Maryland Preferred Drug List The Maryland Medicaid Pharmacy ...

Maryland Preferred Drug ListNo. 107December 29, 2011In an effort to give timely notice to the pharmacy community concerning important pharmacy topics, the Department of Health and Mental Hygiene’s (DHMH)Maryland Medicaid Pharmacy Program (MMPP) has developed the Maryland Medicaid Pharmacy Program Advisory. To expedite information timely to thepharmacy and prescriber communities, an email network has been established which incorporates the email lists of the Maryland Pharmacists Association, EPIC,CARE, Long Term Care Consultants, headquarters of all chain drugstores and prescriber associations and organizations. It is our hope that the information isdisseminated to all interested parties. If you have not received this email through any of the previously noted parties or via DHMH, please contact the MMPPrepresentative at 410-767-1455.UPDATED MARYLAND MEDICAID PREFERRED DRUG LISTEFFECTIVE JANUARY 1, 2012The Maryland Medicaid Pharmacy Program has an open formulary with a Preferred Drug List (PDL) to ensureaccess to efficacious, safe, and cost-effective drug options. This updated PDL also contains changes in thefollowing classes: COPD Agents, previously named “Bronchodilators, Anticholinergics”, is now expanded to include otheravailable treatment options for COPD. Two new classes were introduced: Antihypertensives, Sympatholytics and Ophthalmic Antibiotic/SteroidCombinations.Changes in the Preferred Drug List are highlighted in yellow.Key: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/20121

Maryland Preferred Drug ListOnly drugs that are part of the listed therapeutic categories are affected by the PDL. Therapeutic categories not listed here are not partof the PDL and will continue to be covered as they always have for Maryland Medicaid patients.Note: For most multi-source products, the generic product(s) are usually preferred and branded innovator product(s) are non-preferred. PDL products that are new to market requireprior authorization until they are reviewed.ANALGESICSAnalgesics/Anesthetics, TopicalPreferredcapsaicin OTCLidodermVoltaren GelRequires Prior AuthorizationFlectorPennsaidQutenzaAnalgesics, Narcotics (Long Acting)PreferredRequires Prior Authorizationfentanyl patch (Duragesic)oxycodone ER (Oxycontin)methadone(Brand and generic)morphine sulfate SR (MS Contin) tramadol ER (Ultram ER)Kadian(Brand and generic)AvinzaButransDuragesic MatrixEmbedaExalgoOpana ERRyzoltAnalgesics, Narcotics (Short Acting)PreferredRequires Prior Authorizationapap w/codeine (Tylenol w/Codeine)aspirin w/codeinefentanyl buccal (Actiq)(Brand and generic)*butalbital/apap/codeine/caffeinebutalbital/apap/codeinecodeinelevorphanolmeperidine (Demerol)(Brand and generic)dihydrocodeine/aspirin/caff(Synalgos DC)oxycodone/ibuprofen (Combunox)(Brand and generic)dihydrocodeine/apap/caffeine(Panlor SS)oxymorphone (Opana)(Brand and generic)hydrocodone/apap (Vicodin)Abstral*hydrocodone/ibuprofen (Vicoprofen) Dilaudid Liquidhydromorphone (Dilaudid)Fentoramorphine sulfateIbudoneoxycodoneNucyntaoxycodone/apap (Percocet) Onsolis *oxycodone/aspirin (Percodan)Panlor DCpentazocine/apap (Talacen)Reprexainpentazocine/naloxone (Talwin NX) Rybix ODTtramadol (Ultram)Zamicettramadol/apap (Ultracet)Zolvit*Clinical Criteria applies to fentanyl buccal tablets (Fentora) , fentanyl buccallozenges (Actiq, generic) , Abstral (fentanyl sublingual tablets) and Onsolis (fentanylbuccal film) . To view criteria, please refer tohttp://www.dhmh.state.md.us/mma/mpap/forms.htmKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/20122

Maryland Preferred Drug ListANTI-INFECTIVESAntibiotics, GIPreferredmetronidazole (Flagyl)neomycinAliniaTindamaxVancocinAntibiotics, InhaledPreferredRequires Prior AuthorizationDificidFlagyl ERXifaxanTOBI CaystonAntibiotics, VaginalPreferredclindamycin vaginal (Clindamax)metronidazole vaginal (Metro-Gel)Cleocin OvulesVandazole VaginalRequires Prior AuthorizationRequires Prior AuthorizationClindesse VaginalAntifungals, Topical (Topical Antifungals)Preferredclotrimazole OTCclotrimazole Rx (Lotrimin)clotrimazole/betamethasone(Lotrisone)econazole (Spectazole)ketoconazole (Nizoral)miconazole OTCnystatinnystatin/triamcinolone (Mycolog)terbinafine OTCtolnaftate OTCRequires Prior Authorizationbutenafine OTCciclopirox (Loprox)(Brand and generic)ciclopirox solution (Penlac)(Brand and generic)ciclopirox shampoo (LoproxShampoo) (Brand andgeneric)Bensal HPCNL-8ErtaczoExeldermExtinaKetocon PlusLamisil SolutionMentaxNaftinNuzolePediaderm AFOxistatVusionXolegelAntifungals, Oral (Antifungal Agents, Antifungal Antibiotics)PreferredRequires Prior Authorizationfluconazole (Diflucan)clotrimazole troche (Mycelex)ketoconazole (Nizoral)(Brand and generic)nystatingriseofulvin suspension (Fulvicin,terbinafine (Lamisil)GriFulvin V) (Brand andGris Peggeneric)itraconazole (Sporanox)voriconazole (Vfend)(Brand and generic)AncobonGriFulvin VLamisil GranulesNoxafilOravigTerbinexKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/2012Antiparasitics, TopicalPreferredpermethrin OTCpermethrin Rx (Elimite,Acticin)EuraxOvide (Brand ONLY)Antivirals, Oral (Antivirals, General)Preferredacyclovir (Zovirax)amantadine (Symmetrel)rimantadine (Flumadine)Valtrex (Brand ONLY)Requires Prior Authorizationlindanemalathion (generic only)NatrobaUlesfiaRequires Prior Authorizationfamciclovir (Famvir)(Brand and generic)valacyclovir (generic only)RelenzaTamiflu4

Maryland Preferred Drug ListAntivirals, TopicalPreferredRequires Prior AuthorizationAbreva OTC XereseDenavir Zovirax CreamZovirax OintmentCephalosporin and Related Agents (Cephalosporins, Secondand Third Generation, Penicillins)Preferredamoxicillin/clavulanate(Augmentin, Augmentin ES)cefaclor (Ceclor, Ceclor CD)cefadroxil (Duricef)cefdinir (Omnicef)cefuroxime (Ceftin)cefprozil (Cefzil)cephalexin (Keflex)SupraxRequires Prior Authorizationamoxicillin/clav ER (AugmentinXR) (Brand and generic)cefditoren (Spectracef)(Brand and generic)cefpodoxime (Vantin)(Brand and generic)Augmentin 125 SuspensionAugmentin 250 SuspensionCedaxCeftin Tablets/SuspensionFluoroquinolones (Quinolones)PreferredRequires Prior Authorizationciprofloxacin (Cipro)levofloxacin (Levaquin)ofloxacin (Floxin)(Brand and generic)ciprofloxacin ext-rel (Cipro XR)(Brand and generic)AveloxCipro SuspensionFactiveNoroxinProquin XRHepatitis C Agents (Hepatitis C Treatment Agents,Immunomodulators)PreferredRequires Prior Authorizationribavirin (Copegus, Rebetol) Incivek*PegasysInfergenVictrelis*Peg-IntronPeg-Intron RedipenRibapakKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/2012* Additional criteria may apply to the oral Hepatitis C Protease Inhibitors.Please see the website for details:Macrolides/KetolidesPreferredazithromycin (Zithromax)erythromycinRequires Prior Authorizationclarithromycin (Biaxin)(Brand and generic)clarithromycin ER (Biaxin XL)(Brand and generic)KetekZmaxTetracyclinesPreferredRequires Prior Authorizationdoxycycline hyclate demeclocycline (Declomycin)doxycycline hyclate DR minocycline ERdoxycycline monohydrate Adoxa CKminocycline (Minocin) Adoxa TTtetracycline (Sumycin) DoryxNutridoxOraceaSolodynVibramycin SuspensionTopical AntibioticsPreferredbacitracin OTCbacitracin/polymyxin OTCgentamicinmupirocin (Bactroban Ointment)Requires Prior AuthorizationAltabaxBactroban Cream5

Maryland Preferred Drug ListCARDIOVASCULARAngiotensin Modulator CombinationsPreferredRequires Prior Authorizationamlodipine/benazepril (Lotrel) trandolapril/verapamil (Tarka)Azor/Tribenzor(Brand and generic)Exforge/Exforge HCTTekamlo/AmturnideValturnaTwynstaAntihypertensives, SympatholyticsPreferredclonidine oral (Catapres)guanfacine (Tenex)methyldopa (Aldomet)methyldopa/HCTZ (Aldoril)Catapres-TTS (Brand only)Requires Prior Authorizationclonidine transdermal(generic only)reserpineClorpresNexiclon XR SuspensionNexiclon XR TabletsAngiotensin ModulatorsPreferredbenazepril, benazepril HCTZ(Lotensin, Lotensin HCT)captopril, captopril HCTZ(Capoten, Capozide)enalapril, enalapril HCTZ(Vasotec, Vaseretic)fosinopril, fosinopril HCTZ(Monopril, Monopril HCT)lisinopril, lisinopril HCTZ(Prinivil, Zestril, Prinzide,Zestoretic)losartan (Cozaar)losartan/HCTZ (Hyzaar)quinapril (Accupril)quinaretic (Accuretic)ramipril (Altace)Benicar, Benicar HCTDiovan, Diovan HCTAnticoagulantsPreferredwarfarin (Coumadin)FragminLovenox (Brand only)Key: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/2012Requires Prior Authorizationmoexipril (Univasc)(Brand and generic)moexipril HCTZ (Uniretic)(Brand and generic)perindopril (Aceon)(Brand and generic)trandolapril (Mavik)(Brand and generic)Atacand, Atacand HCTAvapro, AvalideEdarbiMicardis, Micardis HCTTekturna/Tekturna HCTTeveten, Teveten HCTRequires Prior Authorizationenoxaparin (generic only)fondaparinux (Arixtra)(Brand and generic)InnohepPradaxaXareltoBeta Blockers (Alpha/Beta-Adrenergic Blocking Agents,Beta-Adrenergic Blocking Agents)PreferredRequires Prior Authorizationacebutolol (Sectral)betaxolol (Kerlone)atenolol (Tenormin)(Brand and generic)atenolol/chlorthalidone (Tenoretic) Bystolicbisoprolol (Zebeta)Coreg CRbisoprolol/HCTZ (Ziac)carvedilol (Coreg)labetalol (Normodyne, Trandate)metoprolol tartrate (Lopressor)metoprolol tartr/HCTZ (Lopressor HCT)metoprolol succinate ext-rel (Toprol XL)nadolol (Corgard)nadolol/bendroflumethiazide (Corzide)pindolol (Visken)propranolol (Inderal)propranolol LA (Inderal LA)sotalol, sotalol AF(Betapace, Betapace AF)timolol (Blocadren)Innopran XLLevatol6

Maryland Preferred Drug ListCalcium Channel Blocking AgentsPreferredamlodipine (Norvasc)diltiazem (Cardizem)diltiazem SR, diltiazem ER(Cardizem SR, Cardizem CD,Dilacor XR, Tiazac)felodipine (Plendil)isradipine (Dynacirc)nicardipine (Cardene)nifedipine SR(Adalat CC, Procardia XL)verapamil (Calan)verapamil ER, verapamil SR(Calan SR, Verelan)Key: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/2012Requires Prior Authorizationnifedipine (Adalat, Procardia)(Brand and generic)nimodipine (Nimotop)(Brand and generic)nisoldipine (Sular)(Brand and generic)verapamil ER caps (VerelanPM) (Brand and generic)Cardizem LACovera-HSDynacirc CRLipotropics, Other (Lipotropics, Bile Salt Sequestrants)PreferredRequires Prior Authorizationcholestyramine (Questran, Light) colestipol (Colestid)gemfibrozil (Lopid)(Brand and generic)Niacorfenofibrate (Lofibra)Niaspan(Brand and generic)Tricorfenofibric acid (Fibricor)Trilipix(Brand and generic)AntaraFenoglideLipofenLovazaTriglideWelcholZetiaLipotropics, Statins (Lipotropics)Preferredlovastatin (Mevacor)pravastatin (Pravachol)simvastatin (Zocor)CrestorLescol, Lescol XLLipitor (Brand only)SimcorRequires Prior Authorizationatorvastatin (generic only)AdvicorAltoprevCaduetLivaloVytorinPlatelet Aggregation InhibitorsPreferredRequires Prior Authorizationdipyridamole (Persantine) Effientticlopidine (Ticlid)AggrenoxPlavixPulmonary Arterial Hypertension, Oral and Inhaled AgentsPreferredRequires Prior AuthorizationAdcirca* TyvasoLetairisRevatio*TracleerVentavis*Clinical Criteria applies to Adcirca and Revatio. To view criteria, please refer tohttp://www.dhmh.state.md.us/mma/mpap/forms.htmCENTRAL NERVOUS SYSTEMThe Mental Health Carve Out link is located at:http://www.mdmahealthchoicerx.com/healthchoice_docs/mmmh_form.pdfAnticonvulsantsPreferredcarbamazepine (Tegretol)carbamazepine susp (TegretolSusp) (Brand and generic)clonazepam (Klonopin)divalproex (Depakote, ER)gabapentin (Neurontin)lamotrigine (Lamictal)levetiracetam (Keppra) only)oxcarbazepine (Trileptal)oxcarbazepine suspension(Trileptal Suspension) (Brandand generic)phenobarbitalRequires Prior Authorizationcarbamazepine ER caps(generic only)carbamazepine XR (Tegretol XR)clonazepam ODT (KlonopinODT)diazepam rectal (generic only)divalproex sprinkles (genericethosuximide (Zarontin) (Brandand generic)felbamate (Felbatol)levetiracetam ER (Keppra XR)(Brand and generic)phenytoin (Dilantin)primidone (Mysoline)mephobarbital (Mebaral)topiramate sprinkles (Topamaxtopiramate (Topamax) Sprinkles) (Brand and generic)valproic acid (Depakene)zonisamide (Zonegran)BanzelEquetroCarbatrol (Brand only)GraliseCelontinLamictal ODT7

Depakote Sprinkle (Brand only)Diastat Rectal (Brand only)GabitrilPeganoneLamictal XRPhenytekSabrilStavzorVimpatAntidepressants, Other (Alpha-2 Receptor AntagonistAntidepressants, Serotonin-2 Antagonist/ReuptakeInhibitors, Serotonin-Norepinephrine Reuptake-Inhib,Norepinephrine and Dopamine Reuptake Inhib)Preferredbupropion, bupropion SR,buproprion XL (Wellbutrin,Wellbutrin SR, Wellbutrin XL)mirtazapine, mirtazapine soltab(Remeron, Remeron Soltab)phenelzine (Nardil)trazodone (Desyrel)venlafaxine (Effexor)venlafaxine ER caps (EffexorXR)MarplanParnate (Brand only)Venlafaxine ER Tablets(Brand only)Requires Prior Authorizationnefazodone (Serzone)tranylcypromine (generic only)venlafaxine ER tablets (genericonly)AplenzinOleptro EREmsamPristiqViibrydAntidepressants, Selective Serotonin Reuptake Inhibitors(SSRIs)PreferredRequires Prior Authorizationcitalopram (Celexa)fluoxetine weekly (Prozacfluoxetine (Prozac)weekly) (Brand and generic)fluvoxamine (Luvox)paroxetine CR (Paxil CR)paroxetine (Paxil) (Brand and generic)sertraline (Zoloft)selfemra (Sarafem)Lexapro(Brand and generic)Luvox CRPexevaMaryland Preferred Drug ListAntipsychotics**PreferredRequires Prior Authorization1 st Tier- olanzapine (generic only)chlorpromazine (Thorazine) Abilify IMclozapine (Clozaril)Fanaptfluphenazine (Prolixin)Fazaclofluphenazine decanoate inj Invega(Prolixin Inj.)Invega Sustennahaloperidol (Haldol)Latudahaloperidol decanoate injSaphris(Haldol IM)Seroquel XRperphenazine (Trilafon)Symbyaxperphenazine/amitriptyline Zyprexa Relprevv(Triavil)risperidone (Risperdal)thioridazine (Mellaril)thiothixene (Navane)trifluoperazine (Stelazine)GeodonGeodon IMMobanOrapRisperdal ConstaSeroquel2nd TierolanzapineIM (Zyprexa IM)olanzapine ODT (Zyprexa Zydis)AbilifyZyprexa (Brand only)** Additional clinical edits may apply to the Tier 2 products. An adequate trial ofa Tier 1 preferred drug is required prior to use of any Tier 2 product. To viewcriteria, please refer tohttp://www.dhmh.state.md.us/mma/mpap/clinicalcriteria.htmKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/20128

Sedative HypnoticsPreferredRequires Prior Authorizationchloral hydrateestazolam (ProSom)flurazepam (Dalmane)temazepam 7.5 mgtemazepam (Restoril)(Restoril 7.5mg)triazolam (Halcion)(Brand and generic)zaleplon (Sonata)temazepam 22.5 mgzolpidem (Ambien) (Restoril 22.5mg)(Brand and generic)zolpidem ER (Ambien CR)(Brand and generic)EdluarDoralLunesta *RozeremSilenorSomnoteZolpimist* Step therapy for Lunesta may allow it to process without a priorauthorization. Please see specific STEP criteria located at:http://www.dhmh.state.md.us/mma/mpap/clinicalcriteria.htmMaryland Preferred Drug ListFocalin XRIntuniv**Metadate CDMethylin Chew and SolutionVyvanse2nd Tier-Strattera *** (for ages 17 andunder)NuvigilRitalin LA** For recipients 6 – 17 years old, Intuniv is part of the mental health formulary andbilled fee-for-service. For individuals not in this age range, Intuniv continues to be partof the MCO pharmacy benefit.*** To view criteria for Strattera, please refer tohttp://www.dhmh.state.md.us/mma/mpap/clinicalcriteria.htmENDOCRINEAndrogenic AgentsPreferredAndrodermAndrogelRequires Prior AuthorizationAxironFortestaTestimStimulants and Related Agents (Tx for Attention DeficitHyperact (ADHD)/Narcolepsy; Adrenergics, Aromatic, Non-Catecholamine)Preferred1 st Tieramphetaminesalt combo(Adderall)dexmethylphenidate (Focalin)(Brand and generic)dextroamphetamine (Dexedrine)methylphenidate (Ritalin)methylphenidate ER(Ritalin-SR)Adderall XR (Brand only)Concerta (Brand only)DaytranaKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/2012Requires Prior Authorizationamphetamine salt combo ER(generic only)methamphetamine (Desoxyn)(Brand and generic)methylphenidate liquid(Procentra) (Brand andgeneric)methylphenidate controlledrelease (generic only)KapvayProvigilBone Resorption Suppression and Related Agents (BoneResorption Inhibitors, Bone Formation Stim. Agents –Parathyroid Hormone)PreferredRequires Prior Authorizationalendronate (Fosamax)Miacalcin (Brand only)calcitonin salmon nasal(generic only)etidronate (Didronel)(Brand and generic)ActonelActonel with CalciumAtelviaBonivaEvistaFosamax Plus DFosamax SolutionForteoForticalProlia9

Hypoglycemics, Incretin Mimetics and EnhancersPreferredRequires Prior AuthorizationByettaJanumetKombiglyze XRJanuviaOnglyzaVictozaSymlinTradjentaHypoglycemics, Insulins and Related AgentsPreferredRequires Prior AuthorizationHumalogApidraHumalog MixLevemirHumulinLantusNovolinNovoLogNovoLog MixMaryland Preferred Drug ListGASTROINTESTINALAntiemetic/Antivertigo AgentsPreferredRequires Prior Authorizationdimenhydrinate inj. and OTC dronabinol (generic only)meclizine Rx and OTCgranisetron oral and IV (Kytril)(Bonine, Antivert)(Brand and generic)metoclopramide oral and IV trimethobenzamide (all forms)(Reglan) (Tigan) (Brand and generic)ondansetron, ondansetron ODT Aloxi IV(all forms) (Zofran, Zofran Anzemet (oral and IV )ODT)Cesametprochlorperazine (all forms) Emend IV(Compazine, Compro)Sancusopromethazine (oral and rectal) Zuplenz(Phenergan)Marinol (Brand only)Emend (oral only)Metozolv ODTScopaceTransDerm-ScopHypoglycemics, Meglitinides (Hypoglycemics, InsulinRelease Stimulant Type)Preferrednateglinide (Starlix)PrandinRequires Prior AuthorizationPrandimetBile SaltsPreferredursodiol capsule (Actigall)Requires Prior Authorizationursodiol tablet (URSO Forte)ChenodalHypoglycemics, TZDs (Hypoglycemics, Insulin-ResponseEnhancers)PreferredActosAvandiaRequires Prior AuthorizationActoPlusMetActoPlusMet XRAvandametAvandarylDuetactPancreatic EnzymesPreferredpancrelipaseCreonPancreazeZenpepRequires Prior AuthorizationKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/201210

Phosphate Binders and Related AgentsPreferredCalphron OTCPhosLo (Brand Only)RenagelRequires Prior Authorizationcalcium acetate (generic only)EliphosFosrenolRenvelaProton Pump Inhibitors (Gastric Acid Secretion Reducers)Preferredlansoprazole (Prevacid)lansoprazole solutab (PrevacidSolutab)omeprazole (Prilosec)omeprazole OTC (Prilosec OTC)Ulcerative Colitis AgentsPreferredRequires Prior Authorizationpantoprazole (Protonix)(Brand and generic)AciphexDexilantPrevacid OTCPrilosec SuspensionNexium (all forms)Zegerid OTCRequires Prior Authorizationbalsalazide (Colazal)mesalamine enemas (Rowasa)sulfasalazine (Azulfidine) (Brand and generic)AprisoAsacol HDAsacol DipentumCanasa LialdaPentasasFRowasaMaryland Preferred Drug ListINJECTABLESColony Stimulating FactorsPreferredNeupogenRequires Prior AuthorizationLeukineNeulastaCytokine and CAM Antagonists (Anti-Inflammatory,Pyrimidine Synthesis Inhibitor, Anti-Inflammatory, Tumor Necrosis Factor Inhibitor, Anti-Flam,Interleukin-1 Receptor Antagonist, Drugs to Tx ChronicInflamm Disease of Colon, Antimetabolites)PreferredRequires Prior AuthorizationCimziaActemraEnbrelHumiraAmeviveKineretOrenciaOrencia Sub-QRemicadeSimponiStelaraErythropoietins (Hematinics, Other)PreferredRequires Prior AuthorizationAranespEpogenProcritIMMUNOLOGICSImmunosuppressives, OralPreferredazathioprine (Imuran)cyclosporine modified(Gengraf, Neoral)mycophenolate mofetil(Cellcept)Prograf (Brand only)RapamuneSandimmune (Brand only)Requires Prior Authorizationcyclosporine (generic only)tacrolimus (generic only)AzasanMyforticZortressGrowth Hormones (CLINICAL PA REQUIRED)PreferredGenotropinNorditropinNutropin/ Nutropin AQRequires Prior AuthorizationHumatropeOmnitropeSaizenSerostimTev-TropinZorbtiveKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/201211

NEUROLOGICSMaryland Preferred Drug ListOPHTHALMICAlzheimer’s AgentsPreferreddonepezil/donepezil ODT(Aricept/Aricept ODT)rivastigmine (Exelon)Exelon Transdermal PatchNamendaAnti-Parkinson’s AgentsPreferredbenztropine (Cogentin)levodopa/carbidopa Immediateand Extended Release(Sinemet, Sinemet CR)ropinirole (Requip)pramipexole (Mirapex)trihexyphenidyl (Artane)StalevoRequires Prior Authorizationgalantamine (Razadyne, ER)(Brand and generic)Exelon SolutionRequires Prior Authorizationbromocriptine (Parlodel)(Brand and generic)levodopa/carbidopa ODT(Parcopa) (Brand and generic)selegiline (Eldepryl) (Brand andgeneric)AzilectComtanMirapex ERRequip XLTasmarZelaparMultiple Sclerosis Agents (Agents to Treat MultipleSclerosis)PreferredAmpyraAvonexBetaseronCopaxoneRequires Prior AuthorizationExtaviaGilenyaRebifOphthalmics, Allergic Conjunctivitis (Eye AntiinflammatoryAgents, Eye Antihistamines, Ophthalmic Mast CellStabilizers)Preferredcromolyn (Crolom)ketotifen OTC (Zaditor OTC)AlrexPatadayPatanolOphthalmics, AntibioticsPreferredRequires Prior Authorizationazelastine (Optivar)(Brand and generic)epinastine (Elestat)(Brand and generic)AlamastAlocrilAlomideBepreveElestatEmadineLastacaftRequires Prior Authorizationbacitracinlevofloxacin (Quixin)bacitracin/polymixin (Brand and generic)ciprofloxacin solution (Ciloxan) AzaSiteerythromycinIquixgentamicin (Garamycin) (Brand Moxezaand generic)Natacynneomycin/polymixin/gramicidin Zymaxidofloxacin (Ocuflox)polymyxin/trimethoprim(Polytrim)sulfacetamideterramycin/polymyxintobramycintriple antibioticBesivanceCiloxan OintmentTobrex OintmentVigamoxZymarKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/201212

Ophthalmics, Antibiotic/Steroid CombinationsPreferredneomycin/bacitracin/polymyxin/HCneomycin/poly/dexamethasoneneomycin/poly/dexamethasoneneomycin/polymyxin/HCsulfacetamide/prednisolonetobramycin/dexamethasone suspBlephamideBlephamide SOPPred-G Ointment, DropsTobradex OintmentZyletRequires Prior AuthorizationTobradex STOphthalmics, Glaucoma AgentsPreferredRequires Prior Authorizationbetaxololapraclonidine (Iopidine) (Brandbrimonidineand generic)carteolol (Ocupress) brimonidine tartrate 0.15%dorzolamide (Trusopt)(generic only)dorzolamide/timolol (Cosopt) Alphagan P 0.1%latanoprost (Xalatan) Lumiganlevobunolol (Betagan)metipranolol (OptiPranolol)(Brand and generic)pilocarpine (Pilocar)timolol (Timoptic, Timoptic XE)Alphagan P 0.15% (Brand only)AzoptBetimolBetoptic SCombiganIstalolPropineTravatan/Travatan ZMaryland Preferred Drug ListOphthalmics, Anti-InflammatoriesPreferreddexamethasone (Decadron)diclofenac (Voltaren)fluorometholone (FML)flurbiprofen (Ocufen)ketorolac (Acular)ketorolac LS (Acular LS)prednisolone acetateprednisolone sodiumFML ForteFML SOPLotemaxMaxidexOmnipredPred MildOTICOtic AntibioticsPreferredneomycin/polymyxin/HC(Cortisporin)ofloxacin otic (Floxin Otic)CiprodexColy-Mycin SCortisporin TCRESPIRATORYRequires Prior Authorizationbromfenac (Xibrom)AcuvailBromdayDurezolFlarexNevanacOzurdexPred ForteRetisertTriesenceVexolRequires Prior AuthorizationCetraxalCipro HCAntihistamines, Minimally Sedating (Antihistamines)Preferredcetirizine, cetirizine-D(Rx and OTC)fexofenadine OTC 60 mgfexofenadine OTC 180 mglevocetirizine (Xyzal)loratadine, loratadine-D(Rx and OTC)Requires Prior Authorizationfexofenadine (Allegra)fexofenadine D 12 hr, 24 hr(Allegra D)(Brand and generic)Allegra SyrupAllegra ODTClaritin, Claritin-D (Rx)Claritin, Claritin-D (OTC)Key: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/201213

Claritin Chewable (OTC)Claritin LiquiGel (OTC)Clarinex, Clarinex-DSemprex-DXyzal SyrupMaryland Preferred Drug List* Pulmicort Respules are available without prior authorization for children whoare 1 to 8 years of age.Beta 2 -Agonist Bronchodilators (Beta-Adrenergic Agents)PreferredRequires Prior Authorizationalbuterol syrup and tabletalbuterol ext-rel (Vospire ER)(Proventil, Ventolin)albuterol neb low doseterbutaline (Brethine)levalbuterol neb (Xopenex)Foradil (Brand and generic)Maxairmetaproterenol (Alupent)ProAir HFAArcaptaProventil HFABrovanaPerforomistSereventVentolin HFAXopenex HFAIntranasal Rhinitis Agents (Nasal Anti-Inflammatory Steroids)Preferredflunisolide (Nasalide)fluticasone nasal (Flonase)Astelin (Brand only)AsteproBeconase AQNasacort AQ (Brand only)NasonexPatanaseRequires Prior Authorizationazelastine nasal (generic only)flunisolide (Nasarel)(Brand and generic)ipratropium (Atrovent Nasal)(Brand and generic)triamcinolone nasal (genericonly)OmnarisRhinocort AquaVeramystCOPD AgentsPreferredipratropium neb (Atrovent)ipratopium neb/albuterol(DuoNeb)Atrovent HFACombiventSpirivaRequires Prior AuthorizationDalirespLeukotriene ModifiersPreferredzafirlukast (Accolate)SingulairRequires Prior AuthorizationZyflo CRGlucocorticoids, Inhaled (Beta-Adrenergics andGlucocorticoids Combination, Glucocorticoids)PreferredRequires Prior AuthorizationAdvair Diskus/Advair HFAAerobid, Aerobid MAsmanexDuleraFlovent Diskus/Flovent HFAQvarSymbicortbudesonide respules(Pulmicort Respules) *(Brand and generic)(Over Age 8, Under Age 1)AlvescoPulmicort FlexhalerKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/201214

Maryland Preferred Drug ListTOPICAL DERMATOLOGICSAcne Agents, TopicalPreferredRequires Prior Authorizationbenzoyl peroxide adapalene (generic only)clindamycin topical benzoyl peroxide OTCerythromycin clindamycin-benzoyl peroxidesulfacetamide-sulfur erythromycin-benzoyl peroxidetretinoin sodium sulfa-sulfur-meratanAzelex sulfacetamide lotion (Klaron)BenzaClin AcanyaDifferin (Brand only) AczoneEpiduo Akne-MycinRetin-A Micro AtralinBenzefoamBrevoxylClarifoam EFClinac BPOClindagelClindareachDuacEvoclinInovaLavoclenNeobenz MicroNuoxSE BPOSulfoxylTazoracTriazVeltinZaclirZianaZodermUROLOGICBenign Prostatic Hyperplasia (Alpha-Adrenergic BlockingAgents)Preferreddoxazosin (Cardura)finasteride (Proscar)tamsulosin (Flomax)terazosin (Hytrin)UroxatralRequires Prior AuthorizationAvodartCardura XLJalynRapafloBladder Relaxant Preparations (Urinary Tract Antispasmodic/Antiincontinence Agent)PreferredRequires Prior Authorizationoxybutynin (Ditropan)oxybutynin XL (Ditropan XL)Toviaz (Brand and generic)Vesicaretrospium (Sanctura)(Brand and generic)DetrolDetrol LAEnablexGelniqueOxytrolSanctura XRAtopic DermatitisPreferredRequires Prior AuthorizationElidel ProtopicKey: All lowercase letters = generic product.Leading capital letter = brand name product.Posted12/29/2011– Effective Date 01/011/201215