ANTI-INFECTIVE MACROLIDES/KETOLIDES TETRACYCLINES ONYCHOMYCOSIS AGENTS

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1 Diclofenac Potassium Diclofenac Sodium Diflunisal Etodolac Flurbiprofen Ibuprofen Indomethacin Indomathacin SR Ketoprofen South Carolina Department of Health and Human Services Preferred Drug List (PDL) 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 January 4, 2016 ANALGESIC NSAIDs* OPIOIDS, EXTENDED RELEASE SHORT ACTING NARCOTIC ANALGESICS Ketoprofen ER Ketoralac Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Vimovo *COX-2 specific NSAIDs require PA TOPICAL NSAIDs AND ANESTHETICS Embeda Fentanyl Patch Gabapentin Savella Codeine Codeine/APAP Codeine/APAP/caff/butal Codeine/ASA Codeine/ASA/caff/butal Hydrocodone/APAP Meperidine Morphine IR Nalbuphine Oxycodone Oxycodone/APAP Oxycodone/ASA * All agents in this class require Prior Authorization Lyrica ANTI-INFECTIVE MACROLIDES/KETOLIDES TETRACYCLINES ONYCHOMYCOSIS AGENTS Azithromycin Clarithromycin Clarithromycin XL EryPed Ery-Tab Erythromycin Base Cefprozil Cefuroxime Erythromycin Ethylsuc Erythrocin Stearate Erythromycin & Sulfisox *Generic for MS Contin and Kadian NEUROPATHIC PAIN Doxycycline Hyclate IR Doxycycline Monohydrate (50MG, 100MG) capsules Minocycline IR Tetracycline Vibramycin Suspension Vibramycin Syrup Hydrocodone/Ibuprofen Hydromorphone Griseofulvin Suspension Tramadol Griseofulvin Ultramicronized Tablet Terbinafine Tramadol/APAP CEPHALOSPORINS, 2ND GENERATION CEPHALOSPORINS, 3RD GENERATION HERPES ANTIVIRALS Cefdinir (all dosage forms) Cefditoren Morphine Sulfate ER* Morphine Sulfate SA Acyclovir Valacyclovir NITROIMIDAZOLES FLUOROQUINOLONES Metronidazole Ciprofloxacin IR tablets Levofloxacin CARDIOVASCULAR ACE INHIBITORS & CCB COMBINATIONS ANTIHYPERTENSIVES, SYMPATHOLYTICS ANGIOTENSIN RECEPTOR BLOCKERS (ARB) Benazepril Benazepril/HCTZ Captopril Enalapril Enalapril/HCTZ Lisinopril Acebutolol Atenolol Atenolol/Chlorthalidone Betaxolol Bisoprolol Fumarate Bisoprolol/HCTZ Carvedilol Labetalol Lisinopril/HCTZ BETA BLOCKERS CCB Combinations Amlodipine Besylate Metoprolol Tartrate Nadolol Pindolol Propranolol Propranolol ER Propranolol/HCTZ Sotalol Timolol Catapres-TTS Clonidine (Oral) Guanfacine IR (Oral) Methyldopa (Oral) Amlodipine Felodipine Isradipine Nicardipine Nifedical XL CALCIUM CHANNEL BLOCKERS (CCB) DIHYDROPYRIDINES Nifedipine ER and SA Benicar Benicar HCT Eprosartan Irbesartan Irbesartan/HCTZ Losartan/HCTZ Micardis Micardis HCT Valsartan/HCTZ Losartan CALCIUM CHANNEL BLOCKERS (CCB) NON-DIHYDROPYRIDINES Cartia XT Diltiazem Diltiazem ER and XR Taztia XT Verapamil Verapamil ER Verapamil SR CCB/ARB COMBINATION PRODUCTS DIRECT RENIN INHIBITORS ENDOTHELIN RECEPTOR ANTAGONISTS Amlodipine/Valsartan Exforge HCT Tekturna * Tekturna HCT * *Prior Authorization is required if an ARB has not been prescribed previously. Letairis * *Patients currently established on non-preferred therapy will be grandfathered.

2 Adcirca CARDIOVASCULAR (Continued) PAH-PDE5 INHIBITORS** BILE ACID SEQUESTERING RESINS FIBRIC ACID DERIVATIVES Sildenafil ** All agents in this class require verification of PAH diagnosis. Niaspan Cholestyramine Cholestyramine Light Colestipol Tablet Gemfibrozil Fenofibrate Fenofibric Acid capsules *Requires step-therapy with another preferred agent NIACIN DERIVATIVES NIACIN/STATIN COMBINATIONS STATINS Simcor Atorvastatin Fluvastatin Lexcol XL Lovastatin Pravastatin Simvastatin CHOLESTEROL ABSORPTION INHIBITORS STATIN/CCB COMBINATION PRODUCTS NON-NITRATE ANTIANGINALS Donepezil (tablets) CENTRAL NERVOUS SYSTEM ALZHEIMER'S AGENTS NMDA RECEPTOR ANTAGONIST Ranexa Galantamine IR ANTI-CONVULSANTS CARBAMAZEPINE DERIVATIVES FIRST GENERATION ANTICONVULSANTS SECOND GENERATION ANTICONVULSANTS Carbamazepine (all dosage forms) Epitol Oxcarbazepine Diastat Bupropion Bupropion SR Bupropion XL Mirtazapine Nefazodone CHOLINESTERASE INHIBITORS Rivastigmine RECTAL PREPS ANTIDEPRESSANTS, OTHER* Phenelzine Trazodone Venlafaxine Venlafaxine ER CAP *Patients currently receiving a non-preferred agent will be able to continue without a PA. ** Antidepressants indicated for pain have not yet been reviewed and are available without PA. Memantine HCI Celontin Divalproex Sodium Ethosuximide Felbamate Phenytoin Phenytoin Sodium ER Primidone Valproic Acid BEHAVIORAL HEALTH ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS Adderall XR Amphetamine Salt Combo Daytrana Dexmethylphenidate IR Dextroamphetamine Dextroamphetamine SR Focalin XR Guanfacine Metadate CD Metadate ER Methylphenidate Methylphenidate ER/SR Quillivant XR Ritalin LA Strattera Vyvanse Gabapentin Lamotrigine Lamictal ODT Levetiracetam Lyrica Topiramate Zonisamide *Banzel, Fycompa, Gabitril, Onfi, Potiga Sabril & Vimpat require PA, no step therapy req. Clozapine Fanapt Latuda Olanzapine Tablets Quetiapine ATYPICAL ANTIPSYCHOTICS Risperidone Saphris Seroquel XR Ziprasidone (caps) Patients currently receiving a non-preferred agent will be able to continue without a PA. ATYPICAL ANTIPSYCHOTICS LONG ACTING INJECTABLES Invega Sustenna Invega Trinza Risperdal Consta Citalopram Fluvoxamine SELECTIVE SEROTONIN REUPTAKE INHIBITORS Paroxetine IR Sertraline (tabs) Fluoxetine (excludes DR/60mg caps) Patients currently receiving a non-preferred agent will be able to continue without a PA. OTHER CNS AGENTS ANTI-MIGRAINE SEROTONIN AGONISTS MULTIPLE SCLEROSIS AGENTS SKELETAL MUSCLE RELAXANTS Sumatriptan Tablets Sumatriptan Injection Sumatriptan Nasal Spray Avonex Avonex Admin Pack Betaseron Copaxone Extavia Rebif Baclofen Carisoprodol 350mg Chlorzoxazone Cyclovenzaprine IR Dantrolene Sodium Methocarbamol Orphenadrine Tizanidine HCI tablets SEDATIVE/HYPNOTICS, NON-BARBITURATES NON-ERGOT DOPAMINE RECEPTOR Temazepam Zolpidem IR Pramipexole IR Ropinirole IR

3 ENDOCRINE AND METABOLIC ANTI-DIABETICS ALPHA-GLUCOSIDASE INHIBITORS AMYLIN ANALOGS* DPP-4 INHIBITORS AND COMBINATIONS* Acarbose Symlin Janumet Jentadueto Glyset Januvia Tradjenta Bydureon Byetta GLP1 INHIBITORS INSULINS* MEGLITINIDES Tanzeum *PA required if no claim for metformin in history. Glimepiride Glipizide Glyburide* SULFONYLUREAS *Caution: Glyburide may result in a higher risk of severe prolonged Hypoglycemia in older adults. Metformin BIGUANIDES Glyburide/Metformin Metformin * Prior Authorization is required if patient is not currently receiving insulin therapy. Humalog Humulin Lantus *Vials/Pen Devices covered for all drugs listed above THIAZOLIDINEDIONES (Thiazolidinediones/Sulfonylurea Combos) Pioglitazone Levemir Novolin Novolog * Prior Authorization is required if a single agent thiazolidinedione has not been prescribed previously. * PA required if no claim for metformin in history. Nateglinide Invokana Farxiga SODIUM-GLUCOSE TRANSPORTER 2 (SGLT2) INHIBITORS Invokamet Xigduo XR *PA required if no metformin in history. OTHER ENDOCRINE AND METABOLIC AGENTS ELECTROLYTE DEPLETERS BIPHOSPHONATES-OSTEOPOROSIS CALCITONINS Calcium Acetate-capsules Fosrenol Renagel Renvela Alendronate Calcitonin Nasal Spray Fortical Nasal Spray GLUCOCORTICOIDS, ORAL GROWTH HORMONE* PANCREATIC ENZYMES Budesonide EC Methylprednisolone Norditropin Nutropin AQ Creon Zenpep Cortef Orapred/Orapred ODT Nutropin Pancrelipase Cortisone Prednisolone Soln Dexamethasone Prednisolone Sod Phos * A class level PA is in effect for this class. Once criteria Hydrocortisone Prednisone are met, the agents listed on the PDL are preferred. GASTROINTESTINAL ANTIEMETIC AGENTS HISTAMINE-2 RECEPTOR ANTAGONISTS PROTON PUMP INHIBITORS* Emend Promethazine Famotidine tablets Nexium Suspension Pantoprazole Metoclopramide Prochlorperazine Ranitidine Omeprazole Ondansetron *Preferred PPIs will no longer require step therapy *See the listing at for quantity limits. or prior authorization. ** Disintegrating Lansoprazole will continue to be available without PA for patients age 12 and under. ULCERATIVE COLITIS THERAPY PROGESTINS FOR CACHEXIA LAXATIVES & CATHARTICS Apriso Balsalazide Disodium Canasa Rectal Supp. Mesalamine Enema Pentasa Sulfasalazine Megestrol Oral Susp. Milk of Magnesia Magnesium Citrate Lactulose PEG 3350/Electrolyte MiraLAX OTC Tamsulosin Uroxatral ALPHA BLOCKERS FOR BPH Oxybutynin IR Oxytrol GENITOURINARY ANTISPASMODICS Toviaz VESIcare XANTHINE OXYDASE INHIBITORS Allopurinol Probenecid Colchicine Probenecid/Colchicine GOUT

4 HEMATOLOGICAL & ONCOLOGICAL AGENTS ANTICOAGULATNS (Injectable) ANTICOAGULANTS (Oral) HEMATOPOIETIC AGENTS Arixtra Fragmin Eliquis Warfarin Aranesp Enoxaparin Pradaxa Xarelto Procrit PLATELET INHIBITORS PROTEIN TYROSINE KINASE INHIBITORS Aggrenox Clopidogrel Gleevec Brilinta HORMONE RELATED THERAPY ANDROGENIC AGENTS ANDROGEN HORMONE INHIBITOR AndroGel Avodart Finasteride IMMUNOLOGICS IMMUNOMODULATORS, INJECTABLE IMMUNOMODULATORS, TOPICAL IMMUNOSUPPRESSANTS Enbrel Elidel * Azasan Myfortic Humira Azathioprine Neoral Cyclosporine Rapamune *Prescribers: Please use these agents as advised Gengraf Sandimmune by the respective manufacturere and reserve for Imuran Tacrolimus only those patients who have failed traditional Mycophenolate Mofetil eczema therapy. HEPATITIS B THERAPY* HEPATITIS C THERAPY RSV ANTIBODY Baraclude Hepsera Daklinza Viekira Pak Synagis Epivir HBV Tyzeka Technivie *Viread is unaffected by the PDL and is available *Class level PA is in effect for all Hepatitis B & C without Prior Authorization. medications. Once criteria are met, the agents listed on the PDL are preferred. OPHTHALMICS ANTIHISTAMINES, OPHTHALMIC MAST CELL STABILIZERS, OPHTHALMIC NSAIDs, OPTHALMIC Alaway Lastacaft Pazeo Zaditor Alcoril Alomide Cromolyn Sodium Diclofenac Sodium Flurbiprofen Sodium Ketorolac Tromethamine Nevanac Pataday QUINOLONES & MACROLIDS, OPHTHALMIC Ciprofloxacin HCI Vigamox ALPHA-2 ADRENERGICS Brimonidine Tartrate Alphagan P PROSTAGLANDIN AGONISTS Latanoprost Travatan Z Lumigan QUINOLONES, OTIC Ciprodex Ofloxacin Otic Drops ANTI-CHOLINERGICS Atrovent HFA Spiriva Betaxolol HCI Carteolol HCI Combigan Astepro Azelastine GLAUCOMA THERAPY BETA BLOCKERS OTICS Levobunolol HCI Metipranolol Timolol Maleate RESPIRATORY NASAL ANTIHISTAMINES Azopt Dorzolamide CARBONIC ANHYDRASE INHIBITORS Dorzolamide - Timolol BETA ADRENERGIC DEVICES SHORT-ACTING INHALERS Ipratropium ProAir HFA Proventil HFA

5 ANTIHISTAMINES, MINIMALLY SEDATING* Cetirizine Fexofenadine**/Allegra ODT Loratadine *Combination products containing pseudoephedrine have been removed from this class & will be excluded consistent with cough/cold products. **Liquids & orally disintegrating formulations limited to patients age 12 and under. BETA ADRENERGIC AGENTS, SHORT ACTING NEBULIZERS Albuterol Neb Inhalation RESPIRATORY (continued) BETA ADRENERGIC DEVICES, LONG ACTING METERED DOSE INHALERS Foradil *Prescribers are reminded of the warnings associated with use of long acting beta agonists. GLUCOCORTICOIDS AND LONG-ACTING BETA-2 ADRENERGICS Advair Diskus Advair HFA Dulera Symbicort BETA AGONIST AGENTS, SHORT ACTING ORAL AGENTS Albeterol Syrup Bethkis Albuterol IR Tablet INHALED ANTIBIOTICS Kitabis INHALED CORTICOSTEROIDS Asmanex Flovent HFA Flovent Diskus QVAR ANTI-ALLERGENS (ORAL) Grastek Ragwitek Oralair Azelex Clindamycin Phosphate Benzaclin (Gel w/pump) Retin-A Micro Clindagel Tretinoin Ciclopirox (cream/solution/suspension) Clotrimazole (cream/solution) Clotrimazole/Betamethasone (cream/lotion) TOPICAL AGENTS FOR PSORIASIS Calcipotriene 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. GLUCORTICOIDS INHALED (NEB) Pulmicort Respules TOPICAL AGENTS FOR ACNE Generic Benzoyl Peroxide Preparations Generic Erythromycin Preparations Generic Sulfacetamide-Sulfur Preparations TOPICAL ANTIFUNGALS Econazole Ketoconazole (cream/shampoo) Nystatin (cream/ointment) TOPICAL AGENTS FOR PSORIASIS LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast Zafirlukast Nystatin/Triamcinolone (cream/ointment) Mupirocin (oint/cream) TOPICAL ANTIBIOTICS Altabax * TOPICAL ANTIINFECTIVES TOPICAL ANTIVIRALS Abreva Acyclovir Ointment *Generic agents should be considered "first line" therapy when appropriate. TOPICAL ANTIPARASITICS Permethrin, OTC Permethrin 5% Cream Sklice Ulesfia TOPICAL STEROIDS Alclometasone Dipropionate Betameth Diprop (cream/lotion) Betameth Valerate (cream/lotion) Betameth/Dipro/Propyl Glycol (cream) Capex Shampoo Clobetasol Emolient Clobetasol Prop (cream/gel/oint/soln) Desonide Fluocinonide Emollient Fluocinonide-E Fluocinolone Oil Halobetasol Propionate Hydrocortisone Hydrocortisone Butyrate (oint/solution) Hydrocortisone Valerate (cream/soln) Mometasone Furoate Triamcinolone Acetonide

6 MISCELLANEOUS EPINEPHRINE (INJECTABLES) DME SMOKING CESSATION EPIPEN /EPIPEN JR Bupropion SR Chantix / Dose Pack Nicotine Gum Nicotine Lozenge Nicotine Patch