ANTI-INFECTIVE TETRACYCLINES. Doxycycline Monohydrate (50MG, 100MG) capsules. Vibramycin Syrup CEPHALOSPORINS, 3RD GENERATION FLUOROQUINOLONES

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1 Diclofenac Potassium Diclofenac Sodium Diflunisal Etodolac Flurbiprofen Ibuprofen Indomethacin Indomethacin SR Ketoprofen South Carolina Department of Health and Human Services Preferred Drug List Products within PDL Therapeutic Classes are available without Prior Authorization (PA) Those Therapeutic Classes which have a PA requirement are noted with the posting Non-listed products belonging to therapeutic classes that comprise the PDL require PA Note: ALL Therapeutic Classes are not included on the PDL October 15, 2012 ANALGESIC NSAIDs* OPIOIDS, EXTENDED RELEASE SHORT ACTING NARCOTIC ANALGESICS Ketoprofen ER Ketorolac Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Vimovo Fentanyl Patch Kadian Morphine Sulfate ER Codeine Codeine/APAP Codeine/APAP/caff/butal Codeine/ASA Codeine/ASA/caff/butal Hydrocodone/APAP Hydrocodone/Ibuprofen Hydromorphone Meperidine Morphine IR Nalbuphine Oxycodone Oxycodone/APAP Oxycodone/ASA Tramadol Tramadol/APAP * COX-2 specific NSAIDs require PA. TOPICAL NSAIDs AND ANESTHETICS * All agents in this class require Prior Authorization. Azithromycin Clarithromycin Clarithromycin XL EryPed Ery-Tab MACROLIDES / KETOLIDES Erythromycin Estolate Erythromycin Ethylsuc Erythromycin Stearate Erythrocin Stearate NITROIMIDAZOLES Erythromycin & Sulfisox Erythromycin Base CEPHALOSPORINS, 2ND GENERATION Cefprozil Cefuroxime Enalapril Enalapril/HCTZ Lisinopril Doxycycline Hyclate IR Minocycline IR Tetracycline Vibramycin Suspension ANTI-INFECTIVE TETRACYCLINES Doxycycline Monohydrate (50MG, 100MG) capsules Vibramycin Syrup CEPHALOSPORINS, 3RD GENERATION Cefdinir (all dosage forms) Cefditoren FLUOROQUINOLONES Gris-Peg Griseofulvin Terbinafine Acyclovir Valtrex Exforge Tekturna * Letairis * Exforge HCT Tekturna HCT * CALCIUM CHANNEL BLOCKERS (CCB) DIHYDROPYRIDINES *Prior Authorization is required if an ARB has not been prescribed previously ONYCHOMYCOSIS AGENTS HERPES ANTIVIRALS Metronidazole Ciprofloxacin Levofloxacin CARDIOVASCULAR ACE INHIBITORS (ACEI) ACEI, CCB COMBINATIONS ANGIOTENSIN RECEPTOR BLOCKERS (ARB) Benazepril Benazepril/HCTZ Captopril Acebutolol Atenolol Atenolol/Chlorthalidone Betaxolol Bisoprolol Fumarate Bisoprolol/HCTZ Carvedilol Lisinopril/HCTZ BETA BLOCKERS Metoprolol Tartrate Nadolol Pindolol Propranolol Propranolol ER Propranolol/HCTZ Sotalol Labetolol Timolol CCB/ARB COMBINATION PRODUCTS Lotrel Trandolapril/Verapamil Amlodipine Dynacirc CR Felodipine Isradipine Nicardipine Nifedical XL Nifedipine ER and SA DIRECT RENIN INHIBITORS Avalide Avapro Benicar Benicar HCT Diovan Diovan HCT Teveten HCT CALCIUM CHANNEL BLOCKERS (CCB) NON-DIHYDROPYRIDINES Cartia XT Diltia XT Diltiazem Diltiazem ER and XR Taztia XT Verapamil Verapamil ER *Patients currently established on non-preferred therapy will be grandfathered. Eprosartan Losartan Losartan/HCTZ Micardis Micardis HCT Verapamil SR ENDOTHELIN RECEPTOR ANTAGONISTS

2 CARDIOVASCULAR (Continued) PAH-PDE5 INHIBITORS** BILE ACID SEQUESTERING RESINS FIBRIC ACID DERIVATIVES Adcirca Revatio Cholestyramine Colestipol Tablet Gemfibrozil Trilipix Cholestyramine Light Tricor **All agents in this class require verfication of PAH diagnosis. *Requires step-therapy with another preferred agent. NIACIN DERIVATIVES NIACIN/STATIN COMBINATIONS STATINS Niaspan Simcor Atorvastatin Lovastatin Lescol Lescol XL Pravastatin Simvastatin CHOLESTEROL ABSORPTION INHIBITORS CHOLINESTERASE INHIBITORS Donepezil Rivastigmine Galantamine STATIN/CCB COMBINATION PRODUCTS CENTRAL NERVOUS SYSTEM ALZHEIMER'S AGENTS NMDA RECEPTOR ANTAGONIST Namenda Ranexa NON-NITRATE ANTIANGINALS CARBAMAZEPINE DERIVATIVES Carbamazepine (all dosage forms) Epitol Oxcarbazepine RECTAL PREPS Diastat ANTIDEPRESSANTS, OTHER* Bupropion Phenelzine Bupropion SR Trazodone Bupropion XL Venlafaxine Mirtazapine Venlafaxine ER CAP Nefazodone *Patients currently receiving a non-preferred agent **Antidepressants indicated for pain have not yet been reviewed and are available without PA. ATYPICAL ANTIPSYCHOTICS LONG ACTING INJECTABLES Invega Sustenna Risperdal Consta ANTI-MIGRAINE SEROTONIN AGONISTS ANTI-CONVULSANTS FIRST GENERATION ANTICONVULSANTS SECOND GENERATION ANTICONVULSANTS Celontin Mephobarbital Gabapentin Lyrica Divalproex Sodium Phenytoin Lamotrigine Topiramate Ethosuximide Phenytoin Sodium ER Lamictal ODT Zonisamide Felbamate tablets Primidone Levetiracetam Felbatol suspension Valproic Acid BEHAVIORAL HEALTH ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS ATYPICAL ANTIPSYCHOTICS Adderall XR Metadate CD Clozapine Quetiapine Amphetamine Salt Combo Concerta * Dexmethylphenidate IR Methylphenidate Methylphenidate ER/SR Ritalin LA * Fanapt Fazaclo Geodon Risperidone Saphris Seroquel XR Dextroamphetamine Strattera Dextroamphetamine SR Vyvanse * Focalin XR * Intuniv ** *Generic agents considered "first-line" when Patients currently receiving a non-preferred agent appropriate. **Preferred for 6 years of age and older SELECTIVE SEROTONIN REUPTAKE INHIBITORS Citalopram Paroxetine Fluvoxamine Sertraline Fluoxetine (Cap/Soln/Tab not DR) Patients currently receiving a non-preferred agent OTHER CNS AGENTS MULTIPLE SCLEROSIS AGENTS SKELETAL MUSCLE RELAXANTS Sumatriptan Tablets Avonex Copaxone Sumatriptan Injection Avonex Admin Pack Rebif Sumatriptan Nasal Spray Betaseron SEDATIVE/HYPNOTICS, NON-BARBITURATES NON-ERGOT DOPAMINE RECEPTOR Temazepam Zolpidem IR Pramipexole Ropinirole Baclofen Carisoprodol Chlorzoxazone Cyclobenzaprine IR Dantrolene Sodium Methocarbamol Orphenadrine Tizanidine HCI tablets

3 ANTI-DIABETICS ALPHA-GLUCOSIDASE INHIBITORS AMYLIN ANALOGS* ANTIHYPERURICEMICS Acarbose Symlin Allopurinol Probenecid Glyset Colcrys Probenecid/Colchicine *Prior Authorization is required if patient is not BIGUANIDES currently receiving insulin therapy. BIGUANIDE COMBINATION AGENTS DPP-4 INHIBITORS AND COMBINATIONS* Metformin ActoPlus Met Janumet Kombiglyze XR Metformin ER Byetta *PA required if no claim for metformin in history. SULFONYLUREAS, SECOND GENERATION Glimepiride Glipizide Glipizide ER Glyburide INCRELIN MIMETICS* Glyburide Micronized Glyburide/Metformin Janumet XR Onglyza Humalog Humulin Actos ELECTROLYTE DEPLETERS Fosrenol Renagel Alendronate Phoslo Renvela ENDOCRINE AND METABOLIC INSULINS Levemir Novolin Lantus Novolog *Vials and Pen Devices covered for all drugs listed above. THIAZOLIDINEDIONES Januvia Jentadueto Tradjenta *PA required if no claim for metformin in history. MEGLITINIDES Nateglinide THIAZOLIDINEDIONE/SULFONYLUREA COMBINATIONS* Duetact *Prior Authorization is required if a single agent thiazolidinedione has not been prescribed previously. OTHER ENDOCRINE AND METABOLIC AGENTS BIPHOSPHONATES-OSTEOPOROSIS CALCITONINS Calcitonin Nasal Spray Fortical Nasal Spray GROWTH HORMONE* PANCREATIC ENZYMES Norditropin Nutropin AQ Creon Zenpep Nutropin Pancrelipase *A class level PA is in effect for this class. Once criteria are met, the agents listed on the PDL are preferred GASTROINTESTINAL ANTIEMETIC AGENTS HISTAMINE-2 RECEPTOR ANTAGONISTS Emend Promethazine Famotidine tablets Metoclopramide Prochlorperazine Ranitidine Ondansetron *See the listing at: for the quantity limits. ULCERATIVE COLITIS THERAPY PROGESTINS FOR CACHEXIA Apriso Mesalamine Enema Megesterol Oral Susp. Asacol Pentasa Balsalazide Disodium Sulfasalazine Canasa Rectal Supp. PROTON PUMP INHIBITORS* Omeprazole OTC Pantoprazole Omeprazole RX *Preferred PPIs will no longer require step therapy or prior authorization ** Disintegrating Lansoproazole will continue to be available without PA for patients age 12 and under. Tamsulosin Uroxatral ALPHA BLOCKERS FOR BPH GENITOURINARY ANTISPASMODICS Detrol LA Toviaz Oxybutynin IR VESIcare Oxytrol

4 Arixtra Enoxaparin Aggrenox Plavix Gleevec Androderm Androgel Enbrel Epivir HBV Alaway OTC Elestat IMMUNOMODULATORS, INJECTABLE Humira Protopic * Baraclude Tyzeka *Viread is unaffected by the PDL and is available without Prior Authorization. ANTIHISTAMINES, OPHTHALMIC Pataday Patanol Ketotifen OTC Zaditor OTC QUINOLONES & MACROLIDES, OPHTHALMIC Ciprofloxacin HCI Brimonidine Tartrate Alphagan P Iatanoprost Lumigan Ciprodex Ofloxacin Otic Drops Atrovent HFA Combivent ANTICOAGULANTS (Injectable) Fragmin PLATELET INHIBITORS ANDROGENIC AGENTS Testim HEPATITIS B THERAPY* Hepsera Vigamox PROSTAGLANDIN AGONISTS Travatan Travatan Z QUINOLONES, OTIC ANTI-CHOLINERGICS Spiriva HEMATOLOGICAL & ONCOLOGICAL AGENTS Pradaxa Finasteride IMMUNOLOGICS IMMUNOMODULATORS, TOPICAL Elidel * by the respective manufacturer and reserve for only those patients who have failed traditional eczema therapy. HEPATITIS C THERAPY Peg-Intron & Redipen *Class level PA is in effect for all Hepatitis B & C medications. Once criteria are met, the agents listed on the PDL are preferred. OPHTHALMICS MAST CELL STABILIZERS, OPHTHALMIC Alocril ANTICOAGULANTS (Oral) Xarelto Warfarin PROTEIN TYROSINE KINASE INHIBITORS HORMONE RELATED THERAPY ANDROGEN HORMONE INHIBITOR Avodart * Prescribers: Please use these agents as advised Incivek Pegasys & Conv. Pack Ribavirin Victrelis Aranesp Procrit Gengraf Flurbiprofen Sodium Rapamune NSAIDs, OPHTHALMIC Alamast Alomide Diclofenac Sodium Ketorolac Tromethamine Combigan Astepro Azelastine OTICS Cromolyn Sodium Timolol Maleate RESPIRATORY NASAL ANTIHISTAMINES Azasan Azathioprine Cyclosporine Imuran Mycophenolate Mofetil ProAir HFA Proventil HFA HEMATOPOIETIC AGENTS IMMUNOSUPPRESSANTS Myfortic Neoral Prograf Sandimmune Nevanac GLAUCOMA THERAPY ALPHA-2 ADRENERGICS BETA BLOCKERS CARBONIC ANHYDRASE INHIBITORS Betaxolol HCI Carteolol HCI Levobunolol HCI Metipranolol Azopt Dorzolamide Dorzolamide - Timolol BETA ADRENERGIC DEVICES SHORT-ACTING INHALERS Ventolin HFA

5 ANTIHISTAMINES, MINIMALLY SEDATING* Cetirizine *Combination products containing pseudoephedrine have been removed from this drug class and will be excluded consistent with cough and cold products. BETA ADRENERGIC AGENTS, SHORT ACTING NEBULIZERS Albuterol 0.083%, 0.5% Loratadine RESPIRATORY (continued) BETA ADRENERGIC DEVICES, LONG ACTING METERED DOSE INHALERS Foradil Advair Diskus Advair HFA Serevent * * Prescribers are reminded of the warnings associated with use of long acting beta agonists. GLUCOCORTICOIDS AND LONG-ACTING BETA-2 ADRENERGICS Dulera Symbicort BETA ADRENERGIC AGENTS, LONG-ACTING NEBULIZERS * Both agents in this class require Prior Authorization. Asmanex Flovent Diskus INHALED CORTICOSTEROIDS Flovent HFA Qvar INTRANASAL STEROIDS Fluticasone propionate Nasonex * *Step-therapy required for beneficiaries over age 12- must have failed fluticasone within the previous 6 months. Nasonex is available for beneficiaries age 12 and under without step therapy. Azelex Clindamycin Phosphate Benzaclin Retin-A Micro Clindagel Tretinoin TOPICAL AGENTS FOR PSORIASIS Calcipotriene Dovonex TOPICAL ANTIBIOTICS Mupirocin Ointment Bactroban * Cream Altabax * LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Zafirlukast TOPICAL AGENTS FOR ACNE Generic Benzoyl Peroxide Preparations Generic Erythromycin Preparations Generic Sulfacetamide-Sulfur Preparations TOPICAL AGENTS FOR PSORIASIS Abreva TOPICAL ANTIINFECTIVES TOPICAL ANTIVIRALS Zovirax Ointment *Generic agents should be considered "first line" therapy when appropriate. Alclometasone Dipropionate Betameth Diprop (cream/lotion) Capex Shampoo Clobetasol Emollient Betameth Valerate (cream/lotion) Clobetasol Propionate Beta-Val (cream/lotion) Cloderm Betameth/Dipro/Propyl Glycol (cream) Desonide SMOKING CESSATION Bupropion SR Chantix Nicotine Lozenge Nicotine Patch Nicotine Gum TOPICAL STEROIDS Fluocinolone Acetonide Fluocinolone Oil Fluocinonide Emollient Fluocinonide-E Fluticasone Propionate MISCELLANEOUS Halobetasol Propionate Hydrocortisone Hydrocortisone Butyrate Hydrocortisone Valerate Mometasone Furoate Triamcinolone Acetonide