NEBRASKA MEDICAID PREFERRED DRUG LIST As of 10/1/09 (See Legend Below Table)
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1 1 NEBRASKA MEDICAID DRUG LIST As of 10/1/09 (See Legend Below Table) Note: Only drugs that are part of the listed therapeutic categories are affected by the Preferred Drug List. More categories will be added throughout the first year of implementation. Check the Pharmacy First Health website for the most current version at ALZHEIMER S ANDROGENIC (Topical) ANTIBIOTICS, VAGINAL ANTIEMETICS INCLUDING: CANNABINOIDS, 5HT3 RECEPTOR BLOCKERS, NK-1 RECEPTOR ANTAGONIST ANTIFUNGALS, ORAL ANTIFUNGALS, TOPICAL ARICEPT (donepezil) ARICEPT ODT (donepezil) EXELON Transdermal (rivastigmine) galantamine galantamine ER CHOLINESTERASE INHIBITORS NON- COGNEX (tacrine) EXELON Oral Solution (rivastigmine) EXELON Oral (rivastigmine) NMDA RECEPTOR ANTAGONIST NAMENDA (memantine) ANDRODERM (testosterone) TESTIM (testosterone) ANDROGEL (testosterone) clindamycin (vaginal) METROGEL (metronidazole, vaginal) metronidazole (vaginal) Marinol (dronabinol) ondansetron ondansetron ODT fluconazole GRIS-PEG (griseofulvin) griseofulvin suspension ketoconazole nystatin terbinafine clotrimazole OTC and RX econazole ketoconazole ketoconazole shampoo miconazole OTC NAFTIN (naftifine) CLEOCIN OVULES (clindamycin, vaginal suppositories) CLINDESSE (clindamycin, vaginal) CANNABINOIDS CESAMET (nabilone) dronabinol 5HT3 RECEPTOR BLOCKERS ANZEMET (dolasetron) granisetron KYTRIL (granisetron) SANCUSO (granisetron) NK-1 RECEPTOR ANTAGONIST EMEND (aprepitant) ANCOBON (flucytosine) clotrimazole (mucous membrane, troche) GRIFULVIN V (griseofulvin) LAMISIL GRANULES (terbinafine) NOXAFIL (posaconazole) SPORANOX (itraconazole) VFEND (voriconazole) ANTIFUNGAL BENSAL HP (benzoic acid/salicylic acid) ciclopirox cream/gel/suspension ciclopirox nail lacquer (solution) ERTACZO (sertaconazole) EXTINA (ketoconazole)
2 2 ANTIHYPERURICEMICS ANTIPARASITICS, TOPICAL ANTIPARKINSON S (Oral) ANTIVIRALS, ORAL ANTIVIRALS, TOPICAL nystatin selenium sulfide 1% selenium sulfide 2.5% terbinafine OTC tolnaftate OTC NON- LOPROX SHAMPOO (ciclopirox) MENTAX (butenafine) OXISTAT (oxiconazole) selenium sulfide 2.25% VUSION (miconazole/ zinc oxide) XOLEGEL (ketoconazole) ANTIFUNGAL/STEROID COMBINATIONS clotrimazole/betamethasone nystatin/triamcinolone allopurinol ULORIC (febuxostat) colchicine probenecid probenecid/colchicine EURAX (crotamiton) permethrin 1% OTC permethrin 5% RX OVIDE (malathion) benztropine trihexyphenidyl bromocriptine ropinirole lindane malathion ULESFIA (benzyl alcohol) NR ANTICHOLINERGICS COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone) DOPAMINE AGONISTS MIRAPEX (pramipexole) REQUIP (ropinirole) REQUIP XL (ropinirole) MAO-B INHIBITORS selegiline AZILECT (rasagiline) ZELAPAR (selegiline) OTHER ANTIPARKINSON S carbidopa/levodopa carbidopa/levodopa ODT STALEVO (levodopa/carbidopa/entacapone) ANTI-HERPETIC acyclovir VALTREX (valacyclovir) famciclovir FAMVIR (famciclovir) ANTI-INFLUENZA amantadine RELENZA (zanamivir) inhalation QL rimantadine TAMIFLU (oseltamivir) QL DENAVIR (penciclovir) ZOVIRAX Cream (acyclovir) ZOVIRAX Ointment (acyclovir)
3 3 ATOPIC DERMATITIS BONE RESORPTION SUPPRESSION AND RELATED BRONCHODILATORS, ANTICHOLINERGIC BRONCHODILATORS, BETA AGONIST CEPHALOSPORINS (Oral) and RELATED ANTIBIOTICS NON- PROTOPIC (tacrolimus) ELIDEL (pimecrolimus) BISPHOSPHONATES ACTONEL (risedronate) ACTONEL WITH CALCIUM alendronate (risedronate/ calcium) DIDRONEL (etidronate) BONIVA (ibandronate) etidronate disodium FOSAMAX Oral Solution (alendronate) FOSAMAX PLUS D OTHER BONE RESORPTION SUPPRESSION AND RELATED EVISTA (raloxifene) calcitonin-salmon nasal MIACALCIN (calcitonin) nasal FORTEO (teriparatide) subcutaneous FORTICAL (calcitonin) nasal ATROVENT HFA (ipratropium) COMBIVENT (albuterol/ipratropium) SPIRIVA (tiotropium) ipratropium solution PROAIR HFA (albuterol) VENTOLIN HFA (albuterol) FORADIL (formoterol) SEREVENT (salmeterol) albuterol (2.5mg/3ml premix or 2.5mg/0.5ml) albuterol terbutaline INHALERS INHALATION SOLUTION albuterol/ipratropium INHALERS-Short Acting MAXAIR (pirbuterol) PROVENTIL HFA (albuterol) XOPENEX HFA (levalbuterol) INHALERS Long Acting INHALATION SOLUTION albuterol low dose (0.63mg/3ml & 1.25mg/3ml) albuterol/ipratropium BROVANA (arformoterol) PERFOROMIST (formoterol) XOPENEX (levalbuterol) ORAL metaproterenol BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS amoxicillin/clavulanate tablets and suspension AUGMENTIN 125mg/5ml Suspension AUGMENTIN 250mg/5ml Suspension AUGMENTIN XR (amoxicillin/clavulanate) (all forms of brand name AUGMENTIN are non-preferred, except 125 and 250mg/5ml) cephalexin (oral) cefadroxil (oral) CEPHALOSPORINS First Generation
4 4 CYTOKINE & CAM ANTAGONISTS (Note: only self-administered, outpatient medications included in this review) FLUOROQUINOLONES, ORAL GLUCOCORTICOIDS, INHALED cefuroxime (oral) cefprozil (oral) cefdinir (oral) SUPRAX (cefixime) CIMZIA (certolizumab pegol) ENBREL (etanercept) HUMIRA (adalimumab) KINERET (anakinra) AVELOX (moxifloxacin) ciprofloxacin AEROBID (flunisolide) AEROBID-M (flunisolide) AZMACORT (triamcinolone) FLOVENT DISKUS (fluticasone) FLOVENT HFA (fluticasone) QVAR (beclomethasone) NON- CEPHALOSPORINS Second Generation cefaclor (oral) CEFTIN (cefuroxime) CEPHALOSPORINS Third Generation CEDAX (ceftibuten) cefpodoxime (oral) SPECTRACEF (cefditoren) SIMPONI (golimumab) NR CIPRO Suspension (ciprofloxacin) ciprofloxacin ER FACTIVE (gemifloxacin) LEVAQUIN (levofloxacin) NOROXIN (norfloxacin) ofloxacin PROQUIN XR (ciprofloxacin) GLUCOCORTICOIDS ALVESCO (ciclesonide) ASMANEX (mometasone) PULMICORT FLEXHALER (budesonide) GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR (fluticasone/salmeterol) ADVAIR HFA SYMBICORT (budesonide/ formoterol) INHALATION SOLUTION PULMICORT RESPULES (budesonide) budesonide respules HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS HYPOGLYCEMICS, INSULIN AND RELATED HUMALOG (insulin lispro) HUMALOG MIX (insulin lispro/lispro protamine) HUMULIN (insulin) LANTUS (insulin glargine) LEVEMIR (insulin detemir) BYETTA (exenatide) subcutaneous SYMLIN (pramlintide) subcutaneous JANUVIA (sitagliptin) JANUMET (sitagliptin/metformin) APIDRA (insulin glulisine) NOVOLIN (insulin) NOVOLOG (insulin aspart) NOVOLOG MIX (insulin aspart/aspart protamine) Insulin pens /cartridges
5 5 INTRANASAL RHINITIS LEUKOTRIENE MODIFIERS MACROLIDES AND KETOLIDES (Oral) ASTELIN (azelastine) fluticasone NASONEX (mometasone) VERAMYST (fluticasone) ACCOLATE (zafirlukast) SINGULAIR (montelukast) azithromycin erythromycin NON- ANTICHOLINERGICS ipratropium ANTIHISTAMINES ASTEPRO (azelastine) PATANASE (olopatadine) CORTICOSTEROIDS BECONASE AQ (beclomethasone) flunisolide NASACORT AQ (triamcinolone) OMNARIS (ciclesonide) RHINOCORT AQUA (budesonide) ZYFLO CR (zileuton) KETOLIDES KETEK (telithromycin) MACROLIDES clarithromycin ER clarithromycin IR ZMAX (azithromycin) ZITHROMAX (azithromycin) NSAIDS OPHTHALMICS, ANTIBIOTICS diclofenac fenoprofen flurbiprofen ibuprofen OTC, Rx ketoprofen ketorolac meloxicam nabumetone naproxen Rx oxaprozin piroxicam sulindac ciprofloxacin CILOXAN oint. (ciprofloxacin) ofloxacin VIGAMOX (moxifloxacin) COX-I SELECTIVE etodolac indomethacin oral/rectal meclofenamate mefenamic acid tolmetin ALL BRAND NAME NSAIDs ARE NON-. NSAID/GI PROTECTANT COMBINATIONS ARTHROTEC (diclofenac/misoprostol) COX-II SELECTIVE CELEBREX (celecoxib) FLUOROQUINOLONES IQUIX (levofloxacin) QUIXIN (levofloxacin) ZYMAR (gatifloxacin) BESIVANCE (besifloxacin) NR
6 6 erythromycin NON- MACROLIDES AZASITE (azithromycin) gentamicin tobramycin TOBREX ointment (tobramycin) AMINOGLYCOSIDES OTHER ANTIBIOTICS bacitracin NATACYN (natamycin) bacitracin/polymyxin B neomycin/polymyxin B/gramicidin polymyxin B/trimethoprim sulfacetamide triple antibiotic (neomycin/bacitracin/polymyxin B) OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS OPHTHALMICS, ANTI-INFLAMMATORIES OPHTHALMICS, GLAUCOMA ALREX (loteprednol) cromolyn ketotifen OTC PATADAY (olopatadine 0.2%) PATANOL (olopatadine 0.1%) dexamethasone FLAREX (fluorometholone) fluorometholone FML FORTE (fluorometholone) FML S.O.P. (fluorometholone) LOTEMAX (fluorometholone) MAXIDEX (dexamethasone) PRED MILD (prednisolone) diclofenac flurbiprofen pilocarpine brimonidine PROPINE (dipivefrin) ACULAR (ketorolac 0.5%) ALAMAST (pemirolast) ALOCRIL (nedocromil) ALOMIDE (lodoxamide) ELESTAT (epinastine) EMADINE (emedastine) OPTIVAR (azelastine) BEPREVE (bepotastine besilate) NR CORTICOSTEROIDS DUREZOL (difluprednate) VEXOL (rimexolone) NSAID ACULAR LS (ketorolac 0.4%) ACULAR PF (ketorolac 0.5%) XIBROM (bromfenac) NEVANAC (nepafenac) MIOTICS ACUVAIL (ketorolac 0.45%) NR SYMPATHOMIMETICS ALPHAGAN P (brimonidine)
7 7 NON- BETA BLOCKERS betaxolol BETIMOL (timolol) BETOPTIC S (betaxolol) carteolol ISTALOL (timolol) levobunolol metipranolol timolol CARBONIC ANHYDRASE INHIBITORS AZOPT (brinzolamide) dorzolamide TRUSOPT (dorzolamide) PROSTAGLANDIN ANALOGS TRAVATAN (travoprost) LUMIGAN (bimatoprost) TRAVATAN Z (travoprost) XALATAN (latanoprost) COMBINATION COMBIGAN (brimonidine/timolol) dorzolamide/timolol COSOPT (dorzolamide/timolol) PANCREATIC ENZYMES CREON PANCREASE MT pancrelipase ULTRASE VIOKASE PANCRECARB MS ZENPEP (pancrelipase) NR PLATELET AGGREGATION INHIBITORS AGGRENOX (dipyridamole/aspirin) aspirin dipyridamole PLAVIX (clopidogrel) ticlopidine EFFIENT (prasugrel) NR STEROIDS, TOPICAL alclometasone dipropionate CAPEX Shampoo (fluocinolone) DERMA-SMOOTHE-FS (fluocinolone) desonide hydrocortisone LOW POTENCY DESONATE (desonide) VERDESO (desonide) fluocinolone acetonide fluticasone propionate hydrocortisone valerate LUXIQ (betamethasone) mometasone furoate MEDIUM POTENCY CLODERM (clocortolone) CORDRAN TAPE (flurandrenolide) hydrocortisone butyrate LOCOID LIPOCREAM (hydrocortisone) prednicarbate
8 betamethasone valerate fluocinonide fluocinonide E fluocinonide emollient triamcinolone acetonide NON- HIGH POTENCY amcinonide betamethasone dipropionate desoximetasone diflorasone diacetate HALOG (halcinonide) KENALOG AEROSOL (triamcinolone) VANOS (fluocinonide) 8 STIMULANTS AND RELATED Note: Patients on non-preferred stimulants prior to the PDL are eligible for grand-fathering. QL= quantity limits may apply to this class. TETRACYCLINES clobetasol emollient clobetasol propionate halobetasol propionate ADDERALL XR (amphetamine salt combination) amphetamine salt combination ER amphetamine salt combination IR CONCERTA (methylphenidate) dexmethylphenidate dextroamphetamine FOCALIN (dexmethylphenidate) FOCALIN XR (dexmethylphenidate) METADATE CD (methylphenidate) methylphenidate methylphenidate ER PROVIGIL (modafanil) doxycycline hyclate minocycline HCl tetracycline HCl VERY HIGH POTENCY CLOBEX (clobetasol) OLUX-E (clobetasol) OLUX/OLUX-E CP (clobetasol) CNS STIMULANTS DAYTRANA (methylphenidate) DESOXYN (methamphetamine) PROCENTRA (dextroamphetamine) RITALIN LA (methylphenidate) VYVANSE (lisdexamfetamine) MISCELLANEOUS STRATTERA (atomoxetine) INTUNIV (guanfacine) NR ANALEPTICS NUVIGIL (armodafinil) NR ADOXA (doxycycline monohydrate) demeclocycline DORYX (doxycycline pellitized) minocycline HCl extended release ORACEA (doxycycline monohydrate) SOLODYN (minocycline HCl)
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