Drug List - Health Plan of Nevada

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Drug List - Health Plan of Nevada
Preferred Drug List
 Medicaid
21NVMDCD11268
Medicaid Preferred Drug List
Table of Contents
Introduction .............................................................. i
Drug Benefit Guide .................................................. 1
Section 1
Section 2
Section 3
Section 4
Section 5
Section 6
Section 7
Section 8
Section 9
Section 10
Section 11
Section 12
Section 13
Anti-Infectives
Cancer and Transplant
Cardiovascular
Central Nervous System
Dermatologicals
Endocrine and Hormones
Gastrointestinals
Genitourinary
Musculoskeletal and Pain
Vitamins and Hematologicals
Eye, Ear, and Throat
Respiratory
Self-Injectable/Specialty
Alphabetical Index ................................................... 31
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 Brand Name
amoxicillin *AMOXIL
amoxicillin-clavulanate *AUGMENTIN
ampicillin *PRINCIPEN
aztreonam CAYSTON
dicloxacillin *DYNAPEN
penicillin V potassium *VEETIDS
1-B Cephalosporins
Generic Name Brand Name
cefaclor ER CECLOR CD
cefaclor *CECLOR
cefadroxil *DURICEF
cefdinir *OMNICEF (capsules)
cefdinir *OMNICEF (suspension) 125mg/5ml
cefdinir *OMNICEF (suspension) 250mg/5ml
cefpodoxime *VANTIN 200mg
cefprozil *CEFZIL 250mg
cefprozil *CEFZIL 500mg
cefprozil *CEFZIL 125mg/ml
cefprozil *CEFZIL 250mg/ml
cefuroxime *CEFTIN (suspension)
cefuroxime *CEFTIN (tablets)
cephalexin *KEFLEX
1-C Macrolides
Generic Name Brand Name
azithromycin *ZITHROMAX 250mg
azithromycin *ZITHROMAX 500mg
azithromycin *ZITHROMAX 600mg
azithromycin *ZITHROMAX 100mg/5ml
azithromycin *ZITHROMAX 200mg/5ml
clarithromycin *BIAXIN
clarithromycin *BIAXIN suspension
clarithromycin SR *BIAXIN XL
clindamycin *CLEOCIN
erythromycin EC ERY-TAB
erythromycin ethylsuccinate *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 (84 mls/42 days) PA
Notes
QL (2 tabs/per day)
QL (2 caps/per day)
QL (24 ml/day)
QL (12 ml/day)
QL (28 tablets/month)
QL (28 tablets/month)
QL (28 tablets/month)
QL (140 mls/month)
QL (140 mls/month)
QL (28 tablets/month)
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 09/01/16
1-D
1-E
1-F
1-G
1-H
erythromycin ethylsuccinate ERYPED
erythromycin stearate *ERYTHROCIN
ERYTHROMYCIN BASE
Tetracyclines
Generic Name Brand Name
doxycycline hyclate *PERIOSTAT 20mg
doxycycline monohydrate *MONODOX 50mg & 100mg
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
ribavirin *COPEGUS tablets
ribavirin *REBETOL capsules/tablets
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 capsules/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)
QL (180 capsules/tabletsmonth) PA
QL (180 capsules/tabletsmonth) PA
Medicaid Drug Benefit Guide 09/01/16
QL (25ml's per day) PA
QL (14 pills/fill)
QL (60 tablets/month)
QL (30 tablets/month)
ribavirin *REBETOL solution
rimantadine *FLUMADINE
valacyclovir *VALTREX 500mg
valacyclovir *VALTREX 1gm
1-I Antiretrovirals
Generic Name Brand Name
Notes
abacavir sulfate ZIAGEN
abacavir sulfate-lamivudine EPZICOM
QL (30 tablets/month)
abacavir-dolutegravir-lamivudine TRIUMEQ
abacavir sulfate-lamivudine-zidovudine TRIZIVIR
atazanavir REYATAZ
SP QL (30 tablets/month)
cobicistat TYBOST
darunavir PREZISTA
SP QL (30 tablets/month)
darunavir-cobicistat PREZCOBIX
delavirdine RESCRIPTOR
didanosine
didanosine *VIDEX EC
didanosine VIDEX PEDIATRIC
dolutegravir TIVICAY
efavirenz SUSTIVA
efavirenz-emtricitabine-tenofovir df ATRIPLA
elvitegrav-cobicis-emtricitab-tenofov STRIBILD
ST
Stribild ST = requires failure/contraindication to Triumeq
QL (30 capsules/month)
emtricitabine EMTRIVA
emtricitabine-rilpivirine-tenofovir df COMPLERA
emtricitabine-tenofovir disoproxil fumarate TRUVADA
QL ( 30 tablets/month)
enfuvirtide FUZEON
etravirine INTELENCE
fosamprenavir LEXIVA
indinavir sulfate CRIXIVAN
lamivudine-zidovudine *COMBIVIR
lamivudine *EPIVIR
lamivudine
lopinavir-ritonavir KALETRA
PA
maraviroc SELZENTRY
nelfinavir VIRACEPT
nevirapine *VIRAMUNE
nevirapine XR VIRAMUNE XR 100MG
nevirapine XR *VIRAMUNE XR 400MG
raltegravir ISENTRESS
PA
raltegravir ISENTRESS PACKET
rilpivirine EDURANT
ritonavir NORVIR
saquinavir INVIRASE
stavudine *ZERIT
tenofovir VIREAD
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 09/01/16
tipranavir APTIVUS
zidovudine *RETROVIR
1-J Antimalarials
Notes
Generic Name Brand Name
chloroquine *ARALEN
hydroxychloroquine *PLAQUENIL
mefloquine *LARIAM
primaquine *PRIMAQUINE
pyrimethamine DARAPRIM
PA SP
quinine sulfate
1-K Anthelmintics
Notes
Generic Name Brand Name
ivacaftor granules pak and tablets KALYDECO
PA SP
lumacaftor-ivacaftor ORKAMBI
PA SP QL (112 tablets/month)
mebendazole *VERMOX
vancomycin FIRST-VANCOMYCIN ORAL SOL
1-L Misc Anti-Infectives
Notes
Generic Name Brand Name
atovaquone susp *MEPRON
dapsone DAPSONE
PA
dornase alfa PULMOZYME
EES-sulfisoxazole *PEDIAZOLE
iodoquinol YODOXIN
linezolid *ZYVOX
QL (2/day) (max of 84 tablets/365 days)
metronidazole *FLAGYL tablets
metronidazole *FLAGYL capsule
neomycin *MYCIFRADIN
SMZ-TMP *BACTRIM
SMZ-TMP *SEPTRA
sulfadiazine
tobramycin nebu soln 300mg/4ml BETHKIS
PA
trimethoprim *TRIMPEX
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
capecitabine *XELODA
ceritinib ZYKADIA
chlorambucil LEUKERAN
cyclophosphamide CYTOXAN
estramustine EMCYT
etoposide *VEPESID
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)
PA SP
PA SP
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Medicaid Drug Benefit Guide 09/01/16
exemestane *AROMASIN
flutamide *EULEXIN
hydroxyurea *HYDREA
ibrutinib cap IMBRUVICA
letrozole *FEMARA
leucovorin calcium *WELLCOVORIN
lomustine *CEENU
megestrol *MEGACE
melphalan ALKERAN
mercaptopurine *PURINETHOL
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
QL (30 tablets/month)
PA
QL (30 tablets/month)
PA
SP
Notes
CARDIOVASCULAR (drugs to treat heart conditions)
3-A Cardiotonics
Generic Name Brand Name
digoxin *LANOXIN
Notes
3-B Antianginals
Generic Name Brand Name
Notes
isosorbide dinitrate *ISORDIL
isosorbide mononitrate *IMDUR
nitroglycerin ointment NITROBID
nitroglycerin patch *MINITRAN
QL (1 patch/day)
nitroglycerin patch *NITRO-DUR
QL (1 patch/day)
nitroglycerin spray *NITROLINGUAL PUMPSPRAY QL (1 bottle/month)
nitroquick *NITROSTAT
3-C Beta Blockers
Notes
Generic Name Brand Name
acebutolol *SECTRAL
atenolol *TENORMIN
betaxolol *KERLONE
bisoprolol *ZEBETA
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 09/01/16
carvedilol
carvedilol
carvedilol
carvedilol
labetalol
labetalol
metoprolol
metoprolol succinate SR
nebivolol
nebivolol
nebivolol
nebivolol
pindolol
propranolol
propranolol HCL CR
sotalol
sotalol AF
timolol maleate
3-D Calcium Channel Blockers
Generic Name
amlodipine
cartia XT
diltiazem
diltiazem SR
diltiazem SR 12HR
felodipine
isradipine
nicardipine
nifedipine CR
nifedipine CR
nifedipine IR
nifedipine IR
verapamil
verapamil SR
verapamil SR
3-E Antiarrhythmics
Generic Name
amiodarone
disopyramide
flecainide
mexiletine
propafenone
quinidine gluconate
quinidine sulfate
quinidine sulfate er
*COREG 3.125mg
*COREG 6.25mg
*COREG 12.5mg
*COREG 25mg
*NORMODYNE
*TRANDATE
*LOPRESSOR
*TOPROL XL
BYSTOLIC 2.5mg
BYSTOLIC 5mg
BYSTOLIC 10mg
BYSTOLIC 20mg
*VISKEN
*INDERAL
*INDERAL LA
*BETAPACE
*BETAPACE AF
*BLOCADREN
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (120 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (120 tablets/month)
QL (60 tablets/month)
Brand Name
*NORVASC
Notes
QL (60 capsules/month)
*CARDIZEM
*TIAZAC
*CARDIZEM SR
*PLENDIL
*DYNACIRC
*CARDENE
*ADALAT CC
*PROCARDIA XL
*ADALAT CC
*PROCARDIA
*CALAN
*CALAN SR
*VERELAN PM
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
Brand Name
*CORDARONE
*NORPACE
*TAMBOCOR
*MEXITIL
*RYTHMOL
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
Notes
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Medicaid Drug Benefit Guide 09/01/16
3-F Angiotensin Converting Enzyme (ACE) Inhibitors
Generic Name Brand Name
benazepril *LOTENSIN
captopril *CAPOTEN
enalapril *VASOTEC
fosinopril *MONOPRIL
lisinopril *PRINIVIL
lisinopril *ZESTRIL
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
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
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 (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
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 (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)
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Medicaid Drug Benefit Guide 09/01/16
methyldopa-HCTZ *ALDORIL
metoprolol-hctz *LOPRESSOR-HCTZ
moexipril-HCTZ *UNIRETIC
QL (60 tablets/month)
nadolol-bendroflumethiazide *CORZIDE
QL (60 tablets/month)
propranolol-HCTZ *INDERIDE
quinapril-HCTZ *ACCURETIC
QL (60 tablets/month)
sacubitril-valsartan ENTRESTO
PA QL (60 tablets/month)
valsartan-HCTZ *DIOVAN-HCT 80-12.5mg & 160-12.5mg QL (60 tablets/month)
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
alirocumab inj PRALUENT
PA QL (2 inj/28 days) SP
atorvastatin *LIPITOR
QL (30 tablets/month)
cholestyramine *QUESTRAN
colestipol *COLESTID
ezetimibe ZETIA
PA QL (30 tablets/month)
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 54mg & 160mg
QL (30 tablets/month)
gemfibrozil *LOPID
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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lovastatin *MEVACOR 10mg
lovastatin *MEVACOR 20mg
lovastatin *MEVACOR 40mg
niacin tab cr *NIASPAN
pravastatin *PRAVACHOL
simvastatin *ZOCOR
3-M Miscellaneous Cardiovascular
Generic Name Brand Name
ranolazine RANEXA
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
Notes
QL (60 tablets/month)
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
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
desipramine *NORPRAMIN
doxepin *SINEQUAN
duloxetine *CYMBALTA
escitalopram *LEXAPRO 5MG
escitalopram *LEXAPRO 10MG
escitalopram *LEXAPRO 20MG
fluoxetine *PROZAC 10mg
fluoxetine *PROZAC 20mg
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)
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 (60 capsules/month)
QL (45 tablets/month)
QL (45 tablets/month)
QL (30 tablets/month)
QL (30 capsules/month)
QL (120 capsules/month)
Medicaid Drug Benefit Guide 09/01/16
fluoxetine *PROZAC 40mg
QL (60 capsules/month)
fluvoxamine *LUVOX
QL (90 tablets/month)
imipramine *TOFRANIL
maprotiline *LUDIOMIL
mirtazapine *REMERON
QL (30 tablets/month)
mirtazapine soltabs *REMERON SOLTABS
QL (30 tablets/month)
nefazodone HCL *SERZONE
nortriptyline *PAMELOR
paroxetine HCL *PAXIL 10mg
QL (30 tablets/month)
paroxetine HCL *PAXIL 20mg
QL (30 tablets/month)
paroxetine HCL *PAXIL 30mg
QL (60 tablets/month)
paroxetine HCL *PAXIL 40mg
QL (45 tablets/month)
phenelzine sulfate *NARDIL
protriptyline *VIVACTIL
sertraline HCL *ZOLOFT 25mg
QL (45 tablets/month)
sertraline HCL *ZOLOFT 50mg
QL (45 tablets/month)
sertraline HCL *ZOLOFT 100mg
QL (60 tablets/month)
trazodone *DESYREL
venlafaxine *EFFEXOR
QL (90 tablets/month)
venlafaxine SR *EFFEXOR XR (cap) 37.5mg
QL (90 capsules/month)
venlafaxine SR *EFFEXOR XR (cap) 75mg
QL (90 capsules/month)
venlafaxine SR *EFFEXOR XR (cap) 150mg
QL (60 capsules/month)
venlafaxine SR *VENLAFAXINE XR (tab) 37.5mg QL (90 tablets/month)
venlafaxine SR *VENLAFAXINE XR (tab) 75mg QL (90 tablets/month)
venlafaxine SR *VENLAFAXINE XR (tab) 150mg QL (60 tablets/month)
venlafaxine SR *VENLAFAXINE XR (tab) 225mg QL (30 tablets/month)
4-C Hypnotics (Sleep Aids)
Generic Name Brand Name
Notes
chloral hydrate SOMNOTE
estazolam *PROSOM
flurazepam *DALMANE
phenobarbital
temazepam *RESTORIL
QL (30 capsules/month)
triazolam *HALCION
QL (15 tablets/fill; 2 fills/month)
zaleplon *SONATA 5mg
QL (30 capsules/month)
zaleplon *SONATA 10mg
QL (60 capsules/month)
zolpidem *AMBIEN
QL (30 tablets/month)
4-D Antipsychotics
Generic Name Brand Name
Notes
aripiprazole IM inj *ABILIFY
PA
aripiprazole IM extended release susp ABILIFY MAINTENA
PA
brexpiprazole REXULTI
ST QL (30 tablets/month)
Rexulti ST = requires failure/contraindiation to aripiprazole AND one of the following: risperidone, olanzapine,
quetiapine IR, Seroquel XR or ziprasidone
chlorpromazine *THORAZINE
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
10
Medicaid Drug Benefit Guide 09/01/16
ST
clozapine *CLOZARIL (NTI)
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
paliperidone INVEGA TRINZA INJ
PA
lithium carbonate *ESKALITH
lithium carbonate CR *ESKALITH CR
lithium carbonate CR *LITHOBID
loxapine *LOXITANE
olanzapine *ZYPREXA TABLETS
paliperidone palmitate INVEGA SUSTENNA
PA QL (1 syringe/month)
perphenazine *TRILAFONE
prochlorperazine *COMPAZINE
quetiapine fumarate *SEROQUEL 25mg
QL (90 tablets/month)
quetiapine fumarate *SEROQUEL 50mg
QL (90 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)
risperidone *RISPERDAL
risperidone *RISPERDAL M
risperidone microspheres for inj RISPERDAL CONSTA
PA
risperidone soln 1mg/ml RISPERDAL SOLUTION
PA
thioridazine
thiothixene *NAVANE
trifluoperazine *STELAZINE
ziprasidone *GEODON
QL (60 capsules/month)
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)
dextroamphetamine *DEXEDRINE
dextroamphetamine *DEXEDRINE SPANSULES
lisdexamfetamine dimesylate VYVANSE
QL (30 capsules/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)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
11
Medicaid Drug Benefit Guide 09/01/16
methylphenidate *RITALIN 5mg
methylphenidate *RITALIN 10mg
methylphenidate *RITALIN 20mg
methylphenidate CR *RITALIN SR
sodium oxybate XYREM
4-F Misc Psychotherapeutic and Neurological Agents
Generic Name Brand Name
amitriptyline-chlordiazepoxide *LIMBITROL
disulfiram *ANTABUSE
donepezil *ARICEPT
ergoloid mesylates *HYDERGINE
galantamine *RAZADYNE
galantamine *RAZADYNE ER
guanfacine INTUNIV
perphenazine-amitriptyline *ETRAFON
rivastigmine *EXELON
rivastigmine *EXELON PATCH
4-G Anticonvulsants
Generic Name Brand Name
carbamazepine *TEGRETOL
carbamazepine SR *CARBATROL
carbamazepine SR *TEGRETOL XR
clonazepam *KLONOPIN
divalproex sodium EC *DEPAKOTE
divalproex sodium sprinkle *DEPAKOTE 125MG SPRINKLE
ethosuximide *ZARONTIN
felbamate susp 600mg/5ml *FELBATOL SOLUTION
gabapentin *GABARONE
gabapentin *NEURONTIN 100mg
gabapentin *NEURONTIN 300mg
gabapentin *NEURONTIN 400mg
gabapentin *NEURONTIN 600mg
gabapentin *NEURONTIN 800mg
lamotrigine *LAMICTAL
lamotrigine *LAMICTAL STARTER KIT
lamotrigine dispersible chewable *LAMICTAL CHEWABLE
levetiracetam *KEPPRA
levetiracetam SR *KEPPRA XR
oxcarbazepine *TRILEPTAL
phenytoin *DILANTIN
primidone *MYSOLINE
topiramate *TOPAMAX 25mg
topiramate *TOPAMAX 50mg, 100mg, 200mg
topiramate *TOPAMAX SPRINKLES
valproic acid *DEPAKENE
zonisamide *ZONEGRAN 25mg
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
12
QL (180 tablets/month)
QL (180 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
PA
Notes
QL (30 tablets/month)
QL (60 tablets/month)
QL (30 capsules/month)
QL (30 tablets/month)
QL (60 capsules/month)
QL (30 patches/month)
Notes
PA
PA
QL (240 capsules/month)
QL (360 capsules/month)
QL (270 capsules/month)
QL (180 tablets/month)
QL (120 tablets/month)
QL (1 kit/month)
PA
QL (120 tablets/month)
QL (90 tablets/month)
QL (120 capsules/month) PA
QL (120 capsules/month)
Medicaid Drug Benefit Guide 09/01/16
zonisamide *ZONEGRAN 50mg
zonisamide *ZONEGRAN 100mg
4-H Antiparkinsonian Agents
Generic Name 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 (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
Notes
hydrocortisone rectal *ANUSOL-HC
hydrocortisone-pramoxine rectal *ANALPRAM-HC
hydrocortisone-pramoxine rectal PROCTOFOAM-HC
5-B Acne Products
Generic Name Brand Name
Notes
benzoyl peroxide *BREVOXYL
QL (60 gm/month)
benzoyl peroxide-erythromycin gel *BENZAMYCIN
PA
brimonidine tartrate gel 0.33% MIRVASO
clindamycin phosphate-benzoyl peroxide gel *BENZACLIN
QL (50 gm/month)
clindamycin topical *CLEOCIN-T
erythromycin topical *ERYGEL
metronidazole cream *METROCREAM
QL (45gm/month)
metronidazole cream NORITATE**
QL (60 gm/month)
metronidazole 0.75% gel
QL (45gm/month)
metronidazole 1% gel *METROGEL
QL (60 gm/month)
metronidazole lotion *METROLOTION
sulfacetamide lotion (acne) *KLARON
AL
tretinoin *RETIN-A **
tretinoin RETIN-A MICRO **
AL
** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
13
Medicaid Drug Benefit Guide 09/01/16
5-C Topical Antibiotics
Notes
Generic Name Brand Name
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)
hydrocortisone topical *HYTONE
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
14
Medicaid Drug Benefit Guide 09/01/16
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 patch *LIDODERM PATCH
PA
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
conjugated estrogens-bazedoxifene DUAVEE
esterified estrogens MENEST
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 09/01/16
estradiol *ESTRACE
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
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/28 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)
Medicaid Drug Benefit Guide 09/01/16
6-E Progestins
Generic Name Brand Name
Notes
hydroxyprogesterone caproate IM in oil MAKENA
QL (5mls/month)
medroxyprogesterone acetate *DEPO-PROVERA
QL (1ml/90 days)
medroxyprogesterone *PROVERA
norethindrone *AYGESTIN
6-F Oral Antidiabetics (diabetes)
Generic Name Brand Name
Notes
acarbose *PRECOSE
QL (90 tablets/month)
albiglutide pen TANZEUM
QL (4/month) ST
Tanzeum ST - requires a 30-day trial of metformin within the past 2 years
canagliflozin INVOKANA
QL (30 tablets/month) ST
Invokana ST - requires a 30-day trial of metformin within the past 2 years
canagliflozin-metformin INVOKAMET
QL (60 tablets/month)
chlorpropamide *DIABINESE
empagliflozin JARDIANCE
QL (30 tablets/month) ST
Jardiance ST - requires a 30-day trial of metformin within the past 2 years
empagliflozin-metformin SYNJARDY
QL (60 tablets/month)
glimepiride *AMARYL
QL (60 tablets/month)
glipizide *GLUCOTROL 5mg
QL (120 tablets/month)
glipizide *GLUCOTROL 10mg
QL (120 tablets/month)
glipizide CR *GLUCOTROL XL 2.5mg
QL (90 tablets/month)
glipizide CR *GLUCOTROL XL 5mg
QL (60 tablets/month)
glipizide CR *GLUCOTROL XL 10mg
QL (60 tablets/month)
glipizide-metformin *METAGLIP
QL (120 tablets/month)
glyburide *DIABETA
glyburide micronized *GLYNASE
QL (60 tablets/month)
glyburide-metformin *GLUCOVANCE
QL (120 tablets/month)
linagliptin TRADJENTA
QL (30 tablets/month) ST
Tradjenta ST - requires a 30-day trial of metformin within the past 2 years
linagliptin-metformin JENTADUETO
QL (60 tablets/month) ST
Jentadueto ST - requires a 30-day trial of metformin within the past 2 years
metformin *GLUCOPHAGE 500mg
QL (150 tablets/month)
metformin *GLUCOPHAGE 850mg
QL (90 tablets/month)
metformin *GLUCOPHAGE 1000mg
QL (75 tablets/month)
metformin SR *GLUCOPHAGE XR 500mg
QL (120 tablets/month)
metformin SR *GLUCOPHAGE XR 750mg
QL (90 tablets/month)
nateglinide *STARLIX
QL (90 tablets/month)
pioglitazone ACTOS
QL (30 tablets/month)
pioglitazone-glimepiride *DUETACT
QL (30 tablets/month)
pioglitazone-metformin ACTOPLUS MET
QL (90 tablets/month)
repaglinide *PRANDIN
QL (120 tablets/month)
repaglinide-metformin PRANDIMET
saxagliptin ONGLYZA
QL (30 tablets/month) ST
Onglyza ST - requires a 30-day trial of metformin within the past 2 years
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
17
Medicaid Drug Benefit Guide 09/01/16
saxagliptin-metformin KOMBIGLYZE XR 5-500mg
QL (30 tablets/month) ST
Kombiglyze XR ST - requires a 30-day trial of metformin within the past 2 years
saxagliptin-metformin KOMBIGLYZE XR 5-1000mg QL (30 tablets/month) ST
Kombiglyze XR ST - requires a 30-day trial of metformin within the past 2 years
saxagliptin-metformin KOMBIGLYZE XR 2.5-1000mg QL (60 tablets/month) ST
Kombiglyze XR ST - requires a 30-day trial of metformin within the past 2 years
tolazamide *TOLINASE
tolbutamide *TOLBUTAMIDE
6-G Insulins
Generic Name Brand Name
Notes
insulin (human) NOVOLIN
insulin (human) HUMULIN
insulin (human) HUMULIN PEN
insulin aspart NOVOLOG
insulin aspart mix NOVOLOG MIX
insulin glargine LANTUS
ST
LANTUS ST - requires a 30-day trial of Toujeo within the past 180 days
insulin glargine TOUJEO SOLOSTAR
insulin lispro HUMALOG
insulin lispro HUMALOG PEN
insulin lispro mix HUMALOG MIX
insulin lispro mix HUMALOG MIX PEN
6-H Glucagon
Generic Name Brand Name
Notes
GLUCAGON
QL (2 kits/month)
6-I Thyroid Agents
Generic Name Brand Name
Notes
levothroid
QL (60 tablets/month)
levothyroxine
QL (60 tablets/month)
*SYNTHROID
levothyroxine
QL (60 tablets/month)
levoxyl
QL (60 tablets/month)
liothyronine *CYTOMEL
methimazole *TAPAZOLE
methimazole
QL (90 tablets/month)
propylthiouracil *PTU
thyroid NATURE-THROID
unithroid
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)
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 09/01/16
calcitonin (salmon) nasal *FORTICAL
QL (1 bottle/month)
calcitonin (salmon) nasal soln MIACALCIN
QL (2 bottles/month)
deferasirox JADENU
PA SP
QL (5mls/month)
desmopressin (nasal) *DDAVP
QL (30 tablets/month)
desmopressin (oral) *DDAVP 0.1mg
desmopressin (oral) *DDAVP 0.2mg
QL (90 tablets/month)
etidronate *DIDRONEL
levocarnitine *CARNITOR
liraglutide VICTOZA
ST
Victoza ST = requires 30 day trial of metformin within the last 2 years
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
ONE TOUCH PRODUCTS
GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)
7-A Laxatives
Generic Name Brand Name
lactulose
PEG electrolyte *COLYTE
PEG electrolyte GOLYTELY
peg(high)-electrolyte *NULYTELY
7-B Antidiarrheals
Generic Name Brand Name
diphenoxylate-atropine *LOMOTIL
7-C 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
7-D H2 Blockers
Generic Name Brand Name
cimetidine *TAGAMET
famotidine *PEPCID
nizatadine *AXID
ranitidine *ZANTAC
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
Notes
QL (120 tablets/month)
Notes
19
Medicaid Drug Benefit Guide 09/01/16
7-E Proton Pump Inhibitors (PPI)
Generic Name Brand Name
esomeprazole NEXIUM GRANULES
lansoprazole *PREVACID SOLUTAB
omeprazole *PRILOSEC 10mg capsules
omeprazole *PRILOSEC 20mg capsules
omeprazole *PRILOSEC 20mg tablets
omeprazole *PRILOSEC 40mg
pantoprazole *PROTONIX
rabeprazole *ACIPHEX
7-F Antiemetics
Generic Name Brand Name
meclizine *ANTIVERT
granisetron *KYTRIL
ondansetron *ZOFRAN 4mg
ondansetron *ZOFRAN 8mg
ondansetron *ZOFRAN 24mg
ondansetron *ZOFRAN ODT 4mg
ondansetron *ZOFRAN ODT 8mg
ondansetron *ZOFRAN solution
trimethobenzamide *TIGAN
7-G Digestive Aids
Generic Name Brand Name
amylase-lipase-protease CREON
cholic acid CHOLBAM
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
naloxegol MOVANTIK
sevelamer *RENVELA
sulfasalazine *AZULFIDINE
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
PA
PA
QL (60 capsules/month)
QL (60 capsules/month)
QL (60 tablets/month)
QL (60 capsules/month)
QL (60 tablets/month)
QL (30 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)
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
PA
Medicaid Drug Benefit Guide 09/01/16
sulfasalazine EC
ursodiol
ursodiol
ursodiol
*AZULFIDINE EN
*ACTIGALL
*URSO 250MG
*URSO FORTE
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
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 (1 packet/month)
Notes
QL (240 tablets/month)
QL (240 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
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 - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
21
QL (60 capsules/month)
Medicaid Drug Benefit Guide 09/01/16
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
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
ASA-caffeine-but-codeine *FIORINAL w/CODEINE
buprenorphine naloxone SUBOXONE FILM TAB
butorphanol *STADOL NS
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)
PA
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
hydrocodone ZOHYDRO ER
QL (60 tablets/month) ST
ZOHYDRO ER ST- Step through at least 30 days within last 180 days of MSSR
or Oxymorphone ER (non-crush-resistant)
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
naloxone hcl inj 0.4 MG/ML
naltrexone *REVIA
oxycodone *OXYIR
oxycodone *ROXICODONE
QL (360 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
22
Medicaid Drug Benefit Guide 09/01/16
oxycodone-APAP *PERCOCET 2.5-325mg
oxycodone-APAP *PERCOCET 5-325mg
oxycodone-APAP *PERCOCET 7.5-325mg
oxycodone-APAP *PERCOCET 10-325mg
oxycodone-APAP *PERCOCET 7.5-500mg
oxycodone-APAP *PERCOCET 10-650mg
oxycodone-ASA *PERCODAN
oxymorphone ER *OPANA ER
pentazocine-naloxone *TALWIN NX
tramadol *ULTRAM
tramadol-APAP ULTRACET
9-C Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Generic Name Brand Name
diclofenac *VOLTAREN 25mg
diclofenac *VOLTAREN 50mg
diclofenac *VOLTAREN 75mg
diclofenac potassium *CATAFLAM
diclofenac SR *VOLTAREN XR
etodolac *LODINE 200mg
etodolac *LODINE 300mg
etodolac *LODINE 400mg
etodolac *LODINE 500mg
etodolac SR *LODINE XL
fenoprofen *NALFON
flurbiprofen *ANSAID 50mg
flurbiprofen *ANSAID 100mg
ibuprofen *MOTRIN
indomethacin *INDOCIN
indomethacin CR *INDOCIN SR
ketoprofen *ORUDIS 50mg
ketoprofen *ORUDIS 75mg
ketorolac *TORADOL
meclofenamate sodium
meloxicam *MOBIC
meloxicam *MOBIC susp
nabumetone *RELAFEN
naproxen *NAPROSYN
naproxen *NAPROSYN EC
naproxen sodium *ANAPROX
oxaprozin *DAYPRO
piroxicam *FELDENE
sulindac *CLINORIL
tolmetin sodium *TOLECTIN
9-D Anti-Rheumatic Agents
Generic Name Brand Name
auranofin RIDAURA
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 (360 tablets/month)
QL (360 tablets/month)
QL (360 tablets/month)
QL (360 tablets/month)
QL (240 tablets/month)
QL (180 tablets/month)
QL (360 tablets/month)
QL (60 tablets/month)
QL (12 tablets/day)
QL (240 tablets/month)
QL (240 tablets/month)
Notes
QL (240 tablets/month)
QL (120 tablets/month)
QL (90 tablets/month)
QL (120 tablets/month)
QL (90 capsules/month)
QL (90 capsules/month)
QL (90 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (4 tablets/day)
QL (3 tablets/day)
QL (60 capsules/month)
QL (90 capsules/month)
QL (20 tablets/month)
QL (10ml/day)
QL (90 tablets/month)
Notes
Medicaid Drug Benefit Guide 09/01/16
9-E
9-F
9-G
9-H
PA
deferasirox EXJADE
QL (30 tablets/month)
leflunomide *ARAVA
methotrexate
penicillamine CUPRIMINE
penicillamine DEPEN
Migraine Products
Notes
Generic Name Brand Name
ST QL (6 tablets/fill; 2 fills/month)
naratriptan *AMERGE
AMERGE ST = requires trial/failure of sumatriptan
QL (6 tablets/fill; 2 fills/month)
rizatriptan *MAXALT
QL (6 tablets/fill; 2 fills/month)
rizatriptan *MAXALT MLT
QL (9 tablets/fill; 2 fills/month)
sumatriptan *IMITREX
QL (6 vials/month)
sumatriptan *IMITREX NASAL
QL (2 statdose cartridges/fill, 2 fills/mo)
sumatriptan *SUMATRIPTAN INJ
Gout
Notes
Generic Name Brand Name
allopurinol *ZYLOPRIM
colchicine MITIGARE
colchicine-probenecid *COLBENEMID
probenecid *BENEMID
Musculoskeletal Therapy Agents
Notes
Generic Name Brand Name
baclofen *LIORESAL
QL (120 tablets/month)
carisoprodol *SOMA 350mg
QL (120 tablets/month)
carisoprodol-ASA *SOMA COMPOUND
QL (120 tablets/month)
carisoprodol-ASA-codeine *SOMA CPD w/CODEINE
chlorzoxazone *PARAFON FORTE
QL (90 tablets/month)
cyclobenzaprine *FLEXERIL 5mg
cyclobenzaprine *FLEXERIL 10mg
dantrolene *DANTRIUM
methocarbamol *ROBAXIN
orphenadrine citrate *NORFLEX
tizanidine *ZANAFLEX 2mg and 4mg tablets
Miscelleanous Neuromuscular Agents
Generic Name Brand Name
Notes
pyridostigmine *MESTINON
VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood disorders)
10-A Vitamins
Generic Name
calcitriol
calcitriol oral soln 1mg/ml
paricalcitol [vitamin D]
phytonadione
potassium aminobenzoate
Brand Name
*ROCALTROL
*ROCALTROL SOLUTION
*ZEMPLAR
MEPHYTON
POTABA
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)
Medicaid Drug Benefit Guide 09/01/16
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
edoxaban SAVAYSA
rivaroxaban XARELTO STARTER PACK
rivaroxaban XARELTO 15mg
rivaroxaban XARELTO 20mg
warfarin *COUMADIN
10-E Miscelleanous Hematologicals
Generic Name Brand Name
aminocaproic acid *AMICAR 500mg
anagrelide *AGRYLIN
cilostazol *PLETAL
clopidogrel *PLAVIX 75mg
dipyridamole *PERSANTINE
pentoxifylline *TRENTAL
sodium polystyrene sulfonate *KAYEXALATE
ticlopidine *TICLID
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)
QL (30 tablets/month)
Notes
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
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
Notes
25
Medicaid Drug Benefit Guide 09/01/16
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
QL (15ml/month)
neomycin-polymyxin-dexa opth susp
neomycin-polymyxin-dexa opth oint
neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth
ofloxacin ophth *OCUFLOX
sulfacetamide sodium ophth *BLEPH-10
tobramycin ophth *TOBREX
trifluridine ophth *VIROPTIC
trimethoprim-polymy B ophth *POLYTRIM ophth
QL (10 ml/month)
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
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
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
26
Notes
Notes
QL (5 ml/month)
QL (3.5 gm/month)
Notes
QL (one bottle/month)
QL (2.5ml/month)
QL (2.5ml/month)
Notes
Medicaid Drug Benefit Guide 09/01/16
11-F Ophthalmics Miotics
Generic Name Brand Name
pilocarpine ophth *ISOPTO CARPINE
pilocarpine ophth PILOPINE HS
Notes
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
lidocaine *VISCOUS LIDOCAINE
pilocarpine *SALAGEN 5mg
pilocarpine *SALAGEN 7.5mg
sodium fluoride
sodium fluoride *KARIGEL
sodium fluoride *KARIGEL-N
triamcinolone/orabase *KENALOG-ORABASE
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 (10 capsules/ 90 days)
QL (60mls/90 days)
Notes
QL (10 ml/month)
Notes
QL (180 tablets/month)
QL (120 tablets/month)
Medicaid Drug Benefit Guide 09/01/16
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
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
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
cromolyn sodium nebulizer *INTAL (nebulizer)
fluticasone furoate-vilanterol BREO ELLIPTA
indacaterol ARCAPTA NEOHALER
ipratropium nebulizer *ATROVENT (nebulizer)
ipratropium HFA inhaler ATROVENT HFA
metaproterenol nebulizer *ALUPENT (nebulizer)
metaproterenol nebulizer *ALUPENT (syrup)
metaproterenol tablets *ALUPENT (tablets)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
28
Notes
Notes
QL (1 inhaler/month)
QL (1 inhaler/month)
QL (2 inhalers/month)
Notes
Notes
QL (2 inhalers/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (12ml's/day)
QL (120 vials/month)
QL (1/month)
QL (1/month)
QL (450 mls/month)
QL (2 inhalers/month)
QL (120 vials/month (300 ml/month)
Medicaid Drug Benefit Guide 09/01/16
mometasone-formoterol inhalers
montelukast
montelukast
montelukast
montelukast
olodaterol
sodium chloride soln nebu 7%
terbutaline
theophylline
theophylline
theophylline
theophylline CR
theophylline SR
umeclidinium br
umeclidinium-vilanterol
zafirlukast
12-E Steroid Inhalers
Generic Name
budesonide inhalation susp 0.25 MG/2ML
budesonide inhalation susp 0.5 MG/2ML
budesonide inhalation susp 1 MG/2ML
fluticasone furoate
mometasone inhaler
mometasone inhaler
DULERA
*SINGULAIR 4mg
*SINGULAIR 5mg
*SINGULAIR 10mg
*SINGULAIR 4mg Granules
STRIVERDI RESPIMAT
*HYPER-SAL NEBULIZER
*BRETHINE
QL (1 inhaler/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 packets/month)
QL (1 inhaler/month)
QL (30 tablets/month)
*SLO-PHYLLIN
*THEOLAIR
*UNIPHYL
THEO-24
INCRUSE ELLIPTA
ANORO ELLIPTA
*ACCOLATE
QL (1/month)
QL (1/month)
QL (60 tablets/month)
Brand Name
*PULMICORT
*PULMICORT
PULMICORT
ARNUITY ELLIPTA
ASMANEX
ASMANEX HFA
Notes
AL QL (120ml/month)
AL QL (60ml/month)
AL QL (60ml/month)
QL (1/month)
QL (1 inhaler/month)
QL (1 inhaler/month)
SELF-INJECTABLE/SPECIALTY (injectable drugs)
13-A Anticoagulants
Generic Name Brand Name
enoxaparin *LOVENOX
13-B Growth Hormones
Generic Name Brand Name
somatropin NUTROPIN
somatropin SEROSTIM
13-C Hematopoietic Agents
Generic Name Brand Name
darbepoetin alpha ARANESP
filgrastim-sndz soln pref syr ZARXIO
pegfilgrastim NEULASTA
13-D Hepatitis C Agents
Generic Name Brand Name
daclatasvir dihydrochloride DAKLINZA 30MG
daclatasvir dihydrochloride DAKLINZA 60MG
elbasvir-grazoprevir ZEPATIER
ombitasvir-paritaprevir-ritonavir VIEKIRA
peginterferon alfa-2A PEGASYS
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 (covered up to 30 days without prior authorization)
Notes
PA SP
PA SP
Notes
PA SP
QL SP (1st time fill-5 doses x 21 days, then PA)
PA SP
Notes
PA QL (90 tablets/month) SP
PA QL (30 tablets/month) SP
PA SP
PA QL (120 tablets/month)
PA SP
29
Medicaid Drug Benefit Guide 09/01/16
simeprevir sodium cap
sofosbuvir tab
13-E Multiple Sclerosis Agents
Generic Name
dimethyl fumarate
fingolimod
glatiramer acetate
glatiramer acetate
interferon beta-1A
interferon beta-1A
teriflunomide
13-F Osteoporosis Agents
Generic Name
teriparatide (recombinant)
13-G Somatostatin Analogs
Generic Name
lanreotide acetate
nafarelin
octreotide acetate
pegvisomant
13-H Immunomodulators
Generic Name
adalimumab
certolizumab pegol
etanercept for subcutaneous
13-I Miscellaneous Specialty
Generic Name
corticotropin
interferon gamma-1B
nitisinone
oprelvekin
oxandralone
oxymetholone
rilonacept
OLYSIO
SOVALDI
PA SP
PA QL (30 tablets/month) SP
Brand Name
TECFIDERA
GILENYA
COPAXONE
GLATOPA
REBIF
AVONEX
AUBAGIO
PA SP
PA SP
PA SP
PA SP
PA SP
PA SP
PA SP
Notes
Brand Name
FORTEO
Notes
PA SP
Brand Name
SOMATULINE
SYNAREL
*OCTREOTIDE
SOMAVERT
Notes
PA SP
PA
PA SP
PA SP
Brand Name
HUMIRA
CIMZIA
ENBREL
Notes
PA SP
PA SP
PA SP
Brand Name
ACTHAR HP
ACTIMMUNE
ORFADIN
NEUMEGA
*OXANDRIN
ANADROL-50
ARCALYST
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan
Notes
PA SP
PA SP
PA SP
PA SP
PA
PA
PA SP
30
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
abacavir sulfate
ABILIFY
acarbose
ACETIC ACID OTIC SOLN
ACIPHEX
ACCOLATE
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
albuterol nebulizer
albuterol SR tablets
albuterol tablets
albuterol-ipratropium nebulizer
alclometasone
ALDACTAZIDE
ALDACTONE
PDL Section
Drug Name
PDL Section
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
AMERGE
AMICAR 500mg
amiloride
amiloride-HCTZ
aminocaproic acid
aminophylline
amiodarone
amitriptyline
amitriptyline-chlordiazepoxide
amlodipine
amlodipine-benazepril
amoxapine
amoxicillin
amoxicillin-clavulanate
AMOXIL
amphetamine-d-amphetamine
amphetamine-d-amphetamine SR
ampicillin
amprenavir
1-I
4-D
6-F
11-I
7-E
12-D
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
12-D
12-D
12-D
12-D
5-H
3-J
3-J
31
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
9-E
10-E
3-J
3-J
10-F
12-D
3-E
4-B
4-F
3-D
3-I
4-B
1-A
1-A
1-A
4-E
4-E
1-A
1-I
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
amylase-lipase-protease
amy-lip-prot dr
ANADROL-50
anagrelide
ANALPRAM-HC
ANAMANTLE
ANAPROX
anastrozole
ANORO ELLIPTA
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
ARCAPTA NEOHALER
ARICEPT
ARIMIDEX
ARNUITY ELLIPTA
AROMASIN
ARTANE
ASA-caffeine-butalbital
ASA-caffeine-but-codeine
ASA-codeine
ASENDIN
PDL Section
Drug Name
7-G
7-G
13-I
10-F
5-A
5-I
9-C
2-A
12-D
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
12-D
4-F
2-A
12-E
2-A
4-H
9-A
9-B
9-B
4-B
PDL Section
ASMANEX
ASTELIN
ATARAX
atenolol
atenolol-chlorthalidone
ATIVAN
atomoxetine
atorvastatin
ATRIPLA
atropine ophth
ATROVENT (nebulizer)
ATROVENT HFA
ATROVENT INHALER
ATROVENT NASAL
AUBAGIO
augmented betamethasone
AUGMENTIN
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
baclofen
bac-polymy-neomycin HC oint
BACTRIM
BACTROBAN
BACTROBAN CREAM
32
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
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
9-G
5-C
1-L
5-C
5-C
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
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
BREO ELLIPTA
BRETHINE
BREVOXYL
brimonidine ophth
brimonidine timolol ophth
PDL Section
Drug Name
PDL Section
bromocriptine (tablets)
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
12-D
12-D
5-B
11-G
11-B
buconazole vaginal
budesonide formoterol inhaler
budesonide SR
bumetanide
BUMEX
BUPHENYL
buprenorphine naloxone
bupropion
bupropion SR
bupropion XL
BUSPAR
buspirone
busulfan
butorphanol
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
carbamazepine SR
CARBATROL
carbidopa-levodopa
carbidopa-levodopa CR
carbinoxamine-PSE
33
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
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
4-G
4-G
4-H
4-H
12-C
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
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
CAYSTON
CECLOR
CECLOR CD
CEENU
cefaclor
cefaclor ER
cefadroxil
cefdinir
cefpodoxime
cefprozil
CEFTIN
cefuroxime
CEFZIL
CELEXA
CELLCEPT
CENESTIN
cephalexin
cephradine
certolizumab pegol
CHANTIX
chloral hydrate
chlorambucil
PDL Section
Drug Name
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
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
1-B
1-B
13-H
4-I
4-C
2-A
PDL Section
chlordiazepoxide
chlorhexidine
chloroquine
chlorothiazide
chlorpheniramine
chlorpheniramine-PSE
chlorphen-pyrilamine-PE
chlorpromazine
chlorpropamide
chlorthalidone
chlorzoxazone
CHOLBAM
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
clindamycin topical
clindamycin vaginal
CLINORIL
clobetasol foam
clobetasol propionate
34
4-A
11-J
1-J
3-J
12-C
12-C
12-C
4-D
6-F
3-J
9-G
7-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
5-B
8-C
9-C
5-H
5-H
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
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
COLESTID
colestipol
COLYTE
COMBIVIR
COMPAZINE
COMPLERA
COMTAN
CONDYLOX
COPAXONE
CORDARONE
COREG
CORTEF
CORTENEMA
corticotropin
cortisone acetate
CORTISPORIN CREAM
CORTISPORIN OINTMENT
CORTISPORIN OPHTH
CORTISPORIN otic
CORTONE
CORZIDE
PDL Section
Drug Name
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
3-L
3-L
7-A
1-I
4-D
1-I
4-H
5-I
13-E
3-E
3-C
6-A
7-H
13-I
6-A
5-C
5-C
11-C
11-I
6-A
3-I
PDL Section
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
CYMBALTA
cyproheptadine
CYTOMEL
CYTOTEC
CYTOVENE
CYTOXAN
CYTRA K
DAKLINZA
DALMANE
dalteparin sodium
danazol
DANOCRINE
DANTRIUM
dantrolene
dapsone
DAPSONE
DARAPRIM
darbepoetin alpha
DARVOCET N 100
DARVOCET N 50
35
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
4-B
12-A
6-I
7-C
1-H
2-A
8-D
13-D
4-C
13-A
6-B
6-B
9-G
9-G
1-L
1-L
1-J
13-C
9-B
9-B
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
DARVON
DAYPRO
DDAVP
DECADRON
DECADRON ophth
DECONAMINE
deferasirox
DEMADEX
DEMEROL
DEPAKENE
DEPAKOTE
DEPEN
DEPO-PROVERA
DERMATOP
desipramine
desmopressin (nasal)
desmopressin (oral)
desoximetasone
DESYREL
dexamethasone
dexamethasone phosphate ophth
DEXEDRINE
DEXEDRINE SPANSULES
dexmethylphenidate
dextroamphetamine
DIABETA
DIABINESE
DIAMOX
diazepam
dibigatran
diclofenac
diclofenac potassium
diclofenac SR
dicloxacillin
dicyclomine
didanosine
DIDRONEL
diflorasone diacetate
DIFLUCAN
DIFLUCAN SUSP
PDL Section
Drug Name
9-B
9-C
6-J
6-A
11-C
12-C
9-D
3-J
9-B
4-G
4-G
9-D
6-E
5-H
4-B
6-J
6-J
5-H
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
1-A
7-C
1-I
6-J
5-H
1-G
1-G
PDL Section
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
drospirenone-ethyinyl
DRYSOL
DUAVEE
DUET DHA
DUET DHA EC
DUETACT
DULERA
36
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
6-D
5-I
6-C
10-B
10-B
6-F
12-D
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
duloxetine
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
enfuvirtide
ENBREL
ENJUVIA
ENPRESSE
enoxaparin
entacapone
ENTOCORT EC
ENTRESTO
ENTUSS
EPIFOAM
PDL Section
Drug Name
PDL Section
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
ESKALITH
ESKALITH CR
estazolam
esterified estrogens
ESTRACE
ESTRACE vaginal
estradiol
estradiol patch
estradiol TD gel
estradiol vaginal
estradiol-norgestimate
estramustine
ESTRATEST
ESTRATEST HS
estrogen-medroxyprogesterone
estrogens (conjugated synthetic)
4-B
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
1-I
13-H
6-C
6-D
13-A
4-H
7-H
3-I
12-C
5-H
37
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
6-C
6-C
6-C
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
PDL Section
Drug Name
PDL Section
FLONASE
estrogens (conjugated) vaginal
8-C
estrogens-methyltestosterone
6-C
estropipate
6-C
estropipate vaginal
8-C
ESTROSTEP FE
6-D
ethambutol
1-F
ETHMOZINE
3-E
ethosuximide
4-G
etidronate
6-J
etodolac
9-C
etodolac SR
9-C
etoposide
2-A
ETRAFON
4-F
EULEXIN
2-A
EVISTA
6-J
EXELON
4-F
exemestane
2-A
exenatide
6-J
EXJADE
9-D
famciclovir
1-H
famotidine
7-D
FAMVIR
1-H
FA-vit B6-vit B12
10-C
FELDENE
9-C
felodipine
3-D
FEMARA
2-A
fenofibrate
3-L
fenoprofen
9-C
fentanyl patch
9-B
fexofenadine
12-A
filgrastim
13-C
finasteride
8-D
FIORINAL
9-A
FIORINAL w/CODEINE
9-B
FIRST-VANCOMYCIN ORAL SLN 1-K
FLAGYL
1-L
flavoxate
8-B
flecainide
3-E
FLEXERIL
9-G
FLOMAX
8-D
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
FOLBEE
FOLGARD RX
folic acid
FOLTX
formoterol inhaler
FORTEO
FORTICAL
FOSAMAX
fosfomycin
fosinopril
fosinopril-HCTZ
FOSRENOL
FURADANTIN
furosemide
FUZEON
gabapentin
GABARONE
38
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
10-C
10-C
10-C
10-C
12-D
13-F
6-J
6-J
8-A
3-F
3-I
7-H
8-A
3-J
1-I
4-G
4-G
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
galantamine
ganciclovir
GANTANOL
GANTRISIN
GARAMYCIN
gemfibrozil
GENGRAF
GENTAMICIN OINT 3%
gentamicin topical
gentamycin sulfate ophth
GILENYA
glatiramer acetate
GLATOPA
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
GYNAZOLE-1
HALCION
HALDOL
haloperidol
PDL Section
Drug Name
PDL Section
HEXALEN
HIVID
homatropine ophth
HUMALOG
HUMALOG MIX
HUMALOG MIX PEN
HUMALOG PEN
HUMIRA
HUMULIN
HUMULIN PEN
HYCODAN
4-F
1-H
1-L
1-L
5-C
3-L
2-B
11-A
5-C
11-A
13-E
13-E
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
8-C
4-C
4-D
4-D
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
HYTONE
HYTRIN
HYZAAR
ibuprofen
39
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
5-H
3-H
3-I
9-C
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
ibuprofen-hydrocodone
ILOSONE
IMBRUVICA
IMDUR
imipramine
imiquimod
IMITREX
IMITREX NASAL
IMURAN
INCRUSE ELLIPTA
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 TRINZA INJ
INVEGA SUSTENNA
INVIRASE
INVOKAMET
INVOKANA
iodoquinol
IOPIDINE
ipratropium HFA inhaler
PDL Section
Drug Name
9-B
1-C
2-A
3-B
4-B
5-I
9-E
9-E
2-B
12-D
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
4-D
1-I
6-F
6-F
1-L
11-G
12-D
PDL Section
ipratropium inhaler
ipratropium nasal
ipratropium nebulizer
irbesartan
irbesartan-hct
ISENTRESS
ISENTRESS PACKET
isoniazid
ISOPTO ATROPINE
ISOPTO CARPINE
ISOPTO HOMATROPINE
ISORDIL
isosorbide dinitrate
isosorbide mononitrate
isradipine
itraconazole
JADENU
JARDIANCE
JENTADUETO
JOLIVETTE
JUNEL
JUNEL FE
KALETRA
KALYDECO
KARIGEL
KARIGEL-N
KARIVA
KAYEXALATE
KEFLEX
KENALOG
KENALOG-ORABASE
KEPPRA
KEPPRA XR
KERALAC
KERLONE
ketoconazole
ketoconazole shampoo
ketoconazole topical
ketoprofen
ketorolac
40
12-D
12-B
12-D
3-G
3-G
1-I
1-I
1-F
11-E
11-F
11-E
3-B
3-B
3-B
3-D
1-G
6-J
6-F
6-F
6-D
6-D
6-D
1-I
1-K
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
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
ketorolac ophth
ketotifen
KLARON
KLONOPIN
KOMBIGLYZE XR
K-PHOS
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
levetiracetam
LEVLEN
LEVLITE
levobunolol ophth
levocarnitine
levofloxacin
LEVORA
PDL Section
Drug Name
PDL Section
levothroid
11-H
11-H
5-B
4-G
6-F
8-D
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
4-G
6-D
6-D
11-B
6-J
1-E
6-D
levothyroxine
levoxyl
LEVSIN
LEVSINEX
LEXAPRO
LEXIVA
LIBRAX
LIBRIUM
LIDEX
lidocaine
LIDODERM PATCH
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
41
6-I
6-I
6-I
7-C
7-C
4-B
1-I
7-C
4-A
5-H
11-J
5-I
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
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
lopinavir-ritonavir
LOPRESSOR
LOPRESSOR HCTZ
LOPROX
lorazepam
losartan
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
PDL Section
Drug Name
PDL Section
megestrol
meloxicam
melphalan
MENEST
meperidine
mephobarbital
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
1-I
3-C
3-I
5-D
4-A
3-G
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
42
2-A
9-C
2-A
6-C
9-B
4-C
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
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
methylprednisolone
metipranolol ophth
metoclopramide
metolazone
metoprolol
metoprolol succinate SR
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
MITIGARE
mitotane
MOBIC
MODICON
MODURETIC
PDL Section
Drug Name
6-A
11-B
7-H
3-J
3-C
3-C
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
9-F
2-A
9-C
6-D
3-J
PDL Section
moexipril
moexipril-HCTZ
mometasone
mometasone inhaler
MONONESSA
MONOPRIL
MONOPRIL HCT
montelukast
MONUROL
moricizine
morphine sulfate
morphine sulfate SR
MOTRIN
MOVANTIK
MS CONTIN
MUCOMYST
mupirocin
MYAMBUTOL
MYCELEX TROCHE
MYCIFRADIN
mycophenolate mofetil
MYCOSTATIN susp
MYCOSTATIN topical
MYDRIACYL
MYLERAN
MYSOLINE
nabumetone
nadolol-bendroflumethiazide
nafarelin
NALFON
naloxone inj
naltrexone
NAPROSYN
naproxen
naproxen sodium
NARDIL
NASACORT ALLERGY OTC
NATALCARE
nateglinide
NATELLE C
43
3-F
3-I
5-H
12-E
6-D
3-F
3-I
12-D
8-A
3-E
9-B
9-B
9-C
7-H
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-I
13-G
9-C
9-B
9-B
9-C
9-C
9-C
4-B
12-B
10-B
6-F
10-B
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
PDL Section
Drug Name
PDL Section
nitroglycerin spray
NITROLINGUAL PUMPSPRAY
nitroquick
NITROSTAT
nizatadine
NIZORAL
NIZORAL SHAMPOO
NOLVADEX
NORA-BE
NORCO
NORDITROPIN
norethindrone
NORFLEX
NORITATE
NORMODYNE
NORPACE
NORPRAMIN
NORTREL
NORTREL 7/7/7
nortriptyline
NORVASC
NORVIR
NOVAHISTINE
NOVOLIN
NOVOLOG
NOVOLOG MIX
NULEV
NULYTELY
NUVARING
nystatin
nystatin topical
nystatin vaginal
nystatin-triamcinolone
OCTREOTIDE
octreotide acetate
octreotide acetate release
OCUFEN
OCUFLOX
OCUPRESS
ofloxacin
NATURE-THROID
NAVANE
nebivolol
NECON
NECON 10/11
NECON 7/7/7
nedocromil inhaler
nefazodone HCL
neomycin
6-I
4-D
3-C
6-D
6-D
6-D
12-D
4-B
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
NEURONTIN
4-G
NEVANAC
11-H
nevirapine
1-I
nevirapine XR
1-I
NEXIUM GRANULES
7-E
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
44
3-B
3-B
3-B
3-B
7-D
1-G
5-D
2-A
6-D
9-B
13-B
6-E
9-G
5-B
3-C
3-E
4-B
6-D
6-D
4-B
3-D
1-I
12-C
6-G
6-G
6-G
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
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
ofloxacin ophth
ofloxacin otic
OGEN
OGEN vaginal
OGESTREL
OLUX
OLYSIO
omeprazole
OMNICEF
ondansetron
ONGLYZA
ONE TOUCH PRODUCTS
oprelvekin
OPSUMIT
OPTIPRANOLOL
ORAPRED
ORFADIN
ORKAMBI
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
PDL Section
Drug Name
11-A
11-I
6-C
8-C
6-D
5-H
13-D
7-E
1-B
7-F
6-F
6-K
13-I
3-H
11-B
6-A
13-I
1-K
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
PDL Section
oxycodone-APAP
oxycodone-ASA
OXYIR
oxymetholone
oxymorphone ER
paliperidone palmitate
palonosetron
PAMELOR
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
45
9-B
9-B
9-B
13-I
9-B
4-D
13-I
4-B
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
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
pentazocine-naloxone
pentosan polysulfate sodium
pentoxifylline
PEPCID
PE-pyrilamine-hydrocodone
PERCOCET
PERCODAN
pergolide
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
PDL Section
Drug Name
PDL Section
PLEXION
9-B
8-D
10-F
7-D
12-C
9-B
9-B
4-H
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
PNV-DHA
PNV-SELECT
PODOCON
podofilox
podophyllum resin
POLYSPORIN ophth
POLYTRIM ophth
POLY-VI-FLOR
POLY-VI-FLOR-FE
PORTIA
POTABA
potassium aminobenzoate
POTASSIUM CHLORIDE
potassium citrate CR
potassium phosphate
PRALUENT
pramipexole
pramlintide
PRAMOSONE
pramoxine-HC cream
pramoxine-HC foam
PRANDIMET
PRANDIN
PRAVACHOL
pravastatin
prazosin
PRECARE
PRECOSE
PRED FORTE
prednicarbate
prednisolone
PREDNISOLONE
prednisolone ophth
prednisolone sodium
prednisone
PRELONE
PREMARIN
PREMARIN vaginal
PREMPHASE
46
5-B
10-B
10-B
5-I
5-I
5-I
11-A
11-A
10-B
10-B
6-D
10-A
10-A
8-D
8-D
8-D
3-L
4-H
6-J
5-H
5-H
5-H
6-F
6-F
3-L
3-L
3-H
10-B
6-F
11-C
5-H
6-A
6-A
11-C
6-A
6-A
6-A
6-C
8-C
6-C
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
PDL Section
Drug Name
PREMPRO
PDL Section
PRONESTYL
propafenone
propantheline
PROPINE
propoxyphene
propoxyphene nap-APAP
propoxyphene-APAP
propranolol
propranolol HCL CR
propranolol-HCTZquinapril-HCTZ
propylthiouracil
PROSCAR
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
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- 10-B
fa-caprenatal vitamins-FE-FA
10-B
prenatal vitamins-FE-FA-CA-omega 10-B
prenatal vitamins-iron carbonyl-FA
10-B
PRENATE ELITE
10-B
prenate vitamin FE-Fum-Lmethylfol-FA-CA 10-B
PREVACID SOLUTAB
7-E
PREVIFEM
6-D
PREZCOBIX
1-I
PREZISTA
1-I
PRILOSEC
7-E
10-B
PRIMACARE
primaquine
1-J
PRIMAQUINE
1-J
primidone
4-G
PRINCIPEN
1-A
3-F
PRINIVIL
PRINZIDE
3-I
PROAMATINE
3-K
PRO-BANTHINE
7-C
probenecid
9-F
procainamide
3-E
procainamide SR
3-E
PROCANBID
3-E
procarbazine HCL
2-A
PROCARDIA
3-D
PROCARDIA XL
3-D
prochlorperazine
4-D
PROCTOFOAM-HC
5-A
PROGRAF
2-B
PROLIXIN
4-D
promethazine
12-A
promethazine DM
12-C
promethazine VC
12-C
promethazine-codeine
12-C
47
3-E
3-E
7-C
11-G
9-B
9-B
9-B
3-C
3-C
3-I
6-I
8-D
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
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
raloxifene
ramipril
RANEXA
ranitidine
ranolazine
RAPAMUNE
RAZADYNE
RAZADYNE ER
REBETOL capsules/tablets
REBIF
RECLIPSEN
REGLAN
RELAFEN
REMERON
REMERON SOLTABS
RENVELA
repaglinide
repaglinide-metformin
REQUIP
RESCRIPTOR
RESTORIL
RETIN-A
RETIN-A MICRO
RETROVIR
REVIA
REXULTI
REYATAZ
ribavirin
RIDAURA
RIFADIN
rifampin
rilonacept
rimantadine
rimexolone ophth
RISPERDAL
RISPERDAL M
risperidone
RITALIN
RITALIN SR
rivaroxaban
PDL Section
Drug Name
6-J
3-F
3-M
7-D
3-M
2-B
4-F
4-F
1-H
13-E
6-D
7-H
9-C
4-B
4-B
7-H
6-F
6-F
4-H
1-I
4-C
5-B
5-B
1-I
9-B
4-D
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
PDL Section
rivastigmine
ROBAXIN
ROBAXISAL
ROBINUL
ROBINUL FORTE
ROCALTROL
RONDEC
RONDEC DM
ropinirole
ROWASA
ROXANOL
ROXICODONE
RYNA-12
RYNATAN-S
RYTHMOL
sacrosidase
SALAGEN
salsalate
SANDIMMUNE
SAVAYSA
SCOPACE
scopolamine oral
SEASONALE
SECTRAL
SELEGILINE
selenium sulfide shampoo
SELSUN
SELZENTRY
SEPTRA
SERAX
SEROQUEL
SEROSTIM
sertraline HCL
SERZONE
SILVADENE
silver sulfadiazine
simvastatin
SINEMET
SINEMET CR
SINEQUAN
48
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
12-C
3-E
7-G
11-J
9-A
2-B
10-D
7-F
7-F
6-D
3-C
4-H
5-I
5-I
1-I
1-L
4-A
4-D
13-B
4-B
4-B
5-C
5-C
3-L
4-H
4-H
4-B
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
SINGULAIR
sirolimus
SLO-PHYLLIN
SMZ-TMP
sodium chloride soln nebu 7%
sodium fluoride
sodium hyaluronate
sodium oxybate
sodium phenylbutyrate
sodium polystyrene sulfonate
SOLIA
SOMA
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
STRIBILD
STRIVERDI RESPIMAT
STUARTNATAL
SUBOXONE FILM TAB
SUCRAID
sucralfate
sulfacetamide lotion (acne)
sulfacetamide sodium ophth
PDL Section
Drug Name
12-D
2-B
12-D
1-L
12-D
11-J
5-H
4-E
7-G
10-F
6-D
9-G
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
1-I
12-D
10-B
9-B
7-G
7-C
5-B
11-A
PDL Section
sulfacetamide-prednisolone ophth
sulfacetamide-sulfur emulsion
sulfacetamide-urea lotion
sulfadiazine
sulfamethoxazole
sulfanilamide vaginal
sulfasalazine
sulfasalazine EC
sulfinpyrazone
SULFINPYRAZONE
sulfisoxazole
sulindac
sumatriptan
SUMATRIPTAN INJ
SUMYCIN
SUSTIVA
SYMLIN AMYLIN ANALOG
SYNALAR
SYNAREL
SYNJARDY
SYNTHROID
tacrolimus
tacrolimus topical
TAGAMET
TALWIN NX
TAMBOCOR
TAMIFLU
tamoxifen
tamsulosin
TANZEUM
TAPAZOLE
tapentadol sr
TAVIST
TEBAMIDE
TECFIDERA
TEGRETOL
TEGRETOL XR
telaprevir
temazepam
TEMOVATE
TENEX
49
11-C
5-B
5-I
1-L
1-L
8-C
7-H
7-H
9-F
9-F
1-L
9-C
9-E
9-E
1-D
1-I
6-J
5-H
13-G
6-F
6-I
2-B
5-I
7-D
9-B
3-E
11-H
2-A
8-D
6-F
6-I
9-B
12-A
7-F
13-E
4-G
4-G
13-D
4-C
5-H
3-H
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
tenofovir
TENORETIC
TENORMIN
TERAZOL
terazosin
terbinafine HCL
terbutaline
terconazole vaginal
teriparatide (recombinant)
TESLAC
TESSALON
testolactone
testolactone
tetracycline
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
PDL Section
Drug Name
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
1-D
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
PDL Section
TOBRADEX
tobramycin
tobramycin ophth
tobramycin-dexamethasone ophth
TOBREX
tocainide
TOFRANIL
tolazamide
tolbutamide
TOLBUTAMIDE
TOLECTIN
TOLINASE
tolmetin sodium
TONOCARD
TOPAMAX
TOPAMAX SPRINKLES
TOPICORT
topiramate
TOPROL XL
TORADOL
torsemide
TOUJEO
TRADJENTA
TRACLEER
tramadol
tramadol-APAP
TRANDATE
trandolapril
TRANXENE
travaprost ophth
TRAVATAN
trazodone
TRENTAL
tretinoin
tretinoin
triamcinolone acetonide
triamcinolone/orabase
triamterene-HCTZ
triazolam
TRICOR
50
11-C
1-L
11-A
11-C
11-A
3-E
4-B
6-F
6-F
6-F
9-C
6-F
9-C
3-E
4-G
4-G
5-H
4-G
3-C
9-C
3-J
6-G
6-F
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
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
trifluoperazine
trifluridine ophth
trihexyphenidyl
TRILAFONE
TRI-LEGEST FE
TRILEPTAL
TRI-LEVLEN
TRILISATE
trimethobenzamide
trimethobenzamide-benzocaine
trimethoprim
trimethoprim-polymy B ophth
TRIMPEX
TRINALIN
TRINESSA
TRI NORINYL
triple sulfas vaginal
TRI-PREVIFEM
TRI-SPRINTEC
TRIUMEQ
TRI-VI-FLOR
TRI-VI-FLOR-FE
TRIVORA
TRIZIVIR
tropicamide ophth
TRUSOPT
TRUVADA
TRYCET
trypsin-castor oil-peruvian balsam
TUSSI-ORGANIDIN
TWINJECT
TYBOST
TYLENOL w/CODEINE
ULTRACET
ULTRAM
ULTRASE
ULTRASE MT
UNIPHYL
UNIRETIC
unithroid
PDL Section
Drug Name
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
6-D
6-D
8-C
6-D
6-D
1-I
10-B
10-B
6-D
1-I
11-E
11-H
1-I
9-B
5-I
12-C
3-K
1-I
9-B
9-B
9-B
7-G
7-G
12-D
3-I
6-I
PDL Section
UNIVASC
urea
urea (carbamide)
URECHOLINE
URISPAS
UROCIT-K
UROQID
URSO
URSO FORTE
ursodiol
VALISONE
VALIUM
valproic acid
VALTREX
VANAMIDE
VANDAZOLE
VANTIN
VASERETIC
VASOTEC
VECTICAL
VEETIDS
VELOSEF
venlafaxine
venlafaxine SR
VENLAFAXINE XR
VENTOLIN HFA
VEPESID
verapamil
verapamil SR
VERELAN PM
VERMOX
VESANOID
VEXOL
VFEND
VIBRAMYCIN
VICTOZA
VIDEX EC
VIDEX PEDIATRIC
VIEKIRA
VIOKASE
51
3-F
5-I
5-I
8-B
8-B
8-D
8-A
7-H
7-H
7-H
5-H
4-A
4-G
1-H
5-I
8-C
1-B
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
6-F
1-I
1-I
13-D
7-G
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIREAD
VIROPTIC
VISCOUS LIDOCAINE
VISKEN
VISTARIL
VIVACTIL
VIVELLE
VIVELLE DOT
VOLTAREN
VOLTAREN XR
voriconazole
VOSOL-HC
VOSPIRE ER
VYVANSE
warfarin
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
WELLCOVORIN
WESTCORT
XANAX
XANAX XR
XELODA
XARELTO
XENADERM
XYLOCAINE
XYREM
YASMIN
YAZ
YODOXIN
ZADITOR
zafirlukast
zalcitabine
zaleplon
ZANAFLEX
ZANTAC
ZARONTIN
PDL Section
Drug Name
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
4-E
10-F
4-B
4-B
4-B
2-A
5-H
4-A
4-A
2-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
PDL Section
ZAROXOLYN
ZARXIO
ZAVESCA
ZEBETA
ZEMPLAR
ZENPEP
ZEPATIER
ZERIT
ZESTORETIC
ZESTRIL
ZETIA
ZIAC
ZIAGEN
zidovudine
ZITHROMAX
ZOCOR
ZOFRAN
ZOFRAN ODT
ZOHYDRO ER
ZOLOFT
zolpidem
ZONEGRAN
zonisamide
ZOVIRAX
ZOVIRAX topical
ZYBAN
ZYDONE
ZYKADIA
ZYLOPRIM
ZYPREXA
52
3-J
13-C
7-G
3-C
10-A
7-G
13-H
1-I
3-I
3-F
3-L
3-I
1-I
1-I
1-C
3-L
7-F
7-F
9-B
4-B
4-C
4-G
4-G
1-H
5-E
4-I
9-B
2-A
9-F
4-D
Medicaid Drug Benefit Guide 09/01/16
Alphabetical Index
Drug Name
PDL Section
Drug Name
53
PDL Section
Medicaid Drug Benefit Guide 09/01/16

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