Preferred Drug List
 Medicaid
21NVMDCD11268
Medicaid Preferred Drug List
Introduction
Pharmacy services are included in the Health Plan of Nevada Medicaid benefit package. Health
Plan of Nevada Medicaid may design its own pharmacy formulary based on clinical guidelines.
Medications not covered in Health Plan of Nevada’s Medicaid formulary must be available through
a non-formulary request process based on physician certification and justification of medical
necessity.
As a member of Health Plan of Nevada (HPN), you have access to a wide range of effective and
affordable medications. HPN utilizes a Preferred Drug List (PDL) as a tool to guide providers to
prescribe clinically sound yet cost-effective drugs. This list was established to give you access to
the prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost is lower
when you use preferred medications. Please refer to your plan documents for specific pharmacy
benefit information.
The PDL is a list of FDA-approved generic and brand name medications recommended for use by
HPN. The list is developed and maintained by a Pharmacy and Therapeutics (P&T) Committee
comprised of actively practicing primary care and specialty physicians, pharmacists and other
healthcare professionals. Patient needs, scientific data, drug effectiveness, availability of drug
alternatives currently on the PDL and cost are all considerations in selecting "preferred"
medications. Due to the number of drugs on the market and the continuous introduction of new
drugs, the PDL is a dynamic and routinely updated document screened regularly to ensure that it
remains a clinically sound tool for our providers.
Reading the Preferred Drug List
For your convenience, medications are grouped together based on their therapeutic category (i.e.,
Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e., Antidepressants,
Contraceptives, etc.). Each drug class has a designated section number (i.e., 1-A, 1-B, etc.) and is
the reference point noted in the index.
The generic or chemical name is listed to the left of the brand or trade name for each drug. Drugs
with a generic equivalent available are identified by an asterisk (*) before the common brand name
of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicates that
PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy). Drugs
that are not available generically have the brand-name listed in BOLD print (for example, the
listing for rivaroxaban.....XARELTO, indicates that there is no generic for XARELTO and the
brand name product will be dispensed).
Other abbreviations used throughout the PDL are:







AL
= age limitations
M
= mail-order/maintenance drug
NTI
= narrow therapeutic index
(generic not required)
i
PA
QL
SIO
ST
= prior authorization
= quantity limitations
= self-injectable/orphan drug
= step therapy
The amount of your copayment for a preferred prescription drug will vary, depending upon whether
you select a generic drug, a brand name drug or a brand name when a generic is available.
Certain medications may have quantity, age or therapeutic supply limitations based on FDA
approved dosages, literature documentation or P&T Committee decisions. See your plan
documents for a complete list of covered benefits, limitations and exclusions.
Mandatory Generic Substitution Policy
Most of our prescription drug plans include a mandatory generic requirement, therefore, if a
preferred brand name drug is dispensed when a preferred generic equivalent is available, you will
be required to pay the difference between the contracted cost of the generic and brand name drug in
addition to the preferred generic (tier 1) copayment. Please note that not all dosage forms or
strengths may be available in a generic form. The asterisk (*) indicates that at least one form or
strength of the drug is available as a generic at the time of printing. Check with your pharmacist
for more information.
Pharmacy Exceptions
The Medical Necessity/Exceptions Policy allows members and practitioners to request, on the basis
of medical necessity, that Health Plan of Nevada cover a certain pharmaceutical not on the current
Preferred Drug List. This Policy is applicable to members with a closed or 2-tier prescription drug
benefit where no coverage for non-preferred drugs is available. It is anticipated that such
exceptions will be rare and that preferred medications will be appropriate to treat the vast majority
of medical conditions.
Requests for medical necessity or exceptions may be submitted by members, pharmacists or
providers; however, the prescribing practitioner must provide the appropriate information to support
the request on the basis of medical necessity. Pharmacy Services uses pharmacists, practitioners of
appropriate specialists and/or medical guidelines to review exception requests. Each request is
evaluated on an individual basis to determine if the patient meets criteria based on current medical
literature, drug information, opinion or medical professionals and patient specific information.
Exception requests are processed within 24 hours of receipt of all necessary clinical information,
with exception of weekend and holidays. The member and the prescribing practitioner are notified
of the decision by fax, phone or letter. If the exception request is denied, the practitioner or the
member may choose to appeal through the HPN appeal process.
To request an exception, members should contact Member Services at (702) 242-7300 or (800) 7771840.
Since this list is to be used in the decision-making process and does not represent standards of care
for an individual, we encourage you to take this reference to all doctor appointments and verify that
the drug he/she prescribes is included on this list. You and your provider should discuss the best
possible treatment plan and medications to meet your needs. Because a drug is included on our
Preferred Drug List does not guarantee that the provider will prescribe that medication.
If you have any questions regarding HPN’s Preferred Drug List, please contact our Member
Services Department at (702) 242-7300 or (800) 777-1840. We are proud to be your healthcare
provider of choice. Working together, we can achieve our common goal – to keep you healthy!
ii
This summary is not an offer of coverage. If there are any differences between the information
contained within this document and a specific plan document, the plan documents will govern.
Participating pharmacies in our retail and/or mail-order network are independent contractors and
are neither employees nor agents of Health Plan of Nevada or its affiliates. This is not meant to
replace the advice of a healthcare provider. This is a proprietary document and may not be copied
or distributed without the express permission of Health Plan of Nevada.
iii
Medicaid Preferred Drug List
Introduction
Pharmacy services are included in the Health Plan of Nevada Medicaid benefit package. Health
Plan of Nevada Medicaid may design its own pharmacy formulary based on clinical guidelines.
Medications not covered in Health Plan of Nevada’s Medicaid formulary must be available through
a non-formulary request process based on physician certification and justification of medical
necessity.
As a member of Health Plan of Nevada (HPN), you have access to a wide range of effective and
affordable medications. HPN utilizes a Preferred Drug List (PDL) as a tool to guide providers to
prescribe clinically sound yet cost-effective drugs. This list was established to give you access to
the prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost is lower
when you use preferred medications. Please refer to your plan documents for specific pharmacy
benefit information.
The PDL is a list of FDA-approved generic and brand name medications recommended for use by
HPN. The list is developed and maintained by a Pharmacy and Therapeutics (P&T) Committee
comprised of actively practicing primary care and specialty physicians, pharmacists and other
healthcare professionals. Patient needs, scientific data, drug effectiveness, availability of drug
alternatives currently on the PDL and cost are all considerations in selecting "preferred"
medications. Due to the number of drugs on the market and the continuous introduction of new
drugs, the PDL is a dynamic and routinely updated document screened regularly to ensure that it
remains a clinically sound tool for our providers.
Reading the Preferred Drug List
For your convenience, medications are grouped together based on their therapeutic category (i.e.,
Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e., Antidepressants,
Contraceptives, etc.). Each drug class has a designated section number (i.e., 1-A, 1-B, etc.) and is
the reference point noted in the index.
The generic or chemical name is listed to the left of the brand or trade name for each drug. Drugs
with a generic equivalent available are identified by an asterisk (*) before the common brand name
of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicates that
PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy). Drugs
that are not available generically have the brand-name listed in BOLD print (for example, the
listing for rivaroxaban.....XARELTO, indicates that there is no generic for XARELTO and the
brand name product will be dispensed).
Other abbreviations used throughout the PDL are:







AL
= age limitations
M
= mail-order/maintenance drug
NTI
= narrow therapeutic index
(generic not required)
i
PA
QL
SIO
ST
= prior authorization
= quantity limitations
= self-injectable/orphan drug
= step therapy
The amount of your copayment for a preferred prescription drug will vary, depending upon whether
you select a generic drug, a brand name drug or a brand name when a generic is available.
Certain medications may have quantity, age or therapeutic supply limitations based on FDA
approved dosages, literature documentation or P&T Committee decisions. See your plan
documents for a complete list of covered benefits, limitations and exclusions.
Mandatory Generic Substitution Policy
Most of our prescription drug plans include a mandatory generic requirement, therefore, if a
preferred brand name drug is dispensed when a preferred generic equivalent is available, you will
be required to pay the difference between the contracted cost of the generic and brand name drug in
addition to the preferred generic (tier 1) copayment. Please note that not all dosage forms or
strengths may be available in a generic form. The asterisk (*) indicates that at least one form or
strength of the drug is available as a generic at the time of printing. Check with your pharmacist
for more information.
Pharmacy Exceptions
The Medical Necessity/Exceptions Policy allows members and practitioners to request, on the basis
of medical necessity, that Health Plan of Nevada cover a certain pharmaceutical not on the current
Preferred Drug List. This Policy is applicable to members with a closed or 2-tier prescription drug
benefit where no coverage for non-preferred drugs is available. It is anticipated that such
exceptions will be rare and that preferred medications will be appropriate to treat the vast majority
of medical conditions.
Requests for medical necessity or exceptions may be submitted by members, pharmacists or
providers; however, the prescribing practitioner must provide the appropriate information to support
the request on the basis of medical necessity. Pharmacy Services uses pharmacists, practitioners of
appropriate specialists and/or medical guidelines to review exception requests. Each request is
evaluated on an individual basis to determine if the patient meets criteria based on current medical
literature, drug information, opinion or medical professionals and patient specific information.
Exception requests are processed within 24 hours of receipt of all necessary clinical information,
with exception of weekend and holidays. The member and the prescribing practitioner are notified
of the decision by fax, phone or letter. If the exception request is denied, the practitioner or the
member may choose to appeal through the HPN appeal process.
To request an exception, members should contact Member Services at (702) 242-7300 or (800) 7771840.
Since this list is to be used in the decision-making process and does not represent standards of care
for an individual, we encourage you to take this reference to all doctor appointments and verify that
the drug he/she prescribes is included on this list. You and your provider should discuss the best
possible treatment plan and medications to meet your needs. Because a drug is included on our
Preferred Drug List does not guarantee that the provider will prescribe that medication.
If you have any questions regarding HPN’s Preferred Drug List, please contact our Member
Services Department at (702) 242-7300 or (800) 777-1840. We are proud to be your healthcare
provider of choice. Working together, we can achieve our common goal – to keep you healthy!
ii
This summary is not an offer of coverage. If there are any differences between the information
contained within this document and a specific plan document, the plan documents will govern.
Participating pharmacies in our retail and/or mail-order network are independent contractors and
are neither employees nor agents of Health Plan of Nevada or its affiliates. This is not meant to
replace the advice of a healthcare provider. This is a proprietary document and may not be copied
or distributed without the express permission of Health Plan of Nevada.
iii
MEDICAID Preferred Drug List
This Preferred Drug List is applicable to HPN
members with a Medicaid prescription drug program.
ANTI-INFECTIVES (drugs to treat infections)
1-A Penicillins
Generic Name
amoxicillin
amoxicillin-clavulanate
ampicillin
aztreonam
dicloxacillin
penicillin V potassium
1-B Cephalosporins
Generic Name
cefaclor ER
cefaclor
cefadroxil
cefdinir
cefdinir
cefdinir
cefpodoxime
cefprozil
cefprozil
cefprozil
cefprozil
cefuroxime
cefuroxime
cephalexin
1-C Macrolides
Generic Name
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
clarithromycin
clarithromycin
clarithromycin SR
clindamycin
erythromycin EC
erythromycin ethylsuccinate
Brand Name
*AMOXIL
*AUGMENTIN
*PRINCIPEN
CAYSTON
*DYNAPEN
*VEETIDS
Notes
QL (84 mls/42 days) PA
Brand Name
CECLOR CD
*CECLOR
*DURICEF
*OMNICEF (capsules)
Notes
QL (2 tabs/per day)
QL (2 caps/per day)
*OMNICEF (suspension) 125mg/5ml QL (24 ml/day)
*OMNICEF (suspension) 250mg/5ml QL (12 ml/day)
*VANTIN 200mg
QL (28 tablets/month)
*CEFZIL 250mg
QL (28 tablets/month)
*CEFZIL 500mg
QL (28 tablets/month)
*CEFZIL 125mg/ml
QL (140 mls/month)
*CEFZIL 250mg/ml
QL (140 mls/month)
*CEFTIN (suspension)
*CEFTIN (tablets)
QL (28 tablets/month)
*KEFLEX
Brand Name
*ZITHROMAX 250mg
*ZITHROMAX 500mg
*ZITHROMAX 600mg
*ZITHROMAX 100mg/5ml
*ZITHROMAX 200mg/5ml
*BIAXIN
*BIAXIN suspension
*BIAXIN XL
*CLEOCIN
ERY-TAB
*EES
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
1
Notes
QL (6 tablets/fill)
QL (4 tablets/fill)
QL (8 tablets/fill)
QL (30 mls/fill)
QL (30 mls/fill)
QL (28 tablets/month)
QL (28 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
1-D
1-E
1-F
1-G
1-H
erythromycin ethylsuccinate ERYPED
erythromycin stearate *ERYTHROCIN
ERYTHROMYCIN BASE
Tetracyclines
Generic Name Brand Name
doxycycline *VIBRAMYCIN
doxycycline hyclate *PERIOSTAT
doxycycline hyclate
minocycline *DYNACIN
minocycline *MINOCIN caps
tetracycline
Fluoroquinolones
Generic Name Brand Name
ciprofloxacin *CIPRO
ciprofloxacin SR *CIPRO XR
levofloxacin *LEVAQUIN
ofloxacin *FLOXIN
Antimycobacterial Agents
Generic Name Brand Name
ethambutol *MYAMBUTOL
isoniazid
pyrazinamide
rifampin *RIFADIN
Antifungals
Generic Name Brand Name
fluconazole *DIFLUCAN 50mg
fluconazole *DIFLUCAN 100mg
fluconazole *DIFLUCAN 150mg
fluconazole *DIFLUCAN 200mg
fluconazole *DIFLUCAN (suspension 10, 40mg)
griseofulvin microsize *GRIFULVIN V
griseofulvin ultramicrosize *GRIS-PEG
itraconazole *SPORANOX
ketoconazole *NIZORAL
nystatin BIO-STATIN
nystatin *MYCOSTATIN susp
nystatin *MYCOSTATIN tablets
terbinafine HCL *LAMISIL
voriconazole *VFEND 50mg
voriconazole *VFEND 200mg
Miscelleanous Antivirals
Generic Name Brand Name
acyclovir *ZOVIRAX
famciclovir *FAMVIR 125mg
famciclovir *FAMVIR 250mg
famciclovir *FAMVIR 500mg
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
2
Notes
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 capsules/month)
Notes
QL (60 tablets/month)
QL (14 tablets/month)
QL (14 tablets/month)
Notes
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (1 tablet/fill)
QL (30 tablets/month)
QL (14 capsules/fill)
QL (90 tablets/month)
QL (90 tablets/year)
QL (180 tablets/month)
QL (60 tablets/month)
Notes
QL (60 tablets/month)
QL (60 tablets/month)
QL (21 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
ribavirin
ribavirin
ribavirin
rimantadine
*COPEGUS tablets
*REBETOL capsules/tablets
*REBETOL solution
*FLUMADINE
QL (180 capsules/tabletsmonth) PA
QL (180 capsules/tabletsmonth) PA
QL (25ml's per day) PA
QL (14 pills/fill)
1-I Antiretrovirals
Generic Name Brand Name
abacavir sulfate ZIAGEN
abacavir sulfate-lamivudine EPZICOM
abacavir sulfate-lamivudine-zidovudine TRIZIVIR
atazanavir REYATAZ
darunavir PREZISTA
delavirdine RESCRIPTOR
didanosine
didanosine *VIDEX EC
didanosine VIDEX PEDIATRIC
dolutegravir TIVICAY
efavirenz SUSTIVA
efavirenz-emtricitabine-tenofovir df ATRIPLA
elvitegrav-cobicis-emtricitab-tenofov STRIBILD
Notes
ST
Stribild ST = requires failure/contraindication to Atripla and Isentress
emtricitabine EMTRIVA
emtricitabine-rilpivirine-tenofovir df COMPLERA
emtricitabine-tenofovir disoproxil fumarate TRUVADA
enfuvirtide FUZEON
etravirine INTELENCE
fosamprenavir LEXIVA
indinavir sulfate CRIXIVAN
lamivudine-zidovudine *COMBIVIR
lamivudine *EPIVIR
lamivudine
lopinavir-ritonavir KALETRA
maraviroc SELZENTRY
nelfinavir VIRACEPT
nevirapine *VIRAMUNE
nevirapine XR VIRAMUNE XR 100MG
nevirapine XR *VIRAMUNE XR 400MG
raltegravir ISENTRESS
rilpivirine EDURANT
ritonavir NORVIR
saquinavir INVIRASE
stavudine *ZERIT
tenofovir VIREAD
tipranavir APTIVUS
zidovudine *RETROVIR
1-J Antimalarials
Generic Name Brand Name
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
3
QL (30 capsules/month)
PA
PA
Notes
Medicaid Drug Benefit Guide 02/01/2015
chloroquine *ARALEN
hydroxychloroquine *PLAQUENIL
mefloquine *LARIAM
primaquine *PRIMAQUINE
pyrimethamine DARAPRIM
quinine sulfate
1-K Anthelmintics
Generic Name Brand Name
mebendazole *VERMOX
1-L Misc Anti-Infectives
Generic Name Brand Name
atovaquone susp *MEPRON
dapsone DAPSONE
dornase alfa PULMOZYME
EES-sulfisoxazole *PEDIAZOLE
iodoquinol YODOXIN
metronidazole *FLAGYL tablets
metronidazole *FLAGYL capsule
neomycin *MYCIFRADIN
SMZ-TMP *BACTRIM
SMZ-TMP *SEPTRA
sulfadiazine
tobramycin nebu soln 300mg/4ml BETHKIS
trimethoprim *TRIMPEX
Notes
Notes
PA
PA
CANCER and TRANSPLANT (drugs to treat cancers and prevent organ rejection)
2-A Antineoplastics (cancer drugs)
Generic Name Brand Name
altretamine HEXALEN
anastrozole *ARIMIDEX
bicalutamide *CASODEX
busulfan MYLERAN
chlorambucil LEUKERAN
cyclophosphamide CYTOXAN
estramustine EMCYT
etoposide *VEPESID
exemestane *AROMASIN
flutamide *EULEXIN
hydroxyurea *HYDREA
ibrutinib cap IMBRUVICA
letrozole *FEMARA
leucovorin calcium *WELLCOVORIN
lomustine *CEENU
megestrol *MEGACE
melphalan ALKERAN
mercaptopurine *PURINETHOL
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
Notes
QL (30 tablets/month)
QL (30 tablets/month)
PA
QL (30 tablets/month)
4
Medicaid Drug Benefit Guide 02/01/2015
mesna MESNEX
methotrexate
mitotane LYSODREN
procarbazine HCL MATULANE
tamoxifen *NOLVADEX
thioguanine THIOGUANINE
tretinoin *VESANOID
2-B Immunosuppressives
Generic Name Brand Name
azathioprine *IMURAN
cyclosporine *SANDIMMUNE (NTI)
cyclosporine modified *GENGRAF
cyclosporine modified *NEORAL (NTI)
mycophenolate mofetil *CELLCEPT
sirolimus *RAPAMUNE
tacrolimus *PROGRAF
PA
Notes
CARDIOVASCULAR (drugs to treat heart conditions)
3-A Cardiotonics
Generic Name Brand Name
digoxin *LANOXIN
Notes
Generic Name Brand Name
isosorbide dinitrate *ISORDIL
isosorbide mononitrate *IMDUR
nitroglycerin ointment NITROBID
nitroglycerin patch *MINITRAN
nitroglycerin patch *NITRO-DUR
nitroglycerin spray *NITROLINGUAL PUMPSPRAY
nitroquick *NITROSTAT
3-C Beta Blockers
Generic Name Brand Name
acebutolol *SECTRAL
atenolol *TENORMIN
betaxolol *KERLONE
bisoprolol *ZEBETA
carvedilol *COREG 3.125mg
carvedilol *COREG 6.25mg
carvedilol *COREG 12.5mg
carvedilol *COREG 25mg
labetalol *NORMODYNE
labetalol *TRANDATE
metoprolol *LOPRESSOR
metoprolol succinate SR *TOPROL XL
nadolol *CORGARD 20mg
nadolol *CORGARD 40mg
Notes
3-B Antianginals
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
5
QL (1 patch/day)
QL (1 patch/day)
QL (1 bottle/month)
Notes
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (120 tablets/month)
QL (45 tablets/month)
QL (90 tablets/month)
QL (60 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
nadolol *CORGARD 80mg
nebivolol BYSTOLIC 2.5mg
nebivolol BYSTOLIC 5mg
nebivolol BYSTOLIC 10mg
nebivolol BYSTOLIC 20mg
pindolol *VISKEN
propranolol *INDERAL
propranolol HCL CR *INDERAL LA
sotalol *BETAPACE
sotalol AF *BETAPACE AF
timolol maleate *BLOCADREN
3-D Calcium Channel Blockers
Generic Name Brand Name
amlodipine *NORVASC
cartia XT
diltiazem *CARDIZEM
diltiazem SR *TIAZAC
diltiazem SR 12HR *CARDIZEM SR
felodipine *PLENDIL
isradipine *DYNACIRC
nicardipine *CARDENE
nifedipine CR *ADALAT CC
nifedipine CR *PROCARDIA XL
nifedipine IR *ADALAT CC
nifedipine IR *PROCARDIA
verapamil *CALAN
verapamil SR *CALAN SR
verapamil SR *VERELAN PM
3-E Antiarrhythmics
Generic Name Brand Name
amiodarone *CORDARONE
disopyramide *NORPACE
flecainide *TAMBOCOR
mexiletine *MEXITIL
propafenone *RYTHMOL
quinidine gluconate
quinidine sulfate
quinidine sulfate er
3-F Angiotensin Converting Enzyme (ACE) Inhibitors
Generic Name Brand Name
benazepril *LOTENSIN
captopril *CAPOTEN
enalapril *VASOTEC
fosinopril *MONOPRIL
lisinopril *PRINIVIL
lisinopril *ZESTRIL
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
QL (90 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (120 tablets/month)
QL (60 tablets/month)
Notes
QL (60 capsules/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
Notes
Notes
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
6
Medicaid Drug Benefit Guide 02/01/2015
moexipril *UNIVASC
quinapril *ACCUPRIL
ramipril *ALTACE
trandolapril *MAVIK
3-G Angiotensin II Receptor Blockers (ARB's)
Generic Name Brand Name
irbesartan *AVAPRO
irbesartan-hct *AVALIDE
losartan *COZAAR 25mg
losartan *COZAAR 50mg
losartan *COZAAR 100mg
3-H Miscellaneous Antihypertensives
Generic Name Brand Name
bosentan TRACLEER
clonidine *CATAPRES
clonidine patch *CATAPRES-TTS
doxazosin *CARDURA
guanfacine *TENEX
hydralazine *APRESOLINE
macitentan tab OPSUMIT
methyldopa *ALDOMET
minoxidil *LONITEN
prazosin *MINIPRESS
riociguat tab ADEMPAS
terazosin *HYTRIN
3-I Antihypertensive Combinations
Generic Name Brand Name
amlodipine-benazepril *LOTREL
atenolol-chlorthalidone *TENORETIC
benazepril-HCTZ *LOTENSIN HCT
bisoprolol-HCTZ *ZIAC
captopril-HCTZ *CAPOZIDE
clonidine & chlorthalidone CLORPRES
enalapril-HCTZ *VASERETIC
fosinopril-HCTZ *MONOPRIL HCT
irbesartan-hctz AVALIDE
lisinopril-HCTZ *PRINZIDE
lisinopril-HCTZ *ZESTORETIC
losartan-HCTZ *HYZAAR
methyldopa-HCTZ *ALDORIL
metoprolol-hctz *LOPRESSOR-HCTZ
moexipril-HCTZ *UNIRETIC
nadolol-bendroflumethiazide *CORZIDE
propranolol-HCTZ *INDERIDE
quinapril-HCTZ *ACCURETIC
valsartan-HCTZ *DIOVAN-HCT 80-12.5mg & 160-12.5mg
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
7
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 capsules/month)
QL (60 tablets/month)
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
Notes
QL (60 tablets/month) PA
QL (8 patches/month)
QL (60 tablets/month)
PA
PA
QL (60 capsules/month)
Notes
QL (30 capsules/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
valsartan-HCTZ *DIOVAN-HCT 160-25mg, 320-12.5mg, & 320-25mg QL (30 tablets/month)
3-J Diuretics
Generic Name Brand Name
Notes
acetazolamide *DIAMOX
amiloride
amiloride-HCTZ *MODURETIC
bumetanide *BUMEX
chlorothiazide *DIURIL
chlorthalidone *HYGROTON
furosemide *LASIX
hydrochlorothiazide *HYDRODIURIL
hydrochlorothiazide *MICROZIDE
indapamide *LOZOL
methazolamide *NEPTAZANE
methyclothiazide *AQUATENSEN
metolazone *ZAROXOLYN
spironolactone *ALDACTONE
spironolactone-HCTZ *ALDACTAZIDE
torsemide *DEMADEX
triamterene-HCTZ *DYAZIDE
triamterene-HCTZ *MAXZIDE
3-K Pressors
Generic Name Brand Name
Notes
epinephrine inj EPIPEN
epinephrine inj EPIPEN JR
epinephrine inj TWINJECT
midodrine *PROAMATINE
3-L Antihyperlipidemics
Generic Name Brand Name
Notes
*LIPITOR
atorvastatin
QL (30 tablets/month)
cholestyramine *QUESTRAN
colestipol *COLESTID
ezetimibe-simvastatin VYTORIN
QL (30 tablets/month) ST
VYTORIN ST = requires failure of 30 days of simvastatin 80mg within the past 6 months
fenofibrate *LOFIBRA
QL (30 capsules/month)
fenofibrate *TRICOR
QL (30 tablets/month)
gemfibrozil *LOPID
lovastatin *MEVACOR 10mg
QL (30 tablets/month)
lovastatin *MEVACOR 20mg
QL (30 tablets/month)
lovastatin *MEVACOR 40mg
QL (60 tablets/month)
niacin tab cr *NIASPAN
pravastatin *PRAVACHOL
QL (30 tablets/month)
simvastatin *ZOCOR
QL (30 tablets/month)
3-M Miscellaneous Cardiovascular
Generic Name Brand Name
Notes
ranolazine RANEXA
QL (60 tablets/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
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Medicaid Drug Benefit Guide 02/01/2015
CENTRAL NERVOUS SYSTEM (drugs that affect the brain)
4-A Antianxiety Agents
Generic Name Brand Name
alprazolam *XANAX
alprazolam SR *XANAX XR 0.5mg
alprazolam SR *XANAX XR 1mg
alprazolam SR *XANAX XR 2mg
alprazolam SR *XANAX XR 3mg
buspirone *BUSPAR 7.5mg
buspirone *BUSPAR 5mg
buspirone *BUSPAR 10mg
buspirone *BUSPAR 15mg
buspirone *BUSPAR 30mg
chlordiazepoxide *LIBRIUM
clorazepate *TRANXENE
diazepam *VALIUM
hydroxyzine HCL *ATARAX
hydroxyzine pamoate *VISTARIL
lorazepam *ATIVAN
meprobamate
oxazepam *SERAX
4-B Antidepressants
Generic Name Brand Name
amitriptyline *ELAVIL
amoxapine *ASENDIN
bupropion *WELLBUTRIN 75mg
bupropion *WELLBUTRIN 100mg
bupropion SR *WELLBUTRIN SR 100mg
bupropion SR *WELLBUTRIN SR 150mg
bupropion SR *WELLBUTRIN SR 200mg
bupropion XL *WELLBUTRIN XL
citalopram *CELEXA
clomipramine *ANAFRANIL
desipramine *NORPRAMIN
doxepin *SINEQUAN
doxepin *LEXAPRO 5MG
escitalopram *LEXAPRO 10MG
escitalopram *LEXAPRO 20MG
fluoxetine *PROZAC 10mg
fluoxetine *PROZAC 20mg
fluoxetine *PROZAC 40mg
fluvoxamine *LUVOX
imipramine *TOFRANIL
maprotiline *LUDIOMIL
mirtazapine *REMERON
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
9
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (120 tablets/month)
Notes
QL (180 tablets/month)
QL (120 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (45 tablets/month)
QL (45 tablets/month)
QL (45 tablets/month)
QL (30 tablets/month)
QL (30 capsules/month)
QL (120 capsules/month)
QL (60 capsules/month)
QL (90 tablets/month)
QL (30 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
mirtazapine soltabs *REMERON SOLTABS
nefazodone HCL *SERZONE
nortriptyline *PAMELOR
paroxetine HCL *PAXIL 10mg
paroxetine HCL *PAXIL 20mg
paroxetine HCL *PAXIL 30mg
paroxetine HCL *PAXIL 40mg
phenelzine sulfate *NARDIL
protriptyline *VIVACTIL
sertraline HCL *ZOLOFT 25mg
sertraline HCL *ZOLOFT 50mg
sertraline HCL *ZOLOFT 100mg
trazodone *DESYREL
venlafaxine *EFFEXOR
venlafaxine SR *EFFEXOR XR (cap) 37.5mg
venlafaxine SR *EFFEXOR XR (cap) 75mg
venlafaxine SR *EFFEXOR XR (cap) 150mg
venlafaxine SR *VENLAFAXINE XR (tab) 37.5mg
venlafaxine SR *VENLAFAXINE XR (tab) 75mg
venlafaxine SR *VENLAFAXINE XR (tab) 150mg
venlafaxine SR *VENLAFAXINE XR (tab) 225mg
4-C Hypnotics (Sleep Aids)
Generic Name Brand Name
chloral hydrate SOMNOTE
estazolam *PROSOM
flurazepam *DALMANE
phenobarbital
temazepam *RESTORIL
triazolam *HALCION
zaleplon *SONATA 5mg
zaleplon *SONATA 10mg
zolpidem *AMBIEN
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (45 tablets/month)
QL (45 tablets/month)
QL (45 tablets/month)
QL (60 tablets/month)
QL (90 tablets/month)
QL (90 capsules/month)
QL (90 capsules/month)
QL (60 capsules/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
Notes
QL (30 capsules/month)
QL (15 tablets/fill; 2 fills/month)
QL (30 capsules/month)
QL (60 capsules/month)
QL (30 tablets/month)
4-D Antipsychotics
Generic Name Brand Name
Notes
aripiprazole IM inj ABILIFY
PA
aripiprazole IM extended release susp ABILIFY MAINTENA
PA
chlorpromazine *THORAZINE
clozapine *CLOZARIL (NTI)
ST
Clozaril ST = requires failure/contraindication to Risperidone and Seroquel AND supported diagnosis in
the past 2 years
fluphenazine *PROLIXIN
haloperidol *HALDOL
haloperidol decanoate IM soln *HALDOL IM
lithium carbonate *ESKALITH
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
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Medicaid Drug Benefit Guide 02/01/2015
lithium carbonate CR *ESKALITH CR
lithium carbonate CR *LITHOBID
loxapine *LOXITANE
olanzapine *ZYPREXA TABLETS
paliperidone palmitate INVEGA SUSTENNA
QL (1 syringe/month)
perphenazine *TRILAFONE
prochlorperazine *COMPAZINE
quetiapine fumarate *SEROQUEL 25mg
QL (90 tablets/month)
quetiapine fumarate *SEROQUEL 50mg
QL (30 tablets/month)
quetiapine fumarate *SEROQUEL 100mg
QL (90 tablets/month)
quetiapine fumarate *SEROQUEL 200mg
QL (120 tablets/month)
quetiapine fumarate *SEROQUEL 300mg
QL (90 tablets/month)
quetiapine fumarate *SEROQUEL 400mg
QL (60 tablets/month)
quetiapine fumarate SEROQUEL XR 50mg
QL (30 tablets/month)
quetiapine fumarate SEROQUEL XR 150mg
QL (30 tablets/month)
quetiapine fumarate SEROQUEL XR 200mg
QL (30 tablets/month)
quetiapine fumarate SEROQUEL XR 300mg
QL (60 tablets/month)
quetiapine fumarate SEROQUEL XR 400mg
QL (60 tablets/month)
risperidone *RISPERDAL
risperidone *RISPERDAL M
risperidone microspheres for inj RISPERDAL CONSTA
PA
risperidone soln 1mg/ml RISPERDAL SOLUTION
PA
thioridazine
thiothixene *NAVANE
trifluoperazine *STELAZINE
4-E Stimulants
Generic Name Brand Name
Notes
amphetamine-d-amphetamine *ADDERALL
amphetamine-d-amphetamine SR ADDERALL XR 5mg
QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 10mg
QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 15mg
QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 20mg
QL (60 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 25mg
QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 30mg
QL (30 capsules/month)
atomoxetine STRATTERA
QL (30 capsules/month) ST
Strattera ST = requires failure of at least one stimulant ADHD medication in the last 2 years
dexmethylphenidate *FOCALIN
QL (60 tablets/month)
dextroamphetamine *DEXEDRINE
dextroamphetamine *DEXEDRINE SPANSULES
lisdexamfetamine dimesylate VYVANSE
QL (30 capsules/month)
methamphetamine *DESOXYN
QL (150 tablets/month)
methylphenidate *METHYLIN (tablets) 5mg
QL (180 tablets/month)
methylphenidate *METHYLIN (tablets) 10mg
QL (180 tablets/month)
methylphenidate *METHYLIN (tablets) 20mg
QL (90 tablets/month)
methylphenidate *METHYLIN ER
QL (90 tablets/month)
methylphenidate *RITALIN 5mg
QL (180 tablets/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
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Medicaid Drug Benefit Guide 02/01/2015
methylphenidate *RITALIN 10mg
QL (180 tablets/month)
methylphenidate *RITALIN 20mg
QL (90 tablets/month)
methylphenidate CR *RITALIN SR
QL (90 tablets/month)
sodium oxybate XYREM
PA
4-F Misc Psychotherapeutic and Neurological Agents
Generic Name Brand Name
Notes
amitriptyline-chlordiazepoxide *LIMBITROL
disulfiram *ANTABUSE
donepezil *ARICEPT
QL (30 tablets/month)
ergoloid mesylates *HYDERGINE
galantamine *RAZADYNE
QL (60 tablets/month)
galantamine *RAZADYNE ER
QL (30 capsules/month)
guanfacine INTUNIV
QL (30 tablets/month) ST
Intuniv ST = requires failure of at least one stimulant ADHD medication in the last 2 years
perphenazine-amitriptyline *ETRAFON
rivastigmine *EXELON
QL (60 capsules/month)
rivastigmine *EXELON PATCH
QL (30 patches/month)
4-G Anticonvulsants
Generic Name Brand Name
Notes
carbamazepine *TEGRETOL
carbamazepine SR *CARBATROL
carbamazepine SR *TEGRETOL XR
clonazepam *KLONOPIN
divalproex sodium EC *DEPAKOTE
divalproex sodium sprinkle *DEPAKOTE 125MG SPRINKLE
PA
ethosuximide *ZARONTIN
felbamate susp 600mg/5ml *FELBATOL SOLUTION
PA
gabapentin *GABARONE
gabapentin *NEURONTIN 100mg
QL (240 capsules/month)
gabapentin *NEURONTIN 300mg
QL (360 capsules/month)
gabapentin *NEURONTIN 400mg
QL (270 capsules/month)
gabapentin *NEURONTIN 600mg
QL (180 tablets/month)
gabapentin *NEURONTIN 800mg
QL (120 tablets/month)
lamotrigine *LAMICTAL
lamotrigine *LAMICTAL STARTER KIT
QL (1 kit/month)
lamotrigine dispersible chewable *LAMICTAL CHEWABLE
PA
levetiracetam *KEPPRA
levetiracetam SR *KEPPRA XR
oxcarbazepine *TRILEPTAL 150mg
QL (60 tablets/month)
oxcarbazepine *TRILEPTAL 300mg
QL (90 tablets/month)
oxcarbazepine *TRILEPTAL 600mg
QL (120 tablets/month)
phenytoin *DILANTIN
primidone *MYSOLINE
topiramate *TOPAMAX 25mg
QL (120 tablets/month)
topiramate *TOPAMAX 50mg, 100mg, 200mg QL (90 tablets/month)
topiramate *TOPAMAX SPRINKLES
QL (120 capsules/month) PA
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
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Medicaid Drug Benefit Guide 02/01/2015
valproic acid
zonisamide
zonisamide
zonisamide
4-H Antiparkinsonian Agents
Generic Name
*DEPAKENE
*ZONEGRAN 25mg
*ZONEGRAN 50mg
*ZONEGRAN 100mg
Brand Name
AMANTADINE (Symmetrel)
apomorphine APOKYN
benztropine *COGENTIN
bromocriptine (tablets) *PARLODEL
carbidopa-levodopa *SINEMET
carbidopa-levodopa *PARCOPA
carbidopa-levodopa CR *SINEMET CR
entacapone *COMTAN
pramipexole *MIRAPEX
ropinirole *REQUIP
trihexyphenidyl *ARTANE
*SELEGILINE
4-I Smoking Deterrents
bupropion SR *ZYBAN
nicotine inhalation NICOTROL INHALER
nicotine nasal spray NICOTROL NS
varenicline CHANTIX
QL (120 capsules/month)
QL (120 capsules/month)
QL (180 capsules/month)
Notes
QL (240 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
PA QL (60 tablets/month)
PA QL (1 unit per 30 days)
PA QL (1 unit per 30 days)
PA QL (60 tablets/month)
DERMATOLOGICALS (drugs to treat skin disorders or conditions)
5-A Anorectal
Generic Name Brand Name
hydrocortisone rectal *ANUSOL-HC
hydrocortisone-pramoxine rectal *ANALPRAM-HC
hydrocortisone-pramoxine rectal PROCTOFOAM-HC
5-B Acne Products
Generic Name Brand Name
benzoyl peroxide *BREVOXYL
benzoyl peroxide-erythromycin gel *BENZAMYCIN
brimonidine tartrate gel 0.33% MIRVASO
clindamycin phosphate-benzoyl peroxide gel *BENZACLIN
clindamycin topical *CLEOCIN-T
erythromycin topical *ERYGEL
metronidazole cream *METROCREAM
metronidazole cream NORITATE**
metronidazole 0.75% gel
metronidazole 1% gel *METROGEL
metronidazole lotion *METROLOTION
sulfacetamide lotion (acne) *KLARON
tretinoin *RETIN-A **
tretinoin RETIN-A MICRO **
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
13
Notes
Notes
QL (60 gm/month)
PA
QL (50 gm/month)
QL (45gm/month)
QL (60 gm/month)
QL (45gm/month)
QL (60 gm/month)
AL
AL
Medicaid Drug Benefit Guide 02/01/2015
** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply
5-C Topical Antibiotics
Generic Name Brand Name
Notes
bac-polymy-neomycin HC oint CORTISPORIN OINTMENT
gentamicin topical *GARAMYCIN
mupirocin *BACTROBAN
mupirocin *BACTROBAN CREAM
mupirocin BACTROBAN NASAL OINTMENT
neomycin-polymyxin-HC cream CORTISPORIN CREAM
silver sulfadiazine *SILVADENE
5-D Topical Antifungals
Generic Name Brand Name
Notes
ciclopirox *LOPROX
ciclopirox solution *PENLAC
QL (7 ml/month)
clotrimazole *LOTRIMIN
clotrimazole-betamethasone *LOTRISONE
QL (30 ml/month)
econazole *SPECTAZOLE
ketoconazole shampoo *NIZORAL SHAMPOO
ketoconazole topical
nystatin topical *MYCOSTATIN topical
5-E Topical Antivirals
Generic Name Brand Name
Notes
acyclovir topical *ZOVIRAX topical
5-F Antipsoriatics
Generic Name Brand Name
Notes
anthralin *PSORIATEC
calcipotriene *DOVONEX
QL (1 tube/month)
** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply
5-G Scabicides and Pediculicides
Generic Name Brand Name
Notes
lindane shampoo *KWELL
permethrin *ELIMITE
5-H Topical Corticosteroids
Generic Name Brand Name
Notes
alclometasone *ACLOVATE
augmented betamethasone *DIPROLENE
augmented betamethasone *DIPROLENE AF
betamethasone dipropionate *DIPROSONE
betamethasone valerate *VALISONE
clobetasol foam *OLUX
clobetasol propionate *TEMOVATE
desoximetasone *TOPICORT
fluocinolone acetonide *SYNALAR
fluocinonide *LIDEX
fluticasone *CUTIVATE **
hydrocortisone butyrate *LOCOID
QL (45 gm/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
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Medicaid Drug Benefit Guide 02/01/2015
hydrocortisone topical *HYTONE
hydrocortisone valerate *WESTCORT
mometasone *ELOCON
pramoxine-HC cream *PRAMOSONE
pramoxine-HC foam EPIFOAM
prednicarbate *DERMATOP
sodium hyaluronate *HYLIRA
triamcinolone acetonide *KENALOG
** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply
5-I Miscellaneous Topicals
Generic Name Brand Name
Notes
aluminum chloride *DRYSOL
fluorouracil *EFUDEX
imiquimod *ALDARA
QL (12 packets/month)
lactic acid *LAC-HYDRIN
lidocaine (topical) *XYLOCAINE
lidocaine/hydrocortisone *ANAMANTLE
lidocaine-prilocaine *EMLA cream
QL (30 gm/month)
podofilox *CONDYLOX
selenium sulfide shampoo *SELSUN
tacrolimus oint PROTOPIC OINT
trypsin-castor oil-peruvian balsam *XENADERM
urea *KERALAC
urea *VANAMIDE
urea (carbamide) *CARMOL 40
ENDOCRINE AND HORMONES (drugs to treat metabolic or hormone conditions, ie diabetes)
6-A Corticosteroids
Generic Name Brand Name
cortisone acetate *CORTONE
dexamethasone *DECADRON
fludrocortisone *FLORINEF
hydrocortisone acetate *CORTEF
methylprednisolone *MEDROL
prednisolone *PRELONE
prednisolone PREDNISOLONE 5MG
prednisolone sodium *ORAPRED
prednisolone sodium *PEDIAPRED
prednisone
6-B Androgens
Generic Name Brand Name
danazol *DANOCRINE
6-C Estrogens
Generic Name Brand Name
esterified estrogens MENEST
estradiol *ESTRACE
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
15
Notes
Notes
Notes
Medicaid Drug Benefit Guide 02/01/2015
estradiol patch *CLIMARA
estradiol patch VIVELLE
estradiol patch VIVELLE DOT
estradiol TD gel DIVIGEL
estradiol-norgestimate PREFEST
estrogens, conjugated PREMARIN
estrogen-medroxyprogesterone PREMPHASE
estrogen-medroxyprogesterone PREMPRO
estrogens (conjugated synthetic) CENESTIN
estrogens (conjugated synthetic) ENJUVIA
estrogens-methyltestosterone *ESTRATEST
estrogens-methyltestosterone *ESTRATEST HS
estropipate *OGEN
6-D Contraceptives
Generic Name Brand Name
Apri, Solia, Reclipsen *ORTHO CEPT
Aviane, Lessina, Lutera, Sroynx *LEVLITE
balziva, zenchent, briellyn *OVCON-35
drospirenone-ethyinal YAZ
Enpresse, Trivora *TRI-LEVLEN
Errin, Camila, Nora-Be, Jolivette *ORTHO MICRONOR
June1, Microgestin, Gildess *LOESTRIN
Junel FE, Microgestin FE *LOESTRIN FE
Kariva *MIRCETTE
levonorgestrel & ethinyl estradiol (91-DAY) *SEASONALE
Levora, Portia *LEVLEN
Low-Ogestrel
Necon 10/11 *ORTHO NOVUM 10/11
norethindrone-eth estradiol *TRI-NORINYL
norgestrel & ethinyl estradiol *LO/OVRAL
norgestrel & ethinyl estradiol *OGESTREL
norelgestromin-ethinyl estradiol td ptwk *ORTHO EVRA
Nortrel 7/7/7, Necon 7/7/7 *ORTHO NOVUM 7/7/7
Nortrel, Necon *MODICON
Nortrel, Necon *ORTHO NOVUM 1/35
Nortrel, Necon *ORTHO NOVUM 1/50
Ogestrel
Sprintec, Mononessa, Previfem *ORTHO CYCLEN
Tilia FE, Tri-Legest FE *ESTROSTEP FE
Tri-sprintec, Trinessa, Tri-Previfem *ORTHO TRI-CYCLEN
NUVARING
ORTHO TRI-CYCLEN LO
YASMIN
6-E Progestins
Generic Name Brand Name
hydroxyprogesterone caproate IM in oil MAKENA
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
16
QL (4 patches/month)
QL (8 patches/month)
QL (8 patches/month)
QL (1 packet/day)
QL (30 tablets/month)
QL (1 dialpak/month)
QL (1 dialpak/month)
QL (30 tablets/month)
QL (30 tablets/month)
Notes
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/month)
QL (28 tablets/21 days)
QL (28 tablets/month)
QL (28 tablets/month)
QL (91 tablets/90 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/28 days)
QL ( 3 patches/90 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
QL (28 tablets/month)
QL (28 tablets/21 days)
QL (28 tablets/month)
QL (28 tablets/21 days)
QL (1 ring/month)
QL (28 tablets/21 days)
QL (28 tablets/21 days)
Notes
PA
Medicaid Drug Benefit Guide 02/01/2015
medroxyprogesterone acetate *DEPO-PROVERA
medroxyprogesterone *PROVERA
norethindrone *AYGESTIN
6-F Oral Antidiabetics (diabetes)
Generic Name Brand Name
acarbose *PRECOSE
chlorpropamide *DIABINESE
glimepiride *AMARYL
glipizide *GLUCOTROL 5mg
glipizide *GLUCOTROL 10mg
glipizide CR *GLUCOTROL XL 2.5mg
glipizide CR *GLUCOTROL XL 5mg
glipizide CR *GLUCOTROL XL 10mg
glipizide-metformin *METAGLIP
glyburide *DIABETA
glyburide micronized *GLYNASE
glyburide-metformin *GLUCOVANCE
metformin *GLUCOPHAGE 500mg
metformin *GLUCOPHAGE 850mg
metformin *GLUCOPHAGE 1000mg
metformin SR *GLUCOPHAGE XR 500mg
metformin SR *GLUCOPHAGE XR 750mg
nateglinide *STARLIX
piolitazone ACTOS
piolitazone-glimepiride *DUETACT
piolitazone-metformin ACTOPLUS MET
repaglinide *PRANDIN
repaglinide-metformin PRANDIMET
tolazamide *TOLINASE
tolbutamide *TOLBUTAMIDE
6-G Insulins
Generic Name Brand Name
insulin (human) NOVOLIN
insulin (human) HUMULIN
insulin (human) HUMULIN PEN
insulin aspart NOVOLOG
insulin aspart mix NOVOLOG MIX
insulin detemir LEVEMIR
insulin glargine LANTUS
insulin lispro HUMALOG
insulin lispro HUMALOG PEN
insulin lispro mix HUMALOG MIX
insulin lispro mix HUMALOG MIX PEN
6-H Glucagon
Generic Name Brand Name
GLUCAGON
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
17
QL (1ml/90 days)
Notes
QL (90 tablets/month)
QL (60 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (120 tablets/month)
QL (60 tablets/month)
QL (120 tablets/month)
QL (150 tablets/month)
QL (90 tablets/month)
QL (75 tablets/month)
QL (120 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (90 tablets/month)
QL (120 tablets/month)
Notes
Notes
QL (2 kits/month)
Medicaid Drug Benefit Guide 02/01/2015
6-I Thyroid Agents
Generic Name
levothroid
levothyroxine
levothyroxine
levoxyl
liothyronine
methimazole
methimazole
propylthiouracil
thyroid
unithroid
Brand Name
Notes
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
*SYNTHROID
*CYTOMEL
*TAPAZOLE
QL (90 tablets/month)
QL (90 tablets/month)
*PTU
NATURE-THROID
QL (60 tablets/month)
6-J Miscellaneous Endocrine
Generic Name Brand Name
Notes
alendronate * FOSAMAX 5mg
QL (30 tablets/month)
alendronate * FOSAMAX 10mg
QL (30 tablets/month)
alendronate * FOSAMAX 35mg
QL (4 tablets/month)
alendronate * FOSAMAX 40mg
QL (4 tablets/month)
alendronate * FOSAMAX 70mg
QL (4 tablets/month)
cabergoline *DOSTINEX
calcitonin *MIACALCIN
QL (1 bottle/month)
calcitonin (salmon) nasal *FORTICAL
QL (1 bottle/month)
calcitonin (salmon) nasal soln MIACALCIN
QL (2 bottles/month)
desmopressin (nasal) *DDAVP
desmopressin (oral) *DDAVP 0.1mg
QL (30 tablets/month)
desmopressin (oral) *DDAVP 0.2mg
QL (90 tablets/month)
etidronate *DIDRONEL
exenatide BYETTA
PA
levocarnitine *CARNITOR
liraglutide VICTOZA
PA
pramlintide SYMLIN AMYLIN ANALOG
ST
Symlin ST = requires concurrent mealtime insulin therapy (rapid or fast acting)
raloxifene *EVISTA
QL (30 tablets/month)
6-K Diabetic Supplies
Generic Name Brand Name
Notes
ACCU-CHEK ACTIVE CARE KIT
ACCU-CHEK ACTIVE TEST STRIPS
ACCU-CHEK ADVANTAGE CARE KIT
ACCU-CHEK AVIVA CARE KIT
ACCU-CHEK AVIVA TEST STRIPS
ACCU-CHEK COMFORT CURVE TEST STRIPS
ACCU-CHEK COMPACT CARE KIT
ACCU-CHEK COMPACT TEST STRIPS
ACCU-CHECK METER
ONE TOUCH PRODUCTS
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
18
Medicaid Drug Benefit Guide 02/01/2015
SMARTVIEW TEST STRIPS
GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)
7-A Laxatives
7-B
7-C
7-D
7-E
7-F
Generic Name Brand Name
lactulose
PEG electrolyte *COLYTE
PEG electrolyte GOLYTELY
peg(high)-electrolyte *NULYTELY
Antidiarrheals
Generic Name Brand Name
diphenoxylate-atropine *LOMOTIL
Miscelleanous Ulcer Drugs
Generic Name Brand Name
clidinium & chlordiazepoxide *LIBRAX
dicyclomine *BENTYL
glycopyrrolate *ROBINUL
glycopyrrolate *ROBINUL FORTE
hyoscyamine *LEVSIN
hyoscyamine *LEVBID
hyoscyamine *NULEV
misoprostol *CYTOTEC
phenobarbital-belladonna *DONNATAL
propantheline PRO-BANTHINE
sucralfate CARAFATE
H2 Blockers
Generic Name Brand Name
cimetidine *TAGAMET
famotidine *PEPCID
nizatadine *AXID
ranitidine *ZANTAC
Proton Pump Inhibitors (PPI)
Generic Name Brand Name
omeprazole *PRILOSEC 10mg capsules
omeprazole *PRILOSEC 20mg capsules
omeprazole *PRILOSEC 20mg tablets
omeprazole *PRILOSEC 40mg
pantoprazole *PROTONIX
Antiemetics
Generic Name Brand Name
meclizine *ANTIVERT
granisetron *KYTRIL
ondansetron *ZOFRAN 4mg
ondansetron *ZOFRAN 8mg
ondansetron *ZOFRAN 24mg
ondansetron *ZOFRAN ODT 4mg
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
19
Notes
Notes
Notes
QL (120 tablets/month)
Notes
Notes
QL (60 capsules/month)
QL (60 capsules/month)
QL (60 tablets/month)
QL (60 capsules/month)
QL (60 tablets/month)
Notes
QL (2 tablets/fill; 2 fills/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
ondansetron *ZOFRAN ODT 8mg
ondansetron *ZOFRAN solution
trimethobenzamide *TIGAN
7-G Digestive Aids
Generic Name Brand Name
amylase-lipase-protease CREON
pancrelipase ZENPEP
pegademase ADAGEN
sacrosidase SUCRAID
7-H Miscelleanous Gastrointestinal
Generic Name Brand Name
balsalazide *COLAZAL
budesonide SR *ENTOCORT EC
calcium acetate (phosphate binder) *ELIPHOS
hydrocortisone enema *CORTENEMA
lamivudine (hepatitis) EPIVIR HBV
lanthanum FOSRENOL 500mg
lanthanum FOSRENOL 750mg
lanthanum FOSRENOL 1000mg
linaclotide LINZESS
mesalamine CANASA
mesalamine CR APRISO
mesalamine enema *ROWASA
metoclopramide *REGLAN
sulfasalazine *AZULFIDINE
sulfasalazine EC *AZULFIDINE EN
ursodiol *ACTIGALL
ursodiol *URSO 250MG
QL (90 tablets/month)
QL (300ml/fill, 2 fills/mo)
Notes
PA
PA
Notes
QL (270 capsules/month)
QL (90 capsules/month)
QL (30 tablets/month)
QL (150 tablets/month)
QL (150 tablets/month)
QL (120 tablets/month)
PA
GENITOURINARY (drugs to treat genital and bladder or kidney conditions)
8-A Urinary Anti-Infectives
Generic Name Brand Name
fosfomycin MONUROL
methenamine-NA biphosphate *UROQID
nitrofurantoin macro *MACROBID
nitrofurantoin macrocrystals *MACRODANTIN
nitrofurantoin susp *FURADANTIN
8-B Urinary Antispasmodics
Generic Name Brand Name
bethanechol *URECHOLINE
flavoxate *URISPAS
oxybutynin *DITROPAN
oxybutynin CR *DITROPAN XL 5mg
oxybutynin CR *DITROPAN XL 10mg
oxybutynin CR *DITROPAN XL 15mg
8-C Vaginal Products
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
20
Notes
QL (1 packet/month)
Notes
QL (240 tablets/month)
QL (240 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
Generic Name Brand Name
clindamycin vaginal *CLEOCIN vaginal cream
estradiol vaginal ESTRACE vaginal
estrogens (conjugated) vaginal PREMARIN vaginal
metronidazole vaginal *METROGEL vaginal
metronidazole vaginal *VANDAZOLE
nystatin vaginal
sulfanilamide vaginal AVC vaginal
terconazole vaginal *TERAZOL
8-D Miscelleanous Genitourinary Agents
Generic Name Brand Name
citric acid-sodium citrate *BICITRA
finasteride *PROSCAR
pentosan polysulfate sodium ELMIRON
phenazopyridine *PYRIDIUM
potassium citrate CR *UROCIT-K
Notes
QL (42.5gm/mo)
Notes
QL (30 tablets/month)
QL (90 capsules/month)
potassium citrate & citric acid powder pack
potassium citrate & citric acid soln *CYTRA-K
potassium phosphate K-PHOS
POTASSIUM CHLORIDE
tamsulosin *FLOMAX
QL (60 capsules/month)
MUSCULOSKELETAL AND PAIN (drugs to treat pain and muscle conditions)
9-A Analgesics-Non-Narcotic
Generic Name Brand Name
APAP-butalbital *PHRENILIN
DIFLUNISAL
APAP-caffeine-butalbital *ESGIC PLUS
APAP-caffeine-butalbital *APAP-caff-butal 50-325-40 MG
ASA-caffeine-butalbital *FIORINAL
butalbital-acet-caff 50-325-40mg *FIORICET
choline-mag salicylates *TRILISATE
salsalate *DISALCID
9-B Analgesics-Narcotic
Generic Name Brand Name
CODEINE SULFATE 15mg, 30mg,
CODEINE SULFATE 60mg
METHADONE
APAP-codeine *TYLENOL w/CODEINE
APAP-codeine *TYLENOL w/CODEINE soln
APAP-hydrocodone liquid *HYDRO-APAP SOLN 7.5-325 MG
APAP-hydrocodone liquid *HYDRO-APAP SOLN 7.5-500 MG
APAP-hydrocodone *NORCO 5/325mg
APAP-hydrocodone *NORCO 7.5/325mg
APAP-hydrocodone *NORCO 10/325mg
APAP-hydrocodone ZYDONE tabs
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
21
Notes
QL (360 tablets/month)
QL (8 tablets/day)
QL (360 tablets/month)
Notes
QL (11 tablets/day)
QL (12 tablets/day)
QL (390 tablets/month)
QL (150ml/day)
QL (120ml/month)
QL (180ml/month)
QL (360 tablets/month)
QL (360 tablets/month)
QL (360 tablets/month)
QL (8 tablets/day)
Medicaid Drug Benefit Guide 02/01/2015
ASA-caffeine-but-codeine *FIORINAL w/CODEINE
buprenorphine naloxone SUBOXONE FILM TAB
PA
butorphanol *STADOL NS
QL (6 bottles/month)
fentanyl patch *DURAGESIC
QL (10 patches/month) ST
Duragesic ST = requires 30 day trial fill of MSSR in past 2 years
hydromorphone *DILAUDID 2mg
QL (360 tablets/month)
hydromorphone *DILAUDID 4mg
QL (360 tablets/month)
hydromorphone *DILAUDID 8mg
QL (360 tablets/month)
ibuprofen-hydrocodone *VICOPROFEN
QL (480 tablets/month)
meperidine *DEMEROL
QL (360 tablets/month)
meperidine *DEMEROL solution
morphine sulfate *ROXANOL
morphine sulfate SR *MS CONTIN
naltrexone *REVIA
oxycodone *OXYIR
oxycodone *ROXICODONE
QL (360 tablets/month)
oxycodone-APAP *PERCOCET 2.5-325mg
QL (360 tablets/month)
oxycodone-APAP *PERCOCET 5-325mg
QL (360 tablets/month)
oxycodone-APAP *PERCOCET 7.5-325mg
QL (360 tablets/month)
oxycodone-APAP *PERCOCET 10-325mg
QL (360 tablets/month)
oxycodone-APAP *PERCOCET 7.5-500mg
QL (240 tablets/month)
oxycodone-APAP *PERCOCET 10-650mg
QL (180 tablets/month)
oxycodone-ASA *PERCODAN
QL (360 tablets/month)
oxymorphone ER *OPANA ER
QL (60 tablets/month)
pentazocine-naloxone *TALWIN NX
QL (12 tablets/day)
tapentadol SR NUCYNTA ER
QL (60 tablets/month) ST
Nucynta ER ST = requires failure of MSSR within the last 60 days
tramadol *ULTRAM
QL (240 tablets/month)
tramadol-APAP ULTRACET
QL (240 tablets/month)
9-C Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Generic Name Brand Name
Notes
diclofenac *VOLTAREN 25mg
QL (240 tablets/month)
diclofenac *VOLTAREN 50mg
QL (120 tablets/month)
diclofenac *VOLTAREN 75mg
QL (90 tablets/month)
diclofenac potassium *CATAFLAM
QL (120 tablets/month)
diclofenac SR *VOLTAREN XR
etodolac *LODINE 200mg
QL (90 capsules/month)
etodolac *LODINE 300mg
QL (90 capsules/month)
etodolac *LODINE 400mg
QL (90 tablets/month)
etodolac *LODINE 500mg
QL (90 tablets/month)
etodolac SR *LODINE XL
QL (60 tablets/month)
fenoprofen *NALFON
flurbiprofen *ANSAID 50mg
QL (4 tablets/day)
flurbiprofen *ANSAID 100mg
QL (3 tablets/day)
ibuprofen *MOTRIN
indomethacin *INDOCIN
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
22
Medicaid Drug Benefit Guide 02/01/2015
9-D
9-E
9-F
9-G
indomethacin CR *INDOCIN SR
ketoprofen *ORUDIS
ketorolac *TORADOL
meclofenamate sodium
meloxicam *MOBIC 7.5mg
meloxicam *MOBIC 15mg
meloxicam *MOBIC susp
nabumetone *RELAFEN
naproxen *NAPROSYN
naproxen *NAPROSYN EC
naproxen sodium *ANAPROX
oxaprozin *DAYPRO
piroxicam *FELDENE
sulindac *CLINORIL
tolmetin sodium *TOLECTIN
Anti-Rheumatic Agents
Generic Name Brand Name
auranofin RIDAURA
deferasirox EXJADE
leflunomide *ARAVA
methotrexate
penicillamine CUPRIMINE
penicillamine DEPEN
Migraine Products
Generic Name Brand Name
rizatriptan *MAXALT
rizatriptan *MAXALT MLT
sumatriptan *IMITREX
sumatriptan *IMITREX NASAL
sumatriptan *SUMATRIPTAN INJ
Gout
Generic Name Brand Name
allopurinol *ZYLOPRIM
colchicine COLCRYS
colchicine-probenecid *COLBENEMID
probenecid *BENEMID
Musculoskeletal Therapy Agents
Generic Name Brand Name
baclofen *LIORESAL
carisoprodol *SOMA 350mg
carisoprodol-ASA *SOMA COMPOUND
carisoprodol-ASA-codeine *SOMA CPD w/CODEINE
chlorzoxazone *PARAFON FORTE
cyclobenzaprine *FLEXERIL 5mg
cyclobenzaprine *FLEXERIL 10mg
dantrolene *DANTRIUM
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
23
QL (90 capsules/month)
QL (20 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (10ml/day)
QL (90 tablets/month)
Notes
PA
QL (30 tablets/month)
Notes
QL (6 tablets/fill; 2 fills/month)
QL (6 tablets/fill; 2 fills/month)
QL (9 tablets/fill; 2 fills/month)
QL (6 vials/month)
QL (2 kits/fill, 2 fills/month)
Notes
Notes
QL (120 tablets/month)
QL (120 tablets/month)
QL (120 tablets/month)
QL (90 tablets/month)
Medicaid Drug Benefit Guide 02/01/2015
methocarbamol *ROBAXIN
orphenadrine citrate *NORFLEX
tizanidine *ZANAFLEX 2mg and 4mg tablets
9-H Miscelleanous Neuromuscular Agents
Generic Name Brand Name
pyridostigmine *MESTINON
Notes
VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood disorders)
10-A Vitamins
Generic Name Brand Name
calcitriol *ROCALTROL
calcitriol oral soln 1mg/ml *ROCALTROL SOLUTION
paricalcitol [vitamin D] *ZEMPLAR
phytonadione MEPHYTON
potassium aminobenzoate POTABA
10-B Multivitamins
Generic Name Brand Name
B complex-vit C-FA *NEPHROCAPS
ped multi vitamin-fluoride *POLY-VI-FLOR
ped multi vitamin-fluoride-FE *POLY-VI-FLOR-FE
ped vitamins ACD-fluoride *TRI-VI-FLOR
ped vitamins ACD-fluoride-FE *TRI-VI-FLOR-FE
pnv-dha
pnv prenatal plus multivitamin
pnv-select
prenatabs rx
prenatal FE-CBN-DSS-Methylfol-FA *PRENATE ELITE
prenatal vitamins-FE-FA *STUARTNATAL
prenatal vitamins-FE-FA *PRECARE
10-C Minerals
Generic Name Brand Name
cyanocobalamin inj
FA-vit B6-vit B12 *FOLBEE
FA-vit B6-vit B12 *FOLGARD RX
FA-vit B6-vit B12 *FOLTX
folic acid
L-methylfolate B12 B6 *METANX
10-D Anticoagulants
Generic Name Brand Name
apixaban ELIQUIS
rivaroxaban XARELTO 15mg
rivaroxaban XARELTO 20mg
warfarin *COUMADIN
10-E Miscelleanous Hematologicals
Generic Name Brand Name
aminocaproic acid *AMICAR
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
24
Notes
PA
QL (30 capsules/month)
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
Notes
QL (60 tablets/month) PA
QL (42 tablets/21 days) PA
QL (30 tablets/month) PA
Notes
Medicaid Drug Benefit Guide 02/01/2015
anagrelide *AGRYLIN
cilostazol *PLETAL
clopidogrel *PLAVIX 75mg
dipyridamole *PERSANTINE
pentoxifylline *TRENTAL
sodium polystyrene sulfonate *KAYEXALATE
ticlopidine *TICLID
QL (60 tablets/month)
QL (30 tablets/month)
QL (90 tablets/month)
QL (60 tablets/month)
EYE, EAR AND THROAT (drugs to treat eye, ear and throat conditions)
11-A Ophthalmic Anti-infectives
Generic Name Brand Name
bacitracin ophth
bacitracin-polymyxin B ophth *POLYSPORIN ophth
ciprofloxacin ophth *CILOXAN ophth soln
gentamycin sulfate ophth *GENTAMICIN OINT 0.3%
gentamycin sulfate ophth *GENTAMICIN SOLN 0.3%
levofloxacin QUIXIN
Notes
QL (15ml/month)
neomycin-polymyxin-dexa opth susp
neomycin-polymyxin-dexa opth oint
neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth
QL (10 ml/month)
ofloxacin ophth *OCUFLOX
sulfacetamide sodium ophth *BLEPH-10
tobramycin ophth *TOBREX
trifluridine ophth *VIROPTIC
trimethoprim-polymy B ophth *POLYTRIM ophth
11-B Ophthalmics Beta-Blocker
Generic Name Brand Name
carteolol ophth *OCUPRESS
dorzolamide-timolol ophth *COSOPT
levobunolol ophth *BETAGAN
metipranolol ophth *OPTIPRANOLOL
timolol ophth BETIMOL
timolol maleate ophth *TIMOPTIC
timolol maleate ophth *TIMOPTIC XE
11-C Ophthalmic Steroids
Generic Name Brand Name
dexamethasone phosphate ophth *DECADRON ophth
fluorometholone ophth FML FORTE
fluorometholone ophth *FML LIQUIFILM
fluorometholone ophth FML SOP
neomycin-polymyxin-HC ophth *CORTISPORIN OPHTH
prednisolone ophth *PRED FORTE
rimexolone ophth VEXOL
sulfacetamide-prednisolone ophth *BLEPHAMIDE
tobramycin-dexamethasone ophth *TOBRADEX susp
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
25
Notes
Notes
QL (5 ml/month)
Medicaid Drug Benefit Guide 02/01/2015
tobramycin-dexamethasone ophth *TOBRADEX oint
11-D Ophthalmic Prostaglandin
Generic Name Brand Name
bimatoprost ophth LUMIGAN
travaprost ophth TRAVATAN Z
travaprost ophth
11-E Ophthalmic Cycloplegics
Generic Name Brand Name
atropine ophth *ISOPTO ATROPINE
cyclopentolate ophth *CYCLOGYL
homatropine ophth *ISOPTO HOMATROPINE
tropicamide ophth *MYDRIACYL
11-F Ophthalmics Miotics
Generic Name Brand Name
pilocarpine ophth *ISOPTO CARPINE
pilocarpine ophth PILOPINE HS
11-G Ophthalmics Adrenergic Agents
Generic Name Brand Name
brimonidine ophth *ALPHAGAN P 0.1%
brimonidine ophth *ALPHAGAN P 0.2%
brimonidine ophth *ALPHAGAN P 0.15%
apraclonodine hcl ophth soln 0.5% IOPIDINE
11-H Ophthalmics Miscelleanous
Generic Name Brand Name
cromolyn sodium ophth *CROLOM ophth
diclofenac sodium ophth soln *VOLTAREN
dorzolamide ophth *TRUSOPT
epinastine *ELESTAT
flurbiprofen ophth *OCUFEN
ketorolac ophth *ACULAR
ketorolac ophth *ACULAR LS
ketotifen *ZADITOR
nepafenac ophth NEVANAC
oseltamivir capsules TAMIFLU CAPSULES
oseltamivir suspension TAMIFLU SUSPENSION
11-I Otic (Ear) Medications
Generic Name Brand Name
acetic acid otic soln
benzocaine-antipyrine otic *AURALGAN
hydrocortisone-acetic acid otic *VOSOL-HC
neomycin-polymyxin-HC otic *CORTISPORIN otic
ofloxacin otic *FLOXIN OTIC
11-J Mouth and Throat
Generic Name Brand Name
chlorhexidine *PERIDEX
clotrimazole troche *MYCELEX TROCHE
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
26
QL (3.5 gm/month)
Notes
QL (one bottle/month)
QL (2.5ml/month)
QL (2.5ml/month)
Notes
Notes
Notes
Notes
QL (10 capsules/ 90 days)
QL (50mls/90 days)
Notes
QL (10 ml/month)
Notes
Medicaid Drug Benefit Guide 02/01/2015
lidocaine
pilocarpine
pilocarpine
sodium fluoride
sodium fluoride
sodium fluoride
triamcinolone/orabase
*VISCOUS LIDOCAINE
*SALAGEN 5mg
*SALAGEN 7.5mg
QL (180 tablets/month)
QL (120 tablets/month)
*KARIGEL
*KARIGEL-N
*KENALOG-ORABASE
RESPIRATORY (drugs to treat breathing conditions, ie asthma and allergies)
12-A Antihistamines
Generic Name Brand Name
clemastine *TAVIST
cyproheptadine *PERIACTIN
promethazine *PHENERGAN
12-B Topical Nasal Products
Generic Name Brand Name
azelastine nasal *ASTELIN
fluticasone nasal *FLONASE
ipratropium nasal *ATROVENT 0.03% NASAL
ipratropium nasal *ATROVENT 0.06% NASAL
triamcinolone acet nasal aer susp OTC NASACORT ALLERGY 24HR
12-C Cough/Cold/Allergy
Generic Name Brand Name
acetylcysteine *MUCOMYST
benzonatate *TESSALON
cardec DM *RONDEC DM
cetirizine hcl chewable *ZYRTEC CHEWABLE
chlorpheniramine *ED CHLORPED
chlorpheniramine-PSE *DECONAMINE
guaifenesin-codeine *TUSSI-ORGANIDIN
hydrocodone-homatropine *HYCODAN
promethazine DM
promethazine VC
promethazine-codeine *PHENERGAN w/CODEINE
PSE-guaifenesin-codeine *NOVAHISTINE
PSE-methscopolamine *ALLERX-D
12-D Asthma/COPD
Generic Name Brand Name
aclidinium bromide aerosol TUDORZA
albuterol nebulizer *PROVENTIL (nebulizer)
albuterol tablets *PROVENTIL (tablets)
albuterol HFA inhaler VENTOLIN HFA
albuterol SR tablets *VOSPIRE ER 4mg
albuterol SR tablets *VOSPIRE ER 8mg
albuterol-ipratropium nebulizer *DUONEB
aminophylline
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
27
Notes
Notes
QL (1 inhaler/month)
QL (1 inhaler/month)
QL (2 inhalers/month)
Notes
PA
Notes
QL (2 inhalers/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (12ml's/day)
Medicaid Drug Benefit Guide 02/01/2015
budesonide formoterol inhaler
cromolyn sodium nebulizer
formoterol inhaler
ipratropium nebulizer
ipratropium HFA inhaler
metaproterenol nebulizer
metaproterenol nebulizer
metaproterenol tablets
montelukast
montelukast
montelukast
montelukast
sodium chloride soln nebu 7%
terbutaline
theophylline
theophylline
theophylline
theophylline CR
theophylline SR
zafirlukast
12-E Steroid Inhalers
Generic Name
beclomethasone HFA inhaler
beclomethasone HFA inhaler
budesonide inhalation susp 0.25 MG/2ML
budesonide inhalation susp 0.5 MG/2ML
budesonide inhalation susp 1 MG/2ML
mometasone inhaler
mometasone inhaler
SYMBICORT
*INTAL (nebulizer)
FORADIL
*ATROVENT (nebulizer)
ATROVENT HFA
*ALUPENT (nebulizer)
*ALUPENT (syrup)
*ALUPENT (tablets)
*SINGULAIR 4mg
*SINGULAIR 5mg
*SINGULAIR 10mg
*SINGULAIR 4mg Granules
*HYPER-SAL NEBULIZER
*BRETHINE
QL (1 inhaler/month)
QL (120 vials/month)
QL (60 capsules/month)
QL (450 mls/month)
QL (2 inhalers/month)
QL (120 vials/month (300 ml/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 packets/month)
QL (30 tablets/month)
*SLO-PHYLLIN
*THEOLAIR
*UNIPHYL
THEO-24
*ACCOLATE
QL (60 tablets/month)
Brand Name
QVAR 40mcg
QVAR 80mcg
*PULMICORT
*PULMICORT
*PULMICORT
ASMANEX
ASMANEX HFA
Notes
QL (1 inhaler/month)
QL (2 inhaler/month)
QL (120ml/month)
QL (120ml/month)
QL (60ml/month)
QL (1 inhaler/month)
QL (1 inhaler/month)
SELF-INJECTABLE/SPECIALTY (injectable drugs)
13-A Anticoagulants
Generic Name Brand Name
dalteparin sodium FRAGMIN
enoxaparin *LOVENOX
13-B Growth Hormones
Generic Name
somatropin
somatropin
somatropin
13-C Hematopoietic Agents
Generic Name
darbepoetin alpha
filgrastim
Notes
PA (covered up to 14 days without prior authorization)
QL (covered up to 21 days without prior authorization)
Brand Name
NORDITROPIN
TEV-TROPIN
SEROSTIM
PA
PA
PA
Brand Name
ARANESP
NEUPOGEN
PA
PA
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
Notes
Notes
28
Medicaid Drug Benefit Guide 02/01/2015
pegfilgrastim NEULASTA
13-D Hepatitis C Agents
Generic Name Brand Name
ledipasvir-sofosbuvir HARVONI
ombitasvir-paritaprevir-ritonavir VIEKIRA
peginterferon alfa-2A PEGASYS
simeprevir sodium cap OLYSIO
sofosbuvir tab SOVALDI
13-E Multiple Sclerosis Agents
Generic Name Brand Name
dimethyl fumarate TECFIDERA
glatiramer acetate COPAXONE
interferon beta-1A REBIF
interferon beta-1A AVONEX
teriflunomide AUBAGIO
13-F Osteoporosis Agents
Generic Name Brand Name
teriparatide (recombinant) FORTEO
13-G Somatostatin Analogs
Generic Name Brand Name
lanreotide acetate SOMATULINE
nafarelin SYNAREL
octreotide acetate *OCTREOTIDE
pegvisomant SOMAVERT
13-H Immunomodulators
Generic Name Brand Name
adalimumab HUMIRA
certolizumab pegol CIMZIA
etanercept for subcutaneous ENBREL
golimumab SIMPONI
13-I Miscellaneous Specialty
Generic Name Brand Name
corticotropin ACTHAR HP
interferon gamma-1B ACTIMMUNE
nitisinone ORFADIN
oprelvekin NEUMEGA
oxandralone OXANDRIN
oxymetholone ANADROL-50
rilonacept ARCALYST
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
PA
Notes
PA QL (30 tablets/month)
PA QL (120 tablets/month)
PA
PA
PA QL (30 tablets/month)
Notes
PA
PA
PA
PA
PA
Notes
PA
Notes
PA
PA
PA
PA
Notes
PA
PA
PA
QL (1 unit/month) PA
Notes
PA
PA
PA
PA
PA
PA
PA
29
Medicaid Drug Benefit Guide 02/01/2015
Preferred Alternatives
The following table identifies the preferred alternatives for some commonly prescribed non-preferred drugs.
Copayments are lower when preferred drugs are prescribed.
Non-Preferred Drug
ACEON
ACIPHEX
ACTIVELLA
ADVAIR
AEROBID
AEROBID-M
AGGRENOX
ALESSE
ALORA
ALTOCOR
AMERGE
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
AXERT
AZMACORT
AZOPT
BECONASE AQ
BETAPACE AF
BREVICON
CELEBREX
CLIMARA
COGNEX
CONCERTA
COREG CR
COVERA HS
CYCLESSA
DEMULEN
DESOGEN
DESOXYN
DETROL
DETROL LA
DIOVAN
DIOVAN HCT
DYNACIRC
Preferred Alternative(s)
benazepril, fosinopril, lisinopril, quinapril, trandolapril UNIVASC
omeprazole, pantoprazole
ORTHO-PREFEST, PREMPRO, PREMPHASE
SYMBICORT (see section 12-D)
ASMANEX, QVAR
ASMANEX, QVAR
dipyridamole and aspirin
LEVLITE (see section 6-D)
VIVELLE, VIVELLE DOT
simvastatin, lovastatin, LIPITOR
sumatriptan
losartan
losartan-HCTZ
losartan-HCTZ
losartan
sumatriptan
ASMANEX, QVAR
TRUSOPT
sotalol (BETAPACE)
MODICON
ibuprofen, naproxen, others (see section 9-C)
VIVELLE, VIVELLE DOT
donepezil, galantamine
methylphenidate, dextroamphetamine, ADDERALL XR
carvedilol, metoprolol succinate SR
verapamil
another oral contraceptive (see section 6-D)
another oral contraceptive (see section 6-D)
ORTHO-CEPT (see section 6-D)
methylphenidate, dextroamphetamine, ADDERALL XR
oxybutynin, URECHOLINE, URISPAS
oxybutynin XL, URECHOLINE, URISPAS
losartan
losartan-HCTZ
nifedipine XR
29
Medicaid Drug Benefit Guide 01/01/2014
Preferred Alternatives
ESCLIM
ESTRADERM
FAMVIR
FEMHRT
FLOVENT
FOCALIN
FROVA
GEODON
GLYSET
LEXXEL
LIDODERM
LO-OVRAL
MAXAIR
MAXALT
MAXALT MLT
MIRCETTE
NASACORT
NASACORT AQ
NASAREL
NASCOBAL
NEXIUM
NORDETTE
NORINYL
NOR-QD
NULEV
ONE TOUCH TEST STRIPS
ORAMORPH
OVCON
OVRAL
OVRETTE
OXYCONTIN
PATANOL
PAXIL CR
PENTASA
PERIOSTAT
PLETAL
PREVACID
ELIDEL
PROZAC WEEKLY
PULMICORT
RELION insulins
RELPAX
estradiol patch, VIVELLE, VIVELLE DOT
estradiol patch, VIVELLE, VIVELLE DOT
acyclovir
ORTHO-PREFEST, PREMPRO, PREMPHASE
QVAR
methylphenidate, dextroamphetamine, ADDERALL XR
sumatriptan
RISPERDAL, SEROQUEL
PRECOSE
enalapril
lidocaine (topical)
another oral contraceptive (see section 6-D)
VENTOLIN HFA
sumatriptan
sumatriptan
another oral contraceptive (see section 6-D)
fluticasone
fluticasone
fluticasone
cyanocobalamin injection
omeprazole, pantoprazole
LEVLEN (see section 6-D)
ORTHO-NOVUM (see section 6-D)
MICRONOR (see section 6-D)
generic Levsin, Levbid
ACCU-CHECK DIABETIC STRIPS
morphine sulfate (MS CONTIN)
another oral contraceptive (see section 6-D)
another oral contraceptive (see section 6-D)
another oral contraceptive (see section 6-D)
morphine sulfate SR (MS CONTIN)
flurbiprofen, ZADITOR
paroxetine
APRISO
doxycycline
pentoxifylline
omeprazole, pantoprazole
PROTOPIC
fluoxetine
ASMANEX, QVAR
NOVOLIN insulins
sumatriptan
30
Medicaid Drug Benefit Guide 01/01/2014
Preferred Alternatives
RESCULA
RITALIN LA
SAIZEN
SARAFEM
SKELAXIN
TARKA
TEVETEN
Ticlopidine (TICLID)
TOFRANIL PM
TOLBUTAMIDE
TRI-NASAL
TRI-NORINYL
TRIPHASIL
VALCYTE
VALTREX
VERELAN PM
XALATAN
XOPENEX
ZEGERID (generic)
ZYPREXA
LUMIGAN, TRAVATAN
dextroamphetamine, methylphenidate, ADDERALL XR
TEVTROPIN
fluoxetine
baclofen, carisoprodol, methocarbamol
benzepril-hctz , lisinopril-hctz, quinapril-hctz, enalapril-hctz
losartan
PLAVIX
imipramine
glipizide, glyburide, AMARYL
fluticasone
another oral contraceptive (see section 6-D)
TRI-LEVLEN (see section 6-D)
CYTOVENE
acyclovir
verapamil
LUMIGAN, TRAVATAN
albuterol nebs
omeprazole, pantoprazole
RISPERDAL, SEROQUEL
31
Medicaid Drug Benefit Guide 01/01/2014
Alphabetical Index
Drug Name
abacavir sulfate
ABILIFY
acarbose
ACETIC ACID OTIC SOLN
ACCOLATE
ACCU-CHEK ACTIVE CARE KIT
ACCU-CHEK ACTIVE TEST STRIPS
ACCU-CHEK ADVANTAGE CARE KIT
ACCU-CHEK AVIVA CARE KIT
ACCU-CHEK AVIVA TEST STRIPS
ACCU-CHEK COMFORT CURVE TEST STRIPS
ACCU-CHEK COMPACT CARE KIT
ACCU-CHEK COMPACT TEST STRIPS
ACCUPRIL
ACCURETIC
ACCUZYME
acebutolol
acetazolamide
acetylcysteine
ACLOVATE
ACTHAR HP
ACTIGALL
ACTIMMUNE
ACTOPLUS MET
ACTOS
ACULAR
ACULAR LS
acyclovir
acyclovir topical
ADAGEN
ADALAT
ADALAT CC
ADDERALL
ADDERALL XR
ADEMPAS
AEROLATE
AGENERASE
AGRYLIN
albuterol CR tablets
albuterol HFA inhaler
PDL Section
Drug Name
1-I
4-D
6-F
11-I
12-D
6-K
6-K
6-K
6-K
6-K
6-K
6-K
6-K
3-F
3-I
5-I
3-C
3-J
12-C
5-H
13-I
7-H
13-I
6-F
6-F
11-H
11-H
1-H
5-E
7-G
3-D
3-D
4-E
4-E
3-H
12-D
1-I
10-F
12-D
12-D
PDL Section
albuterol nebulizer
albuterol SR tablets
albuterol tablets
albuterol-ipratropium nebulizer
alclometasone
ALDACTAZIDE
ALDACTONE
ALDARA
ALDOMET
ALDORIL
alendronate
ALKERAN
ALLEGRA
ALLERX-D
allopurinol
ALOXI (tablets)
ALPHAGAN P
alprazolam
alprazolam SR
ALTACE
altretamine
aluminum chloride
ALUPENT (nebulizer)
ALUPENT (tablets)
ALUPENT INHALER
AMANTADINE (Symmetrel)
AMARYL
AMBIEN
AMICAR
amiloride
amiloride-HCTZ
aminocaproic acid
aminophylline
amiodarone
amitriptyline
amitriptyline-chlordiazepoxide
amlodipine
amlodipine-benazepril
amoxapine
amoxicillin
32
12-D
12-D
12-D
12-D
5-H
3-J
3-J
5-I
3-H
3-I
6-J
2-A
12-A
12-C
9-F
13-I
11-G
4-A
4-A
3-F
2-A
5-I
12-D
12-D
12-D
4-H
6-F
4-C
10-F
3-J
3-J
10-F
12-D
3-E
4-B
4-F
3-D
3-I
4-B
1-A
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
amoxicillin-clavulanate
AMOXIL
amphetamine-d-amphetamine
amphetamine-d-amphetamine SR
ampicillin
amprenavir
amylase-lipase-protease
amy-lip-prot dr
ANADROL-50
ANAFRANIL
anagrelide
ANALPRAM-HC
ANAMANTLE
ANAPROX
anastrozole
ANSAID
ANTABUSE
anthralin
ANTIVERT
ANUSOL-HC
APAP-butalbital
APAP-caffeine-butalbital
APAP-codeine
APAP-hydrocodone
APAP-isometh-dichlor hydrate
APOKYN
apomorphine
APRESOLINE
APRI
APRISO
APTIVUS
AQUATENSEN
ARALEN
ARANESP
ARAVA
ARCALYST
ARICEPT
ARIMIDEX
AROMASIN
ARTANE
PDL Section
Drug Name
PDL Section
ASA-caffeine-butalbital
ASA-caffeine-but-codeine
ASA-codeine
ASENDIN
ASMANEX
ASTELIN
ATARAX
atenolol
atenolol-chlorthalidone
ATIVAN
atomoxetine
atorvastatin
ATRIPLA
atropine ophth
ATROVENT (nebulizer)
ATROVENT HFA
ATROVENT INHALER
ATROVENT NASAL
AUBAGIO
augmented betamethasone
AUGMENTIN
AURALGAN
AVALIDE
AVAPRO
auranofin
AVC vaginal
AVIANE
AVONEX
AXID
AYGESTIN
azatadine-pseudoephedrine CR
azathioprine
azelastine nasal
azithromycin
aztreonam
AZULFIDINE
AZULFIDINE EN
B complex-vit C-FA
bacitracin ophth
bacitracin-polymyxin B ophth
1-A
1-A
4-E
4-E
1-A
1-I
7-G
7-G
13-I
4-B
10-F
5-A
5-I
9-C
2-A
9-C
4-F
5-F
7-F
5-A
9-A
9-A
9-B
9-B
9-E
4-H
4-H
3-H
6-D
7-H
1-I
3-J
1-J
13-C
9-D
13-I
4-F
2-A
2-A
4-H
33
9-A
9-B
9-B
4-B
12-E
12-B
4-A
3-C
3-I
4-A
4-E
3-L
1-I
11-E
12-D
12-D
12-D
12-B
13-E
5-H
1-A
11-I
3-G
3-G
9-D
8-C
6-D
13-E
7-D
6-E
12-C
2-B
12-B
1-C
1-A
7-H
7-H
10-B
11-A
11-A
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
baclofen
bac-polymy-neomycin HC oint
BACTRIM
BACTROBAN
BACTROBAN CREAM
BACTROBAN NASAL OINTMENT
balsalazide
beclomethasone HFA inhaler
benazepril
benazepril-HCTZ
BENEMID
BENTYL
BENZACLIN
BENZAMYCIN
benzocaine-antipyrine otic
benzonatate
benzoyl peroxide
benzoyl peroxide-erythromycin gel
benztropine
BETAGAN
betamethasone dipropionate
betamethasone valerate
BETAPACE
BETAPACE AF
betaxolol
bethanechol
BETHKIS
BETIMOL
BIAXIN
BIAXIN XL
bicalutamide
BICITRA
bimatoprost ophth
BIO-STATIN
bisoprolol
bisoprolol-HCTZ
BLEPH-10
BLEPHAMIDE
BLOCADREN
bosentan
PDL Section
Drug Name
PDL Section
BRETHINE
BREVOXYL
brimonidine ophth
9-G
5-C
1-L
5-C
5-C
5-C
7-H
12-E
3-F
3-I
9-F
7-C
5-B
5-B
11-I
12-C
5-B
5-B
4-H
11-B
5-H
5-H
3-C
3-C
3-C
8-B
1-L
11-B
1-C
1-C
2-A
8-D
11-D
1-G
3-C
3-I
11-A
11-C
3-C
3-H
brimonidine timolol ophth
bromocriptine (tablets)
buconazole vaginal
budesonide formoterol inhaler
budesonide SR
bumetanide
BUMEX
BUPHENYL
buprenorphine naloxone
bupropion
bupropion SR
bupropion XL
BUSPAR
buspirone
busulfan
butorphanol
BYETTA
BYSTOLIC
caberoline
CAFERGOT
CALAN
CALAN SR
CALCIFEROL
calcipotriene
calcitonin
calcitonin (salmon) nasal
calcitriol
calcitriol ointment
calcium acetate (phosphate binder)
CAMILA
CANASA
CAPOTEN
CAPOZIDE
captopril
captopril-HCTZ
CARAFATE
carbamazepine
34
12-D
5-B
11-G
11-B
4-H
8-C
12-D
7-H
3-J
3-J
7-G
9-B
4-B
4-B
4-B
4-A
4-A
2-A
9-B
6-J
3-C
6-J
9-E
3-D
3-D
10-A
5-F
6-J
6-J
10-A
5-F
7-H
6-D
7-H
3-F
3-I
3-F
3-I
7-C
4-G
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
carbamazepine SR
CARBATROL
carbidopa-levodopa
carbidopa-levodopa CR
carbinoxamine-PSE
carbinoxamine-PSE-DM
cardec DM
CARDENE
CARDIZEM
CARDIZEM SR
CARDURA
carisoprodol
carisoprodol-ASA
carisoprodol-ASA-codeine
CARMOL 40
CARMOL SCALP
CARNITOR
carteolol ophth
cartia XT
carvedilol
CASODEX
CATAFLAM
CATAPRES
CATAPRES-TTS
CAYSTON
CECLOR
CECLOR CD
CEENU
cefaclor
cefaclor ER
cefadroxil
cefdinir
cefpodoxime
cefprozil
CEFTIN
cefuroxime
CEFZIL
CELEXA
CELLCEPT
CENESTIN
PDL Section
Drug Name
4-G
4-G
4-H
4-H
12-C
12-C
12-C
3-D
3-D
3-D
3-H
9-G
9-G
9-G
5-I
5-I
6-J
11-B
3-D
3-C
2-A
9-C
3-H
3-H
1-A
1-B
1-B
2-A
1-B
1-B
1-B
1-B
1-B
1-B
1-B
1-B
1-B
4-B
2-B
6-C
PDL Section
cephalexin
cephradine
certolizumab pegol
CHANTIX
chloral hydrate
chlorambucil
chlordiazepoxide
chlorhexidine
chloroquine
chlorothiazide
chlorpheniramine
chlorpheniramine-PSE
chlorphen-pyrilamine-PE
chlorpromazine
chlorpropamide
chlorthalidone
chlorzoxazone
cholestyramine
choline-mag salicylates
ciclopirox
ciclopirox solution
cilostazol
CILOXAN
cimetidine
CIMZIA
CIPRO
CIPRO XR
ciprofloxacin
ciprofloxacin ophth
ciprofloxacin SR
citalopram
citric acid-sodium citrate
clarithromycin
clarithromycin SR
clemastine
CLEOCIN
CLEOCIN vaginal cream
CLEOCIN-T
CLIMARA
clindamycin
35
1-B
1-B
13-H
4-I
4-C
2-A
4-A
11-J
1-J
3-J
12-C
12-C
12-C
4-D
6-F
3-J
9-G
3-L
9-A
5-D
5-D
10-F
11-A
7-D
13-H
1-E
1-E
1-E
11-A
1-E
4-B
8-D
1-C
1-C
12-A
1-C
8-C
5-B
6-C
1-C
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
clindamycin topical
clindamycin vaginal
CLINORIL
clobetasol foam
clobetasol propionate
clomipramine
clonazepam
clonidine
clonidine patch
clopidogrel
clorazepate
CLORPRES
clotrimazole
clotrimazole troche
clotrimazole-betamethasone
clozapine
CLOZARIL
CODEINE PHOSPHATE
CODEINE SULFATE
CODIMAL DH
COGENTIN
COLAZAL
COLBENEMID
colchicine-probenecid
COLCRYS
COLESTID
colestipol
COLYTE
COMBIVIR
COMPAZINE
COMPLERA
COMTAN
CONDYLOX
COPAXONE
CORDARONE
COREG
CORGARD
CORTEF
CORTENEMA
corticotropin
PDL Section
Drug Name
5-B
8-C
9-C
5-H
5-H
4-B
4-G
3-H
3-H
10-F
4-A
3-I
5-D
11-J
5-D
4-D
4-D
9-B
9-B
12-C
4-H
7-H
9-F
9-F
9-F
3-L
3-L
7-A
1-I
4-D
1-I
4-H
5-I
13-E
3-E
3-C
3-C
6-A
7-H
13-I
PDL Section
cortisone acetate
CORTISPORIN CREAM
CORTISPORIN OINTMENT
CORTISPORIN OPHTH
CORTISPORIN otic
CORTONE
CORZIDE
COSOPT
COTAZYM
COUMADIN
COZAAR
CREON
CRIXIVAN
CROLOM ophth
cromolyn sodium inhaler
cromolyn sodium nebulizer
cromolyn sodium ophth
CUPRIMINE
CUTIVATE
cyanocobalamin inj
cyclobenzaprine
CYCLOGYL
cyclopentolate ophth
cyclophosphamide
cyclosporine
cyclosporine modified
CYLERT
cyproheptadine
CYTOMEL
CYTOTEC
CYTOVENE
CYTOXAN
CYTRA K
DALMANE
dalteparin sodium
danazol
DANOCRINE
DANTRIUM
dantrolene
dapsone
36
6-A
5-C
5-C
11-C
11-I
6-A
3-I
11-B
7-G
10-F
3-G
7-G
1-I
11-H
12-D
12-D
11-H
9-D
5-H
10-C
9-G
11-E
11-E
2-A
2-B
2-B
4-F
12-A
6-I
7-C
1-H
2-A
8-D
4-C
13-A
6-B
6-B
9-G
9-G
1-L
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
DAPSONE
DARAPRIM
darbepoetin alpha
DARVOCET N 100
DARVOCET N 50
DARVON
DAYPRO
DDAVP
DECADRON
DECADRON ophth
DECONAMINE
deferasirox
DEMADEX
DEMEROL
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPEN
DEPO-PROVERA
DERMATOP
desipramine
desmopressin (nasal)
desmopressin (oral)
desoximetasone
DESOXYN
DESYREL
dexamethasone
dexamethasone phosphate ophth
DEXEDRINE
DEXEDRINE SPANSULES
dexmethylphenidate
dextroamphetamine
DIABETA
DIABINESE
DIAMOX
diazepam
dibigatran
diclofenac
diclofenac potassium
diclofenac SR
PDL Section
Drug Name
1-L
1-J
13-C
9-B
9-B
9-B
9-C
6-J
6-A
11-C
12-C
9-D
3-J
9-B
4-G
4-G
9-E
9-D
6-E
5-H
4-B
6-J
6-J
5-H
4-E
4-B
6-A
11-C
4-E
4-E
4-E
4-E
6-F
6-F
3-J
4-A
10-E
9-C
9-C
9-C
PDL Section
dicloxacillin
dicyclomine
didanosine
DIDRONEL
diflorasone diacetate
DIFLUCAN
DIFLUCAN SUSP
DIFLUNISAL
digoxin
DILANTIN
DILAUDID
diltiazem
diltiazem SR
diltiazem SR 12HR
diphenoxylate-atropine
dipivefrin ophth
DIPROLENE
DIPROLENE AF
DIPROSONE
dipyridamole
DISALCID
disopyramide
disulfiram
DITROPAN
DITROPAN XL
DIURIL
divalproex sodium EC
DIVIGEL
donepezil
DONNATAL
dornase alfa
dorzolamide ophth
dorzolamide-timolol ophth
DOSTINEX
DOVONEX
doxazosin
doxepin
doxycycline
doxycycline hyclate
doxycycline monohyclate
37
1-A
7-C
1-I
6-J
5-H
1-G
1-G
9-A
3-A
4-G
9-B
3-D
3-D
3-D
7-B
11-G
5-H
5-H
5-H
10-F
9-A
3-E
4-F
8-B
8-B
3-J
4-G
6-C
4-F
7-C
1-L
11-H
11-B
6-J
5-F
3-H
4-B
1-D
1-D
1-D
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
drospirenone-ethyinyl
DRYSOL
DUET DHA
DUET DHA EC
DUETACT
DUONEB
DURAGESIC
DURICEF
DYAZIDE
DYNACIRC
DYNAPEN
econazole
ED CHLORPED
EDURANT
EES
EES-sulfisoxazole
EFFEXOR
EFFEXOR XR
EFUDEX
ELAVIL
ELESTAT
eletriptan
ELIMITE
ELIPHOS
ELIQUIS
ELMIRON
ELOCON
EMCYT
EMLA cream
EMPIRIN w/CODEINE
emtricitabine
EMTRIVA
enalapril
enalapril-HCTZ
ENBREL
enfuvirtide
ENJUVIA
ENPRESSE
enoxaparin
entacapone
PDL Section
Drug Name
PDL Section
ENTOCORT EC
ENTUSS
EPIFOAM
epinastine
epinephrine inj
EPIPEN
EPIPEN JR
EPIVIR
EPIVIR HBV
EPZICOM
ergocalciferol [vitamin D]
ergoloid mesylates
ergotamine-caffeine
ergotamine-phenobarb-belladona
ERRIN
ERYGEL
ERYPED
ERY-TAB
ERYTHROCIN
ERYTHROMYCIN BASE
erythromycin EC
erythromycin estolate
erythromycin ethylsuccinate
erythromycin stearate
erythromycin topical
escitalopram
ESGIC PLUS
ESKALITH
ESKALITH CR
estazolam
esterified estrogens
ESTRACE
ESTRACE vaginal
estradiol
estradiol patch
estradiol TD gel
estradiol vaginal
estradiol-norgestimate
estramustine
ESTRATEST
6-D
5-I
10-B
10-B
6-F
12-D
9-B
1-B
3-J
3-D
1-A
5-D
12-C
1-I
1-C
1-L
4-B
4-B
5-I
4-B
11-H
9-E
5-G
7-H
10-D
8-D
5-H
2-A
5-I
9-B
1-I
1-I
3-F
3-I
13-H
1-I
6-C
6-D
13-A
4-H
38
7-H
12-C
5-H
11-H
3-K
3-K
3-K
1-I
7-H
1-I
10-A
4-F
9-E
9-E
6-D
5-B
1-C
1-C
1-C
1-C
1-C
1-C
1-C
1-C
5-B
4-B
9-A
4-D
4-D
4-C
6-C
6-C
8-C
6-C
6-C
6-C
8-C
6-C
2-A
6-C
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
ESTRATEST HS
estrogen-medroxyprogesterone
estrogens (conjugated synthetic)
estrogens (conjugated) vaginal
estrogens-methyltestosterone
estropipate
estropipate vaginal
ESTROSTEP FE
etanercept for subcutaneous
ethambutol
ETHMOZINE
ethosuximide
etidronate
etodolac
etodolac SR
etoposide
ETRAFON
EULEXIN
EVISTA
EXELON
exemestane
exenatide
EXJADE
famciclovir
famotidine
FAMVIR
FA-vit B6-vit B12
FELDENE
felodipine
FEMARA
fenofibrate
fenoprofen
fentanyl patch
fexofenadine
filgrastim
finasteride
FIORINAL
FIORINAL w/CODEINE
FLAGYL
flavoxate
PDL Section
Drug Name
PDL Section
flecainide
FLEXERIL
FLOMAX
6-C
6-C
6-C
8-C
6-C
6-C
8-C
6-D
13-H
1-F
3-E
4-G
6-J
9-C
9-C
2-A
4-F
2-A
6-J
4-F
2-A
6-J
9-D
1-H
7-D
1-H
10-C
9-C
3-D
2-A
3-L
9-C
9-B
12-A
13-C
8-D
9-A
9-B
1-L
8-B
FLONASE
FLORINEF
FLOXIN
FLOXIN OTIC
fluconazole
fludrocortisone
FLUMADINE
fluocinolone acetonide
fluocinonide
fluorometholone ophth
fluorouracil
fluoxetine
fluphenazine
flurazepam
flurbiprofen
flurbiprofen ophth
flutamide
fluticasone
fluticasone nasal
fluvoxamine
FML FORTE
FML LIQUIFILM
FML SOP
FOCALIN
FOLBEE
FOLGARD RX
folic acid
FOLTX
FORADIL
formoterol inhaler
FORTEO
FORTICAL
FOSAMAX
fosfomycin
fosinopril
fosinopril-HCTZ
FOSRENOL
39
3-E
9-G
8-D
12-B
6-A
1-E
11-I
1-G
6-A
1-H
5-H
5-H
11-C
5-I
4-B
4-D
4-C
9-C
11-H
2-A
5-H
12-B
4-B
11-C
11-C
11-C
4-E
10-C
10-C
10-C
10-C
12-D
12-D
13-F
6-J
6-J
8-A
3-F
3-I
7-H
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
FRAGMIN
FURADANTIN
furosemide
FUZEON
gabapentin
GABARONE
galantamine
ganciclovir
GANTANOL
GANTRISIN
GARAMYCIN
gemfibrozil
GENGRAF
GENTAMICIN OINT 3%
gentamicin topical
gentamycin sulfate ophth
glatiramer acetate
glimepiride
glipizide
glipizide CR
glipizide-metformin
GLUCAGON
GLUCOPHAGE XR
GLUCOTROL
GLUCOTROL XL
GLUCOVANCE
glyburide
glyburide-metformin
glycopyrrolate
GLYNASE
golimumab
GOLYTELY
granisetron
GRIFULVIN V
griseofulvin microsize
griseofulvin ultramicrosize
GRIS-PEG
guaifenesin-codeine
guanfacine
guanfacine
PDL Section
Drug Name
PDL Section
GYNAZOLE-1
HALCION
HALDOL
haloperidol
HARVONI
HEXALEN
HIVID
homatropine ophth
HUMALOG
HUMALOG MIX
HUMALOG MIX PEN
HUMALOG PEN
HUMIRA
HUMULIN
HUMULIN PEN
HYCODAN
13-A
8-A
3-J
1-I
4-G
4-G
4-F
1-H
1-L
1-L
5-C
3-L
2-B
11-A
5-C
11-A
13-E
6-F
6-F
6-F
6-F
6-H
6-F
6-F
6-F
6-F
6-F
6-F
7-C
6-F
13-H
7-A
7-F
1-G
1-G
1-G
1-G
12-C
3-H
4-F
HYDERGINE
hydralazine
HYDREA
hydrochlorothiazide
hydrocodone-guaifenesin
hydrocodone-homatropine
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone rectal
hydrocortisone topical
hydrocortisone valerate
hydrocortisone-acetic acid otic
hydrocortisone-pramoxine rectal
HYDRODIURIL
hydromorphone
hydroxychloroquine
hydroxyurea
hydroxyzine HCL
hydroxyzine pamoate
HYGROTON
HYLIRA
hyoscyamine
hyoscyamine SR
HYPER-SAL NEBULIZER
40
8-C
4-C
4-D
4-D
13-D
2-A
1-I
11-E
6-G
6-G
6-G
6-G
13-H
6-G
6-G
12-C
4-F
3-H
2-A
3-J
12-C
12-C
6-A
5-H
5-A
5-H
5-H
11-I
5-A
3-J
9-B
1-J
2-A
4-A
4-A
3-J
5-H
7-C
7-C
12-D
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
HYTONE
HYTRIN
HYZAAR
ibuprofen
ibuprofen-hydrocodone
ILOSONE
IMBRUVICA
IMDUR
imipramine
imiquimod
IMITREX
IMITREX NASAL
IMURAN
indapamide
INDERAL
INDERAL LA
INDERIDE
indinavir sulfate
INDOCIN
INDOCIN SR
indomethacin
indomethacin CR
insulin (human)
insulin aspart
insulin aspart mix
insulin detemir
insulin glargine
insulin lispro
insulin lispro mix
INTAL (nebulizer)
INTAL INHALER
INTELENCE
interferon beta-1A
interferon gamma-1B
INTUNIV
INVEGA SUSTENNA
INVIRASE
iodoquinol
IOPIDINE
ipratropium HFA inhaler
PDL Section
Drug Name
5-H
3-H
3-I
9-C
9-B
1-C
2-A
3-B
4-B
5-I
9-E
9-E
2-B
3-J
3-C
3-C
3-I
1-I
9-C
9-C
9-C
9-C
6-G
6-G
6-G
6-G
6-G
6-G
6-G
12-D
12-D
1-I
13-E
13-I
4-F
4-D
1-I
1-L
11-G
12-D
PDL Section
ipratropium inhaler
ipratropium nasal
ipratropium nebulizer
irbesartan
irbesartan-hct
ISENTRESS
isoniazid
ISOPTO ATROPINE
ISOPTO CARPINE
ISOPTO HOMATROPINE
ISORDIL
isosorbide dinitrate
isosorbide mononitrate
isradipine
itraconazole
JOLIVETTE
JUNEL
JUNEL FE
KALETRA
KARIGEL
KARIGEL-N
KARIVA
KAYEXALATE
KEFLEX
KENALOG
KENALOG-ORABASE
KEPPRA
KEPPRA XR
KERALAC
KERLONE
ketoconazole
ketoconazole shampoo
ketoconazole topical
ketoprofen
ketorolac
ketorolac ophth
ketotifen
KLARON
KLONOPIN
K-PHOS
41
12-D
12-B
12-D
3-G
3-G
1-I
1-F
11-E
11-F
11-E
3-B
3-B
3-B
3-D
1-G
6-D
6-D
6-D
1-I
11-J
11-J
6-D
10-F
1-B
5-H
11-J
4-G
4-G
5-I
3-C
1-G
5-D
5-D
9-C
9-C
11-H
11-H
5-B
4-G
8-D
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
KWELL
KYTRIL
labetalol
LAC-HYDRIN
lactic acid
lactulose
LAMICTAL
LAMICTAL STARTER KIT
LAMISIL
lamivudine
lamivudine (hepatitis)
lamivudine-zidovudine
lamotrigine
LANOXIN
lanreotide acetate
lanthanum
LANTUS
LARIAM
LASIX
leflunomide
LESSINA
letrozole
leucovorin calcium
LEUKERAN
leuprolide acetate
LEVAQUIN
LEVBID
LEVEMIR
levetiracetam
LEVLEN
LEVLITE
levobunolol ophth
levocarnitine
levofloxacin
LEVORA
levothroid
levothyroxine
levoxyl
LEVSIN
LEVSINEX
PDL Section
Drug Name
PDL Section
LEXAPRO
LEXIVA
LIBRAX
LIBRIUM
LIDEX
lidocaine
lidocaine (topical)
lidocaine/hydrocortisone
lidocaine-prilocaine
LIMBITROL
lindane shampoo
LINZESS
LIORESAL
liothyronine
LIPITOR
liraglutide
lisdexamfetamine dimesylate
lisinopril
lisinopril-HCTZ
lithium carbonate
lithium carbonate CR
LITHOBID
L-methylfolate B12 B6
LOCOID
LODINE
LODINE XL
LOESTRIN
LOESTRIN FE
LOFIBRA
LOMOTIL
lomustine
LONITEN
LO OVRAL
LOPID
lopinavir-ritonavir
LOPRESSOR
LOPRESSOR HCTZ
LOPROX
lorazepam
losartan
5-G
7-F
3-C
5-I
5-I
7-A
4-G
4-G
1-G
1-I
7-H
1-I
4-G
3-A
13-G
7-H
6-G
1-J
3-J
9-D
6-D
2-A
2-A
2-A
13-I
1-E
7-C
6-G
4-G
6-D
6-D
11-B
6-J
1-E
6-D
6-I
6-I
6-I
7-C
7-C
42
4-B
1-I
7-C
4-A
5-H
11-J
5-I
5-I
5-I
4-F
5-G
7-H
9-G
6-I
3-L
6-J
4-E
3-F
3-I
4-D
4-D
4-D
10-C
5-H
9-C
9-C
6-D
6-D
3-L
7-B
2-A
3-H
6-D
3-L
1-I
3-C
3-I
5-D
4-A
3-G
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
losartan-HCTZ
LOTENSIN
LOTENSIN HCT
LOTREL
LOTRIMIN
LOTRISONE
lovastatin
LOVENOX
LOW-OGESTREL
loxapine
LOXITANE
LOZOL
lubiprostone
LUDIOMIL
LUMIGAN
LUTERA
LUVOX
LYSODREN
MACROBID
MACRODANTIN
MAKENA
maprotiline
MATULANE
MAVIK
MAXALT
MAXIDONE
MAXZIDE
MEBARAL
mebendazole
meclizine
MEDROL
medroxyprogesterone
mefloquine
MEGACE
megestrol
meloxicam
melphalan
MENEST
meperidine
mephobarbital
PDL Section
Drug Name
3-I
3-F
3-I
3-I
5-D
5-D
3-L
13-A
6-D
4-D
4-D
3-J
7-H
4-B
11-D
6-D
4-B
2-A
8-A
8-A
6-E
4-B
2-A
3-F
9-E
9-B
3-J
4-C
1-K
7-F
6-A
6-E
1-J
2-A
2-A
9-C
2-A
6-C
9-B
4-C
PDL Section
MEPHYTON
meprobamate
MEPRON
mercaptopurine
mesalamine
mesalamine CR
mesalamine EC
mesalamine enema
mesna
MESNEX
MESTINON
METAGLIP
METANX
metaproterenol inhaler
metaproterenol nebulizer
metaproterenol tablets
metformin
metformin SR
METHADONE
methamphetamine
methazolamide
methenamine-NA biphosphate
methimazole
methocarbamol
methocarbamol-ASA
methotrexate
methotrexate
methyclothiazide
methyldopa
methyldopa-HCTZ
METHYLIN
METHYLIN ER
methylphenidate
methylphenidate CR
methylprednisolone
metipranolol ophth
metoclopramide
metolazone
metoprolol
metoprolol succinate SR
43
10-A
4-A
1-l
2-A
7-H
7-H
7-H
7-H
2-A
2-A
9-H
6-F
10-C
12-D
12-D
12-D
6-F
6-F
9-B
4-E
3-J
8-A
6-I
9-G
9-G
2-A
9-D
3-J
3-H
3-I
4-E
4-E
4-E
4-E
6-A
11-B
7-H
3-J
3-C
3-C
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
METROCREAM
METROGEL
METROGEL vaginal
METROLOTION
metronidazole
metronidazole cream
metronidazole lotion
metronidazole vaginal
MEVACOR
mexiletine
MEXITIL
MIACALCIN
MICROGESTIN
MICROGESTIN FE
MICROZIDE
midodrine
MIDRIN
miglustat
MINIPRESS
MINITRAN
MINOCIN
minocycline
minoxidil
MIRAPEX
MIRCETTE
mirtazapine
mirtazapine soltabs
MIRVASO
misoprostol
mitotane
MOBIC
MODICON
MODURETIC
moexipril
moexipril-HCTZ
mometasone
mometasone inhaler
MONONESSA
MONOPRIL
MONOPRIL HCT
PDL Section
Drug Name
PDL Section
montelukast
MONUROL
moricizine
morphine sulfate
morphine sulfate SR
MOTRIN
MS CONTIN
MUCOMYST
mupirocin
MYAMBUTOL
MYCELEX TROCHE
MYCIFRADIN
mycophenolate mofetil
MYCOSTATIN susp
MYCOSTATIN topical
MYDRIACYL
MYLERAN
MYSOLINE
nabumetone
nadolol
nadolol-bendroflumethiazide
nafarelin
NALFON
naltrexone
NAPROSYN
naproxen
naproxen sodium
NARDIL
NASACORT ALLERGY OTC
NATALCARE
nateglinide
NATELLE C
NATURE-THROID
NAVANE
nebivolol
NECON
NECON 10/11
NECON 7/7/7
nedocromil inhaler
nefazodone HCL
5-B
5-B
8-C
5-B
1-L
5-B
5-B
8-C
3-L
3-E
3-E
6-J
6-D
6-D
3-J
3-K
9-E
7-G
3-H
3-B
1-D
1-D
3-H
4-H
6-D
4-B
4-B
5-B
7-C
2-A
9-C
6-D
3-J
3-F
3-I
5-H
12-E
6-D
3-F
3-I
44
12-D
8-A
3-E
9-B
9-B
9-C
9-B
12-C
5-C
1-F
11-J
1-L
2-B
1-G
5-D
11-E
2-A
4-G
9-C
3-C
3-I
13-G
9-C
9-B
9-C
9-C
9-C
4-B
12-B
10-B
6-F
10-B
6-I
4-D
3-C
6-D
6-D
6-D
12-D
4-B
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
PDL Section
Drug Name
PDL Section
NORA-BE
NORCO
NORDITROPIN
norethindrone
NORFLEX
NORITATE
NORMODYNE
NORPACE
NORPRAMIN
NORTHYX
NORTREL
NORTREL 7/7/7
nortriptyline
NORVASC
NORVIR
NOVAHISTINE
NOVOLIN
NOVOLOG
NOVOLOG MIX
NUCYNTA ER
NULEV
NULYTELY
NUVARING
nystatin
nystatin topical
nystatin vaginal
nystatin-triamcinolone
OCTREOTIDE
octreotide acetate
octreotide acetate release
OCUFEN
OCUFLOX
OCUPRESS
ofloxacin
ofloxacin ophth
ofloxacin otic
OGEN
OGEN vaginal
OGESTREL
OLUX
neomycin
1-L
neomycin-polymyxin B-gramacidin ophth 11-A
neomycin-polymyxin-HC cream
5-C
neomycin-polymyxin-HC ophth
11-C
neomycin-polymyxin-HC otic
11-I
NEORAL
2-B
NEOSPORIN ophth
11-A
nepafenac ophth
11-H
NEPHROCAPS
10-B
NEPTAZANE
3-J
NESTABS
10-B
NEULASTA
13-C
NEUMEGA
13-I
NEUPOGEN
13-C
4-G
NEURONTIN
NEVANAC
11-H
nevirapine
1-I
nevirapine XR
1-I
NIASPAN
3-L
nicardipine
3-D
NICOTROL INHALER
4-I
NICOTROL NS
4-I
nifedipine CR
3-D
nifedipine IR
3-D
nitisinone
13-I
NITROBID
3-B
NITRO-DUR
3-B
nitrofurantoin macro
8-A
nitrofurantoin macrocrystals
8-A
nitrofurantoin susp
8-A
nitroglycerin ointment
3-B
nitroglycerin patch
3-B
nitroglycerin spray
3-B
NITROLINGUAL PUMPSPRAY
3-B
nitroquick
3-B
NITROSTAT
3-B
nizatadine
7-D
NIZORAL
1-G
NIZORAL SHAMPOO
5-D
NOLVADEX
2-A
45
6-D
9-B
13-B
6-E
9-G
5-B
3-C
3-E
4-B
6-I
6-D
6-D
4-B
3-D
1-I
12-C
6-G
6-G
6-G
9-B
7-C
7-A
6-D
1-G
5-D
8-C
5-D
13-G
13-G
13-G
11-H
11-A
11-B
1-E
11-A
11-I
6-C
8-C
6-D
5-H
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
OLYSIO
omeprazole
OMNICEF
ondansetron
ONE TOUCH PRODUCTS
oprelvekin
OPSUMIT
OPTIPRANOLOL
ORAPRED
ORFADIN
orphenadrine citrate
ORTHO CEPT
ORTHO CYCLEN
ORTHO EVRA
ORTHO MICRONOR
ORTHO NOVUM 1/35
ORTHO NOVUM 1/50
ORTHO NOVUM 10/11
ORTHO NOVUM 7/7/7
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-PREFEST
ORUDIS
OVCON-35
oxandralone
OXANDRIN
oxaprozin
oxazepam
oxcarbazepine
oxybutynin
oxybutynin CR
oxycodone
oxycodone-APAP
oxycodone-ASA
OXYIR
oxymetholone
oxymorphone ER
paliperidone palmitate
palonosetron
PAMELOR
PDL Section
Drug Name
13-D
7-E
1-B
7-F
6-K
13-I
3-H
11-B
6-A
13-I
9-G
6-D
6-D
6-D
6-D
6-D
6-D
6-D
6-D
6-D
6-D
6-C
9-C
6-D
13-I
13-I
9-C
4-A
4-G
8-B
8-B
9-B
9-B
9-B
9-B
13-I
9-B
4-D
13-I
4-B
PDL Section
PANCREASE MT
PANCRECARB
pancrelipase
pantoprazole
papain-urea
papain-urea-chlorophyllin foam
PAPFYLL
PARAFON FORTE
PARCOPA
paricalcitol [vitamin D]
PARLODEL
paroxetine HCL
PAXIL
ped multi vitamin-fluoride
ped multi vitamin-fluoride-FE
ped vitamins ACD-fluoride
ped vitamins ACD-fluoride-FE
PEDIAPRED
PEDIATEX D
PEDIATEX DM
PEDIAZOLE
PEG electrolyte
peg(high)-electrolyte
pegademase
PEGASYS
pegfilgrastim
peginterferon alfa-2A
pegvisomant
pemoline
penicillamine
penicillin V potassium
PENLAC
pentazocine-naloxone
pentosan polysulfate sodium
pentoxifylline
PEPCID
PE-pyrilamine-hydrocodone
PERCOCET
PERCODAN
pergolide
46
7-G
7-G
7-G
7-E
5-I
5-I
5-I
9-G
4-H
10-A
4-H
4-B
4-B
10-B
10-B
10-B
10-B
6-A
12-C
12-C
1-L
7-A
7-A
7-G
13-D
13-C
13-D
13-G
4-F
9-D
1-A
5-D
9-B
8-D
10-F
7-D
12-C
9-B
9-B
4-H
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
PERIACTIN
PERIDEX
PERIOSTAT
PERMAX
permethrin
perphenazine
perphenazine-amitriptyline
PERSANTINE
phenazopyridine
phenelzine sulfate
PHENERGAN
PHENERGAN VC
PHENERGAN w/CODEINE
phenobarbital
phenobarbital-belladonna
phenytoin
PHRENILIN
phytonadione
pilocarpine
pilocarpine ophth
PILOPINE HS
PILOPTIC-1/2
PILOPTIC-3
pindolol
piolitazone
piolitazone-glimepiride
piolitazone-metformin
piroxicam
PLAQUENIL
PLAVIX
PLENDIL
PLETAL
PLEXION
PNV-DHA
PNV-SELECT
PODOCON
podofilox
podophyllum resin
POLYSPORIN ophth
POLYTRIM ophth
PDL Section
Drug Name
PDL Section
POLY-VI-FLOR
12-A
11-J
1-D
4-H
5-G
4-D
4-F
10-F
8-D
4-B
12-A
12-C
12-C
4-C
7-C
4-G
9-A
10-A
11-J
11-F
11-F
11-F
11-F
3-C
6-F
6-F
6-F
9-C
1-J
10-F
3-D
10-F
5-B
10-B
10-B
5-I
5-I
5-I
11-A
11-A
10-B
POLY-VI-FLOR-FE
10-B
PORTIA
6-D
POTABA
10-A
potassium aminobenzoate
10-A
POTASSIUM CHLORIDE
8-D
potassium citrate CR
8-D
potassium phosphate
8-D
pramipexole
4-H
pramlintide
6-J
PRAMOSONE
5-H
pramoxine-HC cream
5-H
pramoxine-HC foam
5-H
PRANDIMET
6-F
PRANDIN
6-F
PRAVACHOL
3-L
pravastatin
3-L
prazosin
3-H
PRECARE
10-B
PRECOSE
6-F
PRED FORTE
11-C
prednicarbate
5-H
prednisolone
6-A
6-A
PREDNISOLONE
11-C
prednisolone ophth
prednisolone sodium
6-A
prednisone
6-A
PRELONE
6-A
PREMARIN
6-C
PREMARIN vaginal
8-C
PREMPHASE
6-C
PREMPRO
6-C
PRENATABS
10-B
prenatal FE-CBN-DSS-Methylfol-FA 10-B
prenatal vitamin-FE-bisglycinate-FA 10-B
prenatal vitamins-fe- bis-fe prot succ-fa-ca10-B
prenatal vitamins-FE-FA
10-B
prenatal vitamins-FE-FA-CA-omega 10-B
prenatal vitamins-iron carbonyl-FA
10-B
PRENATE ELITE
10-B
47
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
prenate vitamin FE-Fum-Lmethylfol-FA-CA
PREVIFEM
PREZISTA
PRILOSEC
PRIMACARE
primaquine
PRIMAQUINE
primidone
PRINCIPEN
PRINIVIL
PRINZIDE
PROAMATINE
PRO-BANTHINE
probenecid
procainamide
procainamide SR
PROCANBID
procarbazine HCL
PROCARDIA
PROCARDIA XL
prochlorperazine
PROCTOFOAM-HC
PROGRAF
PROLIXIN
promethazine
promethazine DM
promethazine VC
promethazine-codeine
PRONESTYL
propafenone
propantheline
PROPINE
propoxyphene
propoxyphene nap-APAP
propoxyphene-APAP
propranolol
propranolol HCL CR
propranolol-HCTZquinapril-HCTZ
propylthiouracil
PROSCAR
PDL Section
Drug Name
PDL Section
PROSOM
PROTONIX
PROTOPIC
PROVENTIL (nebulizer)
PROVENTIL (tablets)
PROVENTIL REPETABS
PROVERA
PROZAC
PSE-guaifenesin-codeine
PSE-methscopolamine
PSORCON
PSORIATEC
PTU
PULMICORT
PULMOZYME
PURINETHOL
pyrazinamide
PYRIDIUM
pyridostigmine
pyrilamine-phenyleph
pyrimethamine
QUESTRAN
quetiapine fumarate
quinapril
quinidine gluconate
quinidine sulfate
quinine sulfate
QUIXIN
QVAR
raloxifene
ramipril
RANEXA
ranitidine
ranolazine
RAPAMUNE
RAZADYNE
RAZADYNE ER
REBETOL capsules/tablets
REBIF
RECLIPSEN
10-B
6-D
1-I
7-E
10-B
1-J
1-J
4-G
1-A
3-F
3-I
3-K
7-C
9-F
3-E
3-E
3-E
2-A
3-D
3-D
4-D
5-A
2-B
4-D
12-A
12-C
12-C
12-C
3-E
3-E
7-C
11-G
9-B
9-B
9-B
3-C
3-C
3-I
6-I
8-D
48
4-C
7-E
5-I
12-D
12-D
12-D
6-E
4-B
12-C
12-C
5-H
5-F
6-I
12-E
1-L
2-A
1-F
8-D
9-H
12-C
1-J
3-L
4-D
3-F
3-E
3-E
1-J
11-A
12-E
6-J
3-F
3-M
7-D
3-M
2-B
4-F
4-F
1-H
13-E
6-D
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
REGLAN
RELAFEN
REMERON
REMERON SOLTABS
repaglinide
repaglinide-metformin
REQUIP
RESCRIPTOR
RESTORIL
RETIN-A
RETIN-A MICRO
RETROVIR
REVIA
REYATAZ
ribavirin
RIDAURA
RIFADIN
rifampin
rilonacept
rimantadine
rimexolone ophth
RISPERDAL
RISPERDAL M
risperidone
RITALIN
RITALIN SR
rivaroxaban
rivastigmine
ROBAXIN
ROBAXISAL
ROBINUL
ROBINUL FORTE
ROCALTROL
RONDEC
RONDEC DM
ropinirole
ROWASA
ROXANOL
ROXICODONE
RYNA-12
PDL Section
Drug Name
PDL Section
RYNATAN-S
RYTHMOL
sacrosidase
SALAGEN
salsalate
SANDIMMUNE
SCOPACE
scopolamine oral
SEASONALE
SECTRAL
SELEGILINE
selenium sulfide shampoo
SELSUN
SELZENTRY
SEPTRA
SERAX
SEROQUEL
SEROQUEL XR
SEROSTIM
sertraline HCL
SERZONE
SILVADENE
silver sulfadiazine
SIMPONI
simvastatin
SINEMET
SINEMET CR
SINEQUAN
SINGULAIR
sirolimus
SLO-PHYLLIN
SMZ-TMP
sodium chloride soln nebu 7%
sodium fluoride
sodium hyaluronate
sodium oxybate
sodium phenylbutyrate
sodium polystyrene sulfonate
SOLIA
SOMA
7-H
9-C
4-B
4-B
6-F
6-F
4-H
1-I
4-C
5-B
5-B
1-I
9-B
1-I
1-H
9-D
1-F
1-F
13-I
1-H
11-C
4-D
4-D
4-D
4-E
4-E
10-D
4-F
9-G
9-G
7-C
7-C
10-A
12-C
12-C
4-H
7-H
9-B
9-B
12-C
49
12-C
3-E
7-G
11-J
9-A
2-B
7-F
7-F
6-D
3-C
4-H
5-I
5-I
1-I
1-L
4-A
4-D
4-D
13-B
4-B
4-B
5-C
5-C
13-H
3-L
4-H
4-H
4-B
12-D
2-B
12-D
1-L
12-D
11-J
5-H
4-E
7-G
10-F
6-D
9-G
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
SOMA COMPOUND
SOMA CPD w/CODEINE
somatropin
SOMATULINE
SOMAVERT
SOMNOTE
SONATA
sotalol
sotalol AF
SOVALDI
SPECTAZOLE
spironolactone
spironolactone-HCTZ
SPORANOX
SPRINTEC
SROYNX
STADOL NS
STARLIX
stavudine
STELAZINE
STRATTERA
STRIBILD
STUARTNATAL
SUBOXONE FILM TAB
SUCRAID
sucralfate
sulfacetamide lotion (acne)
sulfacetamide sodium ophth
sulfacetamide-prednisolone ophth
sulfacetamide-sulfur emulsion
sulfacetamide-urea lotion
sulfadiazine
sulfamethoxazole
sulfanilamide vaginal
sulfasalazine
sulfasalazine EC
sulfinpyrazone
SULFINPYRAZONE
sulfisoxazole
sulindac
PDL Section
Drug Name
PDL Section
sumatriptan
SUMATRIPTAN INJ
SUMYCIN
SUSTIVA
SYMBICORT
SYMLIN AMYLIN ANALOG
SYNALAR
SYNAREL
SYNTHROID
tacrolimus
tacrolimus topical
TAGAMET
TALWIN NX
TAMBOCOR
TAMIFLU
tamoxifen
tamsulosin
TAPAZOLE
tapentadol sr
TAVIST
TEBAMIDE
TECFIDERA
TEGRETOL
TEGRETOL XR
telaprevir
temazepam
TEMOVATE
TENEX
tenofovir
TENORETIC
TENORMIN
TERAZOL
terazosin
terbinafine HCL
terbutaline
terconazole vaginal
teriparatide (recombinant)
TESLAC
TESSALON
testolactone
testolactone
9-G
9-G
13-B
13-G
13-G
4-C
4-C
3-C
3-C
13-D
5-D
3-J
3-J
1-G
6-D
6-D
9-B
6-F
1-I
4-D
4-E
1-I
10-B
9-B
7-G
7-C
5-B
11-A
11-C
5-B
5-I
1-L
1-L
8-C
7-H
7-H
9-F
9-F
1-L
9-C
50
9-E
9-E
1-D
1-I
12-D
6-J
5-H
13-G
6-I
2-B
5-I
7-D
9-B
3-E
11-H
2-A
8-D
6-I
9-B
12-A
7-F
13-E
4-G
4-G
13-D
4-C
5-H
3-H
1-I
3-I
3-C
8-C
3-H
1-G
12-D
8-C
13-F
2-A
12-C
2-A
2-A
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
tetracycline
TEV-TROPIN
THEO-24
THEOLAIR
theophylline
theophylline CR
theophylline SR
thioguanine
THIOGUANINE
thioridazine
thiothixene
THORAZINE
thyroid
TIAZAC
TICLID
ticlopidine
TIGAN
TILADE
TILIA FE
timolol maleate
timolol maleate ophth
timolol ophth
TIMOPTIC
TIMOPTIC XE
tiotropium inhaler
TIROSINT
TIVICAY
tizanidine
TOBRADEX
tobramycin
tobramycin ophth
tobramycin-dexamethasone ophth
TOBREX
tocainide
TOFRANIL
tolazamide
tolbutamide
TOLBUTAMIDE
TOLECTIN
TOLINASE
PDL Section
Drug Name
PDL Section
tolmetin sodium
TONOCARD
TOPAMAX
TOPAMAX SPRINKLES
TOPICORT
topiramate
TOPROL XL
TORADOL
torsemide
TRACLEER
tramadol
tramadol-APAP
TRANDATE
trandolapril
TRANXENE
travaprost ophth
TRAVATAN
trazodone
TRENTAL
tretinoin
tretinoin
triamcinolone acetonide
triamcinolone/orabase
triamterene-HCTZ
triazolam
TRICOR
trifluoperazine
trifluridine ophth
trihexyphenidyl
TRILAFONE
TRI-LEGEST FE
TRILEPTAL
TRI-LEVLEN
TRILISATE
trimethobenzamide
trimethobenzamide-benzocaine
trimethoprim
trimethoprim-polymy B ophth
TRIMPEX
TRINALIN
1-D
13-B
12-D
12-D
12-D
12-D
12-D
2-A
2-A
4-D
4-D
4-D
6-I
3-D
10-F
10-F
7-F
12-D
6-D
3-C
11-B
11-B
11-B
11-B
12-D
6-I
1-I
9-G
11-C
1-L
11-A
11-C
11-A
3-E
4-B
6-F
6-F
6-F
9-C
6-F
51
9-C
3-E
4-G
4-G
5-H
4-G
3-C
9-C
3-J
3-H
9-B
9-B
3-C
3-F
4-A
11-D
11-D
4-B
10-F
2-A
5-B
5-H
11-J
3-J
4-C
3-L
4-D
11-A
4-H
4-D
6-D
4-G
6-D
9-A
7-F
7-F
1-L
11-A
1-L
12-C
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
TRINESSA
TRI NORINYL
triple sulfas vaginal
TRI-PREVIFEM
TRI-SPRINTEC
TRI-VI-FLOR
TRI-VI-FLOR-FE
TRIVORA
TRIZIVIR
tropicamide ophth
TRUSOPT
TRUVADA
TRYCET
trypsin-castor oil-peruvian balsam
TUDORZA
TUSSI-ORGANIDIN
TWINJECT
TYLENOL w/CODEINE
ULTRACET
ULTRAM
ULTRASE
ULTRASE MT
UNIPHYL
UNIRETIC
unithroid
UNIVASC
urea
urea (carbamide)
URECHOLINE
URISPAS
UROCIT-K
UROQID
URSO
ursodiol
VALISONE
VALIUM
valproic acid
VANAMIDE
VANDAZOLE
VANTIN
PDL Section
Drug Name
6-D
6-D
8-C
6-D
6-D
10-B
10-B
6-D
1-I
11-E
11-H
1-I
9-B
5-I
12-D
12-C
3-K
9-B
9-B
9-B
7-G
7-G
12-D
3-I
6-I
3-F
5-I
5-I
8-B
8-B
8-D
8-A
7-H
7-H
5-H
4-A
4-G
5-I
8-C
1-B
PDL Section
VASERETIC
VASOTEC
VECTICAL
VEETIDS
VELOSEF
venlafaxine
venlafaxine SR
VENLAFAXINE XR
VENTOLIN HFA
VEPESID
verapamil
verapamil SR
VERELAN PM
VERMOX
VESANOID
VEXOL
VFEND
VIBRAMYCIN
VIBRATABS
VICTOZA
VIDEX EC
VIDEX PEDIATRIC
VIEKIRA
VIOKASE
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIREAD
VIROPTIC
VISCOUS LIDOCAINE
VISKEN
VISTARIL
VIVACTIL
VIVELLE
VIVELLE DOT
VOLTAREN
VOLTAREN XR
voriconazole
VOSOL-HC
VOSPIRE ER
52
3-I
3-F
5-F
1-A
1-B
4-B
4-B
4-B
12-D
2-A
3-D
3-D
3-D
1-K
2-A
11-C
1-G
1-D
1-D
6-J
1-I
1-I
13-D
7-G
1-I
1-I
1-I
1-I
11-A
11-J
3-C
4-A
4-B
6-C
6-C
9-C
9-C
1-G
11-I
12-D
Medicaid Drug Benefit Guide 02/01/2015
Alphabetical Index
Drug Name
VYVANSE
warfarin
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
WELLCOVORIN
WESTCORT
XANAX
XANAX XR
XARELTO
XENADERM
XYLOCAINE
XYREM
YASMIN
YAZ
YODOXIN
ZADITOR
zafirlukast
zalcitabine
zaleplon
ZANAFLEX
ZANTAC
ZARONTIN
ZAROXOLYN
ZAVESCA
ZEBETA
ZEMPLAR
ZENPEP
ZERIT
ZESTORETIC
ZESTRIL
ZIAC
ZIAGEN
zidovudine
ZITHROMAX
PDL Section
Drug Name
PDL Section
ZOCOR
ZOFRAN
ZOFRAN ODT
ZOLOFT
zolpidem
ZONEGRAN
zonisamide
ZOVIRAX
ZOVIRAX topical
ZYBAN
ZYDONE
ZYLOPRIM
ZYPREXA
4-E
10-F
4-B
4-B
4-B
2-A
5-H
4-A
4-A
10-D
5-I
5-I
4-E
6-D
6-D
1-L
11-H
12-D
1-I
4-C
9-G
7-D
4-G
3-J
7-G
3-C
10-A
7-G
1-I
3-I
3-F
3-I
1-I
1-I
1-C
53
3-L
7-F
7-F
4-B
4-C
4-G
4-G
1-H
5-E
4-I
9-B
9-F
4-D
Medicaid Drug Benefit Guide 02/01/2015

Preferred Drug List (PDF)

Preferred Drug List

Hy-Vee $4 generic program

Product Order Form - FHP India Website

The University Physicians Healthcare drug formulary is subject to

Preferred Drug List

**Please note that generic and Medicaid covered over-the

APO-IMATINIB TABS