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Download MSM 120108 PDL Summary 2 page _final
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MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST The agents listed below are preferred products on the Mississippi Medicaid Preferred Drug List (PDL). The PDL is a medication list recommended to the Division of Medicaid by the Pharmacy and Therapeutics (P&T) Committee and approved by the Executive Director of the Division of Medicaid. These drugs have been selected for the efficaciousness, clinical significance, cost effectiveness and safety for Medicaid beneficiaries. Most generic agents are preferred, do not require prior authorization and are not individually listed below. Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. For more information concerning the PDL including non-preferred agents, the OTC formulary and other specifics, please visit our website at www.dom.state.ms.us. Additions from previous PDL highlighted in yellow. List Effective 01/01/09 THERAPEUTIC DRUG CLASS ACNE AGENTS, TOPICAL (Covered only for patients under 21 years of age) ALZHEIMER’S AGENTS ANALGESICS, NARCOTIC SHORT-ACTING (Non-parenteral) ANALGESICS, NARCOTIC - LONGACTING ANALGESICS, TOPICAL ANDROGENIC AGENTS PREFERRED AGENTS AZELEX BENZACLIN CLINAC BPO NUOX RETIN-A MICRO ZACLIR THERAPEUTIC DRUG CLASS ANTIBIOTICS, VAGINAL ANTICOAGULANTS, INJECTABLE ANTIFUNGALS, ORAL ANTIFUNGALS, TOPICAL NAFTIN ANTIHISTAMINES, MINIMALLY SEDATING (Xyzal will be authorized for patients failing therapy with a preferred OTC generic agent) XYZAL ANTICONVULSANTS ARICEPT ARICEPT ODT EXELON NAMENDA generics only DURAGESIC KADIAN FLECTOR LIDODERM VOLTAREN ANDRODERM ANDROGEL ANGIOTENSIN MODULATOR / CALCIUM CHANNEL BLOCKER COMBINATIONS ANTIBIOTICS, GI ACEON AVALIDE AVAPRO BENICAR BENICAR-HCT COZAAR HYZAAR DIOVAN DIOVAN-HCT MICARDIS MICARDIS-HCT AZOR EXFORGE TARKA ALINIA TINDAMAX CLEOCIN OVULES ARIXTRA FRAGMIN LOVENOX CARBATROL DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE DILANTIN EQUETRO GABITRIL KEPPRA LAMICTAL LYRICA PHENYTEK TOPAMAX TRILEPTAL Suspension generics only (except paroxetine CR) EFFEXOR XR PRISTIQ WELLBUTRIN XL generics only (except dronabinol, granisetron) GRIS- PEG ANTIDEPRESSANTS, SSRIs ANGIOTENSIN MODULATORS PREFERRED AGENTS ANTIDEPRESSANTS, OTHER ANTIEMETICS THERAPEUTIC DRUG CLASS ANTIMIGRAINE AGENTS, TRIPTANS ANTIPARASITICS, TOPICAL ANTIPARKINSON’S AGENTS ANTIPSYCHOTICS, ATYPICAL ANTIVIRALS, ORAL ATOPIC DERMATITIS BETA BLOCKERS (Oral) BLADDER RELAXANT PREPARATIONS BONE RESORPTION SUPPRESSION AND RELATED AGENTS (Oral) BPH AGENTS BRONCHODILATORS, ANTICHOLINERGIC BRONCHODILATORS, BETA AGONIST PREFERRED AGENTS IMITREX RELPAX TREXIMET EURAX OVIDE STALEVO ABILIFY GEODON RISPERDAL SEROQUEL VALTREX ELIDEL PROTOPIC BYSTOLIC COREG CR DETROL LA ENABLEX OXYTROL SANCTURA SANCTURA XR VESICARE ACTONEL BONIVA EVISTA FOSAMAX PLUS D MIACALCIN AVODART FLOMAX UROXATRAL ATROVENT HFA COMBIVENT SPIRIVA MAXAIR PROAIR HFA PROVENTIL HFA VENTOLIN HFA THERAPEUTIC DRUG CLASS CALCIUM CHANNEL BLOCKERS (Oral) CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) CYTOKINE & CAM ANTAGONISTS ERYTHROPOIESIS STIMULATING PROTEINS FLUOROQUINOLONES, ORAL GLUCOCORTICOIDS, INHALED GROWTH HORMONE HEPATITIS C TREATMENTS HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS (includes vials and pens) HYPOGLYCEMICS, INSULIN AND RELATED AGENTS (includes vials and pens) HYPOGLYCEMICS, MEGLITINIDES PREFERRED AGENTS THERAPEUTIC DRUG CLASS COVERA -HS DYNACIRC CR AUGMENTIN XR SUPRAX HYPOGLYCEMICS, TZDS CIMZIA ENBREL HUMIRA KINERET RAPTIVA ARANESP PROCRIT AVELOX PROQUIN XR ADVAIR AEROBID AEROBID-M ASMANEX AZMACORT FLOVENT Diskus FLOVENT HFA PULMICORT Respules QVAR SYMBICORT GENOTROPIN NUTROPIN NUTROPIN AQ SAIZEN PEGASYS BYETTA JANUMET JANUVIA LANTUS NOVOLIN NOVOLOG NOVOLOG MIX PRANDIN STARLIX INTRANASAL RHINITIS AGENTS LEUKOTRIENE MODIFIERS LIPOTROPICS, OTHER LIPOTROPICS, STATINS MACROLIDES / KETOLIDES MULTIPLE SCLEROSIS AGENTS NSAIDS OPHTHALMIC QUINOLONES/ MACROLIDES OPHTHALMICS, NSAIDS PREFERRED AGENTS ACTOS AVANDIA ACTOPLUS MET AVANDAMET AVANDARYL DUETACT ASTELIN NASAREL NASONEX PATANASE VERAMYST ACCOLATE SINGULAIR ANTARA LOVAZA NIASPAN TRICOR ADVICOR CADUET LESCOL LESCOL XL LIPITOR SIMCOR VYTORIN generics only (except clarithromycin ER) AVONEX BETASERON COPAXONE REBIF generics only (except meclofenamate, mefenamic acid) AZASITE IQUIX VIGAMOX ACULAR LS ACULAR PF ALAMAST NEVANAC THERAPEUTIC DRUG CLASS OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS (Drugs in this class with post-operative indications do not require PA) OPHTHALMICS, GLAUCOMA AGENTS OTIC FLUOROQUINOLONES PANCREATIC ENZYMES PHOSPHATE BINDERS PREFERRED AGENTS ALREX ELESTAT OPTIVAR PATADAY PATANOL AZOPT BETIMOL COMBIGAN COSOPT ISTALOL LUMIGAN 2.5 ML TRAVATAN TRAVATAN Z TRUSOPT XALATAN CIPRODEX FLOXIN CREON DYGASE LAPASE LIPRAM PANCREASE MT ULTRASE VIOKASE FOSRENOL PHOSLO RENAGEL PLATELET AGGREGATION INHIBITORS AGGRENOX PLAVIX PROTON PUMP INHIBITORS (Oral) PREVACID ZEGERID LUNESTA ROZEREM generics only (except carisoprodol, carisoprodol compound) SEDATIVE HYPNOTICS SKELETAL MUSCLE RELAXANTS STEROIDS, TOPICAL DESONATE CORDRAN LOCOID LUXIQ CAPEX ULTRAVATE 2 THERAPEUTIC DRUG CLASS STIMULANTS AND RELATED AGENTS ULCERATIVE COLITIS AGENTS PREFERRED AGENTS ADDERALL XR CONCERTA DAYTRANA FOCALIN FOCALIN XR METADATE CD METHYLIN chewable tablets METHYLIN solution STRATTERA VYVANSE ASACOL DIPENTUM LIALDA PENTASA CANASA 3
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