ANTI-INFECTIVE QUINOLONES, 2ND AND 3RD GENERATION CEPHALOSPORINS, 3RD GENERATION. Acyclovir Cefditoren. Valtrex ANTI-BIOTICS MARKED FOR DERMATOLOGIC

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1 Diclofenac Potassium Diclofenac Sodium Diflunisal Etodolac Fenoprofen Flurbiprofen Ibuprofen Indomethacin Indomethacin SR Ketoprofen * COX-2 specific NSAIDs require PA. TOPICAL NSAIDs AND ANESTHETICS * All agents in this class require Prior Authorization. Azithromycin Erythromycin Estolate Avelox Clarithromycin Erythromycin Ethylsuc Ciprofloxacin Clarithromycin XL EryPed Ery-Tab Cefprozil Cefuroxime Benazepril Benazepril/HCTZ Captopril Enalapril Enalapril/HCTZ Lisinopril Acebutolol Atenolol Betaxolol MACROLIDES / KETOLIDES Atenolol/Chlorthalidone Bisoprolol Fumarate Bisoprolol/HCTZ Carvedilol 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 July 25, 2011 ANALGESIC NSAIDs* OPIOIDS, EXTENDED RELEASE SHORT ACTING NARCOTIC ANALGESICS Sulindac Tolmetin Sodium Erythromycin Stearate Erythrocin Stearate Erythromycin & Sulfisox Erythromycin Base CEPHALOSPORINS, 2ND GENERATION Lisinopril/HCTZ Metoprolol Tartrate Nadolol Pindolol Propranolol Propranolol ER Propranolol/HCTZ Sotalol Fentanyl Patch Kadian Morphine Sulfate ER Exforge Tekturna * Letairis * Exforge HCT Tekturna HCT * QUINOLONES, 2ND AND 3RD GENERATION Ofloxacin Lotrel CEPHALOSPORINS, 3RD GENERATION Cefdinir (all dosage forms) Trandolapril/Verapamil CALCIUM CHANNEL BLOCKERS (CCB) DIHYDROPYRIDINES Amlodipine Dynacirc CR Felodipine Isradipine Nicardipine Nifedical XL Nifedipine ER and SA *Prior Authorization is required if an ARB has not been prescribed previously ANTI-INFECTIVE Gris-Peg Griseofulvin Terbinafine Acyclovir Cefditoren Valtrex ANTI-BIOTICS MARKED FOR DERMATOLOGIC INDICATIONS Metronidazole All products require Prior Authorization (PA). CARDIOVASCULAR ACE INHIBITORS (ACEI) ACEI, CCB COMBINATIONS ANGIOTENSIN RECEPTOR BLOCKERS (ARB) BETA BLOCKERS Ketoprofen ER Ketorolac Meclofenamate Sodium Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam NITROIMIDAZOLES Codeine Codeine/APAP Codeine/APAP/caff/butal Codeine/ASA Codeine/ASA/caff/butal Hydrocodone/APAP Hydrocodone/Ibuprofen Hydromorphone 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 HERPES ANTIVIRALS Labetolol Timolol Verapamil SR CCB/ARB COMBINATION PRODUCTS DIRECT RENIN INHIBITORS ENDOTHELIN RECEPTOR ANTAGONISTS *Patients currently established on non-preferred therapy will be grandfathered. Meperidine Morphine IR Nalbuphine Oxycodone Oxycodone/APAP Oxycodone/ASA Tramadol Tramadol/APAP ONYCHOMYCOSIS AGENTS Losartan Losartan/HCTZ Micardis Micardis HCT Teveten

2 Ranexa Niaspan Zetia Avonex Avonex Admin Pack *Requires step-therapy with another preferred agent. NIACIN DERIVATIVES NIACIN/STATIN COMBINATIONS STATINS Carbamazepine (all dosage forms) Epitol Oxcarbazepine ANTI-MIGRAINE SEROTONIN AGONISTS Sumatriptan Tablets Betaseron Copaxone CARDIOVASCULAR (Continued) NON-NITRATE ANTIANGINALS BILE ACID SEQUESTERING RESINS FIBRIC ACID DERIVATIVES CHOLESTEROL ABSORPTION INHIBITORS CHOLINESTERASE INHIBITORS Donepezil Galantamine Rivastigmine (Oral & Patches) CARBAMAZEPINE DERIVATIVES Sumatriptan Injection Sumatriptan Nasal Spray MULTIPLE SCLEROSIS AGENTS Rebif Cholestyramine Cholestyramine Light Advicor Simcor STATIN/CCB COMBINATION PRODUCTS Caduet ALZHEIMER'S AGENTS NMDA RECEPTOR ANTAGONIST Namenda Divalproex Sodium Ethosuximide Felbatol Dexmethylphenidate IR Dextroamphetamine SR Methylin Tablets Vyvanse * *Generic agents considered "first-line" when appropriate. SELECTIVE SEROTONIN REUPTAKE INHIBITORS Fluoxetine Primidone Valproic Acid Mephobarbital OTHER CNS AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS Methylphenidate ER/SR Dextroamphetamine Ritalin LA * Citalopram CENTRAL NERVOUS SYSTEM ANTI-CONVULSANTS FIRST GENERATION ANTICONVULSANTS Celontin Phenytoin Gabapentin Lyrica Concerta * Metadate ER Focalin XR * Paroxetine Sertraline Patients currently receiving a non-preferred agent will be able to continue without a PA. SEDATIVE/HYPNOTICS, NON-BARBITURATES NON-ERGOT DOPAMINE RECEPTOR Temazepam Zolpidem Pramipexole Ropinirole ENDOCRINE AND METABOLIC ANTI-DIABETICS ALPHA-GLUCOSIDASE INHIBITORS AMYLIN ANALOGS* Acarbose Symlin Metformin Glyset Metformin ER *Prior Authorization is required if patient is not currently receiving insulin therapy. BIGUANIDE COMBINATION AGENTS DPP-4 INHIBITORS AND COMBINATIONS* ActoPlus Met Janumet Kombiglyze XR Januvia Onglyza Fanapt Fazaclo Geodon Baclofen Carisoprodol Topiramate ATYPICAL ANTIPSYCHOTICS Adderall XR Methylin ER Clozapine Risperidone Amphetamine Salt Combo Fluvoxamine Colestipol Welchol Phenytoin Sodium ER Methylphenidate *PA required if no claim for metformin in history. Gemfibrozil Tricor Altoprev Crestor Lescol Lescol XL Lipitor SECOND GENERATION ANTICONVULSANTS Lamotrigine Lamictal ODT Levetiracetam Trilipix Lovaza * Lovastatin Pravastatin Simvastatin Zonisamide Saphris Seroquel Seroquel XR Patients currently receiving a non-preferred agent will be able to continue without a PA. Chlorzoxazone SKELETAL MUSCLE RELAXANTS Cyclobenzaprine BIGUANIDES Dantrolene Sodium Methocarbamol Orphenadrine Tizanidine HCI

3 Byetta *PA required if no claim for metformin in history. SULFONYLUREAS, SECOND GENERATION Glimepiride Glipizide Glipizide ER Glyburide INCRELIN MIMETICS* Glyburide Micronized ENDOCRINE AND METABOLIC (continued) INSULINS Lantus Levemir Novolin N Novolog Mix 70/30 Novolin R *Vials and Pen Devices covered for all drugs listed above. THIAZOLIDINEDIONES Actos Novolin 70/30 Novolog Humalog 50/50 Nateglinide THIAZOLIDINEDIONE/SULFONYLUREA COMBINATIONS* Duetact MEGLITINIDES *Prior Authorization is required if a single agent thiazolidinedione has not been prescribed previously. OTHER ENDOCRINE AND METABOLIC AGENTS ELECTROLYTE DEPLETERS BIPHOSPHONATES-OSTEOPOROSIS CALCITONINS Fosrenol Renagel Alendronate Calcitonin Nasal Spray Phoslo Renvela Fortical Nasal Spray Genotropin Norditropin Emend GROWTH HORMONE* Nutropin *A class level PA is in effect for this class. Once criteria are met, the agents listed on the PDL are preferred NK1 ANTAGONISTS GASTROINTESTINAL SEROTONIN RECEPTOR ANTAGONISTS Granisetron Ondansetron HISTAMINE-2 RECEPTOR ANTAGONISTS Famotidine Ranitidine *See the listing at: for the quantity limits. PROTON PUMP INHIBITORS* ULCERATIVE COLITIS THERAPY PROGESTINS FOR CACHEXIA Nexium Capsules Pantoprazole Apriso Mesalamine Enema Megesterol Oral Susp. Omeprazole Asacol Pentasa Balsalazide Disodium Sulfasalazine Canasa Rectal Supp. *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. GENITOURINARY ALPHA BLOCKERS FOR BPH ANTISPASMODICS Tamsulosin Detrol LA Toviaz Uroxatral Oxybutynin VESIcare Oxytrol HEMATOLOGICAL & ONCOLOGICAL AGENTS ANTICOAGULANTS- LOW MOLECULAR WEIGHT HEPARINS HEMATOPOIETIC AGENTS PLATELET INHIBITORS Arixtra Fragmin Aranesp Aggrenox Enoxaparin Procrit Plavix PROTEIN TYROSINE KINASE INHIBITORS Gleevec

4 HORMONE RELATED THERAPY ANDROGENIC AGENTS ANDROGEN HORMONE INHIBITOR Androderm Testim Avodart Androgel IMMUNOMODULATORS, INJECTABLE Enbrel Finasteride IMMUNOLOGICS IMMUNOMODULATORS, TOPICAL Elidel * Humira Protopic * * Prescribers: Please use these agents as advised by the respective manufacturer and reserve for only those patients who have failed traditional eczema therapy. HEPATITIS B THERAPY* HEPATITIS C THERAPY PEGYLATED INTERFERONS* Baraclude Hepsera Pegasys & Conv. Pack Epivir HBV Tyzeka Peg-Intron & Redipen IMMUNOSUPPRESSANTS Azasan Myfortic Azathioprine Neoral Cyclosporine Prograf Gengraf Rapamune Imuran Sandimmune Mycophenolate Mofetil HEPATITIS C THERAPY RIBAVIRINS* Ribavirin *Viread is unaffected by the PDL and is available without Prior Authorization. Alaway OTC Elestat Brimonidine Tartrate Alphagan P *Class level PA is in effect for all Hepatitis B & C listed on the PDL are preferred. OPHTHALMICS ANTIHISTAMINES, OPHTHALMIC MAST CELL STABILIZERS, OPHTHALMIC NSAIDs, OPHTHALMIC Pataday Patanol Ketotifen OTC Zaditor OTC QUINOLONES & MACROLIDES, OPHTHALMIC Ciprofloxacin HCI Vigamox Iatanoprost Lumigan Ciprodex ALPHA-2 ADRENERGICS PROSTAGLANDIN AGONISTS Ofloxacin Otic Drops Zymar Travatan Travatan Z QUINOLONES, OTIC ANTI-CHOLINERGICS Alamast Alocril Betaxolol HCI Carteolol HCI Combigan Alomide Cromolyn Sodium GLAUCOMA THERAPY BETA BLOCKERS OTICS Levobunolol HCI Metipranolol Timolol Maleate RESPIRATORY ANTIHISTAMINES, 2ND GENERATION AND DECONGESTANT COMBINATIONS medications. Once criteria are met, the agents Flurbiprofen Sodium Azopt Dorzolamide Atrovent HFA Spiriva Cetirizine Loratadine OTC Astepro Combivent BETA ADRENERGIC DEVICES SHORT-ACTING INHALERS ProAir HFA Ventolin HFA Serevent Diskus * Proventil HFA Cetirizine D Loratadine-D OTC BETA ADRENERGIC DEVICES, LONG ACTING METERED DOSE INHALERS * Prescribers are reminded of the warnings associated with use of long acting beta agonists. Diclofenac Sodium Dorzolamide - Timolol Azelastine CARBONIC ANHYDRASE INHIBITORS NASAL ANTIHISTAMINES BETA ADRENERGIC AGENTS, LONG-ACTING NEBULIZERS * Both agents in this class require Prior Authorization. Ketorolac Tromethamine Nevanac

5 BETA ADRENERGIC AGENTS, SHORT ACTING NEBULIZERS Albuterol 0.083%, 0.5% RESPIRATORY (continued) GLUCOCORTICOIDS AND LONG-ACTING BETA-2 ADRENERGICS Advair Diskus Advair HFA Symbicort INHALATION DEVICES Asmanex Flovent HFA Flovent Diskus Qvar INTRANASAL STEROIDS LEUKOTRIENE RECEPTOR ANTAGONISTS 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. BENZOYL PEROXIDE/CLINDAMYCIN COMBOS Benzaclin Clindamycin-Benzoyl Peroxide TOPICAL AGENTS FOR PSORIASIS Calcipotriene Dovonex TOPICAL ANTIBIOTICS Mupirocin Ointment Bactroban * Cream Altabax * Singulair Zafirlukast Abreva TOPICAL AGENTS FOR ACNE BENZOYL PEROXIDE PREPARATIONS Generic Benzoyl Peroxide Preparations TOPICAL AGENTS FOR PSORIASIS TOPICAL ANTIINFECTIVES TOPICAL ANTIVIRALS Zovirax Ointment Adapalene Differin Epiduo TOPICAL RETINOIDS Retin-A Micro Tretinoin *Generic agents should be considered "first line" therapy when appropriate.