRICITRATES SYRP
                           MC/DEL       URELIEF PLUS
                            MC          UREX TABS
                           MC/DEL       URISED TABS
                            MC          UROCIT-K
                           MC/DEL       UROQID #2 TABS
                                                                       PHOSPHATE BINDERS
PHOSPHATE BINDERS            MC         PHOSLO1                                 MC/DEL         RENVELA2                      Use PA Form# 20420
                           MC/DEL       MAGNEBIND - 4001                                                                     1. Diag required.
                           MC/DEL       RENAGEL1                                                                             2. Must fail Phoslo,
                           MC/DEL       FOSRENOL1                                                                            Renagel & Fosrenol before
                                                                                                                             non-preferred products.



                                                                        INTRA-VAGINALS
VAGINAL - ANTIBACTERIALS   MC/DEL   1   CLEOCIN CREA                            MC/DEL         METROGEL VAGINAL GEL2         1. Step order must be      Preferred drugs must be tried and failed in step-order due to lack of efficacy or intolerable side effects before less preferred drugs will be approved, unless an acceptable clinical
                           MC/DEL   1   METRONIDAZOLE VAGINAL GEL2              MC/DEL         VANDAZOLE                     followed to avoid PA. Must exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                           MC/DEL                                                                                            fail Cleocin Cream and     another drug and the preferred drug(s) exists.
                                    3   CLEOCIN SUPP1
                                                                                                                             Metronidazole products
                                                                                                                             before moving to next step
                                                                                                                             product without PA.



                                                                                                                             2. Dosing limits apply,
                                                                                                                             please see Dosage
                                                                                                                             Consolidation List.

                                                                                                                             Use PA Form# 20420
VAGINAL - ANTI FUNGALS     MC/DEL       CLOTRIMAZOLE CREA                         MC           AVC CREAM                     1. Quantity limit: 1/script/2 Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                           MC/DEL                                                 MC                                         weeks                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                        GYNE-LOTRIMIN CREA                                     CLOTRIMAZOLE 3 DAY CREA
                                                                                                                                                           drug and the preferred drug(s) exists.
                            MC          MICONAZOLE CREA                           MC           GYNAZOLE-1 CREA               Use PA Form# 20420
                           MC/DEL       MICONAZOLE 3 COMBO PACK KIT1              MC           GYNE-LOTRIMIN 3 TABS
                           MC/DEL       MICONAZOLE 7 CREA                       MC/DEL         MICONAZOLE 3 SUPP
                           MC/DEL       MICONAZOLE NITRATE CREA                   MC           TERAZOL 3 CREA
                            MC          NYSTATIN TABS                             MC           TERAZOL 7 CREA
                            MC          TERAZOL 3 SUPP                          MC/DEL         TERCONAZOLE 0.8MG
                           MC/DEL       TERCONAZOLE 0.4MG                       MC/DEL         TERCONAZOLE SUPP
                            MC          VAGITROL
                            MC          V-R MICONAZOLE-7 CREA
VAGINAL - CONTRACEPTIVES    MC          GYNOL II EXTRA STRENGTH GEL               MC           DELFEN FOAM                   Use PA Form# 20420             Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drug will be approved, unless an acceptable clinical exception is
                                                                                                                                                            offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                            drug and the preferred drug(s) exists.

VAGINAL - ESTROGENS        MC/DEL       ESTRING RING                            MC/DEL         ESTRACE CREA                  Must fail all preferred        Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                           MC/DEL       PREMARIN CREA                           MC/DEL         VAGIFEM TABS                  products before non-           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                             preferred.                     drug and the preferred drug(s) exists.

                                                                                                                             Use PA Form# 20420
VAGINAL - OTHER            MC/DEL       ACID JELLY GEL                            MC           AMINO ACID CERVICAL CREA      Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC          ACI-JEL GEL                                                                                                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC                                                                                                                              drug and the preferred drug(s) exists.
                                        CERVICAL AMINO ACID CREA


                                                                             BPH
BPH                        MC/DEL       AVODART                                MC/DEL      5   FLOMAX CP24                   Non-preferred products         Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
                           MC/DEL       DOXAZOSIN MESYLATE TABS                 MC/DEL     8   CARDURA TABS                  must be used in specified      exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                           MC/DEL                                                 MC                                         order.                         another drug and the preferred drug(s) exists. Approval of a non-preferred 5-alpha reductase inhibitor requires objective clinical evidence of a very enlarged prostate rather than
                                        FINASTERIDE   1
                                                                                           8   HYTRIN CAPS
                                                                                                                                                            just the presence of obstructive urinary outflow symptoms along with adequate trial of preferred Proscar.
                           MC/DEL       TERAZOSIN HCL CAPS                      MC/DEL     8   PROSCAR TABS                  1. There will be dosing
                                                                                MC/DEL     8   RAPAFLO                       limits of 1 tab per day with
                                                                                                                             out PA.
                                                                                MC/DEL     8   UROXATRAL                     Use PA Form# 20420
                                                                          ANXIOLYTICS
ANXIOLYTICS -              MC/DEL       ALPRAZOLAM TABS                         MC/DEL         ALPRAZOLAM ER                 Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
BENZODIAZEPINES            MC/DEL       CHLORDIAZEPOXIDE HCL CAPS               MC/DEL         ATIVAN                                                       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                           MC/DEL                                               MC/DEL                                                                      drug and the preferred drug(s) exists.
                                        CLORAZEPATE DIPOTASSIUM TABS                           NIRAVAM
                           MC/DEL       DIAZEPAM                                MC/DEL         SERAX
                           MC/DEL       LORAZEPAM                               MC/DEL         TRANXENE
                           MC/DEL       OXAZEPAM CAPS                           MC/DEL         XANAX TABS
                                                                                MC/DEL         XANAX XR
ANXIOLYTICS - MISC.        MC/DEL       BUSPIRONE HCL TABS                        MC           ATARAX TABS                   Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC          HYDROXYZINE HCL SOLN                      MC           BUSPAR TABS                                                  offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                            drug and the preferred drug(s) exists.


                                                                                                                          Page 20 of 51
                                                                                                                                                     Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                                                                                                     offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC                                                 MC                                                                       drug and the preferred drug(s) exists.
                                     HYDROXYZINE HCL SYRP                              DROPERIDOL SOLN
                        MC/DEL       HYDROXYZINE PAMOATE CAPS              MC/DEL      HYDROXYZINE HCL TABS
                        MC/DEL       MEPROBAMATE TABS                      MC/DEL      HYDROXYZINE PAM 100MG CAPS
                                                                            MC         INAPSINE SOLN
                                                                           MC/DEL      VISTARIL



                                                                 ANTI-DEPRESSANTS
ANTIDEPRESSANTS - MAO   MC/DEL       NARDIL TABS
INHIBITORS              MC/DEL       PARNATE TABS
ANTIDEPRESSANTS - MAO                                                      MC/DEL      EMSAM1                          1. Dosing limits apply,       Preferred drugs (including a preferred SSRI, a non-SSRI, and either Cymbalta or Effexor) must be tried and failed due to lack of efficacy or intolerable side effects before non-
INHIBITORS TOPICAL                                                                                                     please refer to Dose          preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the
                                                                                                                       consolidation list.           preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.

                                                                                                                       Use PA Form# 20420
ANTIDEPRESSANTS -       MC/DEL       BUPROPION HCL TABS                    MC/DEL      APLENZIN7                       Non-preferred products      Preferred drugs (including failure of at least one preferred SSRI, one SNRI and one non-SSRI/SNRI) must be tried for at least 4 weeks each and failed due to lack of efficacy or
SELECTED SSRI's         MC/DEL       BUPROPION SR                          MC/DEL      CELEXA                          must be used in specified intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a
                        MC/DEL                                              MC                                         step order.                condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
                                     BUPROPION XL                                      DESYREL TABS
                                                                                                                       1. Use Fluoxetine 20 mg in
                        MC/DEL       CITALOPRAM4                           MC/DEL      EFFEXOR TABS
                                                                                                                       multiples.
                         MC          CYMBALTA5                             MC/DEL      EFFEXOR XR CP24 3
                        MC/DEL       FLUOXETINE HCL CAPS                   MC/DEL      FLUOXETINE 40 mg CAPS1
                        MC/DEL       FLUOXETINE HCL LIQD                   MC/DEL      FLUOXETINE 20mg TABS6
                        MC/DEL       FLUOXETINE HCL 10mg TABS               MC         LUVOX TABS                      2. See Zoloft splitting table.
                        MC/DEL       FLUVOXAMINE MALEATE TABS               MC         MAPROTILINE HCL TABS            Sertraline requires splitting Preferred Fluoxetine will be the only preferred antidepressant for members who are less than 18 years of age.
                        MC/DEL                                             MC/DEL                                      of scored tabs to avoid PA. Exceptions to the rule are as follows:
                                     LEXAPRO TABS4                                     MIRTAZAPINE ODT
                                                                                                                                                      1. If the member (<18) is already an established user for any of the preferred or non-preferred drugs under the Antidepressant category on the PDL, then they can continue to get
                        MC/DEL       MIRTAZAPINE                           MC/DEL      PAROXETINE CR3
                                                                                                                                                      that drug.
                        MC/DEL       NEFAZODONE                            MC/DEL      PAXIL3                                                         2. If the member (<18) has a prescription for an antidepressant that is on the PREFERRED side of the PDL and has had a 30 day supply of Fluoxetine at least 30 days before the
                        MC/DEL       PAROXETINE3                           MC/DEL      PAXIL CR 3                      3. Strong caution with         date they are getting it filled, the claim will pay. If they do not have the trial of Fluoxetine in their profile, the claim will reject for PA required.
                        MC/DEL       SERTRALINE2                           MC/DEL      PRISTIQ                         pediatric population.          3. If the member (<18) has a prescription for a medication that is on the NON-PREFERRED side of the PDL regardless of having Fluoxetine in their profile, the prescription will
                        MC/DEL       TRAZODONE HCL TABS                     MC         PROZAC                                                         need a PA.
                        MC/DEL       VENLAFAXINE ER TABS                    MC         PROZAC CAPS                     4. See Celexa/Citalopram
                        MC/DEL       SAVELLA 8                              MC         PROZAC WEEKLY CPDR              and Lexapro splitting
                                                                                                                       tables.
                                                                           MC/DEL      REMERON TABS
                                                                           MC/DEL      SARAFEM CAPS
                                                                           MC/DEL      TRAZODONE HCL 300MG TABS        5. Max daily dose allowed
                                                                           MC/DEL      WELLBUTRIN TABS                 is 60mg, only 1 capsule per   4. Use of a preferred antidepressant for anxiety will require pa to establish anxiety diagnosis.
                                                                                                                       day allowed for all
                                                                           MC/DEL      WELLBUTRIN SR TBCR                                            5. Use of bupropion or Wellbutrin for ADHD diagnosis must show prior trial/failure with methylphenidate and amphetamine
                                                                                                                       strengths. Combination of
                                                                           MC/DEL      WELLBUTRIN XL                   multiple strengths require    Criteria for new starters <18 years of age.
                                                                           MC/DEL      REMERON SOLTAB TBDP             PA.                           Must have had fluoxetine trial for at least 30 days before accessing other preferred antidepressants without PA.
                                                                           MC/DEL      ZOLOFT                                                        DDI: Fluvoxamine will now be non-preferred and require prior authorization if it is currently being used with glimepiride (Amaryl).
                                                                                                                       6. Use Fluoxetine 10mg
                                                                                                                       tabs or capsules in
                                                                                                                       multiples.
                                                                                                                                                     DDI: Preferred nefazodone will now be non-preferred and require prior authorization if it is currently being used in combination with either Enablex 15mg or Vesicare 10mg.
                                                                                                                       7. Provide clinical
                                                                                                                       documentation as to why a
                                                                                                                       preferred generic
                                                                                                                       alternative cannot be used.


                                                                                                                       8. Available w/out PA for
                                                                                                                       Fibromyalgia if first line
                                                                                                                       generic TCA,
                                                                                                                       Cyclobenzaprine, or
                                                                                                                       Gabapentin in profile.

                                                                                                                       Use PA Form# 20420
ANTIDEPRESSANTS -       MC/DEL   *   AMITRIPTYLINE HCL TABS                MC/DEL      AMOXAPINE TABS                  *Users over the age of 65     Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
TRI-CYCLICS                                                                                                            require a pa.                 offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC      *   AVENTYL SOLN                          MC/DEL      ANAFRANIL CAPS
                                                                                                                                                     drug and the preferred drug(s) exists.
                        MC/DEL   *   CLOMIPRAMINE HCL CAPS                 MC/DEL      ELAVIL TABS
                        MC/DEL   *   DESIPRAMINE HCL TABS                  MC/DEL      NORPRAMIN TABS
                        MC/DEL   *   DOXEPIN HCL                           MC/DEL      PAMELOR                         Use PA Form# 20420
                        MC/DEL   *   IMIPRAMINE HCL TABS                   MC/DEL      SINEQUAN                        or 10220
                        MC/DEL       NORTRIPTYLINE HCL                      MC         TOFRANIL
                         MC      *   PROTRIPTYLINE HCL TABS                 MC         VIVACTIL TABS
                         MC      *   SURMONTIL CAPS
                                                                SEDATIVE / HYPNOTICS
SEDATIVE/HYPNOTICS -     MC          BUTISOL SODIUM TABS                     MC        LUMINAL SOLN                    PA required for new users Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
BARBITURATE             MC/DEL       CHLORAL HYDRATE SYRP                  MC/DEL      SOMNOTE CAPS                    of preferred products if over offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC                                                                                            65 years.                     drug and the preferred drug(s) exists.
                                     MEBARAL TABS
                        MC/DEL       PHENOBARBITAL
                                                                                                                       Use PA Form# 20420
SEDATIVE/HYPNOTICS -    MC/DEL       DORAL TABS                             MC         DALMANE                         Previous quantity limits still Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
BENZODIAZEPINES         MC/DEL       ESTAZOLAM TABS                         MC         HALCION TABS                    apply.                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                        MC/DEL                                              MC                                                                        drug and the preferred drug(s) exists. Benzodiazepines do cause dependence with continued use and usage should be limited to 7-10 days at a time. Chronic intermittent use (2-
                                     FLURAZEPAM HCL CAPS                               MIDAZOLAM HCL SYRP              Use PA Form # 30110
                                                                                                                                                      3 Days per week max) is the standard of care

                                                                                                                    Page 21 of 51
                                                                                                                                                               Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                                                                                                               offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                               drug and the preferred drug(s) exists. Benzodiazepines do cause dependence with continued use and usage should be limited to 7-10 days at a time. Chronic intermittent use (2-
                                                                                                                                                               3 Days per week max) is the standard of care
                            MC/DEL       TEMAZEPAM CAPS                   MC/DEL        RESTORIL CAPS
                            MC/DEL       TRIAZOLAM TABS
SEDATIVE/HYPNOTICS - Non-   MC/DEL   1   MIRTAZAPINE                      MC/DEL    7   AMBIEN1                               Must fail all preferred          Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
Benzodiazepines              MC          TRAZODONE                        MC/DEL                                              products before non-             offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                     1                                              8   AMBIEN CR1
                            MC/DEL                  2                     MC/DEL                  1                           preferred 1. Quantity Limt of    drug and the preferred drug(s) exists. Ambien, Ambien CR, Lunesta, Sonata, Zaleplon and Zolpidem may cause dependence with continued use and as with
                                     1   ZOLPIDEM                                   8   LUNESTA
                                                                                                                              12 per 34 days.                  benzodiazepines, usage should be limited to 7-10 days at a time. Chronic intermittent use (2-3 days per week max) is the standard of care. Please refer to
                            MC/DEL   2   ZALEPLON 2,3                     MC/DEL    8   SONATA CAPS1                                                           Sedative/Hypnotic PA form.
                                                                          MC/DEL    8   ROZEREM                               2. Quantity limits will be
                                                                                                                              allowed up to 30/30, but
                                                                                                                              intermittent therapy is
                                                                                                                              recommended.

                                                                                                                              3. Only zolpidem
                                                                                                                              trial/failure will be required
                                                                                                                              to obtain Zaleplon.


                                                                                                                              Use PA Form # 30110
                                                                  ANTI-PSYCHOTICS
ANTIPSYCHOTICS -            MC/DEL       ABILIFY TABS3                     MC/DEL       ABILIFY DISC TAB, INJ and SOL 2       If prescribing 2 or more         Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ATYPICALS                                                                                                                     antipsychotics, PA will be       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL       GEODON                             MC          INVEGA                                required for both drugs,         drug and the preferred drug(s) exists. Non preferred atypicals will be approved for patients with FDA-approved indications, and for specific conditions supported by at least two
                                                                                                                              except if one is Clozapine.      published peer-reviewed double-blinded, placebo-controlled randomized trials that are not contradicted by other studies of similar quality and as long as all first line preferred
                            MC/DEL       RISPERIDONE TAB                    MC          RISPERDAL TAB                         This also includes               therapies have been tried and failed at full therapeutic doses for adequate durations (at least two weeks). * Abilify: doses above 15mg were not shown to be more effective than
                            MC/DEL       RISPERIDONE SOLN                   MC          RISPERDAL CONSA 2                     combination of Seroquel          doses in the 10-15mg range.
                                                                                                                              with Seroquel XR.
                            MC/DEL       SEROQUEL TABS                      MC          RISPERDAL M TAB2                                                       Seroquel 25mg is preferred and available without PA if the following conditions are met: a.) Either 65 years of age or older or less than 18 years of age, b.) dosage is for 3 or
                                                                                                                                                               more per day, c.) Seroquel 25mg is in the profile within the last 45 days OR if any of the following doses are being used in combination with any daily dose of Seroquel 25mg: a.) at
                            MC/DEL       SEROQUEL XR                        MC          RISPERDAL SOLN                                                         least 1.5 Seroquel 100mg tabs, b.) Seroquel 200mg tabs, c.) Seroquel 300mg tabs, d.) Seroquel 400mg tabs OR if dose is beting titrated up.
                             MC          ZYPREXA TABS                     MC/DEL        SEROQUEL 50MG TABS1,2                 See Multiple Antipsychotic
                                                                                                                              PA form #20440.

                                                                            MC          ZYPREXA ZYDIS TBDP 2                                            Seroquel 100mg is preferred and available without pa if the daily dosage is 1.5 tablets or more per day OR if any of the following doses are being used in combination with any
                                                                                                                                                        daily dose of Seroquel 100mg: a.) at least 3- Seroquel 25mg tabs, b.) Seroquel 200mg tabs, c.) Seroquel 300mg tabs, d.) Seroquel 400mg tabs.
                                                                                                                               Please use Miscellaneous
                                                                                                                              PA form # 20420 for non-
                                                                                                                              preferred single therapy  Seroquel 50mg tablets are non-preferred and multiple Seroquel 25mg tablets should be used.
                                                                                                                              atypical requests.



                                                                                                                              All atypicals have dosing    Atypical drugs may require PA if the patient either has or is at risk for Metabolic Syndrome (diabetes, dyslipidemia, hypertension).
                                                                                                                              limitations and maximum
                                                                                                                              daily doses. Please refer to
                                                                                                                                                           DDI: Abilify, Seroquel, and Zyprexa will now be non-preferred and require prior authorization if they are currently being used in combination with carbamazepine.
                                                                                                                              dose consolidation table for
                                                                                                                                                           Please use Drug-Drug Interaction PA form #10400.
                                                                                                                              any potential dosing limits.
                                                                                                                              Maximum daily doses are
                                                                                                                              as follows:
                                                                                                                              Abilify- 30mg daily max
                                                                                                                              Risperdal- 8mg daily max
                                                                                                                              Seroquel- 800mg daily max
                                                                                                                              Seroquel XR- 800mg daily
                                                                                                                              max
                                                                                                                              Zyprexa- 30mg daily max
                                                                                                                              Use PA form #10420 for
                                                                                                                              requests exceeding these
                                                                                                                              maximum daily doses.




                                                                                                                              1. Please use multiple
                                                                                                                              25mg tablets.

                                                                                                                              2. Established users of
                                                                                                                              single therapy atypicals
                                                                                                                              were grandfathered.



                                                                                                                              3. Abilify requires splitting
                                                                                                                              of tab to avoid PA. Please
                                                                                                                              see Abilify splitting table.
ANTIPSYCHOTICS - SPECIAL    MC/DEL       CLOZAPINE TABS                   MC/DEL        CLOZARIL TABS                         Use PA Form# 20420               Preferred generic drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred brand will be approved, unless an acceptable clinical
ATYPICALS                                                                   MC          FAZACLO                                                                exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                                                                               another drug and the preferred drug(s) exists. Patients previously stabilized on brand name drug will be approved.
                                                                                                                                                               DDI: Clozapine will now be non-preferred and require prior authorization if it is currently being used in combination with carbamazepine.
                                                                                                                                                               Please use Drug-Drug Interaction PA form #10400.

ANTIPSYCHOTICS - TYPICAL    MC/DEL       CHLORPROMAZINE HCL               MC/DEL        COMPAZINE                            Use PA Form# 20420                Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                            MC/DEL       FLUPHENAZINE DECANOATE           MC/DEL        COMPRO SUPP                          If prescribing 2 or more           unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant
                                                                                                                             antipsychotics, PA will be        potential drug interaction between another drug and the preferred drug(s) exists.
                                                                                                                             required for both drugs,
                                                                                                                             except one is
                                                                                                                          Page 22ifof 51Clozapine.
                                                                                                                   If prescribing 2 or more         unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant
                          MC/DEL    FLUPHENAZINE HCL                      MC          HALDOL DECANOATE             antipsychotics, PA will be      potential drug interaction between another drug and the preferred drug(s) exists.
                            MC                                          MC/DEL                                     required for both drugs,
                                    HALDOL                                            LOXITANE CAPS
                                                                                                                   except if one is Clozapine.
                          MC/DEL    HALOPERIDOL                           MC          MELLARIL
                                                                                                                   See Multiple Antipsychotic
                            MC      HALOPERIDOL DECANOATE SOLN          MC/DEL        NAVANE CAPS                  PA form #20440. For PA
                            MC      HALOPERIDOL LACTATE SOLN              MC          PROLIXIN                     requests for non preferred
                          MC/DEL    LOXAPINE SUCCINATE CAPS               MC          STELAZINE TABS               single user antipsychotic
                          MC/DEL                                          MC                                       medications, please use
                                    LOXITANE-C CONC                                   THORAZINE
                                                                                                                   miscellaneous PA form
                            MC      MOBAN TABS
                                                                                                                   #20420.
                          MC/DEL    PERPHENAZINE
                          MC/DEL    PROCHLORPERAZINE
                            MC      SERENTIL
                          MC/DEL    THIORIDAZINE HCL
                          MC/DEL    THIOTHIXENE
                            MC      THORAZINE SUPP
                          MC/DEL    TRIFLUOPERAZINE HCL TABS
                                                                    LITHIUM
LITHIUM                   MC/DEL    LITHIUM CARBONATE                   MC/DEL        ESKALITH CAPS                Use PA Form# 20420
                          MC/DEL    LITHIUM CITRATE SYRP                MC/DEL        ESKALITH CR TBCR
                                                        COMBINATION - PSYCHOTHERAPEUTIC
PSYCHOTHERPEUTIC          MC/DEL    CHLORDIAZEPOXIDE/AMITRIPT             MC      8   SYMBYAX1                     Please use individual
COMBINATION               MC/DEL    PERPHENAZINE/AMITRIPTYLIN                                                      preferred medications.

                                                                                                                   Use PA Form# 20420
                                                                  STIMULANTS
                           MC/DEL   ADDERALL TABS                                                                  Preferred stimulants will be
STIMULANT - AMPHETAMINES -                                                                                         available without PA if
                           MC/DEL   AMPHETAMINE SALT COMBO
SHORT ACTING                                                                                                       diagnosis of ADHD.As per
                           MC/DEL   DEXTROAMPHET SULF TABS
                                                                                                                   recent FDA alert, Adderal &
                          MC/DEL    DEXEDRINE                                                                      Dexedrinel should not be
                          MC/DEL    DEXTROSTAT TABS                                                                used in patients with
                                                                                                                   underlying heart defects
                                                                                                                   since they may be at
                                                                                                                   increased risk for sudden
                                                                                                                   death. Stimulants have
                                                                                                                   dosing limitations per
                                                                                                                   strength and maximum daily
                                                                                                                   doses. Please refer to dose
                                                                                                                   consolidation table for any
                                                                                                                   potential dosing limits per
                                                                                                                   strength. Maximum daily
                                                                                                                   doses are as follows: 50mg
                                                                                                                   daily.




STIMULANT - LONG ACTING   MC/DEL    ADDERALL XR CP241                                                              Preferred stimulants will
AMPHETAMINES SALT           MC                                                                                     be available without PA if
                                    VYVANSE2
                                                                                                                   diagnosis of ADHD.
                                                                                                                   Stimulants have dosing
                                                                                                                   limitations per strength
                                                                                                                   and maximum daily
                                                                                                                   doses. Please refer to
                                                                                                                   dose consolidation table
                                                                                                                   for any potential dosing
                                                                                                                   limits per strength.




                                                                                                                   1. As per recent FDA alert,
                                                                                                                   Adderall should not be used
                                                                                                                   in patients with underlying
                                                                                                                   heart defects since they
                                                                                                                   may be at increased risk for
                                                                                                                   sudden death.



                                                                                                                   2. FDA approval is
                                                                                                                   currently for adults and
                                                                                                                   children 6 or older. Will be
                                                                                                                   available without PA for this
                                                                                                                   age group if within dosing
                                                                                                                   limits. Limit of one capsule
                                                                                                                   daily. Max dose of 70MG
                                                                                                                   daily.


LONG ACTING                 MC      DEXEDRINE CAP CR                      MC          DEXTROAMPHET SULF CPCR      Preferred stimulants will be
AMPHETAMINES                                                                                                      available without PA if
                                                                                                                  diagnosis of ADHD. As per
                                                                                                                  recent of 51
                                                                                                               Page 23FDA alert, Adderall &
LONG ACTING                                                                                  Preferred stimulants will be
AMPHETAMINES                                                                                 available without PA if
                                                                                             diagnosis of ADHD. As per
                                                                                             recent FDA alert, Adderall &
                                                                                             Dexedrine should not be
                                                                                             used in patients with
                                                                                             underlying heart defects
                                                                                             since they may be at
                                                                                             increased risk for sudden
                                                                                             death. Stimulants have
                                                                                             dosing limitations per
                                                                                             strength and maximum daily
                                                                                             doses. Please refer to dose
                                                                                             consolidation table for any
                                                                                             potential dosing limits per
                                                                                             strength. Maximum daily
                                                                                             doses are as follows: 50mg
                                                                                             daily.




STIMULANT -              MC/DEL   FOCALIN TABS           MC          METHYLIN CHEWABLES      Preferred stimulants will be Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
METHYLPHENIDATE                   METADATE ER TBCR      MC/DEL                               available without PA if      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC/DEL                                      RITALIN
                                                                                             diagnosis of ADHD.           drug and the preferred drug(s) exists. Please refer to General Criteria category E.
                         MC/DEL   METHYLIN ER TBCR
                         MC/DEL   METHYLIN TABS                                              Use PA Form# 20420
                         MC/DEL   METHYLIN SOL                                               Stimulants have dosing
                         MC/DEL   METHYLPHENIDATE HCL                                        limitations per strength and
                                                                                             maximum daily doses.
                                                                                             Please refer to dose
                                                                                             consolidation table for any
                                                                                             potential dosing limits per
                                                                                             strength. Maximum daily
                                                                                             doses are as follows: 72mg
                                                                                             daily for methylphenidate
                                                                                             and 36mg daily for
                                                                                             dexmethylphenidate.




STIMULANT -               MC      CONCERTA TBCR          MC      5   METADATE CD CPCR        Preferred stimulants will be Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
METHYLPHENIDATE - LONG                                  MC/DEL       DAYTRANA2               available without PA if      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                          MC      FOCALIN XR1                    8
ACTING                                                                                       diagnosis of ADHD. Non-      drug and the preferred drug(s) exists.
                                                        MC/DEL   8   RITALIN LA              preferred products must be
                                                                                             used in specified step
                                                                                             order. Stimulants also
                                                                                             have dosing limitations per
                                                                                             strength and maximum daily
                                                                                             doses. Please refer to dose
                                                                                             consolidation table for any
                                                                                             potential dosing limits per
                                                                                             strength. 1. Available to
                                                                                             those members needing
                                                                                             sprinkles with diagnosis of
                                                                                             ADHD.




                                                                                             2. FDA approval currently
                                                                                             only for ages 6-16. Limit of
                                                                                             one patch daily. Max dose
                                                                                             of 30MG daily.

                                                                                             Use PA Form# 20420
STIMULANT - STIMULANT                                    MC      7   STRATTERA1, 2           1. Failure of both an         Provigil requests require diagnosis of Narcolepsy, ADHD, or Obstructive Sleep Apnea. Previous failures of methylphenidate and amphetamine is required for Narcolepsy and
LIKE                                                     MC      8   CAFCIT SOLN             amphetamine and               ADHD diagnosis, with additional Strattera trial needed with ADHD diagnosis. Please refer to detailed criteria on Provigil PA form
                                                                                             methylphenidate is required
                                                        MC/DEL   8   PROVIGIL TABS
                                                                                             for consideration for
                                                         MC      9   DESOXYN TABS            approval of Strattera,
                                                         MC      9   DESOXYN CR              unless history of substance
                                                                                             abuse without current use
                                                                                             of abusable medication(s)
                                                                                             2. Strattera currently has
                                                                                             dosing limitations allowing
                                                                                             one tablet per day for all
                                                                                             strengths if obtain approval.
                                                                                             Max daily dose of Strattera
                                                                                             is 100mg. Please refer to
                                                                                             PDL dosage consolidation
                                                                                             chart. 3. Non-preferred
                                                                                             products must be used in
                                                                                             specified step order.


                                                                                          Page 24 of 51
                                                                                                                  for consideration for
                                                                                                                  approval of Strattera,
                                                                                                                  unless history of substance
                                                                                                                  abuse without current use
                                                                                                                  of abusable medication(s)
                                                                                                                  2. Strattera currently has
                                                                                                                  dosing limitations allowing
                                                                                                                  one tablet per day for all
                                                                                                                  strengths if obtain approval.
                                                                                                                  Max daily dose of Strattera
                                                                                                                  is 100mg. Please refer to
                                                                                                                  PDL dosage consolidation
                                                                                                                  chart. 3. Non-preferred
                                                                                                                  products must be used in
                                                                                                                  specified step order.




                                                                                                                  Provigil: use PA Form #
                                                                                                                  20710;
                                                                                                                  Use PA Form# 20420
                                                             ANTI-CATAPLECTIC AGENTS
PSYCHOTHERAPEUTIC                                                        MC/DEL        XYREM SOL                  Use PA Form # 20710
AGENTS - MISC.                                                             MC          XENAZINE
                                                                  WEIGHT LOSS
WEIGHT LOSS                                                                                                       No longer covered:              Weight loss drugs are not covered as permitted by Federal Medicaid regulations and Maine Medicaid (MaineCare) Policy.
                                                                                                                  PHENTERMINE,
                                                                                                                  XENICAL,DIDREX, and
                                                                                                                  MERIDIA

                                                               ALZHEIMER DISEASE
ALZHEIMER -               MC      ARICEPT TABS1                           MC       8   RAZADYNE2                  1. PA is required to            Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
Cholinomimetics/Others   MC/DEL   NAMENDA1                                             REMINYL2                   establish dementia              exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                           MC      8
                                                                                                                  diagnosis and baseline          another drug and the preferred drug(s) exists.
                                                                         MC/DEL    8   EXELON2                    mental status score.    2.
                                                                           MC      9   COGNEX CAPS2               Must fail all preferred
                                                                                                                  products before moving to
                                                                                                                  non-preferred.


                                                                                                                  Use PA Form# 20420
                                                               SMOKING CESSATION
NICOTINE PATCHES /       MC/DEL   CHANTIX1, 2                                                                     Bupropion SR 150 mg is          OTC Nicotine products are covered by MaineCare Policy when they have been determined to be cost-effective. Only Nicoderm and the generic nicotine gums have received this
TABLETS                                                                                                           available without a prior       designation as preferred. All other nicotine products (OTC & prescription) are non-preferred by MaineCare Policy. Preferred drug must be tried and failed due to lack of efficacy or
                         MC/DEL   NICODERM CQ PT242
                                                                                                                  authorization.                  intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the
                         MC/DEL   NICOTINE DIS PT242                                                                                              presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. Another version
                                                                                                                  1. Chantix is preferred         of Zyban, Bupropion SR (100 and 150mg) is available without PA.
                                                                                                                  without PA for up to 6          There will be a quantity limit of 3 months supply of nicotine products allowed per 12 months.
                                                                                                                  months of continuous use
                                                                                                                  once per lifetime.

                                                                                                                  2. Preferred nicotine
                                                                                                                  replacement therapy and
                                                                                                                  Chantix will become non-
                                                                                                                  preferred and will require
                                                                                                                  PA if they are being used in
                                                                                                                  combination together.

NICOTINE REPLACEMENT -   MC/DEL   NICOTINE POLACRILEX GUM2               MC/DEL    5   COMMIT LOZENGES1           Use PA Form# 20420               OTC Nicotine products are covered by MaineCare Policy when they have been determined to be cost-effective. Only Nicoderm and the generic nicotine gums have received this
OTHER                    MC/DEL                                          MC/DEL        NICOTROL INHALER           Must fail all preferred         designation as preferred. All other nicotine products (OTC & prescription) are non-preferred by MaineCare Policy. Both preferred Nicotine gum and Nicoderm patch must be tried
                                  NICORETTE GUM2                                   8
                                                                         MC/DEL                                   products from smoking           and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical exception is offered on the
                                                                                   8   NICOTROL NASAL SPRAY
                                                                                                                  cessation category              Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
                                                                                                                  (Nicoderm patch and             preferred drug(s) exists.
                                                                                                                  nicotine gum) before            There will be a quantity limit of 3 months supply of nicotine products allowed per 12 months.
                                                                                                                  moving to non-preferred.
                                                                                                                  Must use Non-preferred
                                                                                                                  products in specified step
                                                                                                                  order.                    1.
                                                                                                                  Will be available to patients
                                                                                                                  unable to tolerate preferred
                                                                                                                  products.



                                                                                                                  2. Preferred nicotine
                                                                                                                  replacement therapy and
                                                                                                                  Chantix will become non-
                                                                                                                  preferred and will require
                                                                                                                  PA if they are being used in
                                                                                                                  combination together.

                                                              ALCOHOL DETERRENTS
ALCOHOL DETERRENTS        MC      ANTABUSE TABS                                                                   1. Should only be used in Preferred generic drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
                                                                                                                 conjunction with formal    exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                                 structured outpatient      another drug and the preferred drug(s) exists.
                                                                                                              Page 25 of 51
                                                                                                                 detoxification program.
                                                                                                                          1. Should only be used in Preferred generic drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
                           MC      CAMPRAL1                                                                              conjunction with formal    exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                                         structured outpatient      another drug and the preferred drug(s) exists.
                           MC      DISULFIRAM TABS
                                                                                                                         detoxification program.
                          MC/DEL   NALTREXONE HCL TABS

                                                            MISCELLANEOUS ANALGESICS
ANALGESICS - MISC.        MC/DEL   ACETAMINOPHEN                                 MC           AXOCET CAPS                Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                   ASPIRIN                                       MC           DOLOBID TABS                                             offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                          MC/DEL
                                                                                                                                                       drug and the preferred drug(s) exists.
                          MC/DEL   ASPRIN/ APAP/ CAFF TAB                        MC           EQUAGESIC TABS
                          MC/DEL   BUTAL/ASA/CAFF                               MC/DEL        ESGIC-PLUS
                          MC/DEL   BUTALBITAL COMPOUND                          MC/DEL        FIORICET TABS
                          MC/DEL   BUTALBITAL/ACET TABS                          MC           FIORINAL CAPS
                          MC/DEL   BUTALBITAL/APAP CAPS                          MC           FIORTAL CAPS
                          MC/DEL   BUTALBITAL/APAP/CAFFEINE                     MC/DEL        FORTABS TABS
                          MC/DEL   CHOLINE MAGNESIUM TRISALI                     MC           PHRENILIN TABS
                          MC/DEL   DIFLUNISAL TABS                               MC           PHRENILIN FORTE CAPS
                           MC      EXCEDRIN                                      MC           TRILISATE LIQD
                          MC/DEL   SALSALATE TABS                                MC           TRILISATE TABS
                                                                                 MC           ZEBUTAL CAPS
                                                                                 MC           ZORPRIN TBCR
                                                                    LONG ACTING NARCOTICS
NARCOTICS - LONG ACTING    MC      AVINZA                                        MC       8   DURAGESIC PT726            Use PA Form # 20510           Preferred drugs (Avinza or morphine sulfate ER tab, Duragesic, Methadone or Methadose) must be tried for at least 2 weeks each & failed due to lack of efficacy or intolerable side
                          MC/DEL   FENTANYL PATCH6                              MC/DEL    8   MORPHINE SULFATE SUPP      Non-preferred products        effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that
                           MC                                                                                            must be used in specific      prevents usage of the preferred drug or a significant potential drug interaction between another drug & the preferred drug(s) exists. Adequate trials include prevention/treatment of
                                   KADIAN7                                      MC/DEL    8   MS CONTIN TB12
                                                                                                                         order.                        common adverse effects associated w/ narcotics (antinausea, antipruritics, etc.) as well as adequate equianalgesic dosing when converting from one narcotic to another.Also,
                          MC/DEL   METHADONE                                    MC/DEL    8   ORAMORPH SR TB12                                         adequate documentation of attempts to titrate dose of preferred agents to achieve adequate pain relief & desired clinical response must be provided. Member’s drug regimen for
                          MC/DEL   METHADOSE                                    MC/DEL    8   OXYCONTIN TB121,5          1. Oxycontin will be          additions &/or discontinuations of medications that may affect absorption &/or metabolism of preferred agents must be monitored. Approvals will not be granted if patient had
                          MC/DEL   MORPHINE SULFATE ER TB12   3,4
                                                                                MC/DEL    9   OXYCODONE ER 3             available without PA for      access to either non-preferred products or high doses of short acting narcotics during the trial period. Non-preferred drugs will not be approved for patients showing evidence of
                                                                                                                         patients treated for or dying usage patterns consistent w/ controlled
                                                                                 MC       9   OPANA
                                                                                                                         from cancer or hospice
                                                                                 MC       9   OPANA ER                   patients. CA (cancer) or
                                                                                                                         HO (hospice) diag code         substance abuse such as: 1. Frequent or persistent early refills of controlled drugs; 2. Multiple instances of early refill overrides due to reports of misplacement, stolen, dropped in
                                                                                                                         may be used but store must toilet or sink, distant travel, etc.;3. Breaches of narcotic contracts with any provider; 4. Failure to comply with patient responsibilities in attached opioid documentation (see PA
                                                                                                                         verify since all scripts will form) including but not limited to failing to submit to and pass pill counts; 5. Failing to take or pass random drug testing; 6. Failing to provide old records regarding prior use of
                                                                                                                         be audited and stores will narcotics; 7. Receiving controlled substances from other prescribers that the provider submitting the PA is unaware of 8. Documented history of substance abuse. Substance
                                                                                                                         be liable.                    abuse evaluations may be required for patients with medical records displaying documented substance abuse or potential signs of narcotic misuse and abuse such as chronic early
                                                                                                                                                       refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and intolerance or "allergy" to all products but Oxycontin. 9. Circumventing MaineCare prior
                                                                                                                                                       authorization requirements for narcotics by paying cash for affected narcotics (prescribers failed to submit prior authorization prior to cash narcotic scripts being filled by member).
                                                                                                                                                       10. Requests for any Brand name controlled


                                                                                                                         2. Established users are
                                                                                                                         grandfathered.
                                                                                                                          3. Oxycodone ER allowed
                                                                                                                         only 2 per day for all
                                                                                                                         strengths except 80 mg,
                                                                                                                         where 4 are allowed to
                                                                                                                         achieve max total daily
                                                                                                                         dose of 320mg.



                                                                                                                         4. Endo products preferred
                                                                                                                         but not exclusive.


                                                                                                                         5. Oxycontin 15mg, 30mg substance, considered by authorities to be highly abused and diverted (Oxycontin, Percocet, Typox, Vicodin, Dilaudid, Ultracet...) with an available AB rated generic equivalent will
                                                                                                                         & 60mg are new strengths. be denied unless it will be provided in a setting that virtually eliminates the risk of diversion. 11. Allergic reactions to any product within a specific narcotic class will justify and
                                                                                                                         Any PA request for the new preclude use of any other product in the same class due to the risk of cross-hypersensitivity.
                                                                                                                         strengths will be required to
                                                                                                                         use combinations of
                                                                                                                         strengths that have
                                                                                                                         previously been available
                                                                                                                         (including 10mg, 20mg,
                                                                                                                         40mg, & 80mg tablets) to
                                                                                                                         obtain requested dose.




                                                                                                                         6. Dosing limits apply.
                                                                                                                         Please see dose
                                                                                                                         consolidation list.

                                                                                                                         7. Kadian 80mg & 200mg
                                                                                                                         are non-preferred.

NARCOTICS - SELECTED      MC/DEL   TRAMADOL HCL TABS                             MC       8   BUPRENEX SOLN              Use PA Form# 20420            Preferred drugs from this and other narcotic classes must be tried for at least 2 weeks each and failed due to lack of efficacy or intolerable side effects before non-preferred drugs
                                                                                MC/DEL    8   BUTORPHANOL                                              from this class will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the
                                                                                                                                                       preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. Approvals will not be granted if patient had access to either non-
                                                                                 MC       8   NALBUPHINE HCL SOLN
                                                                                                                                                       preferred products or high doses of short acting narcotics during the trial period. Substance abuse evaluations may be required for patients with medical records displaying
                                                                                 MC       8   NUBAIN SOLN                                              potential signs of narcotic misuse and abuse such as chronic early refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and intolerance or "allergy"
                                                                                                                                                       to all products but desired product. Allergic reactions to any product within a specific narcotic class will justify and preclude use of any other product in the same class due to the
                                                                                                                                                       risk of cross-hypersensitivity.


                                                                                                                      Page 26 of 51
                                                                                                                                                     preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. Approvals will not be granted if patient had access to either non-
                                                                                                                                                     preferred products or high doses of short acting narcotics during the trial period. Substance abuse evaluations may be required for patients with medical records displaying
                                                                                                                                                     potential signs of narcotic misuse and abuse such as chronic early refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and intolerance or "allergy"
                                                                     MC     8    STADOL NS SOLN                                                      to all products but desired product. Allergic reactions to any product within a specific narcotic class will justify and preclude use of any other product in the same class due to the
                                                                                                                                                     risk of cross-hypersensitivity.
                                                                     MC     8    ULTRACET TABS
                                                                     MC     8    ULTRAM TABS                                                         Non-preferred drugs will not be approved for patients showing evidence of usage patterns consistent with controlled substance abouse such as: 1. frequent or persistant early
                                                                                                                                                     refills of controlled drugs; 2. multiple instances of early refill overrides due to reports of misplacement, stolen, dropped in toilet or sink, distant travel; 3. breaches of narcotic
                                                                     MC     8    ULTRAM ER                                                           contracts with any provider; 4. failure to comply with patient responsibilities in attached opiod documentaion (see PA form) including but not limited to failing to submit to and pass
                                                                   MC/DEL   9    RYZOLT                                                              pill counts; 5. failing to take or pass random drug testing; 6. failing to provide old recoreds regarding prior use of narcotics; 7. receiving controlled substances from other
                                                                                                                                                     prescribers that the provider submitting the PA is unaware of. in Substance abuse evaluations may be required for patients with medical records displaying potential signs of
                                                                                                                                                     narcotic misuse and abuse such as chronic early refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and intolerance or "allergy" to all products
                                                                                                                                                     but Oxycontin. Allergic reactions to any product within a specific narcotic class will justify and preclude use of any other product in the same class due to the risk of cross-
                                                                                                                                                     hypersensitivity.


                                                       MISCELLANEOUS NARCOTICS
NARCOTICS - MISC.   MC/DEL   ACETAMINOPHEN/CODEINE                  MC      8    ANEXSIA TABS                         1. Fentanyl OT loz (Barr)      Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             ASPIRIN/CODEINE TABS                  MC/DEL   8    ASCOMP/CODEINE CAPS                 and Capital and codeine         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                    MC/DEL
                                                                                                                     suspension products             drug and the preferred drug(s) exists. Please refer to General Criteria category E.
                    MC/DEL   BUTAL/ASA/CAFF/COD CAPS               MC/DEL   8    BUTALBITAL/APAP/CAFFEINE/ CAPS
                                                                                                                     require PA for users over
                     MC      BUTALBITAL/ASPIRIN/CAFFEI CAPS         MC      8    DARVOCET-N                          18 years of age. PA is not
                     MC      CAPITAL AND CODEINE SUSP1              MC      8    DARVON                              required if under 18 years
                                                                    MC      8    DEMEROL                             of age.
                     MC      CAPITAL/CODEINE SUSP1
                    MC/DEL   CODEINE PHOSPHATE SOLN                MC/DEL   8    DILAUDID
                    MC/DEL   CODEINE SULFATE TABS                   MC      8    DILAUDID-HP SOLN                     2. Oxycodone/acet 10/650
                                                                    MC      8    FENTANYL CITRATE SOLN               is 8 times more expensive.
                    MC/DEL   ENDOCET TABS3
                                                                                                                     Use twice as many of
                    MC/DEL   ENDODAN TABS                          MC/DEL   8    FENTORA
                                                                                                                     oxycod/acet 5/325 instead.
                    MC/DEL   FENTANYL OT LOZ1                      MC/DEL   8    FIORICET/CODEINE CAPS               You can mix andmatch
                    MC/DEL   HYDROCODONE BITARTRATE/AP TABS         MC      8    FIORINAL/CODEINE #3 CAPS            preferred strengths of
                             HYDROCODONE/ACETAMINOPHEN              MC      8    FIORTAL/CODEINE CAPS                oxycodone and
                    MC/DEL
                                                                                                                     oxycodone/acet to minimize
                    MC/DEL   HYDROMORPHONE HCL3                    MC/DEL   8    HYDROCODONE/IBUPROFEN               acet. dose similar to certain
                    MC/DEL   MEPERIDINE HCL                        MC/DEL   8    LORCET                              non-preferred drugs.
                    MC/DEL   OXYCODONE 5MG                          MC      8    LORTAB                              3. Only preferred
                                                                                                                     manufacturer's products will
                    MC/DEL   OXYCODONE 15MG                         MC      8    MAXIDONE TABS
                                                                                                                     be available without prior
                    MC/DEL   OXYCODONE 30MG                        MC/DEL   8    NORCO TABS                          authorization.
                    MC/DEL   OXYCODONE/ACETAMINOPHEN2,3            MC/DEL   8    OXYCODONE 10MG
                    MC/DEL   PENTAZOCINE/NALOXONE TABS             MC/DEL   8    OXYCODONE 20MG
                     MC      PROPOXYPHENE CMPND-65 CAPS            MC/DEL   8    OXYCODONE/APAP 10/650
                     MC      PROPOXYPHENE COMPOUND CAPS            MC/DEL   8    OXYCODONE/APAP 7.5/500
                    MC/DEL   PROPOXYPHENE HCL CAPS                 MC/DEL   8    PENTAZOCINE/ACET TABS
                    MC/DEL   PROPOXYPHENE/ACET TABS                 MC      8    PERCOCET TABS
                    MC/DEL   PROPOXYPHENE-N/ACET TABS               MC      8    PERCODAN TABS
                    MC/DEL   ROXICET                                MC      8    PHRENILIN W/CAFFEINE/CODE CAPS
                     MC      ROXIPRIN TABS                         MC/DEL   8    ROXICET 5/500 TABS
                                                                    MC      8    ROXICODONE TABS
                                                                    MC      8    SYNALGOS-DC CAPS                    Use PA Form# 20420
                                                                    MC      8    TALACEN TABS
                                                                   MC/DEL   8    TALWIN NX TABS
                                                                    MC      8    TYLENOL/CODEINE #3 TABS
                                                                    MC      8    TYLOX CAPS
                                                                    MC      8    VICODIN
                                                                     MC     8    VICOPROFEN TABS
                                                                     MC     8    ZYDONE TABS
                                                                     MC     9    ACTIQ LPOP
OPIOID DEPENDENCE    MC      SUBOXONE*                               MC          SUBUTEX                             Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
TREATMENTS                                                                                                                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                     drug and the preferred drug(s) exists. Subutex will onlybe approved for use during pregnancy.




                                                                                                                  Page 27 of 51
OPIOID DEPENDENCE                                                                                                                                Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
TREATMENTS                                                                                                          *Suboxone is preferred with offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                    max dosing limits of 32mg drug and the preferred drug(s) exists. Subutex will onlybe approved for use during pregnancy.
                                                                                                                    daily if the following
                                                                                                                    conditions are met: a.)
                                                                                                                    There is not another
                                                                                                                    Suboxone script in
                                                                                                                    member’s drug profile within
                                                                                                                    the past 30 days. and b.)
                                                                                                                    There is not more than one
                                                                                                                    narcotic fill in member’s
                                                                                                                    drug profile between
                                                                                                                    today’s fill of suboxone and
                                                                                                                    a prior suboxone fill within
                                                                                                                    the past 90 days. Should
                                                                                                                    be evidence provided of
                                                                                                                    monthly monitoring
                                                                                                                    including random pill counts
                                                                                                                    urine drug tests and
                                                                                                                    prescription monitoring
                                                                                                                    program reports.




                                                                 NARCOTIC ANTAGONISTS
NARCOTIC - ANTAGONISTS   MC/DEL   NALTREXONE HCL TABS                       MC/DEL      REVIA TABS1                 Use PA Form# 20420               1. Will only be approved for side effects experienced with generic that are not described in the literature as occurring with the brand version.
                                                                             MC/DEL     VIVITROL INJ2               Use PA form #30400 for
                                                                                                                    Vivitrol requests.               2. Please see the criteria listed on the Vivitrrol PA form. Any narcotics attempting to be filled during Vivitrol approval will require prior authorization.

                                                                     COX 2 / NSAIDS
NSAID - PPI                                                                             PREVACID NAPRA-PAC
COX 2 INHIBITORS -       MC/DEL   CELEBREX CAPS 4, 5                         MC/DEL     MOBIC                       The FDA has issued a             Approved without PA for patients 60 years old or over. Patients under 60 can use a preferred proton pump inhibitor with any preferred generic NSAID to achieve similar reductions
SELECTIVE / HIGHLY       MC/DEL                            2,3               MC/DEL     MOBIC SUSP                  Public Health Advisory           in GI bleeding risk to that seen with the COX-II agents. Approvals for Celebrex will be granted for other requests based on failure of at least one generic NSAID from at least 3
                                  KETOROLAC TROMETHAMINE
SELECTIVE                                                                                                           warning of the potential for     different NSAID classes as described in the COX-II PA form. High risk GI bleeding patients must fail on adequate trials of safer agents (non-NSAID/Cox-2) for GI tract, such as
                         MC/DEL   NABUMETONE TABS                            MC/DEL     RELAFEN TABS                increased cardiovascular         acetaminophen.
                         MC/DEL   MELOXICAM 1                                MC/DEL     TORADOL                     risk & GI bleeding with
                                                                             MC/DEL     TORADOL                     NSAID use.


                                                                                                                    Use PA Form # 10310
                                                                                                                    1. Meloxicam has dosing
                                                                                                                    limits allowing one tablet
                                                                                                                    daily of all strengths without
                                                                                                                    PA.

                                                                                                                     2. Ketorolac
                                                                                                                    Tromethamine is indicated
                                                                                                                    for the short term (up to 5
                                                                                                                    days) managment of
                                                                                                                    moderately sever acute
                                                                                                                    pain that requires analgesic
                                                                                                                    at the opiod level in adults.
                                                                                                                    Not indicated for minor of
                                                                                                                    chronic pain conditions.




                                                                                                                    3. Ketorolac has dosing
                                                                                                                    limits allowing 24 tablets for
                                                                                                                    a 5 day supply every 30
                                                                                                                    days.

                                                                                                                    4. Dosing limits will be set
                                                                                                                    at a maximum of 200mg
                                                                                                                    once daily for PA requests.


                                                                                                                    5. Users 60 years of age or
                                                                                                                    older will not require PA. If
                                                                                                                    under 60 years of age,
                                                                                                                    Celebrex will require PA.


NSAIDS                   MC/DEL   CHILDRENS IBUPROFEN                         MC        ADVIL TABS                  The FDA has issued a             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                         MC/DEL   DICLOFENAC POTASSIUM TABS                   MC        ANAPROX TABS                Public Health Advisory           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC/DEL   DICLOFENAC SODIUM                           MC                                    warning of the potential for     drug and the preferred drug(s) exists.
                                                                                        ANAPROX DS TABS
                                                                                                                    increased cardiovascular         Approvals will be granted for other requests based on failure of at least one generic NSAID from at least 3 different NSAID classes as described in the COX-II PA form.
                         MC/DEL   ETODOLAC                                    MC        ANSAID TABS
                                                                                                                    risk & GI bleeding with
                         MC/DEL   FENOPROFEN CALCIUM TABS                    MC/DEL     CATAFLAM TABS               NSAID use.
                         MC/DEL   FLURBIPROFEN TABS                           MC        CHILDRENS ADVIL SUSP
                         MC/DEL   IBUPROFEN                                   MC        CHILD'S IBUPROFEN SUSP      Use PA Form# 20420



                                                                                                                 Page 28 of 51
                             MC/DEL       INDOMETHACIN                             MC/DEL         CHILDREN'S MOTRIN SUSP
                             MC/DEL       KETOPROFEN                               MC/DEL         CLINORIL TABS
                             MC/DEL       MECLOFENAMATE SODIUM CAPS                MC/DEL         DAYPRO TABS                                                DDI: Diclofenac will now be non-preferred and require prior authorization if it is currently being used in combination with lescol.
                             MC/DEL       NAPROSYN SUSP                            MC/DEL         EC-NAPROSYN TBEC
                             MC/DEL       NAPROXEN SUSP                            MC/DEL         ETODOLAC ER 600MG
                             MC/DEL       NAPROXEN TABS                             MC            FELDENE CAPS
                             MC/DEL       NAPROXEN SODIUM TABS                     MC/DEL         IBU-200
                             MC/DEL       OXAPROZIN TABS                            MC            INDOCIN
                             MC/DEL       PIROXICAM CAPS                           MC/DEL         LODINE
                             MC/DEL       SULINDAC TABS                            MC/DEL         MOTRIN
                             MC/DEL       TOLMETIN SODIUM                           MC            NALFON CAPS
                                                                                   MC/DEL         NAPRELAN TBCR
                                                                                   MC/DEL         NAPROSYN TABS
                                                                                   MC/DEL         NAPROXEN DR TBEC
                                                                                   MC/DEL         NAPROXEN SODIUM TBCR
                                                                                    MC            ORUVAIL CP24
                                                                                    MC            PONSTEL CAPS
                                                                                    MC            SB IBUPROFEN TABS
                                                                                    MC            TOLECTIN
                                                                                   MC/DEL         VOLTAREN
                                                                                    MC            V-R IBUPROFEN TABS
                                                                        RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS         MC/DEL   1   AZATHIOPRINE                            MC/DEL     8    ARAVA                       Use PA Form # 20900.           See criteria as listed on Rheumatoid Arthritis PA form.
                             MC/DEL   1   HYDROXYCHLOROQUINE                        MC        8   KINERET SOLN                1. Only one step 1 drug is
                             MC/DEL       LEFLUNOMIDE                                         8   ORENCIA                     required to obtain Enbrel,
                                      1                                             MC
                                                                                                                              Cimzia or Humira without
                             MC/DEL   1   METHOTREXATE                              MC        8   REMICADE
                                                                                                                              PA.
                             MC/DEL   1   SULFASALAZINE TABS                        MC        8   ENBREL 50MG3
                             MC/DEL   2   CIMZIA1                                                                             2. Dosing limits apply.
                              MC      2   ENBREL 25MG INJECTIONS ONLY1, 2                                                     Please see dose
                                                1, 2
                                                                                                                              consolidation list.
                              MC      2   HUMIRA
                                                                                                                              3. Please use multiples of
                                                                                                                              25mg.
                                                                                                                              Please refer to the dose
                                                                                                                              consolidation list.
                                                                                                                              Established users will be
                                                                                                                              grandfathered for Enbrel
                                                                                                                              and Humira.

                                                                     MISCELLANEOUS ARTHRITIS
ARTHRITIS - MISC.             MC          RIDAURA CAPS                             MC/DEL         ARTHROTEC1                  1. The individual              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                              MC          MYOCHRYSINE SOLN                                                                    components of Arthrotec        offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                              are available without PA.      drug and the preferred drug(s) exists. The individual components of Arthrotec are available without PA.

                                                                                                                              Use PA Form# 20420


                                                                         MIGRAINE THERAPIES
MIGRAINE - ERGOTAMINE        MC/DEL       MIGRANAL SOLN                            MC/DEL         D.H.E. 45 SOLN              Use PA Form # 10110            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
DERIVATIVES                   MC          SANSERT TABS                                                                                                       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                             drug and the preferred drug(s) exists.

MIGRAINE - CARBOXYLIC ACID    MC          DIVALPROEX ER TB24                        MC            DEPAKOTE ER TB24
DERIVATIVES
MIGRAINE - SELECTIVE         MC/DEL   1   MAXALT MLT1                              MC/DEL         AMERG TABS                  1. All step 1 medications      Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
SEROTONIN AGONISTS (5HT)--   MC/DEL   1   SUMATRIPTAN TABS1                         MC            AXERT TABS                  must be tried. All drugs in    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
Tabs                                                                                                                          this category have dosing      drug and the preferred drug(s) exists. Quantity limit exceptions will require ongoing therapy with therapeutic doses of highly effective prophylactic medication as listed on the
                                                                                   MC/DEL         FROVA TABS
                                                                                                                              limits. Please refer to dose   Triptan PA form.
                                                                                   MC/DEL         MAXALT                      consolidation table.
                                                                                   MC/DEL         IMITREX TABS1
                                                                                   MC/DEL         RELPAX
                                                                                   MC/DEL         ZOMIG TABS
                                                                                   MC/DEL         ZOMIG NASAL SPARY
                                                                                   MC/DEL         ZOMIG ZMT TBDP              Use PA Form # 10110
MIGRAINE - SELECTIVE         MC/DEL       IMITREX KIT                              MC/DEL         SUMATRIPTAN SOLN            Use PA Form # 10110
SEROTONIN AGONISTS (5HT)--   MC/DEL       IMITREX SOLN
Injectables
                             MC/DEL       IMITREX STATDOSE PEN KIT
                             MC/DEL       IMITREX STATDOSE REFILL KIT



MIGRAINE - SELECTIVE                                                               MC/DEL         TREXIMET1, 2                Use PA Form # 10110
SEROTONIN AGONISTS (5HT)--                                                                                                    1. Dosing limits apply.
Combinations                                                                                                                  Please see dose
                                                                                                                              consolidation list.




                                                                                                                           Page 29 of 51
Combinations


                                                                                                                                   2. Use preferred
                                                                                                                                   Sumatriptan and Naproxen
                                                                                                                                   separately.

MIGRAINE - MISC.      MC/DEL   CAFERGOT SUPP                         MC/DEL           MIGRAZONE CAPS                               Use PA Form # 10110            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                      MC/DEL   CAFERGOT TABS                             MC           BELCOMP-PB SUPP                                                             offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                      MC/DEL                                                                                                                                      drug and the preferred drug(s) exists.
                               SPASTRIN TABS

                                                                 GOUT
GOUT                  MC/DEL   ALLOPURINOL TABS                      MC/DEL           ULORIC1                                      Use PA Form# 20420           Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                               COLCHICINE TABS                           MC                                                        1. Failure of therapeutic    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                      MC/DEL                                                          ZYLOPRIM TABS
                               PROBENECID TABS                                                                                     (300mg) dose of Allopurinol drug and the preferred drug(s) exists.
                      MC/DEL
                                                                                                                                   (failure define as not being
                      MC/DEL   PROBENECID/COLCHICINE TABS
                                                                                                                                   able to get uric acid levels
                       MC      SULFINPYRAZONE TABS                                                                                 below 6mg/dl) or severe
                                                                                                                                   renal disease.



                                                                 MISC.
ANESTHETICS - MISC.    MC      BUPIVACAINE HCL SOLN                      MC           SENSORCAINE-MPF SOLN                         Use PA Form # 30130            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                       MC      LIDOCAINE HCL SOLN                    MC/DEL           SYNVISC INJ                                                                 unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage
                       MC      MARCAINE SOLN                          MC              XYLOCAINE SOLN                                                              of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
                                                            ANTI-CONVULSANTS
ANTICONVULSANTS       MC/DEL   CARBAMAZEPINE                           MC        8    BANZEL                                       1. Quantity limit. 5/month   One time PA is required to determine seizure diagnosis for any non-preferred anticonvulsant. Other approvals will be for patients with a variety of drug-specific FDA-approved
                      MC/DEL   CARBATROL CP12                            MC      8    DEPAKENE                                     Use PA Form# 20420           indications and for specific conditions supported by at least two published peer-reviewed double-blinded, placebo-controlled randomized trials that are not contradicted by other
                      MC/DEL                                                                                                                                    studies of similar quality after recommendation by the DUR Committee and as long as all first line therapies have been tried and failed at full therapeutic doses for adequate
                               CELONTIN CAPS                             MC      8    DEPAKOTE                                     2. 200 mg requires a PA.
                                                                                                                                                                durations (at least two weeks).
                      MC/DEL   CLONAZEPAM TABS                           MC      8    DEPAKOTE ER                                  Use two 100 mg
                       MC                                            MC/DEL                                                        instead.Pharmaceutical
                               DEPAKOTE SPRINKLES CPSP                           8    DIVALPROEX SODIUM SPRINKLE CAPS
                                                                                                                                   supply issues will delay
                      MC/DEL   DIASTAT1                              MC/DEL      8    EQUETRO
                                                                                                                                   implementation until further
                      MC/DEL   DILANTIN                              MC/DEL      8    GABITRIL TABS                                notice.
                      MC/DEL   DIVALPROEX SODIUM                     MC/DEL      8    KEPPRA TABS                                                                 *** SEE CHART AT END OF DOCUMENT
                      MC/DEL   EPITOL TABS                           MC/DEL      8    KEPPRA SOLN                                                                 Topamax and Neurontin - Second line therapy for migraine prophalaxis after trial of at least three preferred preventive medications from Group 1 listed on page 2 of the Acute
                      MC/DEL   ETHOSUXIMIDE SYRP                     MC/DEL      8    KLONOPIN TABS                                                               Migraine PA form.
                      MC/DEL   FELBATOL                              MC/DEL      8    LAMICTAL                                     All non-preferred meds
                      MC/DEL   GABAPENTIN   3
                                                                     MC/DEL                                                        must be used in specified
                                                                                 8    LYRICA4
                                                                                                                                   order
                      MC/DEL   KEPPRA XR                             MC/DEL      8    PRIMIDONE TABS                                                               Lyrica- Second line therapy for Diabetic Peripheral Neuropathy and Post Herpetic Neuralgia. With Fibromyalgia diagnosis, Lyrica will not require PA if previous 4 week trials of the
                      MC/DEL   LAMOTRIGINE                               MC      8    TOPAMAX                                      3. Dosing limits apply,        following are seen in drug profile at full therapeutic doses: TCA or cyclobenzaprine, gabapentin, and savella.
                      MC/DEL                                         MC/DEL      8    TRILEPTAL                                    please see dose
                               LEVETIRACETAM SOLN/TABS
                                                                                                                                   consolidation list.
                      MC/DEL   MYSOLINE TABS                         MC/DEL      8    VIMPAT5
                      MC/DEL   OXCARBAZEPINE                         MC/DEL      8    ZARONTIN SYRP                                4. Dosing limits apply per
                      MC/DEL   PHENYTEK CAPS                                     9                                                 strength as well as a
                                                                     MC/DEL           NEURONTIN
                                                                                                                                   maximum daily dose of
                      MC/DEL   PHENYTOIN                             MC/DEL      9    ZONEGRAN CAPS
                                                                                                                                   600mg. Please see dose
                      MC/DEL   TEGRETOL2                                                                                           consolidation list.            DDI: Any Carbamazepine formulation will now be non-preferred and require prior authorization if any of the following drugs are currently being used in combination with
                      MC/DEL   TEGRETOL-XR TB12                                                                                                                   carbamazepine: Abilify, clozapine, Seroquel, or Zyprexa.
                                                                                                                                                                  Please use Drug-Drug Interaction PA form #10400 for this combination.
                      MC/DEL   TOPIRAMATE                                                                                          5. Adjunctive therapy 17
                      MC/DEL   TRILEPTAL SUSP                                         BIPOLAR DISORDER: STEP ORDER                 and older.
                      MC/DEL   VALPROIC ACID
                      MC/DEL   ZARONTIN CAPS                                  M ~ A                                                SEE ANTICONVULSANT
                      MC/DEL   ZONISAMIDE                                     4 ~ 4                                                INDICATION CHART AT
                                                                                      LAMICTAL
                                                                                                                                   THE END OF THIS
                                                                              4 ~ 4   LITHIUM
                                                                                                                                   DOCUMENT
                                                                              4 ~ 4   CARBAMAZEPINE                                M= Monotherapy
                                                                              4 ~ 4   VALPROATE                                    A= Adjunctive
                                                                              4 ~ 4   ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE       9= No Evidence
                                                                                                                                   The step orders show the
                                                                              5 ~ 5   TRILEPTAL
                                                                                                                                   relative strength of
                                                                              9 ~ 6   TOPAMAX                                      evidence for use in bi-polar
                                                                              9 ~ 7   KEPPRA TABS                                  and will guide prior
                                                                              9 ~ 8   GABITRIL TABS                                authorization
                                                                              9 ~ 9   NEURONTIN                                    determinations.
                                                                                                                                   Step 4 drugs-no PA
                                                                              9 ~ 9   ZONEGRAN CAPS
                                                                                                                                   required.



                                                                                      PEDIATRIC BIPOLAR1 DISORDER: STEP ORDER
                                                                              M ~ A   (6-18 YEARS WITH OR WITHOUT PSYCHOSIS)
                                                                              4 ~ 4   LITHIUM
                                                                                                                                   Two-step 1 preferred drugs
                                                                              4 ~ 4   CARBAMAZEPINE                                must be tried before
                                                                              4 ~ 4   VALPROATE                                    Trileptal.
                                                                              4 ~ 4   ATYPICAL ANTIPSYCHOTICS EXC.CLOZAPINE         The step orders show the
                                                                                                                                   relative strength of
                                                                              4 ~ 4   LAMICTAL
                                                                                                                                   evidence for use in bi-polar
                                                                              5 ~ 5   TRILEPTA                                     and will guide prior
                                                                                                                                   authorization
                                                                                                                                   determinations.
                                                                                                                                   Step 4 drugs-no PA
                                                                                                                                   required.



                                                                                                                                Page 30 of 51
                                                                            ANTI-PARKINSON DRUGS
PARKINSONS -                MC                  AKINETON TABS
ANTICHOLINERGICS           MC/DEL               BENZTROPINE MESYLATE TABS
                            MC                  COGENTIN SOLN
                           MC/DEL               KEMADRIN TABS
                           MC/DEL               TRIHEXYPHENIDYL
PARKINSONS - COMT          MC/DEL               COMTAN TABS                               MC/DEL             TASMAR TABS                             Use PA Form# 20420              Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
INHIBITORS                                                                                                                                                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                                                     drug and the preferred drug(s) exists.

PARKINSONS - SELECTED      MC/DEL               ROPINIROLE                                MC/DEL             MIRAPEX TABS1                           Use PA Form# 20420              Preferred drug must be tried and failed in step-order due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
DOPAMIN AGONISTS                                                                          MC/DEL             REQUIP TABS                             1. As of 12/08 users of         exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
                                                                                                                                                     Mirapex will be                 another drug and the preferred drug(s) exists.
                                                                                          MC/DEL             REQUIP XL TABS
                                                                                                                                                     grandfathered if diagnosis
                                                                                                                                                     is Parkinsons.

PARKINSONS -               MC/DEL               AMANTADINE HCL                            MC/DEL             APOKYN*                                  * Only preferred            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
DOPAMINERGICS/CARBII/      MC/DEL               BROMOCRIPTINE MESYLATE                      MC               AZILECT2                                manufacturer's products will offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
LEVO                                                                                                                                                 be available without prior   drug and the preferred drug(s) exists.
                           MC/DEL               CARBIDOPA/LEVODOPA TABS*                    MC               ELDEPRYL CAPS
                                                                                                                                                     authorization.
                           MC/DEL               CARBIDOPA/LEVODOPA ER                     MC/DEL             PARLODEL CAPS
                            MC                  LARODOPA TABS                             MC/DEL             PARLODEL TABS                           1. Approvals will require
                            MC                  LODOSYN TABS                                MC               SINEMET TABS                            concurrent therapy with
                           MC/DEL               SELEGILINE HCL                              MC                                                       Levodopa and failed trials
                                                                                                             SINEMET TBCR
                                                                                                                                                     of Selegiline, Comtan, and
                                                                                            MC               SYMMETREL TABS
                                                                                                                                                     Stalevo.
                                                                                            MC               ZELAPAR1
                                                                                                                                                     2. Approvals will require
                                                                                                                                                     trials of
                                                                                                                                                     Carbidopa/Levodopa,
                                                                                                                                                     Selegiline, Comtan, and
                                                                                                                                                     Stalevo.

                                                                                                                                                     Use PA Form# 20420
PARKINSONS - COMBO.        MC/DEL               STALEVO


                                                                              MUSCLE RELAXANTS
ALS DRUG                   MC/DEL               RILUTEK TABS
MUSCLE RELAXANTS           MC/DEL               BACLOFEN TABS                             MC/DEL       7     ORPHENADRINE CITRATE                    Non-preferred drugs will not    At least 4 preferred drugs (including tizanidine) must be tried for at least 2 weeks and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be
                           MC/DEL               CHLORZOXAZONE TABS                        MC/DEL       8     CARISOPRODOL TABS                       be approved if members          approved, unless an…… acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
                           MC/DEL               CYCLOBENZAPRINE HCL TABS                  MC/DEL                                                     circumventing MaineCare         significant potential drug interaction between another drug and the preferred drug(s) exists. Elderly patients, over 65, will require written notice of the increased sedative risks and
                                                                                                       8     DANTRIUM CAPS
                                                                                                                                                     prior authorization             impaired driving.Prior Authorization will not be given for:1. frequent or persistent early refills of controlled drugs; 2. multiple instances of early refill overrides due to reports of
                            MC                  LIORESAL INTRATHECAL KIT                  MC/DEL       8     FLEXERIL TABS
                                                                                                                                                     requirements by paying          misplacement, stolen, dropped in toilet or sink, distant travel, etc.
                           MC/DEL               METHOCARBAMOL TABS                          MC         8     LIORESAL TABS                           (prescribers failed to submit
                           MC/DEL               TIZANIDINE HCL TABS                          MC        8     NORFLEX TBCR                            prior authorization prior to
                                                                                                                                                     cash narcotic scripts being
                                                                                             MC        8     ROBAXIN-750 TABS
                                                                                                                                                     filled by member).
                                                                                           MC/DEL      8     ZANAFLEX TABS                           Non-preferred products
                                                                                           MC/DEL      9     SKELAXIN TABX                           must be used in specified
                                                                                                       9     SOMA TABS                               step order.
                                                                                           MC/DEL




                                                                                                                                                     Use PA Form# 20420
MUSCLE RELAXANT - COMBO.                                                                   MC/DEL            CARISOPRODOL/ASPIRIN TABS               Use PA Form# 20420              Individual components are available with PA described in the section above.1. frequent or persistent early refills of non-controlled drugs; 2. multiple instances of early refill
                                                                                                             CARISOPRODOL/ASPIRIN/CODE                                               overrides due to reports of misplacement stolen, dropped in toilet or sink, distant trave, etc.
                                                                                           MC/DEL
                                                                                             MC              NORGESIC TABS
                                                                                           MC/DEL            ORPHENADRINE COMPOUND
                                                                                           MC/DEL            ORPHENADRINE/ASA/CAFF
                                                                                             MC              ORPHENGESIC
                                                                                    VITAMINS
                                    **Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
VITAMINS                   MC/DEL               ASCORBIC ACID TABS                          MC               AQUASOL E SOLN                          Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC                  BIOTIN                                      MC               AQUAVIT-E SOLN                          1. PA required to confirm       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                     diagnosis and prior use of      drug and the preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
                            MC                  CYANOCOBALAMIN SOLN                       MC/DEL             CALOMIST NASAL SPRAY   1
                                                                                                                                                     IM Vit B12. Lab results
                            MC                  FOLGARD RX 2.2 TABS                         MC               DHT SOLN
                                                                                                                                                     should be submitted.
                           MC/DEL               FOLIC ACID TABS                             MC               NASCOBAL GEL
                             MC                 FOLTX TABS
                                                                                                                                                                                     DDI: B-12 will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, Protonix, Prilosec, or any currently non
                           MC/DEL               MEPHYTON TABS                                                                                        Please refer to OTC list.       preferred PPI.
                           MC/DEL               NIACIN
                            MC                  NIACOR TABS
                           MC/DEL               NICOTINIC ACID SR CPCR
                            MC                  PYRIDOXINE HCL TABS
                           MC/DEL               SLO-NIACIN TBCR
                           MC/DEL               THIAMINE HCL SOLN



                                                                                                                                                  Page 31 of 51
                   MC/DEL               VITAMIN B-1 TABS
                   MC/DEL               VITAMIN B-12
                    MC                  VITAMIN B-6 TABS
                   MC/DEL               VITAMIN C
                   MC/DEL               VITAMIN E CAPS
                   MC/DEL               VITAMIN E/D-ALPHA CAPS
                    MC                  VITAMIN K1 SOLN
                    MC                  V-R VITAMIN E CAPS
VITAMIN D's        MC/DEL               CALCITRIOL CAPS1                          MC/DEL             DRISDOL CAPS                            1. Diagnosis of dialysis    Preferred products require dialysis/renal failure diagnosis.
                   MC/DEL               VITAMIN D                                   MC               CALCIJEX                                (renal failure) required.   Non-preferred products require: Secondary hyperparathyroidism in patients with Chronic Kidney Disease on dialysis., iPTH>400 pg/ml, Phosophorous ,6.5mg/dl, corrected calcium
                    MC                  ZEMPLAR TABS                              MC/DEL             HECTOROL (ORAL)                         Use PA Form# 20420          <12.2mg/dl, corrected calcium x phosphorous products <70mg 2/dl2
                                                                                  MC/DEL             HECTOROL (PARENTERAL)
                                                                                  MC/DEL             ROCALTROL
                                                                                    MC               ZEMPLAR INJ
                                                                      MISC MULTI-VITAMINS
                            **Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
VITAMINS - MISC.    MC                  CENTRUM LIQD                                MC               ADEKS                                   Diag codes are no longer    Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                    MC                  CENTRUM TABS                              MC/DEL             ADVANCED NATALCARE TABS                 required on prenatal        unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of
                    MC                                                              MC                                                       vitamins.
                                        CENTRUM JR/IRON CHEW                                         AQUADEKS                                                            the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. As listed in MaineCare
                    MC                  CENTRUM SILVER TABS                         MC               CENTRUM JR/EXTRA C CHEW                 Please refer to OTC list.   Policy, certain drugs require specific diagnoses for approval.
                    MC                  CENTRUM-LUTEIN TABS                         MC               CENTRUM PERFORMANCE TABS
                    MC                  CEROVITE ADVANCED FO TABS                   MC               DALYVITE LIQD                           Use PA Form# 20420
                   MC/DEL               CHEWABLE MULTIVIT/FL CHEW                   MC               EMBREX 600 MISC
                    MC                  COD LIVER OIL CAPS                          MC               IBERET
                    MC                  COMPLETE SENIOR TABS                        MC               MATERNA TABS
                    MC                  DAILY MULTI VIT/IRON                        MC               MULTIRET FOLIC -500 TBCR
                   MC/DEL               DIALYVITE 1MG                             MC/DEL             NATAFORT TABS
                   MC/DEL               DIALYVITE 800MG                           MC/DEL             NATALCARE CFE 60 TABS
                   MC/DEL               FULL SPECTRUM B                           MC/DEL             NATALCARE GLOSS TABS
                    MC                  M.V.I.-12 INJ                               MC               NATALCARE PIC TABS
                    MC                  MULTI-VIT/FLUORIDE                          MC               NATALCARE PIC FORTE TABS
                   MC/DEL               NATALCARE RX TABS                         MC/DEL             NATALCARE PLUS TABS
                   MC/DEL               NEPHRONEX                                   MC               NATALCARE THREE TABS
                   MC/DEL               NUTRINATE CHEW                            MC/DEL             NATACHEW CHEW
                   MC/DEL               O-CAL PRENATAL                              MC               NATALFIRST TABS
                   MC/DEL               ONE DAILY TABS                              MC               NATATAB RX TABS
                   MC/DEL               ONE-DAILY MULTIVITAMINS                   MC/DEL             NEPHPLEX RX TABS
                   MC/DEL               ONE-TABLET-DAILY                          MC/DEL             NEPHROCAPS CAPS
                   MC/DEL               POLY-VIT/IRON/FLUORID SOLN                MC/DEL             NEPHRO-VITE TABS
                   MC/DEL               POLY-VITAMIN/FLUORIDE SOLN                  MC               NESTABS RX TABS
                   MC/DEL               POLY-VITAMINS/IRON SOLN                   MC/DEL             NIFEREX
                    MC                  PRENATAL 19 CHEW                          MC/DEL             OCUVITE TABS
                   MC/DEL               PRENATAL TABS                               MC               POLY-VI-FLOR SOLN
                   MC/DEL               PRENATAL FORMULA 3 TABS                     MC               POLY-VI-SOL SOLN
                   MC/DEL               PRENATAL PLUS TABS                          MC               POLY-VI-SOL/IRON SOLN
                   MC/DEL               PRENATAL PLUS NF TABS                       MC               POLY-VITAMIN DROPS SOLN
                    MC                  PRENATAL PLUS/27MG IRON                     MC               PRECARE
                    MC                  PRENATAL PLUS/IRON TABS                     MC               PREMESIS RX TABS
                   MC/DEL               PRENATAL RX/BETA-CAROTENE                   MC               PRENATABS CBF TABS
                   MC/DEL               RENA-VITE RX TABS                           MC               PRENATAL CARE TABS
                   MC/DEL               RENAL CAPS                                  MC               PRENATAL MR 90 TBCR
                   MC/DEL               RENAPHRO CAPS                             MC/DEL             PRENATAL MTR/SELENIUM TABS
                    MC                  STRESS TAB NF TABS                          MC               PRENATAL OPTIMA ADVANCE TABS
                    MC                  THERAPEUTIC-M TABS                          MC               PRENATAL PC 40 TABS
                    MC                  THERAVITE LIQD                            MC/DEL             PRENATAL RX TABS
                   MC/DEL               TRI-VITAMIN/FLUORIDE SOLN                   MC               PRENATE
                    MC                  VITA CON FORTE CAPS                         MC               PRENATE ELITE
                    MC                  VITAMIN B COMPLEX CAPS                      MC               PRIMACARE MISC
                    MC                  VITAPLEX PLUS TABS                          MC               PROTEGRA CAPS
                                                                                     MC              STUARTNATAL PLUS 3 TABS
                                                                                     MC              TRI-VI-SOL SOLN
                                                                                     MC              TRI-VI-SOL/IRON SOLN
                                                                                   MC/DEL            ULTRA NATALCARE TABS
                                                                                     MC              ULTRA-NATAL TABS
                                                                                     MC              VICON FORTE CAPS
                                                                                     MC              VINATAL FORTE TABS
                                                                                    MC               VINATE
                                                                                   MC/DEL            VINATE ADVANCED TABS

                                                                    MISCELLANEOUS MINERALS



                                                                                                                                          Page 32 of 51
                    **Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
MINERALS    MC                  CALCARB                                     MC               ANEMAGEN                                Use PA Form# 20420          Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
            MC                  CALCI-MIX CAPSULE CAPS                      MC               CALCET TABS                             Please refer to OTC list.   offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the

            MC                  CALCIQUID SYRP                            MC/DEL             CALCIUM 600-D TABS                                                  preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. As listed in MaineCare Policy,
            MC                  CALCITRATE/VITAMIN D TABS                   MC               CALCIUM/VITAMIN D TABS                                              certain drugs require specific diagnoses for approval.
           MC/DEL               CALCIUM                                     MC               CALTRATE 600 PLUS/VIT D TABS
           MC/DEL               CALCIUM CARBONATE                           MC               CALTRATE PLUS TABS                                                  DDI: Fe salts will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, Protonix, Prilosec, or any currently non
           MC/DEL               CALCIUM CITRATE TABS                        MC               CHROMAGEN                                                           preferred PPI.
           MC/DEL               CALCIUM GLUCONATE TABS                      MC               CITRACAL PLUS TABS
           MC/DEL               CALCIUM LACTATE TABS                        MC               CONTRIN CAPS
            MC                  CALCIUM/MAGNESIUM TABS                      MC               FEOGEN FORTE CAPS
           MC/DEL               CALCIUM/VITAMIN D TABS                      MC               FEROCON CAPS
            MC                  CALTRATE 600 TABS                         MC/DEL             FERREX 150 CAPS
           MC/DEL               CHEWABLE CALCIUM CHEW                       MC               FERRO-SEQUELS TBCR
            MC                  CITRACAL TABS                               MC               FE-TINIC CAPS
            MC                  CITRACAL + D TABS                           MC               FE-TINIC 150 FORTE CAPS
            MC                  CITRUS CALCIUM TABS                       MC/DEL             FLUOR-A-DAY SOLN
            MC                  CITRUS CALCIUM 1500 + D TABS              MC/DEL             K-DUR TBCR
            MC                  MC/DEL                                      MC               KLOR-CON PACK
            MC                  EFFERVESCENT POTASSIUM TBEF                 MC               K-LYTE
           MC/DEL               FEOSTAT CHEW                              MC/DEL             K-PHOS TABS NEUTRAL
            MC                  FERATAB TABS                                MC               K-TABS TBCR
           MC/DEL               FER-GEN-SOL SOLN                            MC               K-VESCENT PACK
            MC                  FER-IN-SOL SOLN                             MC               MICRO-K 10 MEG CPCR
            MC                  FER-IRON SOLN                               MC               NU-IRON 150 CAPS
            MC                  FERRONATE TABS                            MC/DEL             OYSTER SHELL CALCIUM/VITA TABS
           MC/DEL               FERROUS SULFATE                           MC/DEL             POLY-IRON 150 CAPS
           MC/DEL               FLUOR-A-DAY CHEW                          MC/DEL             POLYSACCHARIDE IRON CAPS
            MC                  FLUORIDE CHEW                             MC/DEL             POTASSIUM BICARB/CHLORIDE
            MC                  FLUORIDE SODIUM CHEW                      MC/DEL             POTASSIUM CHLORIDE 10MEQ
            MC                  FLUORITAB CHEW                            MC/DEL             SLOW FE TBCR
            MC                  HEMOCYTE TABS                               MC               TUMS 500 CHEW
            MC                  HM CALCIUM TABS                             MC               VIACTIV CHEW
            MC                  K+ POTASSIUM PACK
            MC                  KAON ELIX
            MC                  KAON-CL-10 TBCR
            MC                  KCL 0.075%/D5W/NACL 0.2% SOLN
            MC                  K-EFFERVESCENT TBEF
            MC                  KLOR-CON
            MC                  KLOTRIX TBCR
           MC/DEL               K-PHOS TABS
           MC/DEL               K-VESCENT TBEF
           MC/DEL               LURIDE CHEW
           MC/DEL               MAGNESIUM GLUCONATE TABS
           MC/DEL               MAGNESIUM SULFATE SOLN
            MC                  MAGTABS
            MC                  MICRO-K 8 MEG
           MC/DEL               OS-CAL TABS
           MC/DEL               OS-CAL 500 + D TABS
           MC/DEL               OYSCO
           MC/DEL               OYST-CAL TABS
           MC/DEL               OYST-CAL D TABS
           MC/DEL               OYST-CAL/VITAMIN D TABS
           MC/DEL               OYSTER CALCIUM TABS
           MC/DEL               OYSTER SHELL
            MC                  PHARMA FLUR
           MC/DEL               PHOSPHA 250 NEUTRAL TABS
            MC                  POTASSIUM BICARBONATE TBEF
           MC/DEL               POTASSIUM CHLORIDE 8MEQ
            MC                  POTASSIUM EFFERVESCENT
           MC/DEL               SELENIUM TABS
            MC                  SLOW-MAG TBCR
           MC/DEL               SODIUM FLUORIDE
           MC/DEL               SSKI SOLN
            MC                  V-R CALCIUM
            MC                  V-R OYSTER SHELL CALCIUM
            MC                  ZINC SULFATE CAPS
                                                      MISC. ELECTROLYTES/NUTRITIONALS


                                                                                                                                  Page 33 of 51
ELECTROLYTES/           MC/DEL   PED ELECTROLYTE SOLN.                     MC          BOOST                            This list of nutritionals is  Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
NUTRITIONALS            MC/DEL   FISH OIL CAPS                             MC          CASEC POWD                       incomplete. All nutritionals offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                        still require a PA except for drug and the preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
                         MC      INTRALIPID EMUL                           MC          CHOICE DM LIQD
                                                                                                                        the miscellaneous products
                         MC      ORALYTE SOLN                              MC          DELIVER 2.0 LIQD                 listed as preferred. SGA
                         MC      P.T.E. -5 SOLN                            MC          ENFAMIL                          form required for
                        MC/DEL   SEA-OMEGA CAPS                            MC          ENSURE                           nutritionals unless member
                                                                                                                        has a G/I tube.
                                                                           MC          GLUCERNA
                                                                           MC          ISOCAL LIQD
                                                                           MC          KINDERCAL TF LIQD
                                                                           MC          KINDERCAL TF/FIBER LIQD          1. Formerly known as
                                                                         MC/DEL        L-CARNITINE CAPS                 Omacor.
                                                                           MC          LIPISORB LIQD
                                                                           MC          LOVAZA1                          Use PA Form# 20420
                                                                           MC          MODULEN IBD POWD                 & SGA Form
                                                                           MC          NUTRAMIGEN POWD
                                                                         MC/DEL        NUTREN
                                                                           MC          NUTRITIONAL SUPPLEMENT LIQD
                                                                           MC          NUTRIVENT 1.5 LIQD
                                                                         MC/DEL        PEPTAMEN
                                                                           MC          PHENYL-FREE
                                                                           MC          PKU 3 POWD
                                                                           MC          PREGESTIMIL POWD
                                                                         MC/DEL        PROBALANCE LIQD
                                                                           MC          PROSOBEE
                                                                           MC          SCANDISHAKE PACK
                                                                 ERYTHROPOEITINS
ERYTHROPOEITINS          MC      PROCRIT SOLN1                             MC      6   EPOGEN SOLN                      Use PA Form# 10520            Non-Preferred drugs must be tried and failed in step-order, due to lack of efficacy or intolerable side effects before non-preferred drugs will be
                                                                           MC      8   ARANESP SOLN                     1. Clinical PA is required to approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents
                                                                                                                        establish medical necessity usage of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. Please see the
                                                                                                                        and that appropriate lab
                                                                                                                                                      EPO PA form for other approval and renewal criteria.
                                                                                                                        monitoring is being done.



                                                                 GRANULOCYTE CSF
GRANULOCYTE CSF                                                            MC      8   LEUKINE                          Must be used in specified See approval criteria detailed on Neupogen PA form.
                                                                                   8                                    step order. 1. 10 day
                                                                           MC          NEUPOGEN SOLN1
                                                                                                                        supply/month may be used
                                                                           MC      9   NEULASTA
                                                                                                                        without a PA.

                                                                                                                        Use PA Form # 20520
                                                     ANTICOAGULANTS / PLATELET AGENTS
ANTICOAGULANTS           MC      ARIXTRA SOLN1                          MC          COUMADIN TABS                       1. Arixtra, Fragmin and     Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                        MC/DEL   FRAGMIN INJ1                              MC          IPRIVASK                         Lovenox therapy durations offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC                                                                                             greater than 7 days require drug and the preferred drug(s) exists. Exceeding days supply limits for LMWH class requires PA.
                                 HEPARIN SODIUM/NACL 0.9% SOLN
                                                                                                                        PA.
                         MC      HEP-LOCK SOLN
                        MC/DEL   INNOHEP
                        MC/DEL   LOVENOX SOLN1                                                                          Use PA Form# 20420
                        MC/DEL   WARFARIN SODIUM TABS
                         MC      HEPARIN LOCK SOLN
                        MC/DEL   HEPARIN LOCK FLUSH SOLN
                        MC/DEL   HEPARIN SODIUM SOLN
                        MC/DEL   HEPARIN SODIUM LOCK FLUSH SOLN
                        MC/DEL   JANTOVEN
ANTIHEMOPHILIC AGENTS    MC      ALPHANATE                                 MC          ADVATE1,2                        1. Only if other products     Non-preferred will only be approved if other preferred products are unavailable.
                                 ALPHANINE SD                                                                           unavailable.
                        MC/DEL   BENEFIX SOLR
                         MC      BIOCLATE                                                                               2. Advate may be available
                        MC/DEL   HELIXATE FS KIT                                                                        with PA in cases of large
                         MC                                                                                             volume dosing in patients
                                 HEMOFIL - M
                                                                                                                        with poor venous access.
                         MC      HUMATE-P SOLR
                         MC      KOGENATE FS
                         MC      KONYNE - 80                                                                            Use PA Form# 20420
                                 MONARC - M
                         MC      MONOCLATE - P
                         MC      MONONINE
                         MC      NOVOSEVEN SOLR
                        MC/DEL   PROFILNINE
                         MC      PROPLEX -T
                         MC      RECOMBINATE SOLR
                         MC      REFACTO
PLATELET AGGREGATION    MC/DEL   ASPIRIN                                 MC/DEL    7   TICLOPIDINE HCL TABS             Use PA Form # 20715 for       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
INHIBITORS                                                                                                              Plavix requests.              offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                      drug and the preferred drug(s) exists.
                                                                                                                     Page 34 of 51
PLATELET AGGREGATION                                                                                                   Use PA Form # 20715 for         Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
INHIBITORS                   MC/DEL   DIPYRIDAMOLE TABS                    MC/DEL    8   PERSANTINE TABS               Plavix requests.                offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                           MC/DEL                                                                      drug and the preferred drug(s) exists.
                                                                                     8   PLAVIX TABS1, 2               For all other requests
                                                                             MC      8   TICLID TABS                   please use form # 20420.        A special PA may be obtained at the pharmacy for members scheduled for "stent" placement or have had placement if in the last 12months. Please indicate on prescription date of
                                                                                                                                                       stent placement.
                                                                                                                       1. As of 10.16.08 all new
                                                                                                                       users of Plavix will require
                                                                                                                       prior authorization.


                                                                                                                       2. A special PA may be
                                                                                                                       obtained at the pharmacy
                                                                                                                       for members scheduled for
                                                                                                                       "stent" placement or have
                                                                                                                       had placement if in the last
                                                                                                                       12months. Please indicate
                                                                                                                       on prescription date of stent
                                                                                                                       placement.



PLATELET AGGR. INHIBITORS    MC/DEL   PENTOXIFYLLINE ER TBCR               MC/DEL        AGGRENOX CP121                1. Asprin and dipyridamole Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
/ COMBO'S - MISC.            MC/DEL   CILOSTAZOL                           MC/DEL        AGGRENOX2                     are available separately       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                       without PA. Use PA Form drug and the preferred drug(s) exists.
                                                                           MC/DEL        AGRYLIN CAPS
                                                                                                                       # 20420
                                                                           MC/DEL        PLETAL TABS                   2. Aggrenox will be
                                                                             MC          TRENTAL TBCR                  approved if submitted with
                                                                                                                       documentation supporting
                                                                                                                       that it is being used for non-
                                                                                                                       embolic stroke.



                                                                                                                       Use PA Form# 20420
                                                                    HEMATOLOGICALS
MONOCLONAL ANTIBODY                                                          MC          SOLIRIS                       Use PA Form# 20420              A diagnosis of Paroxysmal nocturnal hemoglobinuria (PNH) using the HAM test or flow cytometry is required. In addition, the patient must show evidence of having received a
                                                                                                                                                       meningitis vaccine at least 2 weeks prior to the start of therapy.

HEMATOLOGICAL AGENTS-                                                       MC/DEL   7   PROMACTA                      Use PA Form# 20420              Clinical PA required. Must see prior trial with insufficient response to corticosteroids and immunoglobulins.
THROMBOPOIETIN RECEPTOR                                                      MC      8   NPLATE
AGONISTS

                                                                      HEMOSTATIC
HEMOSTATIC                   MC/DEL   AMICAR
                              MC      AMINOCAPROIC ACID
                                                                     OPHTHALMICS
OP. - ANTIBIOTICS             MC      AK-SPORE OINT                          MC          AK-POLY-BAC OINT              Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                              MC      BACITRACIN OINT                        MC          AK-SULF OINT                                                  offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                              MC                                             MC                                                                        drug and the preferred drug(s) exists.
                                      BACITRACIN/NEOMYCIN/POLYM                          AK-TOB SOLN
                             MC/DEL   BACITRACIN/POLYMYXIN B OINT            MC          AZASITE
                              MC      CHLOROPTIC SOLN                        MC          BLEPH-10 SOLN
                             MC/DEL   ERYTHROMYCIN OINT                      MC          GENTAK
                             MC/DEL   GENTAMICIN SULFATE                     MC          ILOTYCIN OINT
                             MC/DEL   NEOMYCIN/POLYMYXIN/GRAMIC            MC/DEL        NEOMYCIN/BACI/POLYM OINT
                              MC      NEOSPORIN SOLN                         MC          NEOSPORIN OINT
                              MC      POLYSPORIN                             MC          OCUSULF-10 SOLN
                             MC/DEL   SODIUM SULFACETAMIDE SOLN              MC          OCUTRICIN SOLN
                             MC/DEL   SULFACETAMIDE SODIUM                   MC          TERAK OINT
                              MC      TERRAMYCIN OINT                      MC/DEL        TOBREX OINT
                             MC/DEL   TOBRAMYCIN SULFATE SOLN              MC/DEL        TRIFLURIDINE SOLN
                             MC/DEL   TRIMETHOPRIM SULFATE/POLY
                             MC/DEL   VIROPTIC SOLN
OP. - QUINOLONES             MC/DEL   CILOXAN OINT                         MC/DEL        CILOXAN SOLN                  Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC/DEL   CIPROFLOXACIN SOL 0.3%                 MC          OCUFLOX SOLN                                                  offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                       drug and the preferred drug(s) exists.
                             MC/DEL   OFLOXACIN
                             MC/DEL   QUIXIN SOLN
OP.QUINOLONES-4TH            MC/DEL   VIGAMOX
GENERATION                    MC      ZYMAR
OP. - ARTIFICIAL TEARS AND    MC      AKWA TEARS OINT                        MC          AKWA TEARS SOLN               Use PA Form# 20420              Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
LUBRICANTS                   MC/DEL   ARTIFICIAL TEARS OINT                MC/DEL        ARTIFICIAL TEARS SOLN OP      1. Dosing limits apply,         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC/DEL                                          MC                                        please see dose                 drug and the preferred drug(s) exists.
                                      ARTIFICIAL TEARS SOLN                              BION TEARS SOLN
                              MC                                             MC                                        consolidation list.
                                      CELLUVISC SOLN                                     DRY EYES OINT
                              MC      EYE LUBRICANT OINT                     MC          DURATEARS OINT
                             MC/DEL   GENTEAL                              MC/DEL        HYPO TEARS
                              MC      LIQUITEARS SOLN                      MC/DEL        ISOPTO TEARS SOLN
                              MC      MAJOR TEARS SOLN                       MC          LACRI-LUBE
                              MC      PURALUBE OINT                          MC          LUBRIFRESH P.M. OINT
                              MC      PURALUBE TEARS SOLN                    MC          MURINE SOLN
                              MC      REFRESH SOLN OP                      MC/DEL        MUROCEL SOLN
                              MC      REFRESH PLUS SOLN1                   MC/DEL        NATURE'S TEARS SOLN


                                                                                                                    Page 35 of 51
                             MC      REFRESH PM OINT               MC      REFRESH SOLN
                                                                   MC      REFRESH TEARS SOLN1
                                                                   MC      SYSTANE
                                                                   MC      TEARGEN SOLN
                                                                   MC      TEARISOL SOLN
                                                                  MC/DEL   TEARS NATURALE
                                                                  MC/DEL   TEARS PURE SOLN
                                                                   MC      TEARS RENEWED OINT
                                                                  MC/DEL   THERATEARS SOLN
                                                                   MC      V-R ARTIFICIAL TEARS SOLN
OP. - BETA - BLOCKERS       MC/DEL   BETOPTIC-S SUSP               MC      BETAGAN SOLN                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   CARTEOLOL HCL SOLN           MC/DEL   BETAXOLOL HCL SOLN                                           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL   LEVOBUNOLOL HCL SOLN         MC/DEL   BETIMOL SOLN                                                 drug and the preferred drug(s) exists.

                            MC/DEL   METIPRANOLOL SOLN             MC      ISTALOL
                            MC/DEL   TIMOLOL MALEATE SOLG (GEL)   MC/DEL   OCUPRESS SOLN
                            MC/DEL   TIMOLOL MALEATE SOLN          MC      OPTIPRANOLOL SOLN
                                                                  MC/DEL   TIMOPTIC SOLN
                                                                  MC/DEL   TIMOPTIC-XE SOLG
OP. - ANTI-INFLAMMATORY /    MC      AK-SPORE HC OINT              MC      AK-TROL SUSP                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
STEROIDS OPHTH.             MC/DEL   ALREX SUSP                    MC      BAC/POLY/NEOMY/HC OINT                                       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC                                    MC                                                                   drug and the preferred drug(s) exists.
                                     BLEPHAMIDE SUSP                       BLEPHAMIDE S.O.P. OINT
                            MC/DEL   CORTISPORIN SUSP              MC      ECONOPRED
                            MC/DEL   DEXAMETH SOD PHOS SOLN        MC      EFLONE SUSP
                            MC/DEL   FLAREX SUSP                   MC      FLUOR-OP SUSP
                            MC/DEL   FLUOROMETHOLONE SUSP          MC      FML LIQUIFILM SUSP
                             MC      FML S.O.P. OINT               MC      MAXITROL
                             MC      FML-S LIQUIFILM SUSP          MC      NEO/POLY/BAC/HC OINT
                             MC      INFLAMASE SOLN                MC      PRED FORTE SUSP
                            MC/DEL   LOTEMAX SUSP                  MC      PRED-G SUSP
                            MC/DEL   NEOM/POLIN/DEX                MC      PRED-G S.O.P. OINT
                             MC      PRED MILD SUSP               MC/DEL   SULFACET SOD/PRED SOLN
                            MC/DEL   PREDNISOLONE                  MC      VASOCIDIN SOLN
                            MC/DEL   TOBRADEX                     MC/DEL   VEXOL SUSP
OP. - PROSTAGLANDINS         MC      LUMIGAN SOLN                 MC/DEL   RESCULA SOLN                   All preferreds must be tried. Preferred drugs must be tried and failed, in step-order, due to lack of efficacy (failure to reach target IOP reduction) or intolerable side effects before non-preferred drugs will be
                            MC/DEL   TRAVATAN SOLN                MC/DEL   XALATAN SOLN                                                 approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
                                                                                                                                        significant potential drug interaction between another drug and the preferred drug(s) exists.
                                                                                                          Use PA Form# 20420
OP. - CYCLOPLEGICS           MC      AK-PENTOLATE SOLN            MC/DEL   CYCLOGYL SOLN                  Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   ATROPINE SULFATE              MC      ISOPTO ATROPINE SOLN                                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL                                MC/DEL                                                                drug and the preferred drug(s) exists.
                                     CYCLOPENTOLATE HCL SOLN               ISOPTO HOMATROPINE SOLN
                            MC/DEL   ISOPTO HYOSCINE SOLN          MC      MUROCOLL-2 SOLN
OP. - MIOTICS - DIRECT      MC/DEL   ISOPTO CARBACHOL SOLN
ACTING                               ISOPTO CARPINE SOLN
                             MC
                             MC      PILOCAR SOLN
                            MC/DEL   PILOCARPINE HCL SOLN
                            MC/DEL   PILOPINE HS GEL
OP. - ADRENERGIC AGENTS     MC/DEL   DIPIVEFRIN HCL SOLN           MC      PROPINE SOLN                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC                                                                                                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                     EPIFRIN SOLN
                                                                                                                                        drug and the preferred drug(s) exists.

OP. - SELECTIVE ALPHA        MC      ALPHAGAN SOLN                MC/DEL   IOPIDINE SOLN                  Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ADRENERGIC AGONISTS          MC      ALPHAGAN P SOLN                                                                                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL                                                                                                      drug and the preferred drug(s) exists.
                                     BRIMONIDINE 0.2%
OP. - ANTI-ALLERGICS        MC/DEL   OPTIVAR                       MC      ALOCRIL SOLN                   Use PA Form# 20420            All preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   PATADAY SOLN                 MC/DEL   ALOMIDE SOLN                                                 offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC/DEL                                 MC                                                                   drug and the preferred drug(s) exists.
                                     PATANOL SOLN                          ELESTAT
                                                                  MC/DEL   EMADINE SOLN
                                                                  MC/DEL   LIVOSTIN SUSP
                                                                   MC      OPTICROM SOLN
                                                                  MC/DEL   ZADITOR SOLN
OP. ANTI-ALLERGICS-                                               MC/DEL   ALAMAST SOLN                   Use PA Form# 20420
MASTCELL STABILIZER
CLASS

OP. - CARBONIC ANHYDRASE    MC/DEL   AZOPT SUSP                   MC/DEL   DORZOLAMIDE                    Use PA Form# 20420
INHIBITORS/COMBO            MC/DEL   COSOPT SOLN                  MC/DEL   DORZOLAMIDE/TIMOLOL
                             MC      COMBIGAN
                            MC/DEL   TRUSOPT SOLN
OP. - NSAID'S                MC      ACULAR LS                     MC      OCUFEN SOLN                    Must fail all preferred       Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC      ACULAR SOLN                  MC/DEL   NEVANAC                        products before non-          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC                                    MC                                     preferred.                    drug and the preferred drug(s) exists.
                                     FLURBIPROFEN SODIUM SOLN              XIBROM
                             MC      VOLTAREN SOLN                                                        Use PA Form# 20420
OP. - OF INTEREST           MC/DEL   ENUCLENE SOLN                 MC      BOTOX SOLR                     1. Must have kerato           Must fail adequate trials of multi agents from artificial tears and lubricant category.
                                                                                                          conjuctivitus sicca and
                                                                                                          failed other dry eye
                                                                                                          therapies.
                                                                                                       Page 36 of 51
OP. - OF INTEREST                                                                                          1. Must have kerato         Must fail adequate trials of multi agents from artificial tears and lubricant category.
                                                                       MC      RESTASIS1                   conjuctivitus sicca and
                                                                                                           failed other dry eye
                                                                                                           therapies.

                                                                                                           Use PA Form #20420
                                                              DERMATOLOGICAL
TOPICAL - ACNE           MC      AZELEX CREA                                   AZONE                       1. Users 24 or under, PA    Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
PREPARATIONS             MC      BENZOYL PEROXIDE                      MC      ALTINAC CREA                will not be required.       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                        MC/DEL                                         MC                                                              drug and the preferred drug(s) exists.
                                 CLINDAMYCIN PHOSPHATE 2                       AVITA CREA                  2. Dosing limits allowing
                         MC      ERYDERM SOLN                          MC      BENZAC                      one package per month.
                                                                                                           Please refer to Dose
                        MC/DEL   ERYTHROMYCIN GEL                    MC/DEL    BENZACLIN GEL
                                                                                                           Consolidation List.
                        MC/DEL   ERYTHROMYCIN PADS                   MC/DEL    BENZAGEL-10 GEL
                        MC/DEL   ERYTHROMYCIN SOLN                   MC/DEL    BENZAMYCIN GEL
                         MC      ISOTRETINOIN                        MC/DEL    BENZAMYCINPAK PACK          If requesting any brands
                         MC      METRONIDAZOLE CREAM2                  MC      BREVOXYL                    use PA Form # 10220,
                         MC      METRONIDAZOLE GEL    2              MC/DEL    CLEOCIN-T  2                for all others use
                         MC      METRONIDAZOLE LOTN       2            MC      CLINAC BPO GEL              PA Form # 20420
                        MC/DEL   PLEXION                               MC      CLINDAGEL GEL
                          MC     RETIN-A GEL1,2                        MC      CLINDETS SWAB
                        MC/DEL   SODIUM SULFACET/SULF LOTN             MC      DESQUAM-E GEL
                         MC      TAZORAC GEL                           MC      DESQUAM-X
                                                                       MC      DIFFERIN 0.3% GEL
                                                                       MC      DIFFERIN
                                                                       MC      DUAC GEL
                                                                       MC      EMGEL GEL
                                                                       MC      EPIDUO
                                                                       MC      ERYCETTE PADS
                                                                       MC      ERYGEL GEL
                                                                     MC/DEL    EVOCLIN
                                                                       MC      FINEVIN CREA
                                                                      MC/DEL   KLARON LOTN
                                                                       MC      METROCREAM CREAM2
                                                                       MC      METROGEL GEL2
                                                                       MC      METROLOTION LOTN2
                                                                       MC      NEOBENZ MICRO
                                                                      MC/DEL   NORITATE CREA
                                                                       MC      RETIN-A MICRO GEL
                                                                       MC      RETIN-A CREAM2
                                                                      MC/DEL   SULFACET-R LOTN
                                                                      MC/DEL   TRETINOIN1, 2
                                                                      MC/DEL   TRIAZ
                                                                       MC      ZETACET
                                                                      MC/DEL   ZIANA
TOPICAL - ANTIBIOTIC     MC      BACIT/NEOMYCIN/POLYM OINT           MC/DEL    ALTABAX 1                   1. Dosing limits apply,     Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                        MC/DEL   BACITRACIN OINT                     MC/DEL    BACTROBAN OINT.             please see dosing           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                        MC/DEL                                       MC/DEL                                consolidation list.         drug and the preferred drug(s) exists.
                                 BACTROBAN CREAM                               CORTISPORIN
                        MC/DEL   BACTROBAN NASAL OINT                MC/DEL    TRIPLE ANTIBIOTIC OINT
                        MC/DEL   CENTANY OINT 2%1
                        MC/DEL   GENTAMICIN SULFATE
                        MC/DEL   MUPIROCIN1
                                                                                                           Use PA Form# 20420
TOPICAL - ANTIFUNGALS    MC      CICLOPIROX 0.77 CREAM                 MC      EXELDERM
                         MC      CICLOPIROX 0.77 SUSP                  MC      FUNGIZONE CREA              Use PA Form # 10120         Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                        MC/DEL   CLOTRIMAZOLE                        MC/DEL    HYDROCORT/IODOQ CREA                                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                       drug and the preferred drug(s) exists.
                        MC/DEL   CLOTRIMAZOLE/BETA CREAM             MC/DEL    LAMISIL
                         MC      ECONAZOLE NITRATE CREAM             MC/DEL    LOPROX 0.77 LOTN
                        MC/DEL   KETOCONAZOLE CREAM                  MC/DEL    LOPROX 0.77 CREAM
                        MC/DEL   LOPROX 1.0 CREAM                    MC/DEL    LOPROX 0.77 SUSP                                        DDI: Ketoconazole will now be non-preferred and require prior authorization if they are currently being used in combination with any of the following medications: Prevacid,
                        MC/DEL   LOPROX 1.O LOTN                     MC/DEL    LOPROX SHAMPOO SHAM                                     Protonix, or Omeprazole.
                        MC/DEL   LOPROX GEL                            MC      LOTRIMIN
                        MC/DEL   LOPROX TS LOTN                      MC/DEL    LOTRISONE
                        MC/DEL   MICONAZOLE NITRATE CREA             MC/DEL    MENTAX CREA
                         MC      MYCO-TRIACET II CREA                  MC      MYCOGEN II CREA
                         MC      NIZORAL SHAM                          MC      MYCOLOG-II CREA
                         MC      NTA OINT                              MC      MYCOSTATIN POWD
                        MC/DEL   NYSTATIN                              MC      NAFTIN
                        MC/DEL   NYSTATIN/TRIAMCINOLONE                MC      NIZORAL CREA
                          MC     PEDI-DRI POWD                         MC      NYSTAT-RX POWD
                        MC/DEL   TINACTIN                            MC/DEL    NYSTOP POWD
                         MC      TRI-STATIN II CREA                   MC/DEL   OXISTAT



                                                                                                        Page 37 of 51
                                                                         MC/DEL   PENLAC NAIL LACQUER SOLN
                                                                          MC      SPECTAZOLE CREAM
TOPICAL - ANTIPRURITICS      MC      ZONALON CREA                         MC      PRUDOXIN CREA                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                                                                                                offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                drug and the preferred drug(s) exists.

TOPICAL - ANTIPSORIATICS     MC      DOVONEX                              MC      OXSORALEN ULTRA CAPS            Must fail all preferred      Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   SORIATANE CAPS                       MC      PSORIATEC CREA                  products before non-         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                  preferred. 1. Individual     drug and the preferred drug(s) exists.
                             MC      TAZORAC                             MC/DEL   SORIATANE CK KIT
                                                                                                                  ingredients are available as
                                                                         MC/DEL   TACLONEX1                       preferred witout PA.
                                                                          MC      VANAMIDE
                                                                          MC      VECTICAL                        Use PA Form# 20420
TOPICAL - ANTISEBORRHEICS    MC      CAPITROL SHAM                        MC      CARMOL SCALP TREATMENT KIT      Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC/DEL   SELENIUM SULFIDE SHAM                MC      ZNP BAR                                                       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC                                                                                                                 drug and the preferred drug(s) exists.
                                     SELSUN BLUE SHAM
TOPICAL - ANTIVIRALS                                                     MC/DEL   DENAVIR CREA1                   1. Must fail oral treatment
                                                                          MC                                      with Acyclovir or Valtrex.
                                                                                  ZOVIRAX OINT1


                                                                                                                  Use PA Form# 20420
TOPICAL - ANTINEOPLASTICS    MC      EFUDEX                              MC/DEL   CARAC CREA                      Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC      FLUOROPLEX CREA                     MC/DEL   FLUOROURACIL                                                  offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                             MC                                                                                                                 drug and the preferred drug(s) exists.
                                     SOLARAZE GEL
TOPICAL - BURN PRODUCTS      MC      FURACIN CREA                        MC/DEL   SILVADENE CREA                  Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
                             MC      SSD CREA                            MC/DEL   SILVER SULFADIAZINE CREA                                       unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage
                            MC/DEL   THERMAZENE CREA                      MC      SSD AF CREA                                                    of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
TOPICAL - CORTICOSTEROIDS                        LOW POTENCY             MC/DEL   ACLOVATE                        Use PA Form# 20420            At least 1 drug from each potency of preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless
                             MC      DESOWEN                              MC      AMCINONIDE CREA                                               an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential
                                                                                                                                                drug interaction between another drug and the preferred drug(s) exists.
                            MC/DEL   HYDROCORTISONE CREA                  MC      ANUSOL HC-1 OINT
                             MC      HYDROCORTISONE LOTN                  MC      ARISTOCORT A
                             MC      LACTICARE-HC LOTN                    MC      CLOBEX
                             MC      NUTRACORT LOTN                       MC      CLODERM CREA
                             MC      TEXACORT SOLN                       MC/DEL   CORDRAN
                             MC      TRIDESILON CREA                     MC/DEL   CORMAX
                                                  MEDIUM POTENCY         MC/DEL   CUTIVATE CREAM / OINT
                            MC/DEL   DESOXIMETASONE .05%                 MC/DEL   CUTIVATE LOTION
                            MC/DEL   ELOCON                              MC/DEL   DERMATOP
                            MC/DEL   FLUOCINOLONE ACETONIDE .025-.01%             DESONATE GEL
                             MC      FLUROSYN CREA                       MC/DEL   DIPROLENE
                             MC      FLUTICASONE PROPIONATE CREAM/OINT    MC      ELOCON OINT
                             MC      HYDROCORTISONE BUTYRATE              MC      HYDROCORTISONE POWD
                             MC      HYDROCORTISONE OINT                  MC      KENALOG AERS
                             MC      HYDROCORTISONE VALERATE              MC      LIDA MANTLE HC CREA
                             MC      MOMETASONE FUROATE OINT              MC      LIDEX
                            MC/DEL   TRIAMCINOLONE ACETONIDE .025-.1%     MC      LIDEX-E CREA
                                                                         MC/DEL   LOCOID
                                                    HIGH POTENCY         MC/DEL   LUXIQ FOAM
                             MC      CYCLOCORT                           MC/DEL   OLUX FOAM
                            MC/DEL   BETAMETHASONE DIPROPIONATE           MC      PANDEL CREA
                            MC/DEL   DESOXIMETASONE .25%                  MC      PROCTOCORT CREA
                            MC/DEL   DESONIDE                            MC/DEL   PSORCON
                            MC/DEL   FLUOCINOLONE ACETONIDE .02%         MC/DEL   PSORCON E
                            MC/DEL   FLUOCINONIDE                         MC      SYNALAR OINT
                             MC      HALOG                               MC/DEL   TEMOVATE
                             MC      HALOG-E CREA                         MC      TOPICORT
                            MC/DEL   TRIAMCINOLONE ACETONIDE .5%          MC      TOPICORT LP CREA
                                                 VERY HIGH POTENCY        MC      ULTRAVATE
                            MC/DEL   AUGMENTED BETA DIP                  MC/DEL   VERDESO
                            MC/DEL   BETAMETHASONE VALERATE               MC      WESTCORT
                            MC/DEL   BETA-VAL
                            MC/DEL   CLOBETASOL PROPIONATE
                             MC      DIFLORASONE DIACETATE
                             MC      HALOBETASOL
                                                  MISCELLANEOUS
                             MC      CAPEX SHAM
                             MC      DERMA-SMOOTHE/FS OIL
                             MC      PROCTO-KIT CREA 1%
TOPICAL - STEROID LOCAL      MC      ZONE-A FORTE LOTN                    MC      EPIFOAM FOAM                    Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ANESTHETICS                                                                                                                                     offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                drug and the preferred drug(s) exists.

TOPICAL - STEROID            MC      DERMA-SMOOTHE/FS ATOPIC P KIT        MC      CARMOL-HC CREA                  Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
COMBINATIONS                                                                                                                                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                drug and the preferred drug(s) exists.


                                                                                                               Page 38 of 51
TOPICAL - STEROID                                                                                                                                    Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
COMBINATIONS                                                                                                                                         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                     drug and the preferred drug(s) exists.

TOPICAL - EMOLLIENTS        MC      AMMONIUM LACTATE LOTION 12%      MC/DEL       AMMONIUM LACTATE CREA               Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                            MC      LAC-HYDRIN CREAM                  MC          LAC-HYDRIN LOTION 12%                                              offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC                                       MC/DEL                                                                          drug and the preferred drug(s) exists.
                                    LACTINOL-E CREA                               LACTINOL LOTN
                            MC      UREACIN-20 CREA                   MC          MEDERMA GEL
                            MC      VITAMIN A & D MEDICATED OINT      MC          MIMYX
                                                                      MC          RENOVA CREA



TOPICAL - ENZYMES /         MC      GRANUL-DERM AERS                  MC          CARMOL 40 CREA                      Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
KERATOLYTICS / UREA        MC/DEL   GRANULEX AERS                     MC          SALEX CREAM                         Ziox, Panafil and Papain   unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage
                            MC      TBC AERS                          MC          SALEX LOTION                        products have been         of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
                            MC                                                                                        removed from the PDL due
                                    SANTYL OINT
                                                                                                                      to FDA safety concerns
                                                                                                                      regarding drugs containing
                                                                                                                      Papain.



TOPICAL - GENITAL WARTS    MC/DEL   ALDARA                           MC/DEL   5   PODOFILOX SOLN                      Use PA Form# 20420
                                                                     MC/DEL   8   CONDYLOX                            Non-preferred products
                                                                      MC      8   VEREGEN                             must be used in specified
                                                                                                                      order.

TOPICAL -                                                            MC/DEL   8   ELIDEL CREA                         Use PA Form# 20420             Preferred corticosteroids from other classes must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an
IMMUNOMODULATORS                                                      MC      9   PROTOPIC OINT                       Non-preferred products         acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
                                                                                                                      must be used in specified      interaction between another drug and the preferred drug(s) exists. Approvals will be made for small amounts of non-preferred products for the treatment of very steroid-sensitive
                                                                                                                      order. The FDA has issued      areas in conjunction with topical steroids for the treatment of atopic dermatitis.
                                                                                                                      a Publilc Health Advisory
                                                                                                                      for both Elidel and Protopic
                                                                                                                      concerning the potential
                                                                                                                      cancer risk associated with
                                                                                                                      their use. Use for children
                                                                                                                      less than 2 years of age is
                                                                                                                      not recommended.




TOPICAL - LOCAL             MC      AF CAPSICUM OLEORESIN CREA       MC/DEL       EMLA PADS                           1. Lidocaine/Prilocaine     Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
ANESTHETICS                MC/DEL   CAPSAICIN CREA                   MC/DEL       EMLA CREA                           cream and Ela-Max           offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                      products require PA for     drug and the preferred drug(s) exists.
                            MC      ELA-MAX1                          MC          LIDA MANTLE CREA
                                                                                                                      users over 18 years of age.
                           MC/DEL   LIDOCAINE/PRILOCAINE CREA1        MC          LIDODERM PTCH
                           MC/DEL   XYLOCAINE                         MC          PONTOCAINE SOLN
                                                                      MC          ZOSTRIX                             Use PA Form# 20420


TOPICAL - DEPIGMENTING                                                MC      8   ALUSTRA CREA                        Not covered for cosmetic       As per Medicaid Policy, cosmetic drugs are not covered. Non-cosmetic clinical applications will be considered by prior authorization on a case by case basis.
AGENTS                                                                        8   EPIQUIN MICRO                       purposes.
                                                                      MC
                                                                      MC      8   GLYQUIN CREA
                                                                     MC/DEL   8   HYDROQUINONE CREA                   Use PA Form# 20420
                                                                     MC/DEL   8   HYDROQUINONE/SUNSCREENS
                                                                      MC      8   SOLAQUIN FORTE CREA
                                                                      MC      8   TRI-LUMA CREA
                                                                      MC      9   ELDOQUIN
TOPICAL - SCABICIDES AND   MC/DEL   ACTICIN CREA                     MC/DEL       LINDANE                             Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
PEDICULICIDES               MC                                                    OVIDE LOTN                                                         unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of
                                    ELIMITE CREA                      MC
                            MC      EURAX                             MC          MALATHION                                                          the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
                            MC      LICE KILLING SHAM                 MC          ULESFIA
                           MC/DEL   LICE TREATMENT CREME RINS LIQD
                           MC/DEL   PERMETHRIN LOTN
TOPICAL - WOUND /                                                     MC          REGRANEX GEL                        Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
DECUBITUS CARE                                                       MC/DEL       REGENECARE                          Accuzyme and Ethezyme          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                     MC/DEL                                           products have been             drug and the preferred drug(s) exists. Regranex will be approved for diabetic patients in good control (hgba1c <8), who are not smoking, with a stage III or IV WOCN AND NPUAP
                                                                                  RADIAPLEXRX
                                                                                                                      removed from the PDL due       lower extremity diabetic ulcer and with an adequate blood supply (Tcp 02 >30, ABI>0.7 or ASP> 70), and where the underlying cause has been corrected. The wound must be free
                                                                                                                      to FDA concerns regarding      of infection and have been previously treated with preferred standard therapies for at least 2 months. Maximum approval for 20 weeks.
                                                                                                                      drugs containing Papain.




TOPICAL - ASTRINGENTS /     MC      ALUMINUM CHLORIDE SOLN            MC          LOWILA BAR                          Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
PROTECTANTS                 MC      DRYSOL SOLN                       MC          MOISTURIN DRY SKIN CREA                                            offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                            MC                                        MC                                                                             drug and the preferred drug(s) exists.
                                    XERAC AC SOLN                                 PROSHIELD PLUS SKIN PROTE CREA
                                                                                  SURGILUBE GEL

                                                                      MC
TOPICAL - ANTISEPTICS /    MC/DEL   PHISOHEX LIQD                     MC          BETADINE OINT                       Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
DISINFECTANTS              MC/DEL   POVIDONE-IODINE SOLN              MC          FORMALYDE-10 AERS                                                  unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage



                                                                                                                   Page 39 of 51
                                                                            MC           IODOSORB                                                          of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
                                                                            MC           LAZERFORMALYDE SOLUTION SOLN

                                                                 MISCELLANEOUS EYE
OP. - EYE                MC      AK-DILATE SOLN                             MC           LENS PLUS REWETTING DROPS           Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                         MC      EYE WASH SOLN                            MC/DEL         MURO 128                                                          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                         MC                                                 MC                                                                             drug and the preferred drug(s) exists.
                                 NAPHAZOLINE HCL SOLN                                    NEO-SYNEPHRINE SOLN
                         MC      PHENYLEPHRINE HCL SOLN
                         MC      PONTOCAINE SOLN
                        MC/DEL   SODIUM CHLORIDE
                                                              MISCELLANEOUS EAR
EAR                     MC/DEL   A/B OTIC SOLN                           MC              AERO OTIC HC SOLN                   Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                         MC      ACETASOL SOLN                              MC           ANTIBIOTIC EAR SOLN                                               offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                            MC                                                                             drug and the preferred drug(s) exists.
                        MC/DEL   ACETASOL HC SOLN                                        ANTIBIOTIC EAR SUSP
                        MC/DEL   ACETIC ACID                                MC           AURALGAN SOLN
                        MC/DEL   ACETIC ACID/HYDROCORTISON                MC/DEL         CIPRO HC SUSP
                        MC/DEL   ALLERGEN SOLN                              MC           COLY-MYCIN-S SUSP
                        MC/DEL   ANTIPYRINE/BENZOCAINE SOLN                 MC           CORTISPORIN SUSP
                        MC/DEL   AURODEX SOLN                             MC/DEL         CORTISPORIN-TC SUSP
                         MC      AUROGUARD SOLN                           MC/DEL         DEBROX SOLN
                        MC/DEL   AUROTO OTIC SOLN                           MC           DOMEBORO SOLN
                         MC      CARBAMIDE PEROXIDE 6.5% OTIC SOLN.         MC           FLOXIN OTIC SOLN
                        MC/DEL   CIPRODEX                                 MC/DEL         PEDIOTIC SUSP
                         MC      CORTISPORIN SOLN                           MC           VOSOL-HC SOLN
                        MC/DEL   CORTOMYCIN                               MC/DEL         ZOTANE HC SOLN
                         MC      EAR DROPS SOLN                             MC           ZOTO-HC SOLN
                         MC      EAR DROPS RX SOLN
                        MC/DEL   EAR WAX REMOVAL DROPS
                         MC      EAR-GESIC SOLN
                        MC/DEL   NEOMYCIN/POLYMYXIN/HC
                        MC/DEL   OFLOXACIN 0.3% OTIC
                        MC/DEL   OTICAINE OTIC SOLN
                                                              MOUTH ANTISEPTICS
MOUTH ANTI-INFECTIVES    MC      NILSTAT SUSP                               MC           MYCELEX TROC                        Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless
                          MC     EAR-GESIC SOLN                             MC           MYCOSTATIN LOZG                                                   an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the
                        MC/DEL   NYSTATIN SUSP                              MC                                                                             preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
MOUTH ANTISEPTICS       MC/DEL   CHLORHEXIDINE GLUCONATE                    MC           APHTHASOL PSTE                      Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                        MC/DEL   LIDOCAINE VISCOUS SOLN                     MC           PERIDEX SOLN                        Must fail all preferred       offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                            MC                                               products before non-          drug and the preferred drug(s) exists.
                         MC      TRIAMCINOLONE IN ORABASE PSTE                           PERIOGARD SOLN
                                                                                                                             preferred.
                         MC      TRIAMCINOLONE ORADENT PSTE                 MC           TRIAMCINOLONE ACETONIDE PSTE
                                                                            MC           XYLOCAINE VISCOUS SOLN
                                                               DENTAL PRODUCTS
DENTAL PRODUCTS         MC/DEL   ETHEDENT CREA                            MC0MC          APF GEL GEL                         Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                        MC/DEL   GEL-KAM CONC                             MC/DEL         DENTAGEL GEL                                                      offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                        MC/DEL                                            MC/DEL                                                                           drug and the preferred drug(s) exists.
                                 GEL-KAM GEL 0.4%                                        PHOS-FLUR GEL
                        MC/DEL   PHOS FLUR SOLN                           MC/DEL         PREVIDENT CREAM
                        MC/DEL   PREVIDENT GEL                              MC           THERA-FLUR-N GEL
                        MC/DEL   PREVIDENT SOLN
                        MC/DEL   SF 5000 PLUS CREA
                        MC/DEL   SF GEL
                         MC      STANNOUS FLUORIDE ORAL RI CONC
                                                          ARTIFICIAL SALIVA/STIMULANTS
ARTIFICIAL               MC      SALIVA SUBSTITUTE SOLN                     MC           EVOXAC CAPS                         Use PA Form# 20420            Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
SALIVA/STIMULANTS                                                           MC           RADIACARE SOLR                                                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                            MC                                                                             drug and the preferred drug(s) exists.
                                                                                         SALAGEN TABS


                                                          MISCELLANEOUS ANORECTAL
ANORECTAL - MISC.       MC/DEL   COLOCORT ENEM                            MC/DEL         ANUSOL-HC CREA                      Use PA Form# 20420
                         MC      CORTENEMA ENEM                           MC/DEL         CORTIFOAM FOAM
                         MC      ELA-MAX 5 CREA                           MC/DEL         PROCTOCREAM-HC CREA
                        MC/DEL   HYDROCORTISONE ENEM                      MC/DEL         PROCTOFOAM HC FOAM
                        MC/DEL   PROCTOZONE-HC CREA                       MC/DEL         PROCTO-KIT CREA 2.5%
                                                                          MC/DEL         PROCTOSOL HC CREA




                                                          T-CELL ACTIVATION INHIBITOR
PSORIASIS BIOLOGICALS    MC      ENBREL 25 MG1                              MC           AMEVIVE2                           1. Will not require a PA if Approved for severe chronic plaque psoriasis unresponsive to first line therapies. A trial of at least several potent topicals from the following categories: corticosteroids, coal tars,
                         MC               1                                 MC                                             at least one systemic drug anthralin, calcipotriene and tazorotene, and at least one systemic drug such as methotrexate, cyclosporine, methoxsalen or acitretin and phototherapy/UVA.
                                 HUMIRA                                                  ENBREL 50 MG3
                                                                                                                           such as methotrexate,
                                                                                                                           cyclosporine, methoxsalen
                                                                                                                           or 40 of 51
                                                                                                                        Pageacitretin is in members
                                                                                                                      1. Will not require a PA if Approved for severe chronic plaque psoriasis unresponsive to first line therapies. A trial of at least several potent topicals from the following categories: corticosteroids, coal tars,
                                                                                                                     at least one systemic drug anthralin, calcipotriene and tazorotene, and at least one systemic drug such as methotrexate, cyclosporine, methoxsalen or acitretin and phototherapy/UVA.
                                                                                                                     such as methotrexate,
                                                                                                                     cyclosporine, methoxsalen
                                                                                                                     or acitretin is in members
                                                                                                                     drug profile. Please refer to
                                                                                                                     dose consolidation list.




                                                                                                                     2. Trial of both preferred
                                                                                                                     drugs are required.
                                                                                                                     3. Use multiple 25mg
                                                                                                                     injections.

                                                                                                                     Use PA Form # 20910
                                                                   ALTERNATIVE MEDICINES
ALTERNATIVE MEDICINES         MC      DIMETHYL SULFOXIDE SOLN                 MC/DEL       CO-ENZYME Q-10            Use PA Form# 20420             Will only be approved for specific conditions supported by at least two double-blinded, placebo-controlled randomized trials that are not contradicted by other studies of similar
                                                                                           GLUCOSAMINE                                              quality.

                                                                                MC         MELATONIN TABS
                                                                     CHELATING AGENTS
CHELATING AGENTS             MC/DEL   CUPRIMINE CAPS                            MC         DEPEN TITRATABS TABS      Use PA Form# 20420             1. FDA indication of treatment of chronic iron ovrload due to blood transfustions in membes 2 years of age and older is requried for approval of Exjade
                                                                              MC/DEL       EXJADE1
                                                                       ANTILEPROTIC
ANTILEPROTIC                                                                    MC         THALOMID CAPS1            1. All PA requests for    Approved for indications of leprosy, treatment-resistant multiple myeloma and AIDS.
                                                                                                                     150mg dosing will require
                                                                                                                     use of Thalomid 100mg and
                                                                                                                     50mg capsules.


                                                                                                                     Use PA Form# 20420
                                                                ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS -      MC/DEL   BICALUTAMIDE                            MC/DEL       CASODEX                   Use PA Form# 20420
ANTIADNDROGENS
ANTINEOPLASTIC AGENTS-        MC      LUPRON DEPOT1                                        VANTAS2                   1. Dosing limits apply,
LHRH ANALOGS                                                                                                         please refer to dosage
                                                                                                                     consolidation list.
                                                                                MC         FIRMAGON2                 2. PA required to confirm
                                                                              MC/DEL       TRELSTAR                  FDA approved indication.

                                                                                                                     Use PA Form# 20420
ANTINEOPLASTIC AGENTS -       MC      GLEEVEC                                   MC         SPRYCEL1                  Use PA Form# 20420
TYROSINE KINASE INHIBITORS                                                    MC/DEL                                 1. Verification of diagnosis
                                                                                           TYKERB2
                                                                                                                     and prior trial of at least
                                                                                                                     Gleevec is required.


                                                                                                                     2. PA required to confirm
                                                                                                                     FDA approved indication
                                                                                                                     and to monitor for potential
                                                                                                                     drug-drug interactions.


ANTINEOPLASTICS-             MC/DEL   MERCAPTOPURINE                          MC/DEL       ZOLINZA                   Use PA Form# 20420
MISCELLANEOUS                                                                 MC/DEL       PURINETHOL
ANTINEOPLASTICS-                                                              MC/DEL       HERCEPTIN1                1. PA required to confirm
MONOCLONAL ANTIBODIES                                                                                                FDA approved indication.

                                                                                                                     Use PA Form# 20420
                                                                          CANCER
CANCER                        MC      ALIMTA                                    MC         NEXAVAR1                  1. PA required to confirm
                             MC/DEL   AVASTIN                                 MC/DEL       SUTENT1,2                 FDA approved indication

                              MC      ERBITUX                                                                        2. Avoid CYP3AY drug
                                                                                                                     drug interaction.
                                      VIDAZA                                                                         Use PA Form# 20420
                             MC/DEL
                                                                   IMMUNOSUPPRESSANTS
IMMUNOSUPPRESSANTS           MC/DEL   CYCLOSPORINE MODIFIED                   MC/DEL       CELLCEPT                  1. Established users will      Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                             MC/DEL   CYCLOSPORINE SOL. MODIFIED              MC/DEL       CYCLOSPORINE CAPS         require a one time PA.         offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                    drug and the preferred drug(s) exists.
                              MC      GENGRAF CAPS                            MC/DEL       NEORAL1,2                 2. Established users will
                             MC/DEL   MYCOPHENOLATE                                                                  require a one time PA
                             MC/DEL   MYFORTIC                                                                       Use PA Form# 20420             DDI: Cyclosporine will now be non-preferred and require prior authorization if it is currently being used in combination with either Lipitor (doses greater than 20mg/day), Crestor, or
                              MC      PROGRAF CAPS                                                                                                  lovastatin (doses greater than 20mg).
                             MC/DEL   RAPAMUNE
                             MC/DEL   SANDIMMUNE                                                                                                    DDI: All preferred immunosuppressants will require clinical PA for patients over 60 that are currently on fluoroquinolone therapy.

                                                                      PURINE ANALOG
PURINE ANALOG                 MC      AZASAN TABS                             MC/DEL       IMURAN TABS               Use PA Form# 20420             Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                                                                                                                                                    offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                    drug and the preferred drug(s) exists.
                                                                                                                  Page 41 of 51
                                                                                                                                                                                               Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
                              MC/DEL                AZATHIOPRINE TABS                                                                                                                          offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another
                                                                                                                                                                                               drug and the preferred drug(s) exists.

                                                                                     K REMOVING RESINS
K REMOVING RESINS             MC/DEL                KAYEXALATE POWD                                                                                                    Use PA Form# 20420
                                 MC                 KIONEX POWD
                              MC/DEL                SODIUM POLYSTYRENE SULFON
                              MC/DEL                SPS SUSP
                              MC/DEL                SPS 30GM/120ML ENEMA SUSP


New drugs are initially non-preferred until reviewed by the DUR Committee and the State. According to State policy, any drug requiring specific diagnosis still requires the specific diagnosis unless otherwise noted within this document.
                                                                                                                                                                       Revised Jan. 1, 2006




     ANTI-CONVULSANTS INDICATION CHART
                                     POST             DIABETIC
                                   HERPETIC         PERIPHERAL      MONOTHERAPY          ADJUNCTIVE         MIGRAINE
                     SEIZURES      NEURALGIA        NEUROPATHY        BIPOLAR             BIPOLAR         PROPHYLAXIS       FIBROMYALGIA

     GABITRIL            X                                                  9                  8

    LAMICTAL             X                                                  4                  4

      LYRICA             X            X(2nd line)    X(2nd line)                                                               X(2nd line)

    TOPAMAX              X                                                  9                  6           X (2nd line)

    TRILEPTAL            X                                                  5                  5



           PEDIATRIC ANTI-CONVULSANTS INDICATION CHART
                                                       SEIZURES MONOTHERAPY BIPOLAR                ADJUNCTIVE BIPOLAR

                       LITHIUM                                                   1                           1
                   CARBMAZEPINE                            X                     1                           1
                     VALPROATE                             X                     1                           1
  ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE                   X                     1                           1
                      LAMICTAL                             X                     1                           1
                     TRILEPTAL
                                                           X                     5                           5
                     CLOZAPINE                             X                     6                           6




                                                                                                                                                                   Page 42 of 51
Last update 1/10                        PDL DOSAGE CONSOLIDATION LIST
Tabs/Caps/Patches: Quantities in units                               Shaded areas are non-preferred agents - Quantities of these
Sprays/Inhalers/Nebulizers: Quantities in GM, ML, OR MCG             non-preferred agents are available up the limit only with
Injectibles: Quantities in ML                                         prior authorization
      Drug Name                 Strength   Limit/Day       Limit/Days            Drug Name             Strength      Limit/Day          Limit/Days
        ABILIFY                  5MG           0.5           18/35             ATROVENT HFA             17MCG       12 INHALATIONS       25.8/34
        ABILIFY                  10MG          0.5           18/35            ATROVENT 30ML             0.03%       12 SPRAYS             30/30
        ABILIFY                  15MG          0.5           18/35            ATROVENT 15ML             0.06%        16 SPRAYS            45/30
        ABILIFY                  20MG          0.5           18/35                AVANDIA                2MG              1.5             53/35
        ABILIFY                  30MG          0.5           18/35                AVANDIA                4MG               1              35/35
  ABILIFY SOLUTION              1MG/ML        30ML          1020/34                AVAPRO               75MG              1.5             53/35
       ACCUPRIL                  5MG            1            35/35                 AVAPRO               150MG              1              35/35
       ACCUPRIL                  10MG           1            35/35             AXERT (Step 8)          6.25MG                             12/30
       ACCUPRIL                  20MG           1            35/35             AXERT (Step 8)          12.5MG                             12/30
         ACEON                   2MG            1            35/35                 AZILECT          All Strengths          1              35/35
         ACEON                   4MG            1            35/35               AZMACORT              100MCG       16 INHALATIONS        40/30
       ACTONEL                   5MG            1            35/35              BECONASE AQ             42MCG        8 INHALATIONS        50/30
       ACTONEL                   35MG         1/WK           5/35                BENAZEPRIL              5MG               1              35/35
         ACTOS                   15MG           2            70/35               BENAZEPRIL             10MG              1.5             53/35
         ACTOS                   45MG           1            35/35               BENAZEPRIL             20MG               1              35/35
     ADDERALL XR           All Strengths        1            35/35             BENAZEP/HCTZ             5-6.25             1              35/35
       AEROBID                  250MCG     8 INHALATIONS     21/35             BENAZEP/HCTZ            10/12.5             1              35/35
      AEROBID-M                 250MCG     8 INHALATIONS     21/35                 BONIVA               2.5MG              1              35/35
 ALAVERT-NON DROW                 TAB           1            96/96                 BONIVA               150MG           1/MO              1/30
        ALDARA                    5%                         12/30            BOTOX (ADULTS)          100U/ML       1 session/90 days   600U/90
    ALENDRONATE            All Strengths      1/WK           35/35           BOTOX (CHILDREN>12)      100U/ML       1 session/90 days   400U/90
       ALTABAX                   5GM                       1 TUBE/30               BYETTA             5mcg inj         0.04ML           1.2ML/30
       ALTABAX                   10GM                      1 TUBE/30               BYETTA            10mcg inj         0.08ML           2.4ML/30
        ALTACE                  1.25MG          1            35/35                CALAN SR              120MG              1              35/35
        ALTACE                   2.5MG          1            35/35                CALAN SR              180MG              2              70/35
        ALTACE                   5MG            1            35/35                CALAN SR              240MG              2              70/35
        AMARYL                   1MG            1            35/35              CARDIZEM CD           120MG/24             1              35/35
        AMARYL                   2MG            1            35/35              CARDIZEM CD           180MG/24             1              35/35
        AMBIEN                   5MG                         12/34              CARDIZEM CD           240MG/24             1              35/35
        AMBIEN                   10MG                        12/34              CARDIZEM CD           300MG/24             1              35/35
      AMBIEN CR                 6.25MG                       12/34              CARDIZEM CD           360MG/24             1              35/35
      AMBIEN CR                 12.5MG                       12/34              CARDIZEM LA           120MG/24             1              35/35
   AMERGE (Step 8)               1MG                         12/30              CARDIZEM LA           180MG/24             1              35/35
   AMERGE (Step 8)               2.5MG       2.5MG           12/30              CARDIZEM LA           240MG/24             1              35/35
     AMLODIPINE                  2.5MG         1.5         53/35 DAYS           CARDIZEM LA           300MG/24             1              35/35
     AMLODIPINE                  5MG           1.5         53/35 DAYS           CARDIZEM LA           360MG/24             1              35/35
 AMPHETAMINE SALT           5,10,15MG           3           105/35                CARDURA                1MG               1              35/35
 AMPHETAMINE SALT                20MG           2            70/35                CARDURA                2MG              1.5             53/35
 AMPHETAMINE SALT                30MG           1            35/35                CARDURA                4MG              1.5             53/35
     ANDRODERM                   2.5MG          2            60/30                CARTIA XT             120MG              1              90/90
     ANDRODERM                   5MG            1            30/30                CARTIA XT             180MG              1              90/90
         ARAVA                   10MG           1            35/35                CARTIA XT             240MG              1              90/90
        ARICEPT                  5MG            1            35/35                CARTIA XT             300MG              1              90/90
        ARICEPT                  10MG           1            35/35             CATAPRES-TTS1        0.1 MG/24HR                           5/35
 ARIXTRA INJECTION        2.5MG/0.5ML                        7/30             CATAPRES- TTS2        0.2 MG/24HR                           5/35
 ARIXTRA INJECTION         5MG/0.4ML                         7/30             CATAPRES- TTS3        0.3 MG/24HR                           5/35
 ARIXTRA INJECTION        7.5MG/0.6ML                        7/30                 CELEBREX              100MG              1              35/35
 ARIXTRA INJECTION        10MG/0.8ML                         7/30                 CELEBREX              200MG              1              35/35
 ASMANEX 30 UNITS               220MCG     1 INHALATION     30U/30                 CELEXA               20mg              0.5             17/34
 ASMANEX 60 UNITS               220MCG     2 INHALATIONS    60U/30                 CELEXA               40mg               1              51/34
 ASMANEX 120 UNITS              220MCG     4 INHALATIONS    120U/30               CIPRO XR                                 3             105/35
       ATACAND                   4MG           1.5           53/35              CITALOPRAM              20MG              0.5             90/90
       ATACAND                   8MG           1.5           53/35              CITALOPRAM              40MG               1              90/90
       ATACAND                   16MG           1            35/35                CLARINEX            REDI TAB             1              35/35
        ATRIPLA                 600MG           1            35/35               CLEOCIN-T                           1 PACKAGE            1/30
     Drug Name             Strength         Limit/Day        Limit/Days      Drug Name           Strength       Limit/Day      Limit/Days
CLINDAMYCIN PHOSPHATE                       1 PACKAGE          1/30       DURAGESIC PATCHES    100MCG/HR                         22/33
    COMBIVENT            103-18MCG          12 INHALATIONS     30/35            EDEX           All Strengths                     1/30
     CONCERTA           All Strengths             1            35/35         EFFEXOR XR          37.5MG             1            35/35
   COPAXONE INJ              20MG                              1/32          EFFEXOR XR           75MG              1            35/35
   COPAXONE KIT           20MG/ML                              1/30            EMSAM           All Strengths        1            34/34
     COREG CR           All Strengths             1            34/34         ENALAPRIL             2.5              1            90/90
      COZAAR                 25MG                 4           140/35         ENALAPRIL             5MG             1.5          135/90
      CRESTOR                 5MG                 1            35/35         ENALAPRIL            10MG             1.5          135/90
      CRESTOR                10MG                 1            35/35       ENALAPR/HCTZ           5-12.5            1            90/90
      CRESTOR                20MG                 1            35/35           ENBREL           25MG/ML                          16/28
      CRESTOR                40MG                 1            35/35         ESTAZOLAM             1MG                           10/30
     CYMBALTA           All Strengths             1            35/35         ESTAZOLAM             2MG                           10/30
     DALMANE                 15MG                              10/30        ESTRING MIS            2MG                           1/90
     DALMANE                 30MG                              10/30         FELODIPINE           2.5MG             1            90/90
      DAYPRO                600MG                 2            70/35         FELODIPINE            5MG             1.5          135/90
     DAYTRANA           10mg/9hr (27.5mg)         1            34/34          FENTANYL         25MCG/HR                          11/33
     DAYTRANA           15mg/9hr (41.3mg)         1            34/34          FENTANYL         50MCG/HR                          11/33
     DAYTRANA           20mg/9hr (55.0mg)         1            34/34          FENTANYL         75MCG/HR                          11/33
     DAYTRANA           30mg/9hr (82.5mg)         1            34/34          FENTANYL         100MCG/HR                         22/33
       DDAVP                  5ML                              15/34        FINASTERIDE            5MG              1            90/90
   DEPO-PROVERA          150MG/ML                              1/90           FLONASE            50MCG          4 SPRAYS         32/34
   DEPO-PROVERA          400MG/ML                             2.5/90      FLOVENT HFA 44MCG      44MCG         4 INHALATIONS    10.6/30
DEPO-TESTOSTERONE        200MG/ML                              20/90      FLOVENT HFA 110MCG     110MCG        4 INHALATIONS     12/30
   DESMOPRESSIN             0.1MG                12           420/35      FLOVENT HFA 220MCG     220MCG        8 INHALATIONS     24/30
   DESMOPRESSIN             0.2MG                 6           210/35        FLUCONAZOLE          150MG                            1/7
     DETROL LA                2MG                 1            35/35      FLUNISOLIDE SOLN       0.025%        16 SPRAYS         75/30
     DEXEDRINE          All Strengths             3            90/30         FLUOXETINE           20MG              4           140/35
DEXTROAMPHETAMINE All Strengths                   3            90/30        FLURAZEPAM            15MG                           10/30
     DIFLUCAN               150MG                               1/7         FLURAZEPAM            30MG                           10/30
    DILACOR XR           240MG/24                 1            35/35      FLUTICASONE SPR                       4 SPRAYS         32/34
    DILACOR XR           120MG/24                 1            35/35        FLUVOXAMINE           25MG              1            90/90
    DILACOR XR           180MG/24                 1            35/35        FLUVOXAMINE           50MG              1            90/90
     DILTIA - XT         120MG/24                 1            90/90          FOCALIN          All Strengths        3           105/35
     DILTIA - XT            180MG                 1            90/90         FOCALIN XR        All Strengths        1            35/35
     DILTIA - XT         240MG/24                 1            90/90          FOSAMAX              5MG              1            35/35
 DILTIAZEM CAP ER           120MG                 1            90/90          FOSAMAX             10MG              1            35/35
 DILTIAZEM CAP XR           120MG                 1            90/90          FOSAMAX             70MG            1/WK           5/35
  DILTIAZEM CAP          120MG/24                 1            90/90          FOSAMAX             40MG            2/WK           10/35
   DILTIAZEM CAP         180MG/24                 1            90/90         FOSINOPRIL           10MG             1.5          135/90
 DILTIAZEM CAP ER           240MG                 1            90/90         FOSINOPRIL           20MG              2           180/90
 DILTIAZEM CAP XR           240MG                 1            90/90        FRAGMIN INJ        10000U/ML           2ML           14/7
 DILTIAZEM XR CAP        240MG/24                 1            90/90        FRAGMIN INJ        2500U/.2ML         0.4ML         2.80/7
   DILTIAZEM CAP         240MG/24                 1            90/90        FRAGMIN INJ        25000U/ML          0.8ML          5.6/7
   DILTIAZEM CAP         300MG/24                 1            90/90        FRAGMIN INJ        5000U/.2ML         0.4ML         2.80/7
   DILTIAZEM CAP         360MG/24                 1            90/90        FRAGMIN INJ        7500U/.3ML         0.6ML          4.2/7
      DIOVAN                 80MG                 1            35/35      FROVA TAB (Step 8)      2.5MG                         12/30
   DIOVAN - HCT            80 - 12.5              1            35/35           FUZEON              KIT              1            1/30
    DITROPAN XL               5MG                 1            35/35         GABAPENTIN          300MG              3           270/90
    DITROPAN XL              10MG                 2            70/35         GABAPENTIN          600MG              3           270/90
       DORAL                7.5MG                              10/30           GEODON             20MG              2            70/35
       DORAL                 15MG                              10/30           GEODON             40MG              2            70/35
    DOXAZOSIN                 1MG                 1            90/90           GEODON             60MG              2            70/35
    DOXAZOSIN                 2MG                1.5          135/90           GEODON             80MG              2            70/35
    DOXAZOSIN                 4MG                1.5          135/90           GEODON              INJ              2            70/35
DURAGESIC PATCHES 12.5MCG/HR                                   11/33        GLIMEPIRIDE            1MG              1            90/90
DURAGESIC PATCHES        25MCG/HR                              11/33        GLIMEPIRIDE            2MG              1            90/90
DURAGESIC PATCHES        50MCG/HR                              11/33      GLUCOSE TES STRP                          12          420/35
DURAGESIC PATCHES        75MCG/HR                              11/33
   Drug Name         Strength      Limit/Day        Limit/Days           Drug Name            Strength       Limit/Day        Limit/Days
   GLYCOLAX*         255GM                          255GM/90
    HALCION         0.125MG                            10/35            LOVENOX INJ          100MG/ML             2          14 injections/7
    HALCION            0.25                            10/35            LOVENOX INJ         120MG/.8ML           1.6         14 injections/7
    HUMIRA         40mg/0.8ml                          4/28             LOVENOX INJ          150MG/ML             2          14 injections/7
     HYTRIN            1MG              1              35/35              LUNESTA               1MG                              12/34
     HYTRIN            5MG              1              35/35              LUNESTA               2MG                              12/34
     HYZAAR          50-12.5            1              35/35              LUNESTA               3MG                              12/34
     IMDUR            30MG             1.5             53/35         LUPRON DEPOT INJ         11.25MG            KIT             1/90
     IMDUR            60MG             1.5             53/35         LUPRON DEPOT INJ           22.5             KIT             1/90
    IMITREX           25MG                             12/30         LUPRON DEPOT INJ          30MG                              1/90
    IMITREX           50MG                             12/30         LUPRON DEPOT INJ          30MG              KIT             1/90
    IMITREX          100MG                             12/30               LYRICA            25,50,75MG           3             102/35
   IMITREX INJ      4MG/.5ML                        6 boxes/30             LYRICA           100,150,200MG         3             102/35
   IMITREX INJ      6MG/.5ML                        6 boxes/30             LYRICA            225,300MG            2              70/35
  IMITREX KIT       6MG/.5ML                           6/30                MAVIK                1MG               1              35/35
  IMITREX SPR          5MG                             12/30               MAVIK                2MG               1              35/35
  IMITREX SPR         20MG                             12/30           MAXAIR AUTO            200MCG        12 INHALATIONS       14/30
     INTAL           800MCG        8 INHALATIONS     28.4/34              MAXALT                5MG                              12/30
IPRATROPIUM 30ML      0.03%        12 SPRAYS           90/90              MAXALT               10MG                              12/30
IPRATROPIUM 15ML      0.06%        16 SPRAYS          135/90            MAXALT MLT              5MG                              12/30
   ISOPTIN SR        180MG              2              70/35            MAXALT MLT             10MG              0.4             12/30
   ISOPTIN SR        240MG              2              70/35          MEDROXYPR AC           150MG/ML                            1/90
ISOSORBIDE MONO       30MG             1.5            135/90            MELOXICAM              7.5MG              1              35/35
ISOSORBIDE MONO       60 MG            1.5            135/90            MELOXICAM              15MG               1              35/35
    JANUMET        All Strengths        2              70/35           METADATE ER            10,20MG             3              90/30
    JANUVIA        All Strengths        1              35/35          METFORMIN ER             500MG              4             360/90
    KAPIDEX        All Strengths        1              35/35             METHYLIN           All Strengths         3              90/30
  KETOPROFEN         100MG              2             180/90         METHYLPHENIDATE All Strengths                3              90/30
  KETOPROFEN         200MG              1              90/90           METROCREAM                           1 PACKAGE            1/30
   KETOROLAC          10MG             4.8             24/30             METROGEL                           1 PACKAGE            1/30
    LAMICTAL          25MG              6             210/35           METROLOTION                          1 PACKAGE            1/30
    LAMICTAL       25MG CHW             6             210/35         METRONIDAZOLE CREAM                    1 PACKAGE            1/30
    LAMICTAL         100MG              2              70/35         METRONIDAZOLE GEL                      1 PACKAGE            1/30
    LAMISIL          250MG              1              35/35         METRONIDAZOLE LOTION                   1 PACKAGE            1/30
  LAMOTRIGINE         25MG              6             540/90             MEVACOR               10MG              1.5             53/35
  LEFLUNOMIDE         10MG              1              90/90             MEVACOR               20MG              1.5             53/35
     LESCOL           20MG              1              35/35            MIACALCIN                              3.75ml         1 bottle/34
    LEVAQUIN         250MG              1              35/35             MICARDIS              40MG              1.5             53/35
    LEXAPRO            5MG             0.5             15/30              MIRALAX               255G            8.5G          1 bottle/30
    LEXAPRO           10MG             0.5             15/30              MIRALAX           17G/PACKET      0.5 packet 15 packets/30
    LEXAPRO           20MG              1              35/35           MIRTAZAPINE             15mg               1              53/35
    LIPITOR           10MG              1              35/35               MOBIC               7.5 MG             1              35/35
    LIPITOR           20MG              1              35/35               MOBIC               15MG               1              35/35
    LIPITOR           40MG             1.5             53/35             MOEXIPRIL               7.5             1.5            135/90
   LISINOPRIL         2.5MG             1              90/90             MONOPRIL              10MG              1.5             53/35
   LISINOPRIL          5MG              1              90/90             MONOPRIL              20MG               2              70/35
   LISINOPRIL         10MG             1.5            135/90            MUPIROCIN                                             1 TUBE/30
   LISINOPRIL         20MG             1.5            135/90           NABUMETONE              500MG              2             180/90
  LISINOP/HCTZ     10/12.5MG            1              90/90           NABUMETONE              750MG              2             180/90
    LOTENSIN           5MG              1              35/35          NASACORT AERS            55 MCG        4 SPRAYS           9.3/25
    LOTENSIN          10MG             1.5             35/35           NASACORT AQ             55MCG         4 SPRAYS            17/30
    LOTENSIN          20MG              1              53/35              NASAREL             0.025%        16 SPRAYS            75/35
 LOTENSIN - HCT      5 - 6.25           1              35/35              NASONEX              50MCG         4 SPRAYS            17/30
 LOTENSIN - HCT     10 - 12.5           1              35/35           NEUPOGEN INJ         300MCG/ML                            10/30
   LOVASTATIN         10MG             1.5            135/90           NEUPOGEN INJ         480MCG/1.6                           16/30
   LOVASTATIN         20MG             1.5            135/90           NEUPOGEN INJ         300MCG/.5ML                          5/30
  LOVENOX INJ      30MG/.3ML           0.6         14 injections/7
                                                                      * Available for once daily dosing to members under
  LOVENOX INJ      40MG/.4ML           0.8         14 injections/7
                                                                                       the age of 18 years
  LOVENOX INJ      60MG/.6ML           1.2         14 injections/7
  LOVENOX INJ      80MG/.8ML          1.6         14 injections/7
   Drug Name        Strength     Limit/Day         Limit/Days           Drug Name           Strength       Limit/Day      Limit/Days
  NEUPOGEN INJ     480MCG/.8ML                        8/30           PULMICORT FLEX       All Strengths 8 Inhalations        2/30
   NEURONTIN         300MG             3             105/35            QUINAPRIL              5MG              1            90/90
   NEURONTIN         600MG             3             105/35            QUINAPRIL             10MG              1            90/90
     NEXIUM           20MG             1              35/35            QUINAPRIL             20MG              1            90/90
     NEXIUM           40MG             2              70/35             QVAR AERS         All Strengths 8 Inhalations       14.6/25
  NIFEDIPINE CR       90MG             1              90/90         RANITIDINE SYRUP***    15MG/ML           20ML         700ML/35
  NIFEDIPINE ER       60MG             1              90/90              RELAFEN             500MG             2            70/35
  NIFEDIPINE ER       30MG             1              90/90              RELAFEN             750MG             2            70/35
  NIFEDIPINE ER       60MG             1              90/90              RELPAX           All Strengths                     12/30
  NIFEDIPINE ER       90MG             1              90/90             REMERON              15MG             1.5           53/35
NIFEDIPINE ER,CR      30MG             1              90/90              RELAFEN             750MG             2            70/35
    NORVASC          2.5MG            1.5         53/35 DAYS             RELPAX           All Strengths                     12/30
    NORVASC           5MG             1.5         53/35 DAYS            REMERON              15MG             1.5           53/35
   NUVARING                         1/MO              1/28             REMODULIN          All Strengths                   1 MDV/30
  OMEPRAZOLE          10MG             1                                RESTORIL             7.5MG                          10/30
  OMEPRAZOLE          20MG             2                                RESTORIL             15MG                           10/30
 ONDANSETRON*         4MG              3              90/30             RESTORIL             30MG                           10/30
 ONDANSETRON*         8MG             1.5             45/30              RETIN-A                            1 TUBE        1 TUBE/30
 ONDANSETRON*         24MG            0.5             15/30             REVLIMID          All Strengths        1            35/35
ONDANSETRON INJ*                                                         REZINE              10MG              3            90/30
  ORTHO-EVRA                                          3/28
    ORUVAIL          100MG             2              70/35          RHINOCORT AQ            32MCG         8 SPRAYS         18/30
    ORUVAIL          200MG             1              35/35           REFRESH PLUS                           15 ML        1 bottle/30
   OXAPROZIN         600MG             2             180/90           REFRESH PLUS                           30 ML        2 bottles/30
 OXYCODONE ER      10,20,40MG          2              70/35          REFRESH TEARS                           15 ML        1 bottle/30
 OXYCODONE ER         80MG             4             140/35          REFRESH TEARS                           30 ML        2 bottles/30
  OXYCONTIN**      10,20,40MG          2              70/35             RISPERDAL            0.5MG            1.5           53/35
  OXYCONTIN**         80MG             4             140/35             RISPERDAL           0.25MG            1.5           53/35
   PAROXETINE         10MG            1.5            135/90             RISPERDAL             1MG             1.5           53/35
   PAROXETINE         20MG             1              90/90             RISPERDAL             2MG             1.5           53/35
     PAXIL            10MG            1.5             53/35             RISPERDAL             3MG              2            70/35
     PAXIL            20MG             1              35/35             RISPERDAL             4MG              2            70/35
  PEGASYS KIT                         KIT             1/28            RISPERDAL INJ          25MG                            2/28
     PLAN B                                       2/15 or 4/30        RISPERDAL INJ           37.5                           2/28
    PLENDIL          2.5MG             1              35/35           RISPERDAL INJ          50MG                            2/28
    PLENDIL           5MG             1.5             53/35         RISPERDAL M-TAB          0.5MG            1.5           53/35
   PRAVACHOL          10MG             1              35/35         RISPERDAL M-TAB           1MG             1.5           53/35
   PRAVACHOL          20MG             1              35/35         RISPERDAL M-TAB           2MG              4            140/35
   PRAVACHOL          40MG             1              35/35          RISPERDAL SOL.         1MG/ML            8ML           280/35
   PRAVACHOL          80MG             1              35/35           RISPERIDONE            0.5MG            1.5           53/35
  PRAVASTATIN         10MG             1              35/35           RISPERIDONE           0.25MG            1.5           53/35
  PRAVASTATIN         20MG             1              35/35           RISPERIDONE             1MG             1.5           53/35
  PRAVASTATIN         40MG             2             180/90           RISPERIDONE             2MG             1.5           53/35
  PRAVASTATIN         80MG             1              35/35           RISPERIDONE             3MG              2            70/35
  PREVPAC MIS      500MG-30MG                         14/30           RISPERIDONE             4MG              2            70/35
  PRILOSEC OTC        20MG             2             168/84         RISPERIDONE SOL.        1MG/ML            8ML           280/35
    PRINIVIL         2.5MG             1              35/35         SEREVENT DISKUS          50MCG        2 INHALATIONS     60/30
    PRINIVIL          5MG              1              35/35             SEROQUEL            100MG                           45/30
    PRINIVIL          10MG            1.5             53/35           SEROQUEL XR            150MG             1            35/35
    PRINIVIL          20MG            1.5             53/35           SEROQUEL XR           200MG              1            35/35
    PRINZIDE         10-12.5           1              35/35           SEROQUEL XR           300MG              2            70/35
   PROAIR HFA        90mcg       12 INHALATIONS       17/35           SEROQUEL XR           400MG              2            70/35
   PROTONIX           20MG             2              70/35            SERTRALINE            25MG             0.5           18/35
   PROTONIX           40MG             2              70/35            SERTRALINE            50MG             0.5           18/35
   PROVENTIL         90MCG       12 INHALATIONS       34/34            SERTRALINE            100MG             3            105/35
 PROVENTIL HFA       90MCG       12 INHALATIONS       14/34           SIMVASTATIN             5MG              1            35/35
    PROZAC            10MG            1.5             53/35           SIMVASTATIN            10MG             1.5           53/35
   PULMICORT         200MCG      8 INHALATIONS        1/25            SIMVASTATIN            20MG             1.5           53/35
     Drug Name           Strength      Limit/Day        Limit/Days     SIMVASTATIN           40MG              1.5            53/35
   SIMVASTATIN            80MG               1            35/35          Drug Name          Strength       Limit/Day        Limit/Days
    SINGULAIR              4MG               1            35/35         VERELAN SR           120MG              1             35/35
    SINGULAIR              5MG               1            35/35         VERELAN SR           180MG              1             35/35
    SINGULAIR             10MG               1            35/35         VERELAN SR           240MG              2             70/35
      SONATA               5MG                            12/34          VERAMYST           27.5MCG         4 sprays          10/30
      SONATA              10MG                            12/34           VYVANSE            30MG               1             35/35
      SPIRIVA           HANDIHLR       1 INHALTION        30/30           VYVANSE            50MG               1             35/35
   SPORANOX SOL         10MG/ML         10ML/ML          300cc/30        VYVANSE             70MG               1             35/35
SPORANOX PULSEPAK        100MG                            30/30        XOPENEX HFA                        12 INHALATIONS   2 INHALERS/34
    SPORANOX             100MG                            30/30        XOPENEX NEB                           12CC             408/34
    STADOL INJ           1MG/ML                           9/35           ZALEPLON         All Strengths                       30/30
    STADOL INJ           2MG/ML                           9/35          ZESTORETIC          10-12.5             1             35/35
    STRATTERA          All Strengths         1            35/35           ZESTRIL            2.5MG              1             35/35
       SULAR              10MG              1.5           53/35           ZESTRIL             5MG               1             35/35
       SULAR              20MG               1            35/35           ZESTRIL            10MG              1.5            53/35
   SUMATRIPTAN         All Strengths                      12/30           ZESTRIL            20MG              1.5            53/35
    SYMBICORT          All Strengths   4 Inhalations     10.2/30           ZOCOR              5MG               1             35/35
    SYNVISC INJ          8MG/ML                           2/30             ZOCOR             10MG              1.5            53/35
     SYRINGES                               10          1000/100           ZOCOR             20MG              1.5            53/35
   TAMIFLU CAPS           75MG                            10/30            ZOCOR             40MG              1.5            53/35
   TAZTIA XT CAP        120MG/24             1            90/90           ZOFRAN*             4MG               3             90/30
   TAZTIA XT CAP        180MG/24             1            90/90           ZOFRAN*             8MG              1.5            45/30
   TAZTIA XT CAP        240MG/24             1            90/90           ZOFRAN*            24MG              0.5            15/30
   TAZTIA XT CAP        300MG/24             1            90/90           ZOFRAN*          4MG/5ML           15ML             450/30
   TAZTIA XT CAP        360MG/24             1            90/90         ZOFRAN INJ*
    TEMAZEPAM             7.5MG                           10/30            ZOLOFT            25MG              0.5            18/35
    TEMAZEPAM             15MG                            10/30            ZOLOFT            50MG              0.5            18/35
    TEMAZEPAM             30MG                            10/30            ZOLOFT            100MG              3             105/35
      TEQUIN             200MG               1            35/35          ZOLPIDEM             5MG                             30/30
    TERAZOSIN              1MG               1            90/90          ZOLPIDEM            10MG                             30/30
    TERAZOSIN              5MG               1            90/90        ZOMIG (Step 8)         5MG                             12/30
   TERBINAFINE           250MG               1            35/35           ZYPREXA            2.5MG             1.5            53/35
    TEST STRIPS        Blood Glucose        12           420/35           ZYPREXA             5MG               1             35/35
      TIAZAC            120MG/24             1            35/35           ZYPREXA            7.5MG              1              35/35
      TIAZAC            180MG/24             1            35/35           ZYPREXA            10MG               1             35/35
      TIAZAC            240MG/24             1            35/35           ZYPREXA            15MG               1             35/35
      TIAZAC            300MG/24             1            35/35           ZYPREXA            20MG               1             35/35
      TIAZAC            360MG/24             1            35/35        ZYPREXA ZYDIS          5MG               1             35/35
      TIAZAC            420MG/24             1            35/35        ZYPREXA ZYDIS         10MG               1             35/35
      TILADE             1.75MG        8 INHALATIONS     48.6/35       ZYPREXA ZYDIS         15MG               1             35/35
     TOPROL XL            25MG              1.5           53/35        ZYPREXA ZYDIS         20MG               1             35/35
     TOPROL XL            50MG              1.5           53/35
     TORADOL              10MG              4.8           24/30      *Cancer diagnosis with non-daily chemotherapy required
     TRAMADOL             50MG               8           720/90
  TRAMADOL/ APAP       37.5/325MG            8           720/90
    TRETINOIN                            1 TUBE         1 TUBE/30    **Available without pa with CA and HO diag.
     TREXIMET            85/500             2.5           12/30
    TRIAZOLAM            0.125MG                          10/30
    TRIAZOLAM            0.25MG                           10/30      *** Ranitidine syrup available without PA to users less than
      ULTRAM              50MG               8           280/35      6 years old.
     UNIVASC              7.5MG             1.5         53/35 DAYS   MDV=Multidose Vial
     VASERETIC          5-12.5MG             1            35/35
     VASOTEC              2.5MG              1            35/35
     VASOTEC               5MG              1.5           53/35
     VASOTEC              10MG              1.5           53/35
   VENTOLIN HFA          90MCG         12 INHALATIONS     36/35
 VERAPAMIL ER, SR        120MG               1            90/90
VERAPAMIL ER, CR, SR     180MG               2            90/90
VERAPAMIL ER, CR, SR     240MG               2            90/90
VERELAN   180MG   1   35/35
     CELEXA/CITALOPRAM SPLITTING TABLE
    The most cost effective way to utilize Celexa/citalopram
NON PREFERRED: PA                        DESIRED          PREFERRED: NO PA                savings per 30
     NEEDED                               DOSE           Required (splitting tabs)          day supply
                                                                                  COST/
 10MG      20MG   40MG COST/DAY           MG/DAY        10MG     20MG    40MG      DAY
   30                       $1.50          10mg                   15              $0.75        $22.50
            30              $1.50          20mg                            15     $0.75        $22.50
            45              $3.00          30mg                   15       15     $1.50        $45.00
                   30       $1.50          40mg                            30     $1.50         N/A
* Citalopram requires splitting of 20mg and/or 40mg scored tabs to avoid PA. Celexa is non-preferred but still
requires splitting with a PA.
* At present these represent the most commonly written scripts. The shaded areas require no changes since
they do not offer savings opportunities. Celexa is flat priced across all strengths. They are scored and easily
split. The unshaded rows on the left side all have less expensive ways of being written involving splitting of the
* Max daily dose of Celexa / citalopram is 40mg. Clinical studies of effectiveness did not demonstrate an
advantage for the 60mg/day dose over the 40mg/day dose. There is an increased risk of side effects at doses
greater than 40mg/day. (Celexa® Package Insert 2005 Forest Laboratories, Inc.)




                LEXAPRO SPLITTING TABLE
              The most cost effective way to utilize Lexapro
NON PREFERRED: PA                        DESIRED          PREFERRED: NO PA                savings per 30
     NEEDED                               DOSE           Required (splitting tabs)          day supply
                                                                                  COST/
  5MG      10MG   20MG COST/DAY           MG/DAY         5MG     10MG    20MG      DAY
 15 tabs                                  2.5MG        15 tabs
           15               $0.75          5MG                    15              $0.75         N/A
           30               $1.50         10MG                             15     $0.75        $22.50
           45               $2.25         15MG                    15       15     $1.50        $22.50
           30               $1.50         20MG                             30     $1.50         N/A
* Lexapro requires splitting of 5mg, 10mg and/or 20mg scored tabs to avoid PA.
* At present these represent the most commonly written scripts. The shaded areas require no changes since
they do not offer savings opportunities. Lexapro is flat priced across all strengths. They are scored and easily
split. The unshaded rows on the left side all have less expensive ways of being written involving splitting of the
* Max daily dose of Lexapro is 20mg.




        ZOLOFT/ SERTRALINE SPLITTING TABLE
        The most cost effective way to utilize Zoloft/Sertraline
NON PREFERRED: PA                        DESIRED          PREFERRED: NO PA                 savings per
     NEEDED                               DOSE           Required (splitting tabs)        30 day supply
                                                                                  COST/
 25MG     50MG 100MG COST/DAY             MG/DAY        25MG     50MG   100MG      DAY
15 tabs                     $1.00         12.5mg       15 tabs                    $1.00         N/A
  30                        $2.00           25*                   15              $1.00        $30.00
  45                        $3.00          37.5           15      15              $2.00        $30.00
           30               $2.00           50*                            15     $1.00        $30.00
           45               $3.00            75                   15       15     $2.00        $30.00
                   30       $2.00          100*                            30     $2.00         N/A
   30              30       $4.00           125                   15       30     $3.00        $30.00
           30      30       $4.00          150*                            45     $3.00        $30.00
   30      30      30       $6.00           175                   15       45     $4.00        $60.00
                   60       $4.00          200*                            60     $4.00         N/A
   30              60       $6.00           225                   15       60     $5.00        $30.00
           30      60       $6.00          250*                            75     $5.00        $30.00
   30      30      60       $8.00           275                   15       75     $6.00        $60.00
                   90       $6.00          300*                            90     $6.00         N/A
* Sertraline requires splitting of scored tabs to avoid PA. Zoloft is non-preferred but still requires splitting with a PA.
* At present these represent the most commonly written scripts. The shaded areas require no changes since they do not offer
savings opportunities. Zoloft is flat priced across all strengths. They are scored and easily split. The unshaded rows on the left
side all have less expensive ways of being written involving splitting of the Zoloft scored tabs.




           ABILIFY SPLITTING TABLE
    The most cost effective way to utilize Abilify

      NON PREFERRED: PA NEEDED
                                                                    DESIRED          PREFERRED: NO PA Required
                                                                     DOSE                             (splitting tabs)
  2MG      5MG     10MG      15MG          20MG          30MG         MG/DAY          2MG      5MG      10MG    15MG 20MG      30MG
   30                                                                    2.5                    15
            30                                                            5                              15
                    30                                                   10                                               15
                               30                                        15                                                     15
                                             30                          20
                                                          30             30

								
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