MHS Indiana Preferred Drug List HIP State - c.ymcdn.com · MHS Indiana Preferred Drug List HIP...

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender

67 Antivirals

Antivirals, Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors abacavir abacavir NO NO NO 213461 1210500510 0 0 2 13 thru 999

67 Antivirals


Transcriptase Inhibitors EPZICOM Abacavir Sulfate-LamivudineMG NO NO NO 602395 1210990220 0 0 1

67 Antivirals


Transcriptase Inhibitors TRIZIVIR Abacavir Sulfate-Lamivudine-Zidovudine NO NO NO 307650 1210990320 0 0 2

132 Immunological Agents Immunological Agents, Immune Suppressants ORENCIA Abatacept Subcutaneous Soln Prefilled Syringe NO NO NO 616018 6640001000

81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying REOPRO Abciximab NO NO NO 108911 8515301000

5 Anti-Addiction/Substance Abuse Treatment Agents

Anti-Addiction/Substance Abuse Treatment Agents, Alcohol

Deterrents/Anti-craving CAMPRAL acamprosate NO NO NO 835726 6280201020

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents acarbose acarbose NO NO NO 199149 2750001000 0 0 3

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents acebutolol acebutolol NO NO NO 998687 3320001010

Analgesics Other Analgesics Other Tylenol 100mg/mL Suspension Drops Acetaminophen 100mg/mL Suspension Drops 6420001000 Max DS/Dosage 12 claim

Analgesics Other Analgesics Other Acetaminophen 80mg Suppository Acetaminophen 80mg Suppository 6420001000 Max DS/Dosage 12 claim

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Chew Tab 160 MG NO NO NO 313820 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Chew Tab 80 MG NO NO NO 307696 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Elixir 160 MG/5ML NO NO NO 307675 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Liquid 160 MG/5ML NO NO NO 614857 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Soln 100 MG/ML NO NO NO 243675 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Soln 160 MG/5ML NO NO NO 307684 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Suppos 120 MG NO NO NO 209353 6420001000



ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Susp 160 MG/5ML NO NO NO 828555 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Susp 80 MG/0.8ML NO NO NO 828558 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Tab 325 MG NO NO NO 798926 6420001000

ANALGESICS - NonNarcotic Analgesics Other TYLENOL Acetaminophen Tab 500 MG NO NO NO 798928 6420001000

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting acetaminophen w/ codeine acetaminophen w/ codeine NO NO NO 993755 6599100205 0 0 13

90 Cardiovascular Agents Cardiovascular Agents, Diuretics, Carbonic Anhydrase Inhibitors acetazolamide acetazolamide NO NO NO 1343876 9642461565

144 Otic Agents Otic Agents, Otic Agents acetic acid acetic acid NO NO NO 804369 9610101000

#N/A Otic Agents - Miscellaneous VOSOL Acetic Acid Otic Soln 2% NO NO NO 211798 8740001010 Maximum Quantity 15 Claim

DIAGNOSTIC PRODUCTS Diagnostic Tests Acetone (Urine) Test Strip NO NO NO #N/A 9410000500

152 Respiratory Tract Agents Respiratory Tract Agents, Respiratory Tract Agents, Other acetylcysteine acetylcysteine NO NO NO 465377 9300000700

COUGH/COLD/ALLERGY Mucolytics Mucinyst Acetylcysteine Inhal Soln 10% NO NO NO 307718 4330001000

COUGH/COLD/ALLERGY Mucolytics Mucinyst Acetylcysteine Inhal Soln 20% NO NO NO 307719 4330001000

105 Dermatological Agents Dermatological Agents, Dermatological Agents SORIATANE Acitretin NO NO NO 199690 9025051000 0 0 1

65 Antivirals Antivirals, Antiherpetic Agents acyclovir acyclovir NO NO NO 209977 9035001000 Maximum Quantity 1 claim 0

132 Immunological Agents Immunological Agents, Immune Suppressants HUMIRA Adalimumab Inj Kit NO NO NO 763565 6627001500

105 Dermatological Agents Dermatological Agents, Dermatological Agents adapalene adapalene NO NO NO 307731 9005000300

64 Antivirals Antivirals, Antihepatitis Agents HEPSERA Adefovir NO NO NO 881341 1235201510 0 0 1

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers FABRAZYME Agalsidase beta NO NO NO 404491 3090361010

51 Antiparasitics Antiparasitics, Anthelmintics ALBENZA Albendazole NO NO NO 211148 1500000200

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic VENTOLIN Albuterol NO NO NO #N/A 4420101000

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic PROVENTIL Albuterol Inhal Aerosol NO NO NO #N/A 4420101000

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents LASTACAFT Alcaftadine Ophth Soln 0.25% NO NO NO 1000089 8680200400

118

Hormonal Agents,

Stimulant/Replacement/Modifying

(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids alclometasone alclometasone NO NO NO 855474 9055000510

MEDICAL DEVICES Misc. Devices Alcohol Swabs NO NO NO 797544 9770304000 Maximum Quantity 400 Claim

134 Immunological Agents Immunological Agents, Immunomodulators Proleukin Aldesleukin YES NO NO 213377 2170302000 0 0 1

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents FOSAMAX + D alendronate NO NO NO 904465 3004201020 Maximum Quantity 4 28 1

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents alfuzosin sr alfuzosin sr NO NO NO 861134 5685201010 0 0 1

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers LUMIZYME Alglucosidase Alfa NO NO NO 993072 3090771500

89 Cardiovascular Agents Cardiovascular Agents, Cardiovascular Agents, Other TEKTURNA Aliskiren NO NO NO 1011738 3617001010 0 0 2

50 Antineoplastics Antineoplastics, Retinoids PANRETIN Alitretinoin NO NO NO 213502 9037601500

32 Antigout Agents Antigout Agents, Antigout Agents allopurinol allopurinol NO NO NO 213995 6800001000

37 Antimigraine Agents Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists AXERT almotriptan NO YES NO 284588 6740601010 Maximum Quantity 6 30 0

110 Gastrointestinal Agents Gastrointestinal Agents, Irritable Bowel Syndrome Agents LOTRONEX Alosetron HCl NO NO NO 261362 5255401510

71 Anxiolytics Anxiolytics, Anxiolytics, Other alprazolam alprazolam NO NO NO 600475 9642644854

ANTACIDS Antacid Combinations MYLANTA Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML NO NO NO 313792 4899100310 Maximum Quantity 496 30

ANTACIDS Antacid Combinations MAALOX SUS Aluminum & Magnesium Hydroxides Susp 225-200 MG/5ML NO NO NO 686368 4899000210 Maximum Quantity 496 30

ANTACIDS Antacids - Aluminum Salts Amphojel, Alternagel Aluminum Hydroxide Gel Susp 320 MG/5ML NO NO NO 308078 4810001020

ANTACIDS Antacids - Aluminum Salts Amphojel, Alternagel Aluminum Hydroxide Gel Susp 600 MG/5ML NO NO NO 308084 4810001020

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other ENTEREG Alvimopan NO NO NO 801731 5258001000

70 Antivirals Antivirals, Anti-influenza Agents Amantadine amantadine NO NO NO 261315 1250406020 Maximum Quantity 20 30 0 13 thru 999

55 Antiparkinson Agents Antiparkinson Agents, Antiparkinson Agents, Other amantadine amantadine NO NO NO 849385 7320001010

38 Antimyasthenic Agents Antimyasthenic Agents, Parasympathomimetics MYTELASE ambenonim NO NO NO 686922 7600001010

151 Respiratory Tract Agents Respiratory Tract Agents, Pulmonary Antihypertensives LETAIRIS Ambrisentan Tab 0 MG NO NO NO 722120 4016000700

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender8 Antibacterials Antibacterials, Aminoglycosides amikacin amikacin NO NO NO 1438474 9642662600

92 Cardiovascular Agents Cardiovascular Agents, Diuretics, Potassium-sparing amiloride amiloride NO NO NO 977882 3750001010 0 0 4

DIURETICS Diuretic Combinations Moduretic Amiloride & Hydrochlorothiazide Tab 5-50 MG NO NO NO 977883 3799000210 1

HEMOSTATICS Hemostatics - Systemic AMICAR Aminocaproic Acid Syrup 25% NO NO NO 754890 8410001000 Maximum Quantity 60 Claim

HEMOSTATICS Hemostatics - Systemic AMICAR Aminocaproic Acid Tab 500 MG NO NO NO 211465 8410001000 Maximum Quantity 24 Claim

149 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Phosphodiesterase aminophylline aminophylline NO NO NO 308119 4430001000

40 Antimycobacterials Antimycobacterials, Antituberculars PASER aminosalicylate sodium, aminosalicylic acid NO NO NO #N/A 0900001000 13 thru 999

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics PACERONE amiodarone NO NO NO 834346 3540000500

28 Antidepressants Antidepressants, Tricyclics amitriptyline amitriptyline NO NO NO 856762 5820001010

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents APHTHASOL Amlexanox NO NO NO 351712 8827001500

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents amlodipine amlodipine NO NO NO 212549 3400000310 0 0 1

ANTIHYPERTENSIVES Antihypertensive Combinations LOTREL Amlodipine Besylate-Benazepril HCl Cap 10-20 MG NO NO NO 898344 3699150220 1

ANTIHYPERTENSIVES Antihypertensive Combinations LOTREL Amlodipine Besylate-Benazepril HCl Cap 2.5-10 MG NO NO NO 898352 3699150220 1



158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral AMMONIUM CHL Ammonium Chloride NO NO NO 239018 7920001000

12 Antibacterials Antibacterials, Beta-lactam, Penicillins amoxicillin & k clavulanate amoxicillin & k clavulanate NO NO NO 824190 0199000220

12 Antibacterials Antibacterials, Beta-lactam, Penicillins amoxicillin (trihydrate) amoxicillin (trihydrate) NO NO NO 313797 0120001010

99 Central Nervous System Agents

Central Nervous System Agents, Attention Deficit Hyperactivity

Disorder Agents, Amphetamines amphetamine-dextroamphetamine amphetamine-dextroamphetamine NO NO NO 541365 6110990210

31 Antifungals Antifungals, Antifungals AMPHOTERICIN AMPHOTERICIN NO NO NO 239240 1100001000

31 Antifungals Antifungals, Antifungals ABELCET amphotericin B Lipid NO NO NO 984082 1100001030

31 Antifungals Antifungals, Antifungals AMBISOME amphotericin B Lipid NO NO NO 967388 1100001040

31 Antifungals Antifungals, Antifungals AMPHOTEC amphotericin B Lipid NO NO NO 1088117 1100001010

12 Antibacterials Antibacterials, Beta-lactam, Penicillins ampicillin ampicillin NO NO NO 313800 0120002020

12 Antibacterials Antibacterials, Beta-lactam, Penicillins ampicillin & sulbactam sodium ampicillin & sulbactam sodium NO NO NO 205842 0199000225

121

Hormonal Agents,


(Sex

Hormones/Modifiers), Anabolic

Steroids Anabolic Steroids ANADROL-50 ANADROL-50 NO NO NO 91792 2320005000

79 Blood Product/Modifiers/Volume Expanders

Blood Products/Modifiers/Volume Expanders, Blood Formation

Modifiers anagrelide anagrelide NO NO NO 597850 8515601010

132 Immunological Agents Immunological Agents, Immune Suppressants KINERET Anakinra Subcutaneous Inj NO NO NO 727714 6626001000

46 Antineoplastics Antineoplastics, Aromatase Inhibitors, 3rd Generation anastrozole Anastrazole NO NO NO 795142 2140281000

31 Antifungals Antifungals, Antifungals ERAXIS anidulafungin NO NO NO 630683 1150001000

144 Otic Agents Otic Agents, Otic Agents antipyrine-benzocaine antipyrine-benzocaine NO NO NO 244309 8799200220 Maximum Quantity 1 claim 0

56 Antiparkinson Agents Antiparkinson Agents, Dopamine Agonists APOKYN Apomorphine NO NO NO 855858 7320301010

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents apraclonidine apraclonidine NO NO NO 211020 8660201010

30 Antiemetics Antiemetics, Emetogenic Therapy Adjuncts EMEND aprepitant; fosaprepitant NO NO NO 404465 5028002000 Maximum Quantity 2 30 0

25 Antidepressants Antidepressants, Antidepressants, Other ABILIFY aripiprazole NO NO NO 352307 5925001500

52 Antiparasitics Antiparasitics, Antiprotozoals COARTEM Artemeter-Lumefantrine NO NO NO 847734 1399000203 Maximum Quantity 24 claim 0

MOUTH/THROAT/DENTAL AGENTS Throat Products - Misc. Artificial Saliva - Solution NO NO NO #N/A 8850100000 Maximum Quantity 900 Claim

OPHTHALMIC AGENTS Artificial Tears and Lubricants REFRESHP.M. Artificial Tear Ophth Ointment NO NO NO 746083 8620200000 Maximum Quantity 4 Claim

52 Antiparasitics Antiparasitics, Antiprotozoals LACRISERT Artificial Tears NO NO NO 754512 8620300000

Artificial Tears and Lubricants Artificial Tears and Lubricants Artificial Tears Ophthalmic Ointment Artificial Tears Ophthalmic Ointment 8620200000 Max DS/Dosage 4 claim

Artificial Tears and Lubricants Artificial Tears and Lubricants Artificial Tears Ophthalmic Ointment, PFArtificial Tears Ophthalmic Ointment, PF 8620200000 Max DS/Dosage 4 claim

Artificial Tears and Lubricants Artificial Tears and Lubricants Artificial Tears Ophthalmic Solution Artificial Tears Ophthalmic Solution 8620100000

Artificial Tears and Lubricants Artificial Tears and Lubricants Artificial Tears Ophthalmic Solution, PF Artificial Tears Ophthalmic Solution, PF 8620100000

Vitamin C Ascorbic Acid Ascorbic Acid 1500mg Caplet SA Ascorbic Acid 1500mg Caplet SA 7710801000 Max DS/Dosage 100 30

Vitamin C Ascorbic Acid Ascorbic Acid 500mg/5mL Syrup Ascorbic Acid 500mg/5mL Syrup 7710801000 Max DS/Dosage 100 30

Bulk Chemicals - As Ascorbic Acid (Bulk) Ascorbic Acid Powder Ascorbic Acid Powder 9642781000

VITAMINS Water Soluble Vitamins Vitamin C Ascorbic Acid Tab 1000 MG NO NO NO 308382 7710801000 Maximum Quantity 100 34



60 Antipsychotics Antipsychotics, 2nd Generation/Atypical SAPHRIS Aseapine NO NO NO 859983 5915501510

Analgesics - Non Narcotic Salicylates Aspirin 325mg Tablet Aspirin 325mg Tablet 6410001000 Max DS/Dosage 12 claim

Analgesics - Non Narcotic Salicylates Aspirin 325mg Tablet EC Aspirin 325mg Tablet EC 6410001000 Max DS/Dosage 12 claim

Analgesics - Non Narcotic Salicylates Aspirin 81mg Tablet Chew Aspirin 81mg Tablet Chew 6410001000 Max DS/Dosage 12 claim

Analgesics - Non Narcotic Salicylates Aspirin 81mg Tablet EC Aspirin 81mg Tablet EC 6410001000 Max DS/Dosage 12 claim

Analgesics - Non Narcotic Salicylates Combinations Aspirin Buffered 5 grains Aspirin Buffered 5 grains 6410990210

81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying AGGRENOX Aspirin-Dipyridamole Cap NO NO NO 1362082 8515990220 0 0 2

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors REYATAZ Atazanavir Sulfate NO NO NO 402093 1210451520 0 0 4

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents atenolol atenolol NO NO NO 197380 3320002000 0 0 2

ANTIHYPERTENSIVES Antihypertensive Combinations TENORETIC Atenolol & Chlorthalidone Tab 100-25 MG NO NO NO 746023 3699200210 1

ANTIHYPERTENSIVES Antihypertensive Combinations TENORETIC Atenolol & Chlorthalidone Tab 50-25 MG NO NO NO 746030 3699200210 1



Disorder Agents, Non-amphetamines STRATTERA Atomoxetine NO NO NO 352317 6135401510

95 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin atorvastatin NO NO NO 262095 3940001010 0 0 1

52 Antiparasitics Antiparasitics, Antiprotozoals MEPRON atovaquone NO NO NO 211947 1640002000 13 thru 999

52 Antiparasitics Antiparasitics, Antiprotozoals atovaquone-proguanil atovaquone-proguanil NO NO NO 864679 1399000205

140 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Agents, Other Atropine atropine NO NO NO 313521 8635005000 Maximum Quantity 15 claim 0

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender110 Gastrointestinal Agents Gastrointestinal Agents, Irritable Bowel Syndrome Agents Atropine atropine NO NO NO 261362 5255401510

107 Gastrointestinal Agents Gastrointestinal Agents, Antispasmodics, Gastrointestinal atropine atropine NO NO NO 359226 9642805400

ANTIDIARRHEALS Gastrointestinal Adsorbents KAOPECTATE Attapulgite Susp 750 MG/15ML NO NO NO #N/A 4720003000

134 Immunological Agents Immunological Agents, Immunomodulators RIDAURA Auranofin Cap NO NO NO 213510 6620001000

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors INLYTA Axitinib NO NO NO 1243010 2153400800

132 Immunological Agents Immunological Agents, Immune Suppressants azathioprine azathioprine NO NO NO 197388 9940601000 0 0 3

132 Immunological Agents Immunological Agents, Immune Suppressants AZASAN Azathioprine Tab NO NO NO 197388 9940601000 0 0 3

ASSORTED CLASSES Immunosuppressive Agents IMURAN Azathioprine Tab 100 MG NO NO NO 404476 9940601000



141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents azelastine azelastine NO NO NO 860798 4240101510

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines ASTEPRO Azelastine HCl Nasal Spray 0.15% NO NO NO 860798 4240101510

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists EDARBI Azilsartan NO NO NO 1091654 3615001020 0 0 1

13 Antibacterials Antibacterials, Macrolides azithromycin azithromycin NO NO NO 226827 0340001000 Maximum Quantity 6 claim 0

11 Antibacterials Antibacterials, Beta-lactam, Other aztreonam aztreonam NO NO NO 201828 1600000500

9 Antibacterials Antibacterials, Antibacterials, Other BACITRACIN bacitracin NO NO NO 308508 8610100500

Opthalmic Agents Opthalmic Anti-Infectives Bacitracin 500 units/gm Ointment Bacitracin 500 units/gm Ointment 8610100500

Opthalmic Agents Opthalmic Anti-Infectives Combinations Bacitracin/Polymixin B Sulfate OintmentBacitracin/Polymixin B Sulfate Ointment 8610990210 Max DS/Dosage 4 claim

105 Dermatological Agents Dermatological Agents, Dermatological Agents bacitracin-polymyxin-neomycin bacitracin-polymyxin-neomycin NO NO NO 1116150 8630990410

62 Antispasticity Agents Antispasticity Agents, Antispasticity Agents baclofen baclofen NO NO NO 197391 7510001000

135 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Aminosalicylates balsalazide balsalazide NO NO NO 885859 5250002010 0 0 9

132 Immunological Agents Immunological Agents, Immune Suppressants SIMULECT Basiliximab For IV Soln NO NO NO 227146 9940501500

MULTIVITAMINS B-Complex Vitamins B-Complex Vitamin Cap NO NO NO 284345 7811000000 1

MULTIVITAMINS B-Complex w/ Folic Acid NEPHROCAPS B-Complex w/ C & Folic Acid Cap 1 MG NO NO NO 891522 7813300000 1

MULTIVITAMINS B-Complex w/ C B-Complex w/ C Cap NO NO NO 262040 7812000000 1

132 Immunological Agents Immunological Agents, Immune Suppressants NULOJIX Belatacept For IV Infusion NO NO NO 1112980 9940802000

85 Cardiovascular Agents

Cardiovascular Agents, Angiotensin-converting Enzyme (ACE)

Inhibitors benazepril benazepril NO NO NO 898689 3610000510 0 0 1

ANTIHYPERTENSIVES Antihypertensive Combinations Lotensin HCT Benazepril & Hydrochlorothiazide Tab 10-12.5 MG NO NO NO 898366 3699180215 1


ANTIHYPERTENSIVES Antihypertensive Combinations Lotensin HCT Benazepril & Hydrochlorothiazide Tab 20-25 MG NO NO NO 898376 3699180215 1


COUGH/COLD/ALLERGY Antitussives TESSALON PER Benzonatate Cap 100 MG NO NO NO 208365 4310201000 0-9

COUGH/COLD/ALLERGY Antitussives TESSALON PER Benzonatate Cap 200 MG NO NO NO 351906 4310201000

105 Dermatological Agents Dermatological Agents, Dermatological Agents benzoyl peroxide benzoyl peroxide NO NO NO 846034 9005990217

Dermatologicals Acne Products Benzoyl Peroxide 10% Cream/Oint. Benzoyl Peroxide 10% Cream/Oint. 9005001000

Dermatologicals Acne Products Benzoyl Peroxide 10% Gel Benzoyl Peroxide 10% Gel 9005001000

Dermatologicals Acne Products Benzoyl Peroxide 5% Gel/Oint./Cream Benzoyl Peroxide 5% Gel/Oint./Cream 9005001000

Dermatologicals Acne Products Benzoyl Peroxide Cleanser Benzoyl Peroxide Cleanser 9005001000

Dermatologicals Acne Products Benzoyl Peroxide Creamy Wash Benzoyl Peroxide Creamy Wash 9005001050

Dermatologicals Acne Products Benzoyl Peroxide Wash Benzoyl Peroxide Wash 9005001050

Dermatologicals Acne Products Benzoyl Peroxide Wash Kit Benzoyl Peroxide Wash Kit 9005001050

105 Dermatological Agents Dermatological Agents, Dermatological Agents benzoyl peroxide-erythromycin benzoyl peroxide-erythromycin NO NO NO 213082 9005990210

54 Antiparkinson Agents Antiparkinson Agents, Anticholinergics benztropine benztropine NO NO NO 997010 1300006010 Maximum Quantity 84 365 0

53 Antiparasitics Antiparasitics, Pediculicides/Scabicides ULESFIA Benzyl Alcohol NO NO NO 1356673 9090000400

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents BEPREVE Bepotastine Besilate Ophth Soln NO NO NO 863042 8680200810

14 Antibacterials Antibacterials, Quinolones BESIVANCE besifloxacin NO NO NO 850309 8610100710

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers CYSTADANE Betaine Powder For Oral Solution NO NO NO 404539 3090452000

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids betamethasone betamethasone NO NO NO 197405 9055002000 Maximum Quantity 1 claim 0

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents betaxolol betaxolol NO NO NO 998687 3320001010

116 Genitourinary Agents Genitourinary Agents, Genitourinary Agents, Other bethanechol bethanechol NO NO NO 857325 5430001010

49 Antineoplastics Antineoplastics, Monoclonal Antibodies AVASTIN Bevacizumab NO NO NO 544558 2133502000

50 Antineoplastics Antineoplastics, Retinoids TARGRETIN Bexarotene NO NO NO 261349 2170822000

130

Hormonal Agents, Suppressant (Sex

Hormones/Modifiers),

Antiandrogens Antiandrogens bicalutamide bicalutamide NO NO NO 199123 2140242000

139 Ophthalmic Agents

Ophthalmic Agents, Ophthalmic Prostaglandin and Prostamide

Analogs LUMIGAN Bimatoprost Ophth Soln NO NO NO 285128 8633001500

Vitamins Water Soluable Vitamins Biotin 5mg Capsule Biotin 5mg Capsule 7710601000

LAXATIVES Stimulant Laxatives DULCOLAX Bisacodyl Suppos 10 MG NO NO NO 284283 4620001000 1

LAXATIVES Stimulant Laxatives DULCOLAX Bisacodyl Tab Delayed Release 5 MG NO NO NO 807213 4620001000 1

Antidiarrheals Antidiarrheal Agents - Misc. Bismuth Subsalicylate 262mg Tablet Bismuth Subsalicylate 262mg Tablet 4730001000

ANTIDIARRHEALS Antidiarrheal Agents - Misc. PEPTO-BISMOL Bismuth Subsalicylate Chew Tab 262 MG NO NO NO 308761 4730001000

ANTIDIARRHEALS Antidiarrheal Agents - Misc. PEPTO-BISMOL Bismuth Subsalicylate Susp 262 MG/15ML NO NO NO 643943 4730001000

ANTIDIARRHEALS Antidiarrheal Agents - Misc. PEPTO-BISMOL Bismuth Subsalicylate Susp 527 MG/30ML NO NO NO 308762 4730001000

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents bisoprolol bisoprolol NO NO NO 854903 3320002210 0 0 1

ANTIHYPERTENSIVES Antihypertensive Combinations ZIAC Bisoprolol & Hydrochlorothiazide Tab 10-6.25 MG NO NO NO 854910 3699200213 1

ANTIHYPERTENSIVES Antihypertensive Combinations ZIAC Bisoprolol & Hydrochlorothiazide Tab 5-6.25 MG NO NO NO 854921 3699200213 1

45 Antineoplastics Antineoplastics, Antineoplastics, Other bleomycin bleomycin NO NO NO 308770 2120001010

MEDICAL DEVICES Diabetic Supplies Blood Glucose Calibration - Liquid NO NO NO #N/A 9720200710 Maximum Quantity 1 90

MEDICAL DEVICES Diabetic Supplies Blood Glucose Calibration - Liquid - High NO NO NO #N/A 9720200710 Maximum Quantity 1 90

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderMEDICAL DEVICES Diabetic Supplies Blood Glucose Calibration - Liquid - Low NO NO NO #N/A 9720200710 Maximum Quantity 1 90

MEDICAL DEVICES Diabetic Supplies Blood Glucose Calibration - Liquid - Normal NO NO NO #N/A 9720200710 Maximum Quantity 1 90

MEDICAL DEVICES Diabetic Supplies Blood Glucose Monitoring Kit w/ Device NO NO NO #N/A 9720201000

64 Antivirals Antivirals, Antihepatitis Agents VICTRELIS Boceprevir NO NO NO 1102136 1235301500 0 0 12

151 Respiratory Tract Agents Respiratory Tract Agents, Pulmonary Antihypertensives TRACLEER Bosentan Tab 6 NO NO NO 352066 4016001500

36 Antimigraine Agents Antimigraine Agents, Prophylactic BOTOX botulinum toxin NO NO NO 897368 7440002005

Dermatologicals Acne Products BPO – 10 Wash BPO – 10 Wash 9005001050

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents brimonidine brimonidine NO NO NO 861200 8660202010 Maximum Quantity 1 claim 0

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents AZOPT Brinzolamide Ophth Susp % NO NO NO 213272 8680232000 Maximum Quantity 1 claim 0

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories BROMDAY Bromfenac Sodium Ophth Soln 0.09% NO NO NO 578018 8680500510

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents CYCLOSET Bromocriptine NO NO NO 859081 2757402010

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines Brompheniramine Brompheniramine NO NO NO 1111337 4240106010

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Children's Cold & Allergy, Dimaphen Elixir, Dimetapp Cold & AllergyBrompheniramine & Phenylephrine Elixir 1-2.5 MG/5ML NO NO NO 197803 4399300220

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Children's Cold & Allergy, Dimaphen Elixir, Dimetapp Cold & AllergyBrompheniramine & Phenylephrine Elixir 2-5 MG/5ML NO NO NO 1251804 4399300220

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Children's Cold & Allergy, Dimaphen Elixir, Dimetapp Cold & AllergyBrompheniramine & Phenylephrine Liqd 2-5 MG/ML NO NO NO 1251804 4399300220

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Bromfed-PD Brompheniramine & Pseudoephedrine Cap CR 12-120 MG NO NO NO 688874 4399300224 4

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Bromfed-PD Brompheniramine & Pseudoephedrine Cap CR 6-60 MG NO NO NO 688874 4399300224

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Bromaxefed RF Syrup Brompheniramine & Pseudoephedrine Elixir 1-15 MG/5ML NO NO NO 1098498 4399300224 4

146 Respiratory Tract Agents

Respiratory Tract Agents, Anti-inflammatories, Inhaled

Corticosteroids budesonide budesonide NO NO NO 616817 4440001500 0 0 4 13 thru 999



Corticosteroids PULMICORT Budesonide Inhalation Susp NO NO NO 616817 4440001500 0 0 4 13 thru 999



Corticosteroids RHINOCORT Budesonide Nasal NO NO NO 746823 4220001500 Maximum Quantity 18 30 0

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids budesonide sr budesonide sr NO NO NO 1244213 2210001200

91 Cardiovascular Agents Cardiovascular Agents, Diuretics, Loop bumetanide bumetanide NO NO NO 197417 3720001000


Anti-Addiction/Substance Abuse Treatment Agents, Opioid

Antagonists buprenorphine buprenorphine NO NO NO 904878 6520001000 Maximum Quantity 4 28 0



Antagonists SUBOXONE buprenorphine; naloxone NO NO NO 351266 6520001020 0 0 3


Anti-Addiction/Substance Abuse Treatment Agents, Smoking

Cessation BUPROBAN Bupropion NO NO NO 993954 6210000210 0 0 2 0 thru 17

25 Antidepressants Antidepressants, Antidepressants, Other bupropion bupropion NO NO NO 993528 5830004010

71 Anxiolytics Anxiolytics, Anxiolytics, Other buspirone buspirone NO NO NO 866086 5720000510 0 changed 4/29/133

41 Antineoplastics Antineoplastics, Alkylating Agents BUSULFEX busulfan NO NO NO 105551 2110001000

ANALGESICS - NonNarcotic Analgesic Combinations Butalbital-Acetaminophen Cap 50-650 MG NO NO NO 993948 6499100212

ANALGESICS - NonNarcotic Analgesic Combinations BUTAPAP Butalbital-Acetaminophen Tab 50-325 MG NO NO NO 209827 6499100212

ANALGESICS - NonNarcotic Analgesic Combinations BUTAPAP Butalbital-Acetaminophen Tab 50-650 MG NO NO NO 94048 6499100212

101 Central Nervous System Agents Central Nervous System Agents, Central Nervous System, Other butalbital-acetaminophen-caff w/ cod butalbital-acetaminophen-caff w/ cod NO NO NO 993945 6599100410 0 0 0 0

ANALGESICS - NonNarcotic Analgesic Combinations ESGIC Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG NO NO NO 238153 6499100310

ANALGESICS - NonNarcotic Analgesic Combinations ESGIC Butalbital-Acetaminophen-Caffeine Tab 50-500-40 MG NO NO NO 240093 6499100310

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting butalbital-aspirin-caff w/ codeine butalbital-aspirin-caff w/ codeine NO NO NO 994277 6599100430

ANALGESICS - NonNarcotic Analgesic Combinations FIORINAL Butalbital-Aspirin-Caffeine Cap 50-325-40 MG NO NO NO 238135 6499100330

ANALGESICS - NonNarcotic Analgesic Combinations FIORINAL Butalbital-Aspirin-Caffeine Tab 50-325-40 MG NO NO NO 238135 6499100330

31 Antifungals Antifungals, Antifungals GYNAZOLE-1 butoconazole NO NO NO 890783 5510401512

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting butorphanol butorphanol NO NO NO 886634 6520002010

129

Hormonal Agents, Suppressant

(Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline cabergoline NO NO NO 199703 3040202000

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSAnaleptics CAFCIT Caffeine Citrate Oral Soln 60 MG/3ML (10 MG/ML Base Equiv) NO NO NO 849930 6130001010

105 Dermatological Agents Dermatological Agents, Dermatological Agents calcipotriene calcipotriene NO NO NO 308865 9025002500 Maximum Quantity 60 claim 0

105 Dermatological Agents Dermatological Agents, Dermatological Agents TACLONEX Calcipotriene-Betamethaone NO NO NO 833463 9055990232

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents calcitonin calcitonin NO NO NO #N/A 9646420210

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents calcitriol calcitriol NO NO NO #N/A 9646420236

ENDOCRINE AND METABOLIC AGENTS - MISC.Metabolic Modifiers ROCALTROL Calcitriol Cap 0.25 MCG NO NO NO 308867 3090503000

ENDOCRINE AND METABOLIC AGENTS - MISC.Metabolic Modifiers ROCALTROL Calcitriol Cap 0.5 MCG NO NO NO 308868 3090503000

117 Genitourinary Agents Genitourinary Agents, Phosphate Binders calcium calcium NO NO NO 308891 7910000700

117 Genitourinary Agents Genitourinary Agents, Phosphate Binders PHOSLYRA Calcium Acetate (Phosphate Binder) NO NO NO 645216 5280002010

ANTACIDS Antacids - Calcium Salts TUMS, TUMS LASTING Calcium Carbonate (Antacid) Chew Tab 500 MG NO NO NO 998704 4830001000

Antacids Antacids - Calcium Salts Calcium Carbonate 1.25gm Tab Chew Calcium Carbonate 1.25gm Tab Chew 7910000700 Max DS/Dosage 500 30

Antacids Antacids - Calcium Salts Calcium Carbonate 1.25gm Tablet Calcium Carbonate 1.25gm Tablet 7910000700 Max DS/Dosage 500 30

Antacids Antacids - Calcium Salts Calcium Carbonate 1000mg Tablet Chewable/Non-chewableCalcium Carbonate 1000mg Tablet Chewable/Non-chewable 4830001000

Antacids Antacids - Calcium Salts Calcium Carbonate 750mg Tablet Chewable/Non-chewableCalcium Carbonate 750mg Tablet Chewable/Non-chewable 7910000700 Max DS/Dosage 500 30

Antacids Antacids - Calcium Salts Calcium Carbonate Liquid 1.25mg/5mL Calcium Carbonate Liquid 1.25mg/5mL 7910000700 Max DS/Dosage 500 30

Minerals & Electrolytes Calcium Combinations Calcium Carbonate/Vitamin D Calcium Carbonate/Vitamin D 7910990263 Daily Dose 2

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral calcium chloride calcium chloride NO NO NO 828527 7910001000

Minerals & Electrolytes Calcium Calcium Citrate 950mg Tablet Calcium Citrate 950mg Tablet 7910001500

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral calcium gluconate calcium gluconate NO NO NO 198546 7910003000

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderLAXATIVES Bulk Laxatives FIBERCON Calcium Polycarbophil Tab 625 MG NO NO NO 308934 4630002010 10

DERMATOLOGICALS Antipruritics - Topical SARNA Camphor & Menthol Lotion 0.5-0.5% NO NO NO 617666 9022990210

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists ATACAND Candesartan NO NO NO 577787 3615002010 0 0 2

40 Antimycobacterials Antimycobacterials, Antituberculars CAPASTAT capreomycin NO NO NO 201860 0900002010

Dermatologicals Local Anesthetics - Topical Capsaicin 0.025% Cream Capsaicin 0.025% Cream 9085002500 Package Limit 1 claim

Dermatologicals Local Anesthetics - Topical Capsaicin 0.075% Cream Capsaicin 0.075% Cream 9085002500 Package Limit 1 claim



Inhibitors captopril captopril NO NO NO 308962 3610001000 0 0 3

ANTIHYPERTENSIVES Antihypertensive Combinations Capozide Captopril & Hydrochlorothiazide Tab 25-15 MG NO NO NO 211053 3699180225




21 Anticonvulsants Anticonvulsants, Sodium Channel Agents carbamazepine carbamazepine NO NO NO 308974 7260002000 0 0 6

Otic Agents Otic Agents - Misc. Carbamide Peroxide 6.5% Drops Carbamide Peroxide 6.5% Drops 8740003000 Max DS/Dosage 15 30

OTIC AGENTS Otic Agents - Miscellaneous DEBROX Carbamide Peroxide 6.5% Otic Soln NO NO NO 827778 8740003000

57 Antiparkinson Agents

Antiparkinson Agents, Dopamine Precursors/L-Amino Acid

Decarboxylase Inhibitors 3 LODOSYN Carbidopa NO NO NO 261330 7340303000



Decarboxylase Inhibitors 3 carbidopa & levodopa carbidopa & levodopa NO NO NO 724598 7320990210



Decarboxylase Inhibitors 3 carbidopa-levodopa-entacapone carbidopa-levodopa-entacapone NO NO NO 810087 7320990330

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines carbinoxamine carbinoxamine NO NO NO 1012906 4120001015

HEMATOPOIETIC AGENTS Iron ICAR Carbonyl Iron Chew Tab 15 MG (Elemental Iron) NO NO NO 578104 8230000300

45 Antineoplastics Antineoplastics, Antineoplastics, Other carboplatin carboplatin NO NO NO 597195 2110001500

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers CARBAGLU Carglumic Acid NO NO NO 905394 3090823000

154 Skeletal Muscle Relaxants Skeletal Muscle Relaxants, Skeletal Muscle Relaxants carisoprodol carisoprodol NO NO NO 730918 7510002000 0 0 3

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents carteolol carteolol NO NO NO 978573 8625001210 Maximum Quantity 1 30 0

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents carvedilol carvedilol NO NO NO 212388 3330000700 0 0 3

31 Antifungals Antifungals, Antifungals CANCIDAS caspofungin NO NO NO 828757 1150002510

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefaclor cefaclor NO NO NO 309043 0220004010

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefadroxil cefadroxil NO NO NO 309047 0210001000

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefazolin cefazolin NO NO NO 309053 0210001510

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefdinir cefdinir NO NO NO 544198 0230004000 Maximum Quantity 20 claim 0

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins CEFDITOREN CEFDITOREN NO NO NO 847365 0230004520

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefepime cefepime NO NO NO 309055 0240004012

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins SUPRAX cefixime NO NO NO 213927 0230006000 13 thru 999

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefotaxime cefotaxime NO NO NO 543678 0230007510

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins CEFOTETAN CEFOTETAN NO NO NO 309071 0220005710

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefoxitin cefoxitin NO NO NO 309072 0220006010

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefpodoxime cefpodoxime NO NO NO 214078 0230006510 13 thru 999

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefprozil cefprozil NO NO NO 197452 0220006200 Maximum Quantity 20 claim 0 13 thru 999

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins TEFLARO ceftaroline NO NO NO 1040016 0250003010

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins ceftazidime ceftazidime NO NO NO 313890 0230008000

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins CEDAX ceftibuten NO NO NO 309085 0230008300 13 thru 999

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins ceftriaxone ceftriaxone NO NO NO 359339 9646501857

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cefuroxime cefuroxime NO NO NO 211974 0220006505 Maximum Quantity 20 claim 0 13 thru 999

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs CELEBREX celecoxib NO NO NO 213468 6610052500 0 0 2

10 Antibacterials Antibacterials, Beta-lactam, Cephalosporins cephalexin cephalexin NO NO NO 309114 0210002000

132 Immunological Agents Immunological Agents, Immune Suppressants CIMZIA Certolizumab Pegol For Inj Kit NO NO NO 849599 5250502010

Antihistamines Antihistamines-Non Sedating Cetirizine 1mg/mL Syrup Cetirizine 1mg/mL Syrup 4155002010 Daily Dose 1 13 thru 999

Antihistamines Antihistamines-Non Sedating Cetirizine 5mg Tablet Cetirizine 5mg Tablet 4155002010 Daily Dose 1 13 thru 999

ANTIHISTAMINES Antihistamines - Non-Sedating Zyrtec Cetirizine HCl Chew Tab 10 MG NO NO NO 1086794 4155002010 1




ANTIHISTAMINES Antihistamines - Non-Sedating Zyrtec Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) NO NO NO 1087174 4155002010 Maximum Quantity 240 Claim 13-999

ANTIHISTAMINES Antihistamines - Non-Sedating Zyrtec Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) NO NO NO 1087174 4155002010 Maximum Quantity 240 Claim 13-999

ANTIHISTAMINES Antihistamines - Non-Sedating Zyrtec Cetirizine HCl Tab 10 MG NO NO NO 1087169 4155002010 1




COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations ZYRTEC-D Cetirizine-Pseudoephedrine Tab SR 12HR 5-120 MG NO NO NO 1014583 4399300227 2

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents cevimeline cevimeline NO NO NO 309140 8850152510

9 Antibacterials Antibacterials, Antibacterials, Other CHLORAMPHEN chloramphenicol NO NO NO 795513 1620001000

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents chlorhexidine gluconate chlorhexidine gluconate NO NO NO 834137 8815002010

41 Antineoplastics Antineoplastics, Alkylating Agents LEUKERAN chlormbucil NO NO NO 105553 2110101000

52 Antiparasitics Antiparasitics, Antiprotozoals chloroquine phosphate chloroquine phosphate NO NO NO 1116760 1300001020 Maximum Quantity 60 30 0

93 Cardiovascular Agents Cardiovascular Agents, Diuretics, Thiazide chlorothiazide chlorothiazide NO NO NO 197475 3760002000 0 0 2

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Chlorphen Tan-Pyrilamine Tan-PE Tan Susp 2-12.5-5 MG/5ML NO NO NO 1293468 4399300325 20

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Chlorpheniramine & Phenylephrine Liquid 1-3.5 MG/ML NO NO NO 1100509 4399300230 Maximum Quantity 30 Claim

Antihistamines Antihistamines - Alkylamines Chlorpheniramine Maleate 2mg/5mL SyrupChlorpheniramine Maleate 2mg/5mL Syrup 4110002015 Max DS/Dosage 120 claim

Antihistamines Antihistamines - Alkylamines Chlorpheniramine Maleate 4mg Tablet Chlorpheniramine Maleate 4mg Tablet 4110002015 Max DS/Dosage 120 claim

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations RYNATAN PED Chlorpheniramine Tan-Phenylephrine Tan Susp 4.5-5 MG/5ML NO NO NO 1293472 4399300236 10 0-2

59 Antipsychotics Antipsychotics, 1st Generation/Typical CHLORPROMAZ CHLORPROMAZ NO NO NO 991039 5920001510

59 Antipsychotics Antipsychotics, 1st Generation/Typical chlorpromazine chlorpromazine NO NO NO #N/A 9690001000

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents chlorpropamide chlorpropamide NO NO NO #N/A 9690001000

93 Cardiovascular Agents Cardiovascular Agents, Diuretics, Thiazide chlorthalidone chlorthalidone NO NO NO 197499 3760002500

154 Skeletal Muscle Relaxants Skeletal Muscle Relaxants, Skeletal Muscle Relaxants chlorzoxazone chlorzoxazone NO NO NO 309113 7510004000

VITAMINS Oil Soluble Vitamins Vitamin D-3 Cholecalciferol Cap 1000 Unit NO NO NO 245500 7720203200




96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other cholestyramine cholestyramine NO NO NO 848949 3910001000 0 0 6

119

Hormonal Agents,


(Pituitary), Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary), chorionic gonadotropin chorionic gonadotropin NO NO NO 896856 3006202000



Corticosteroids ALVESCO Ciclesonide Inhal Aerosol NO NO NO 799037 4440001700 Maximum Quantity 7 30 0

31 Antifungals Antifungals, Antifungals ciclopirox ciclopirox NO NO NO 309289 9015003010

63 Antivirals Antivirals, Anti-cytomegalovirus (CMV) Agents VISTIDE Cidofovir NO NO NO 199388 1220001000

81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying cilostazol cilostazol NO NO NO 261116 8515551600 0 0 2

109 Gastrointestinal Agents Gastrointestinal Agents, Histamine2 (H2) receptor Antagonists cimetidine cimetidine NO NO NO 197505 4920001000 0 0 4

Ulcer Drugs H-2 Antagonists Cimetidine 200mg Tablet Cimetidine 200mg Tablet 4920001000 Daily Dose 4

128


(Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR Cinacalcet HCl Tab NO NO NO 656137 3090522510

14 Antibacterials Antibacterials, Quinolones CIPRO I.V. ciprofloxacin NO NO NO 213226 0500002000 13 thru 999

14 Antibacterials Antibacterials, Quinolones ciprofloxacin ciprofloxacin NO NO NO 848956 8710001210

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories CIPRODEX Ciprofloxacin-Dexamethasone Otic Susp 0.3-0.1% NO NO NO 404630 8799100236 Maximum Quantity 8 claim 0

45 Antineoplastics Antineoplastics, Antineoplastics, Other cisplatin cisplatin NO NO NO 309311 2110002000

27 Antidepressants Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide citalopram hydrobromide NO NO NO 213344 5816002010

45 Antineoplastics Antineoplastics, Antineoplastics, Other cladribine cladribine NO NO NO 240754 2130000700

13 Antibacterials Antibacterials, Macrolides clarithromycin clarithromycin NO NO NO 197517 0350001000 Maximum Quantity 28 claim 0

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines clemastine clemastine NO NO NO 857443 4120002040 0 0 2

9 Antibacterials Antibacterials, Antibacterials, Other clindamycin clindamycin NO NO NO 706461 1622002030

ANTI-INFECTIVE AGENTS - MISC. Lincosamides CLEOCIN Clindamycin HCl Cap 150 MG NO NO NO 748746 1622002010

ANTI-INFECTIVE AGENTS - MISC. Lincosamides CLEOCIN Clindamycin HCl Cap 300 MG NO NO NO 748748 1622002010

ANTI-INFECTIVE AGENTS - MISC. Lincosamides CLEOCINPED Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base Equiv) NO NO NO 748743 1622002022 Package Limit 1 Claim

105 Dermatological Agents Dermatological Agents, Dermatological Agents clindamycin phosphate clindamycin phosphate NO NO NO 804973 9005101010 Maximum Quantity 1 claim 0

105 Dermatological Agents Dermatological Agents, Dermatological Agents clindamycin phosphate-benzoyl peroxideclindamycin phosphate-benzoyl peroxide NO NO NO 358917 9005990219 Maximum Quantity 1 claim 0

105 Dermatological Agents Dermatological Agents, Dermatological Agents VELTIN Clindamycin Phosphate-Tretinoin NO NO NO 999927 9005990265

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral CLINIMIX CLINIMIX NO NO NO 1361499 8030201010

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids clobetasol clobetasol NO NO NO 861440 9055002510 Maximum Quantity 1 claim 0

28 Antidepressants Antidepressants, Tricyclics clomipramine clomipramine NO NO NO 857299 5820002510

19 Anticonvulsants

Anticonvulsants, Gamma-aminobutyric Acid (GABA) Augmenting

Agents clonazepam clonazepam NO NO NO 206157 7210001000 0 0 4

82 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Agonists clonidine clonidine NO NO NO 884187 3620101010 0 0 6

81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying clopidogrel bisulfate clopidogrel bisulfate NO NO NO 309362 8515802010 0 0 1

31 Antifungals Antifungals, Antifungals clotrimazole clotrimazole NO NO NO 309370 9015402000 Maximum Quantity 1 claim 0

Dermatologicals Imidazole - Related Antifungals - Topical Clotrimazole 1% Cream Clotrimazole 1% Cream 9015402000 Package Limit 1 claim

Vaginal Products Imidazole - Related Antifungals Clotrimazole 2% Cream Clotrimazole 2% Cream 5510402000 Max DS/Dosage 45 claim

105 Dermatological Agents Dermatological Agents, Dermatological Agents clotrimazole w/ betamethasone clotrimazole w/ betamethasone NO NO NO 308714 9015990205 Maximum Quantity 1 claim 0

61 Antipsychotics Antipsychotics, Treatment-Resistant clozapine clozapine NO NO NO 197535 5915202000

Hematopoietic Agents Hematopoietic Mixtures Vitamin B Complex with/without Minerals LiquidCobalamine Combinations 8299100000

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting codeine codeine NO NO NO 238124 6510002010

32 Antigout Agents Antigout Agents, Antigout Agents COLCRYS colchicine NO NO NO 858071 6800002000 Maximum Quantity 6 30 0

32 Antigout Agents Antigout Agents, Antigout Agents colchicine w/ probenecid colchicine w/ probenecid NO NO NO 198153 6899000210

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents WELCHOL Colesevelam NO NO NO 866912 3910001610 0 0 7

96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other colestipol colestipol NO NO NO 1048447 3910002010 0 0 16

105 Dermatological Agents Dermatological Agents, Dermatological Agents SANTYL Collagenase NO NO NO 1149617 9070001000

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents COMBIGAN COMBIGAN NO NO NO 861637 8625990215

MEDICAL DEVICES Contraceptives Condoms Latex Lubricated NO NO NO #N/A 9740101010 Maximum Quantity 36 Claim

MEDICAL DEVICES Contraceptives Condoms Latex Non-Lubricated NO NO NO #N/A 9740101020 Maximum Quantity 36 Claim

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids cortisone cortisone NO NO NO 828248 2210001510

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors XALKORI Crizotinib NO NO NO 1148506 2153401500

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents cromolyn cromolyn NO NO NO 831246 4415001010 Maximum Quantity 240 30 0

NASAL AGENTS - SYSTEMIC AND TOPICALNasal Antiallergy NASALCROM Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%) NO NO NO 746341 4240503010 Maximum Quantity 26 Claim

53 Antiparasitics Antiparasitics, Pediculicides/Scabicides EURAX Crotamiton NO NO NO 207864 9090001000 Maximum Quantity 60 claim 0

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderHEMATOPOIETIC AGENTS Cobalamins Vitamin B-12 Cyanocobalamin Inj 1000 MCG/ML NO NO NO 309594 8210001000

154 Skeletal Muscle Relaxants Skeletal Muscle Relaxants, Skeletal Muscle Relaxants cyclobenzaprine cyclobenzaprine NO NO NO #N/A 9646880905

41 Antineoplastics Antineoplastics, Alkylating Agents CYCLOPHOSPH cyclophosphamide NO NO NO 197549 2110102000

41 Antineoplastics Antineoplastics, Alkylating Agents SEROMYCIN cycloserine NO NO NO 212797 0900003000

132 Immunological Agents Immunological Agents, Immune Suppressants cyclosporine cyclosporine NO NO NO 359423 9646881000

140 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Agents, Other RESTASIS Cyclosporine (Ophth) Emulsion NO NO NO 402092 8672002000

ASSORTED CLASSES Immunosuppressive Agents SANDIMMUNE Cyclosporine Cap 100 MG NO NO NO 328160 9940202000 4

ASSORTED CLASSES Immunosuppressive Agents SANDIMMUNE Cyclosporine Cap 25 MG NO NO NO 212810 9940202000 4

ASSORTED CLASSES Immunosuppressive Agents NEORAL Cyclosporine Modified Cap 100 MG NO NO NO 835911 9940202030 4



ASSORTED CLASSES Immunosuppressive Agents NEORAL Cyclosporine Modified Oral Soln 100 MG/ML NO NO NO 835899 9940202030 8

ASSORTED CLASSES Immunosuppressive Agents SANDIMMUNE Cyclosporine Oral Soln 100 MG/ML NO NO NO 309632 9940202000 8

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines cyproheptadine cyproheptadine NO NO NO 668346 9646887220

ANTIHISTAMINES Antihistamines - Piperidines Periactin Cyproheptadine HCl Syrup 2 MG/5ML NO NO NO 866021 4150002010

ANTIHISTAMINES Antihistamines - Piperidines Periactin Cyproheptadine HCl Tab 4 MG NO NO NO 866144 4150002010

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers CYSTAGON Cysteamine Bitartrate NO NO NO 209789 5640003010

45 Antineoplastics Antineoplastics, Antineoplastics, Other cytarabine Cytarabine Inj PF NO NO NO 249364 2130001000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral d5w/lytes d5w/lytes NO NO NO 807396 7999300235

78 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Anticoagulants PRADAXA Dabigatran NO NO NO 1037181 8333703020 0 0 1

45 Antineoplastics Antineoplastics, Antineoplastics, Other Dacarbazine Dacarbazine For Inj NO NO NO 309638 2170002000

45 Antineoplastics Antineoplastics, Antineoplastics, Other dactinomycin Dactinomycin For Inj NO NO NO 239179 2120002000

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents AMPYRA Dalfampridine NO NO NO 897025 6240603000

78 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Anticoagulants FRAGMIN Dalteparin NO NO NO 978757 8310101010

122

Hormonal Agents,


(Sex

Hormones/Modifiers), Androgens Androgens danazol Danazol Cap NO NO NO 197555 2310000500

62 Antispasticity Agents Antispasticity Agents, Antispasticity Agents dantrolene dantrolene NO NO NO 856660 7520001010 0 0 4

39 Antimycobacterials Antimycobacterials, Antimycobacterials, Other DAPSONE dapsone NO NO NO 197557 1630001000

9 Antibacterials Antibacterials, Antibacterials, Other CUBICIN daptomycin NO NO NO 404652 1627003000

114 Genitourinary Agents Genitourinary Agents, Antispasmodics, Urinary ENABLEX Darifenacin NO NO NO 543021 5410001020

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors PREZISTA Darunavir Ethanolate NO NO NO 794610 1210452010 0 0 2

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors SPRYCEL Dasatinib NO NO NO 643177 2153402000

45 Antineoplastics Antineoplastics, Antineoplastics, Other daunorubicin daunorubicin NO NO NO 309650 2120003010

157 Therapeutic Nutrients/Minerals/Electrolytes

Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral

Modifiers EXJADE Deferasirox Tab For Oral Susp NO NO NO 616163 9310002500



Modifiers FERRIPROX Deferiprone Tab NO NO NO 1190357 9310002800

66 Antivirals

Antivirals, Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors RESCRIPTOR Delavirdine Mesylate NO NO NO 856562 1210902020 0 0 12

16 Antibacterials Antibacterials, Tetracyclines demeclocycline demeclocycline NO NO NO 197985 0400004010

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents PROLIA Denosumab Inj NO NO NO 993456 3004453000

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents XGEVA Denosumab Inj NO NO NO 993456 3004453000

28 Antidepressants Antidepressants, Tricyclics desipramine desipramine NO NO NO 1099290 5820003010

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines desloratadine desloratadine NO NO NO 755661 4155002100 0 0 1 13 thru 999

119

Hormonal Agents,


(Pituitary), Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary), desmopressin desmopressin NO NO NO 849517 3020101010 0 0 6

119

Hormonal Agents,


(Pituitary), Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary), STIMATE Desmopressin Acetate Nasal Soln .5 MG/ML NO NO NO 849517 3020101010 0 0 6

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids desonide desonide NO NO NO 205530 9055003500 Maximum Quantity 1 claim 0

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids desoximetasone desoximetasone NO NO NO 94345 9055004000 Maximum Quantity 1 claim 0

27 Antidepressants Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors PRISTIQ desvenlafaxine NO NO NO 790267 5818002020

33 Anti-inflammatory Agents Glucocorticoids Dexamethasone Dexamethasone NO NO NO 197577 2210002000

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines DEXCHLORPHEN Dexchlorpheniramine NO NO NO 702220 4110003015

113 Gastrointestinal Agents Gastrointestinal Agents, Proton Pump Inhibitors DEXILANT Dexlansoprazole NO NO NO #N/A 4927002000 0 0 1



Disorder Agents, Non-amphetamines dexmethylphenidate dexmethylphenidate NO NO NO 1101934 6140001610



Disorder Agents, Amphetamines dextroamphetamine dextroamphetamine NO NO NO 884385 6110002010

MHS Indiana

Preferred Drug List

HIP State


101 Central Nervous System Agents Central Nervous System Agents, Central Nervous System, Other NUEDEXTA Dextromethorphan HBr-Quinidine Sulfate Cap 0-10 MG NO NO NO 1040058 6260990230

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral dextrose 5% dextrose 5% NO NO NO 309778 9460002400

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral dianeal dianeal NO NO NO 212315 9970000000

MEDICAL DEVICES Contraceptives Diaphragm Arc-Spring 65 MM NO NO NO #N/A 9740201000




MEDICAL DEVICES Contraceptives Diaphragm Coil Spring Kit 100 MM NO NO NO #N/A 9740202000 Maximum Quantity 1 180



MEDICAL DEVICES Contraceptives Diaphragm Flat Spring Kit 55 MM NO NO NO #N/A 9740204000 Maximum Quantity 1 180









19 Anticonvulsants


Agents DIAZEPAM DIAZEPAM NO NO NO 197589 5710004000 0 0 4

62 Antispasticity Agents Antispasticity Agents, Antispasticity Agents diazepam diazepam NO NO NO 197589 5710004000 0 0 4

76 Blood Glucose Regulators Blood Glucose Regulators, Glycemic Agents PROGLYCEM Diazoxide Susp NO NO NO 207634 2730002000

Anorectal Agents Rectal Local Anesthetics Dibucaine 1% Ointment Dibucaine 1% Ointment 8920001700

105 Dermatological Agents Dermatological Agents, Dermatological Agents SOLARAZE Diclofenac NO NO NO 855644 9037403530

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs diclofenac diclofenac NO NO NO 1442130 6610000700

105 Dermatological Agents Dermatological Agents, Dermatological Agents VOLTAREN Diclofenac Sodium Ophth NO NO NO 854803 8680501010 Maximum Quantity 1 claim 0

12 Antibacterials Antibacterials, Beta-lactam, Penicillins dicloxacillin dicloxacillin NO NO NO 197595 0130002010

107 Gastrointestinal Agents Gastrointestinal Agents, Antispasmodics, Gastrointestinal dicyclomine dicyclomine NO NO NO 991063 4910301010

67 Antivirals


Transcriptase Inhibitors didanosine didanosine NO NO NO 284498 1210501500 0 0 40 13 thru 999

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other MOTOFEN Difenoxin NO NO NO 1190740 4710001510

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids diflorasone diacetate diflorasone diacetate NO NO NO 966577 9055005010 Maximum Quantity 1 claim 0

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs diflunisal diflunisal NO NO NO 197603 6410005000

89 Cardiovascular Agents Cardiovascular Agents, Cardiovascular Agents, Other digoxin digoxin NO NO NO 197606 3120001000

35 Antimigraine Agents Antimigraine Agents, Ergot Alkaloids dihydroergotamine dihydroergotamine NO NO NO 861670 6700003010 Maximum Quantity 8 30 0

35 Antimigraine Agents Antimigraine Agents, Ergot Alkaloids MIGRANAL dihydroergotamine NO NO NO 861670 6700003010 Maximum Quantity 8 30 0

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents diltiazem diltiazem NO NO NO 830865 3400001010 0 0 3

29 Antiemetics Antiemetics, Antiemetics, Other Dimenhydrinate Dimenhydrinate NO NO NO #N/A 5020003000

29 Antiemetics Antiemetics, Antiemetics, Other diphenhydramine diphenhydramine NO NO NO 1020479 4120003010 0 0 4

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Benaphen Plus Diphenhydramine & Pseudoephedrine Cap CR 25-60 MG NO NO NO #N/A 4399300258 4

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Benaphen Plus Diphenhydramine & Pseudoephedrine Tab 25-60 MG NO NO NO #N/A 4399300258

Antihistamines Antihistamines - Ethanolamines Diphenhydramine 12.5mg/mL Syrup Diphenhydramine 12.5mg/mL Syrup 4120003010 Daily Dose 4

HYPNOTICS Antihistamine Hypnotics UNISOM SLEEP Diphenhydramine HCl (Sleep) Cap 50 MG NO NO NO 1093113 6030002010

HYPNOTICS Antihistamine Hypnotics UNISOM SLEEP Diphenhydramine HCl (Sleep) Tab 25 MG NO NO NO 1092466 6030002010

HYPNOTICS Antihistamine Hypnotics UNISOM SLEEP Diphenhydramine HCl (Sleep) Tab 50 MG NO NO NO 1086859 6030002010

Antihistamines Antihistamines - Topical Diphenhydramine HCL 2% Cream Diphenhydramine HCL 2% Cream 9020001010

DERMATOLOGICALS Antihistamines-Topical Benadryl Diphenhydramine HCl Cream 2% NO NO NO 1087026 9020001010

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other diphenoxylate w/ atropine diphenoxylate w/ atropine NO NO NO 1190568 4710001010

81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying dipyridamole dipyridamole NO NO NO 207569 8515003000

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics disopyramide disopyramide NO NO NO 834346 3540000500



Deterrents/Anti-craving disulfiram disulfiram NO NO NO 210628 6280204000

36 Antimigraine Agents Antimigraine Agents, Prophylactic divalproex divalproex NO NO NO 1099598 7250001010

74 Bipolar Agents Bipolar Agents, Mood Stabilizers Divalproex divalproex NO NO NO 672908 5940001500

Antivirals-Topical Antivirals-Topical Abreva 10% Cream Docosanol Cream 10% 9035002200

Laxatives Surfactant Laxatives Docusate Calcium 240mg Capsule Docusate Calcium 240mg Capsule 4650001010

LAXATIVES Surfactant Laxatives COLACE Docusate Sodium Cap 100 MG NO NO NO 1483571 4650001030



LAXATIVES Surfactant Laxatives COLACE Docusate Sodium Liquid 150 MG/15ML NO NO NO 1248119 4650001030

LAXATIVES Surfactant Laxatives COLACE Docusate Sodium Syrup 60 MG/15ML NO NO NO 1247758 4650001030

LAXATIVES Surfactant Laxatives COLACE Docusate Sodium Tab 100 MG NO NO NO 1483574 4650001030

30 Antiemetics Antiemetics, Emetogenic Therapy Adjuncts ANZEMET dolasetron NO NO NO 213093 5025002520 Maximum Quantity 5 30 0

68 Antivirals Antivirals, Anti-HIV Agents, Other Tivicay Dolutegravir NO NO NO 729201 1210206000 0 0 2

23 Antidementia Agents Antidementia Agents, Cholinesterase Inhibitors donepezil hydrochloride donepezil hydrochloride NO NO NO 997224 6205102510 0 0 1

11 Antibacterials Antibacterials, Beta-lactam, Other DORIBAX DORIBAX NO NO NO 1039657 1615002000

152 Respiratory Tract Agents Respiratory Tract Agents, Respiratory Tract Agents, Other PULMOZYME Dornase Alfa Inhal Soln NO NO NO 205532 4530402000

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents dorzolamide dorzolamide NO NO NO 310015 8680234010 Maximum Quantity 10 claim 0

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents dorzolamide -timolol dorzolamide -timolol NO NO NO 313954 8625990220 Maximum Quantity 10 claim 0

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents doxazosin doxazosin NO NO NO 197625 3620200510

83 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Blocking Agents doxazosin doxazosin NO NO NO 197625 3620200510

28 Antidepressants Antidepressants, Tricyclics doxepin doxepin NO NO NO 1000048 5820004010

105 Dermatological Agents Dermatological Agents, Dermatological Agents ZONALON Doxepin HCl Cream NO NO NO 1000093 9022001510

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents HECTOROL Doxercalciferol Cap NO NO NO 284411 3090504000

45 Antineoplastics Antineoplastics, Antineoplastics, Other doxorubicin doxorubicin NO NO NO 1191138 2120004010

16 Antibacterials Antibacterials, Tetracyclines doxycycline doxycycline NO NO NO 861061 0400002000

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents Doxycycline Doxycycline oral (20mg for Peridontitis) NO NO NO 360187 9680762703

HYPNOTICS Antihistamine Hypnotics UNISOM Doxylamine Succinate (Sleep) Tab 25 MG NO NO NO 1101448 6030001010

30 Antiemetics Antiemetics, Emetogenic Therapy Adjuncts dronabinol dronabinol NO NO NO 205641 5030003000

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics MULTAQ Dronedarone NO NO NO 854859 3540002810

72 Anxiolytics Anxiolytics, SSRI/SNRI CYMBALTA Duloxetine NO NO NO 596928 5818002510

102 Central Nervous System Agents Central Nervous System Agents, Fibromyalgia Agents Duloxetine Duloxetine NO NO NO 833139 6250405010 0 0 2

27 Antidepressants Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors Duloxetine duloxetine NO NO NO 596928 5818002510

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents AVODART Dutasteride NO NO NO 352118 5685102000 0 0 1

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents JALYN Dutasteride/tamsulosin NO NO NO #N/A 5685990225

149 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Phosphodiesterase LUFYLLIN Dyphylline Tab NO NO NO 93181 4430002000

31 Antifungals Antifungals, Antifungals econazole econazole NO NO NO 857366 9015403510 Maximum Quantity 1 claim 0

66 Antivirals


Inhibitors SUSTIVA Efavirenz NO NO NO 213390 1210903000 0 0 3

66 Antivirals


Inhibitors ATRIPLA Efavirenz-Emtricitabine-Tenofovir NO NO NO 643070 1210990330 0 0 1

37 Antimigraine Agents Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists RELPAX eletriptan NO Yes NO 404443 6740602510 Maximum Quantity 6 30 0



Modifiers PROMACTA Eltrombopag Olamine NO NO NO 825429 8240503010

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents EMADINE Emedastine Difumarate Ophth Soln NO NO NO 213204 8680202510

Emollients Emollients Aquaphor Ointment Emollient Ointment 9065000000

67 Antivirals


Transcriptase Inhibitors EMTRIVA Emtricitabine NO NO NO 404587 1210603000 0 0 1 13 thru 999

67 Antivirals


Transcriptase Inhibitors TRUVADA Emtricitabine-Tenofovir Disoproxil Fumarate NO NO NO 639888 1210990230 0 0 1



Inhibitors enalapril enalapril NO NO NO 858806 3610002010 0 0 2

ANTIHYPERTENSIVES Antihypertensive Combinations Vaseretic Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG NO NO NO 858830 3699180235 2

ANTIHYPERTENSIVES Antihypertensive Combinations Vaseretic Enalapril Maleate & Hydrochlorothiazide Tab 5-12.5 MG NO NO NO 858824 3699180235 2

68 Antivirals Antivirals, Anti-HIV Agents, Other FUZEON Enfuvirtide NO NO NO 404460 1210253000 Maximum Quantity 1 30 0

78 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Anticoagulants enoxaparin enoxaparin NO NO NO 854232 8310102010

55 Antiparkinson Agents Antiparkinson Agents, Antiparkinson Agents, Other COMTAN Entacapone NO NO NO 261318 7315303000

64 Antivirals Antivirals, Antihepatitis Agents BARACLUDE Entecavir NO NO NO 607579 1235203000 0 0 1 13 thru 999

130



Antiandrogens Antiandrogens XTANDI Enzalutamide NO NO NO 197726 2140244000

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents epinastine epinastine NO NO NO 860656 8680202810

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic epinephrine epinephrine NO NO NO 727386 3890004000 Maximum Quantity 2 30 0

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants Adrenalin Epinephrine HCl Nasal Soln 0.1% NO NO NO 313967 4210202010

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic EPIPEN Epinephrine Solution Auto-injector NO NO NO 727386 3890004000 Maximum Quantity 2 30 0

45 Antineoplastics Antineoplastics, Antineoplastics, Other epirubicin epirubicin NO NO NO 836380 2120004210

92 Cardiovascular Agents Cardiovascular Agents, Diuretics, Potassium-sparing eplerenone eplerenone NO NO NO 402105 3625003000 0 0 2



Modifiers EPOGEN Epoetin Alfa NO NO NO 205913 8240102000



Modifiers PROCRIT Epoetin Alfa NO NO NO 205913 8240102000

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists TEVETEN Eprosartan NO NO NO 261301 3615002420 0 0 2

VITAMINS Oil Soluble Vitamins DRISDOL Ergocalciferol Cap 50000 IU NO NO NO 1367416 7720203000

VITAMINS Oil Soluble Vitamins DRISDOL Ergocalciferol Cap 50000 Unit NO NO NO 1367416 7720203000

22 Antidementia Agents Antidementia Agents, Antidementia Agents, Other ERGOLOID ergoloid NO NO NO 318179 6200001000

35 Antimigraine Agents Antimigraine Agents, Ergot Alkaloids ERGOMAR ergotamine NO NO NO 1293864 6700002010

35 Antimigraine Agents Antimigraine Agents, Ergot Alkaloids ergotamine w/ caffeine ergotamine w/ caffeine NO NO NO 1293506 6799100210

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors TARCEVA Erlotinib NO NO NO #N/A 2153402510

11 Antibacterials Antibacterials, Beta-lactam, Other INVANZ ertapenem NO NO NO 352068 1615003010

13 Antibacterials Antibacterials, Macrolides E.E.S. erythromycin NO NO NO 310154 0310000500

13 Antibacterials Antibacterials, Macrolides ERYPED erythromycin NO NO NO 686405 0310003030

105 Dermatological Agents Dermatological Agents, Dermatological Agents erythromycin erythromycin NO NO NO 310154 0310000500

72 Anxiolytics Anxiolytics, SSRI/SNRI escitalopram escitalopram NO NO NO 352272 5816003410

113 Gastrointestinal Agents Gastrointestinal Agents, Proton Pump Inhibitors NEXIUM Esomeprazole NO NO NO 861570 4927002510 0 0 1 13 thru 999

MHS Indiana

Preferred Drug List

HIP State


123

Hormonal Agents,


(Sex

Hormones/Modifiers), Estrogens Estrogens estradiol Estradiol Tab NO NO NO 205909 2400003500 0 0 0.29

43 Antineoplastics Antineoplastics, Antiestrogens/Modifiers EMCYT estramustine NO NO NO 205562 2140302010

123

Hormonal Agents,


(Sex

Hormones/Modifiers), Estrogens Estrogens PREMARIN Estrogens, Conjugated Vaginal Cream NO NO NO 688242 5535002500 Maximum Quantity 43 30 0

132 Immunological Agents Immunological Agents, Immune Suppressants ENBREL Etanercept For Subcutaneous Inj Kit NO NO NO 261105 6629003000

91 Cardiovascular Agents Cardiovascular Agents, Diuretics, Loop EDECRIN Ethacrynic Acid NO NO NO 1251905 3720002000

40 Antimycobacterials Antimycobacterials, Antituberculars ethambutol ethambutol NO NO NO 995607 0900004010

123

Hormonal Agents,


(Sex

Hormones/Modifiers), Estrogens Estrogens JUNEL 0 Ethinyl Estradiol; Norethindrone NO NO NO #N/A 2599000250

123

Hormonal Agents,


(Sex

Hormones/Modifiers), Estrogens Estrogens SPRINTEC 8 0 Ethinyl Estradiol; Norgestimate NO NO NO #N/A 2599000295

40 Antimycobacterials Antimycobacterials, Antituberculars TRECATOR Ethionamide NO NO NO 835721 0900005000

18 Anticonvulsants Anticonvulsants, Calcium Channel Modifying Agents ethosuximide ethosuximide NO NO NO 1093372 9650800950

ANTICONVULSANTS Succinimides ZARONTIN Ethosuximide Cap 250 MG NO NO NO 201737 7240001000

ANTICONVULSANTS Succinimides ZARONTIN Ethosuximide Soln 250 MG/5ML NO NO NO 755357 7240001000

21 Anticonvulsants Anticonvulsants, Sodium Channel Agents PEGANONE Ethotoin NO NO NO 206750 7220001000

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents etidronate etidronate NO NO NO 904549 3004204010

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs etodolac etodolac NO NO NO 197684 6610000800

47 Antineoplastics Antineoplastics, Enzyme Inhibitors ETOPOPHOS Etoposide NO NO NO 226719 2150001060

47 Antineoplastics Antineoplastics, Enzyme Inhibitors ETOPOSIDE Etoposide NO NO NO 197687 2150001000

66 Antivirals


Inhibitors INTELENCE Etravirine NO NO NO 758555 1210903500 0 0 8

132 Immunological Agents Immunological Agents, Immune Suppressants AFINITOR Everolimus NO NO NO 206289 9940254010

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors ZORTRESS Everolimus NO NO NO 977436 9940403500

46 Antineoplastics Antineoplastics, Aromatase Inhibitors, 3rd Generation exemestane exemestane NO NO NO 310261 2140283500

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents BYETTA Exenatide Soln NO NO NO 847913 2717002000 Maximum Quantity 4 28 0

96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other ZETIA Ezetimibe NO NO NO 349556 3930003000 0 0 1

96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other VYTORIN Ezetimibe-Simvastatin NO NO NO 1245449 3999400230 0 0 1

17 Anticonvulsants Anticonvulsants, Anticonvulsants, Other POTIGA Ezogabine NO NO NO 1113001 7260002600 0 0 3

65 Antivirals Antivirals, Antiherpetic Agents famciclovir famciclovir NO NO NO 199193 1240804000 0

109 Gastrointestinal Agents Gastrointestinal Agents, Histamine2 (H2) receptor Antagonists famotidine famotidine NO NO NO 212072 4920003000 0 0 2 13 thru 999

Ulcer Drugs H-2 Antagonists Famotidine 10mg Tablet Famotidine 10mg Tablet 4920003000 Daily Dose 2 13 thru 999

32 Antigout Agents Antigout Agents, Antigout Agents ULORIC febuxostat NO NO NO 834243 6800003000

20 Anticonvulsants Anticonvulsants, Glutamate Reducing Agents felbamate felbamate NO NO NO 209026 7212002000 0 0 9 22 thru 999

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents felodipine sr felodipine sr NO NO NO 402695 3400001300 0 0 1

94 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Fibric Acid Derivatives fenofibrate fenofibrate NO NO NO 351842 3920002510 0 0 1

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs fenoprofen calcium fenoprofen calcium NO NO NO 310291 6610001010

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting fentanyl fentanyl NO NO NO 261184 6510002500 0 0 4

HEMATOPOIETIC AGENTS Iron HEMOCYTE Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe) NO NO NO 897256 8230003000 2

HEMATOPOIETIC AGENTS Hematopoietic Mixtures Centratex Ferrous Fumarate-FA-B Complex-C-Zn-Mg-Mn-Cu Tab 106-1 MG NO NO NO 1095285 8299200870 1

HEMATOPOIETIC AGENTS Iron FERGON Ferrous Gluconate Tab 225 MG (27 MG Fe Equivalent) NO NO NO 261386 8230002000

HEMATOPOIETIC AGENTS Iron FERGON Ferrous Gluconate Tab 240 MG (27 MG Elemental Fe) NO NO NO 261386 8230002000

HEMATOPOIETIC AGENTS Iron FERGON Ferrous Gluconate Tab 246 MG (28 MG Elemental Fe) NO NO NO 261386 8230002000

HEMATOPOIETIC AGENTS Iron FERGON Ferrous Gluconate Tab 324 MG NO NO NO 261386 8230002000

HEMATOPOIETIC AGENTS Iron FERGON Ferrous Gluconate Tab 324 MG (38 MG Elemental Iron) NO NO NO 198630 8230002000

HEMATOPOIETIC AGENTS Iron FERGON Ferrous Gluconate Tab 325 MG NO NO NO 198632 8230002000

HEMATOPOIETIC AGENTS Iron FERGON Ferrous Gluconate Tab 325 MG (37.5 MG Elemental Fe) NO NO NO 198632 8230002000

Hematopoietic Agents Iron Ferrous Sulfate 220mg/5mL Elixir Ferrous Sulfate 220mg/5mL Elixir 8230001000 Daily Dose 16

Hematopoietic Agents Iron Ferrous Sulfate 220mg/5mL Liquid Ferrous Sulfate 220mg/5mL Liquid 8230001000 Daily Dose 16

Hematopoietic Agents Iron Ferrous Sulfate 325mg Tablet Ferrous Sulfate 325mg Tablet 8230001000 Daily Dose 16

Hematopoietic Agents Iron Ferrous Sulfate 325mg Tablet EC Ferrous Sulfate 325mg Tablet EC 8230001000 Daily Dose 16

Hematopoietic Agents Iron Ferrous Sulfate 75mg/mL Drops Ferrous Sulfate 75mg/mL Drops 8230001000 Daily Dose 16

HEMATOPOIETIC AGENTS Iron SLOWFE Ferrous Sulfate Dried Tab CR 160 MG (50 MG Fe Equivalent) NO NO NO 310318 8230001010

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML Elemental Fe) NO NO NO 702249 8230001000

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Soln 75 MG/0.6ML NO NO NO 885580 8230001000

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Soln 75 MG/0.6ML (15 MG/0.6ML Elemental Fe) NO NO NO 310316 8230001000

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental Fe) NO NO NO 995613 8230001000

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Tab 28 MG (Elemental Fe) NO NO NO 885580 8230001000

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) NO NO NO 310325 8230001000

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Tab EC 324 MG (65 MG Fe Equivalent) NO NO NO 310324 8230001000

HEMATOPOIETIC AGENTS Iron Iron Sulfate Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent) NO NO NO 310324 8230001000

Antihistamines-Non Sedating Antihistamines-Non Sedating Allegra 30mg/5mL Suspension Fexofenadine HCl Susp 30 MG/5ML (6 MG/ML) 4155002410 Daily Dose 2

ANTIHISTAMINES Antihistamines - Non-Sedating Allegra Fexofenadine HCl Tab 180 MG NO NO NO 997422 4155002410 2

ANTIHISTAMINES Antihistamines - Non-Sedating Allegra Fexofenadine HCl Tab 30 MG NO No NO 997489 4155002410 2

ANTIHISTAMINES Antihistamines - Non-Sedating Allegra Fexofenadine HCl Tab 60 MG NO No NO 997502 4155002410 2

13 Antibacterials Antibacterials, Macrolides DIFICID fidaxomicin NO NO NO 1111110 0353002500

MHS Indiana

Preferred Drug List

HIP State




Modifiers NEUPOGEN Filgrastim NO NO NO 207052 8240152000

130



Antiandrogens Antiandrogens finasteride finasteride NO NO NO 213178 9073603000

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents GILENYA Fingolimod HCl NO NO NO 1012899 6240702510

114 Genitourinary Agents Genitourinary Agents, Antispasmodics, Urinary flavoxate flavoxate NO NO NO 1095229 5440002510

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics flecainide flecainide NO NO NO 834346 3540000500

45 Antineoplastics Antineoplastics, Antineoplastics, Other floxuridine Floxuridine (Bulk) Powder NO NO NO #N/A 9652640650

31 Antifungals Antifungals, Antifungals fluconazole fluconazole NO NO NO 207106 1140701500 Maximum Quantity 7 claim 0 13 thru 999

31 Antifungals Antifungals, Antifungals flucytosine flucytosine NO NO NO 1247596 9652640950

45 Antineoplastics Antineoplastics, Antineoplastics, Other fludarabine fludarabine NO NO NO 877490 2130002510

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids fludrocortisone fludrocortisone NO NO NO 313979 2220003010



Corticosteroids flunisolide flunisolide NO NO NO 752378 4220003000 Maximum Quantity 25 30 0

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids fluocinonide fluocinonide NO NO NO 103456 9055006000 Maximum Quantity 1 claim 0

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories fluorometholone fluorometholone NO NO NO 359539 9652646339

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories FML Fluorometholone Ophth Oint 0.1% NO NO NO 545243 8630002000 Maximum Quantity 1 claim 0

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories FML FORTE Fluorometholone Ophth Susp 0.25% NO NO NO 545243 8630002000 Maximum Quantity 1 claim 0

45 Antineoplastics Antineoplastics, Antineoplastics, Other fluorouracil fluorouracil NO NO NO 359540 9652646363

27 Antidepressants Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors fluoxetine fluoxetine NO NO NO 799026 6220604000

122

Hormonal Agents,


(Sex

Hormones/Modifiers), Androgens Androgens ANDROXY Fluoxymesterone Tab NO NO NO 692688 2310001000

59 Antipsychotics Antipsychotics, 1st Generation/Typical fluphenazine fluphenazine NO NO NO 859841 5920002510

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs flurbiprofen flurbiprofen NO NO NO 197725 6610001200

45 Antineoplastics Antineoplastics, Antineoplastics, Other flutamide flutamide NO NO NO 197726 2140244000



Corticosteroids FLOVENT fluticasone NO NO NO 896019 4440003320 0 0 2

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids fluticasone fluticasone NO NO NO 895697 9055006810 Maximum Quantity 1 30 0



Corticosteroids ADVAIR Fluticasone & Salmeterol NO NO NO 896185 4420990270 Maximum Quantity 12 30 0

95 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors fluvastatin fluvastatin NO NO NO 103918 3940003010 0 0 1

27 Antidepressants Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors fluvoxamine fluvoxamine NO NO NO 903884 5816004510

HEMATOPOIETIC AGENTS Folic Acid/Folates Folic Acid Tab 1 MG NO NO NO 310410 8220001000

HEMATOPOIETIC AGENTS Folic Acid/Folates Folic Acid Tab 400 MCG NO NO NO 198640 8220001000 1

HEMATOPOIETIC AGENTS Folic Acid/Folates Folic Acid Tab 800 MCG NO NO NO 198641 8220001000 1

78 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Anticoagulants fondaparinux fondaparinux NO NO NO 861366 8310303010

ANTISEPTICS & DISINFECTANTS Antiseptics & Disinfectants Formaldehyde Solution 10% NO NO NO 310416 9200000500 Maximum Quantity 90 Claim

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic FORADIL Formoterol NO NO NO 1246328 4420102710 0 0 2 13 thru 999

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors LEXIVA Fosamprenavir Calcium NO NO NO 402110 1210452510 0 0 4 13 thru 999

63 Antivirals Antivirals, Anti-cytomegalovirus (CMV) Agents FOSCARNET Foscarnet NO NO NO 199388 1220001000

65 Antivirals Antivirals, Antiherpetic Agents FOSCARNET FOSCARNET NO NO NO 313412 7510009010 0 0 9

9 Antibacterials Antibacterials, Antibacterials, Other MONUROL fosfomycin NO NO NO 808921 5300001520



Inhibitors fosinopril fosinopril NO NO NO 857171 3610002710 Daily Dosage 0 0 1

ANTIHYPERTENSIVES Antihypertensive Combinations Monopril HCT Fosinopril Sodium & Hydrochlorothiazide Tab 10-12.5 MG NO NO NO 857166 3699180240 1

ANTIHYPERTENSIVES Antihypertensive Combinations Monopril HCT Fosinopril Sodium & Hydrochlorothiazide Tab 20-12.5 MG NO NO NO 857174 3699180240 1

21 Anticonvulsants Anticonvulsants, Sodium Channel Agents fosphenytoin fosphenytoin NO NO NO 855895 7220001310

37 Antimigraine Agents Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists FROVA frovatriptan NO NO NO 352058 6740603010 Maximum Quantity 12 30 0

91 Cardiovascular Agents Cardiovascular Agents, Diuretics, Loop furosemide furosemide NO NO NO 197730 3720003000

19 Anticonvulsants


Agents gabapentin gabapentin NO NO NO 1053638 9654424400

101 Central Nervous System Agents Central Nervous System Agents, Central Nervous System, Other HORIZANT Gabapentin Enacarbil NO NO NO 1101337 6256003020

23 Antidementia Agents Antidementia Agents, Cholinesterase Inhibitors galantamine hydrobromide galantamine hydrobromide NO NO NO 602734 6205103010 0 0 2

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers NAGLAZYME Galsulfase NO NO NO 584222 3090753500

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender63 Antivirals Antivirals, Anti-cytomegalovirus (CMV) Agents ganciclovir ganciclovir NO NO NO 200206 1220003000

14 Antibacterials Antibacterials, Quinolones gatifloxacin gatifloxacin NO NO NO 402090 8610102900

MEDICAL DEVICES Bandages-Dressings-Tape Gauze Pads & Dressings - Pads 2" X 2" NO NO NO #N/A 9730300000



45 Antineoplastics Antineoplastics, Antineoplastics, Other gemcitabine gemcitabine NO NO NO 1233324 2130003410

94 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Fibric Acid Derivatives gemfibrozil gemfibrozil NO NO NO 310459 3920003000 0 0 2

14 Antibacterials Antibacterials, Quinolones FACTIVE gemifloxacin NO NO NO 637562 0500008310

8 Antibacterials Antibacterials, Aminoglycosides gentamicin gentamicin NO NO NO 239204 0700002010

ALTERNATIVE MEDICINES Alternative Medicine - G's Ginger (Zingiber officinalis) Cap 250 MG NO NO NO 284059 9521274100 4

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents COPAXONE Glatiramer Acetate NO NO NO 1111642 6240003010

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents glimepiride glimepiride NO NO NO 199245 2720002700 0 0 2

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents glipizide glipizide NO NO NO 310488 2720003000

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents glipizide-metformin glipizide-metformin NO NO NO 861733 2799700235 0 0 2

76 Blood Glucose Regulators Blood Glucose Regulators, Glycemic Agents GLUCAGEN Glucagon HCl NO NO NO 153095 2730001015 Maximum Quantity 1 claim 0

76 Blood Glucose Regulators Blood Glucose Regulators, Glycemic Agents GLUCAGON Glucagon HCl NO NO NO #N/A 2730001000

DIAGNOSTIC PRODUCTS Diagnostic Tests Glucose Blood Test Strip NO NO NO #N/A 9410003000

Antidiabetics Diabetic Other Dextrose 4gm Tab Chew Glucose Chew Tab 4 GM 2730003000 Max DS/Dosage 50 30

Antidiabetics Diabetic Other Dextrose 5gm Tab Chew Glucose Chew Tab 5 GM 2730003000 Max DS/Dosage 50 30

Antidiabetics Diabetic Other Dextrose 40% Gel Glucose Gel 40% 2730003000 Max DS/Dosage 50 30

NUTRIENTS Carbohydrates Glucose Polymers Liqd NO NO NO #N/A 8010002500 Package Limit 1 30

NUTRIENTS Carbohydrates Glucose Polymers Powder 94% NO NO NO #N/A 8010002500 Package Limit 1 30

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents glyburide glyburide NO NO NO 205873 2720004000

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents glyburide-metformin glyburide-metformin NO NO NO 861747 2799700240 0 0 2

LAXATIVES Laxatives - Miscellaneous Glycerin Suppos 1.5 GM NO NO NO 1151094 4660001000 Maximum Quantity 12 Claim

LAXATIVES Laxatives - Miscellaneous Glycerin Suppos 2 GM NO NO NO 583084 4660001000 Maximum Quantity 12 Claim

LAXATIVES Laxatives - Miscellaneous Glycerin Suppos 3 GM NO NO NO 583084 4660001000 Maximum Quantity 12 Claim

Dermatologicals Skin Protectants Glycerin/Dimethicone/Shea Tree/Stearyl Alcohol CreamGlycerin/Dimethicone/Shea Tree/Stearyl Alcohol Cream 9097205030

Dermatologicals Skin Protectants Glycerin/Dimethicone/Urea/Petrolatum/Cetyl Al LotionGlycerin/Dimethicone/Urea/Petrolatum/Cetyl Al Lotion 9097205030

Dermatologicals Skin Protectants Glycerin/Lanolin/Mineral Oil Cream Glycerin/Lanolin/Mineral Oil Cream 9097207900

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral glycine irrigation glycine irrigation NO NO NO 310571 5670005000

107 Gastrointestinal Agents Gastrointestinal Agents, Antispasmodics, Gastrointestinal glycopyrrolate glycopyrrolate NO NO NO 197739 4910203000

132 Immunological Agents Immunological Agents, Immune Suppressants SIMPONI Golimumab Subcutaneous Soln Prefilled Syring NO NO NO 1431647 6627004000

30 Antiemetics Antiemetics, Emetogenic Therapy Adjuncts granisetron granisetron NO NO NO 825005 5025003500

31 Antifungals Antifungals, Antifungals griseofulvin griseofulvin NO NO NO 241606 9654762710

ANTIFUNGALS Antifungals GRIFULVINV Griseofulvin Microsize Susp 125 MG/5ML NO NO NO 239238 1100003010

ANTIFUNGALS Antifungals GRIFULVINV Griseofulvin Microsize Tab 500 MG NO NO NO 310600 1100003010

ANTIFUNGALS Antifungals GRIS-PEG Griseofulvin Ultramicrosize Tab 125 MG NO NO NO 242831 1100003020

ANTIFUNGALS Antifungals GRIS-PEG Griseofulvin Ultramicrosize Tab 250 MG NO NO NO 239239 1100003020

Cough/Cold/Allergy Expectorants Guaifenesin 100mg/5mL Syrup Guaifenesin 100mg/5mL Syrup 4320001000

Cough/Cold/Allergy Expectorants Guaifenesin/D-Methorphan Syrup Guaifenesin/D-Methorphan Syrup 4399700252

Cough/Cold/Allergy Expectorants Guaifenesin/D-Methorphan Tablet Guaifenesin/D-Methorphan Tablet 4399700252

Cough/Cold/Allergy Expectorants Guaifenesin/pseudoephedrine Syrup Guaifenesin/pseudoephedrine Syrup 4399620230

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Robitussin A-C Guaifenesin-Codeine Liquid 200-10 MG/5ML NO NO NO 996552 4399700228

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Robitussin A-C Guaifenesin-Codeine Liquid 300-10 MG/5ML NO NO NO 996512 4399700228

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Robitussin A-C Guaifenesin-Codeine Soln 100-10 MG/5ML NO NO NO 996484 4399700228

Cough/Cold/Allergy Expectorants Guaifensesin/D-Methorphan Capsule Guaifensesin/D-Methorphan Capsule 4399700252

82 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Agonists GUANABENZ Guanabenz NO NO NO #N/A 3620102010

82 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Agonists guanfacine guanfacine NO NO NO 206412 3620102510



Disorder Agents, Non-amphetamines INTUNIV Guanfacine ER NO NO NO 862021 6135303010

38 Antimyasthenic Agents Antimyasthenic Agents, Parasympathomimetics GUANIDINE guanidine NO NO NO 1298099 7600003010

Cough/Cold/Allergy Expectorants Guifenesin 100mg/5mL Liquid Guifenesin 100mg/5mL Liquid 4320001000

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids halobetasol halobetasol NO NO NO 977980 9055007310 Maximum Quantity 1 claim 0

59 Antipsychotics Antipsychotics, 1st Generation/Typical haloperidol haloperidol NO NO NO 197754 5910001010

Anorectal Agents Rectal Combinations - Misc. Hemorrhoidal Preparation Ointment Hemorrhoidal Preparation Ointment 8999400240

Anorectal Agents Rectal Combinations - Misc. Hemorrhoidal Preparation Suppository Hemorrhoidal Preparation Suppository 8999400233

78 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Anticoagulants heparin heparin NO NO NO 240345 9656504820

105 Dermatological Agents Dermatological Agents, Dermatological Agents hexachlorophene hexachlorophene NO NO NO 106421 9656507200

97 Cardiovascular Agents Cardiovascular Agents, Vasodilators, Direct-acting Arterial hydralazine hydralazine NO NO NO 905199 3640001010

93 Cardiovascular Agents Cardiovascular Agents, Diuretics, Thiazide hydrochlorothiazide hydrochlorothiazide NO NO NO 197770 3760004000

COUGH/COLD/ALLERGY Antitussives Hycodan, Hydromet Hydrocodone w/ Homatropine Syrup 5-1.5 MG/5ML NO NO NO 992675 4310101000

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting hydrocodone-acetaminophen hydrocodone-acetaminophen NO NO NO 856898 6599170210 0 0 8

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Codiclear D-H Hydrocodone-Guaifenesin Syrup 5-100 MG/5ML NO NO NO 856915 4399700270 Maximum Quantity 240 Claim

136 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Glucocorticoids hydrocortisone hydrocortisone NO NO NO 103401 9055007500 Maximum Quantity 30 claim 0

Dermatologicals Corticosteroids - Topical Hydrocortisone Acetate 0.5% Ointment/CreamHydrocortisone Acetate 0.5% Ointment/Cream 9055007510

Dermatologicals Corticosteroids - Topical Hydrocortisone Acetate 1% Ointment/CreamHydrocortisone Acetate 1% Ointment/Cream 9055007510

ANORECTAL AGENTS Rectal Steroids ANUSOL-HC Hydrocortisone Acetate Suppos 25 MG NO NO NO 1429379 8910001010 2

ANORECTAL AGENTS Rectal Combinations ANALPRAM-HC Hydrocortisone Acetate w/ Pramoxine Rectal Cream 1-1% NO NO NO 1539198 8999100231 Maximum Quantity 60 30

ANORECTAL AGENTS Rectal Combinations ANALPRAM-HC Hydrocortisone Acetate w/ Pramoxine Rectal Cream 2.5-1% NO NO NO 1362211 8999100231 Package Limit 1 Claim

ANORECTAL AGENTS Intrarectal Steroids CORTENEMA Hydrocortisone Enema 100 MG/60ML NO NO NO 802059 8915001000 Maximum Quantity 420 Claim

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderANORECTAL AGENTS Rectal Steroids ANUSOL-HC Hydrocortisone Rectal Cream 2.5% NO NO NO 759717 8910001000 Package Limit 1 Claim

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids SOLU-CORTEF hydrocortisone sodium succinate NO NO NO 105398 2210002540

144 Otic Agents Otic Agents, Otic Agents hydrocortisone w/ acetic acid hydrocortisone w/ acetic acid NO NO NO 313786 8730002010 Maximum Quantity 10 claim 0

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting EXALGO hydromorphone NO NO NO 897698 6510003510 0 0 8

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting hydromorphone hydromorphone NO NO NO 897698 6510003510 0 0 8

52 Antiparasitics Antiparasitics, Antiprotozoals hydroxychloroquine sulfate hydroxychloroquine sulfate NO NO NO 979094 1300002010

OPHTHALMIC AGENTS Artificial Tears and Lubricants Hydroxypropyl Methylcellulose Ophth Soln 0.4% NO NO NO 1363484 8620002500 Maximum Quantity 15 Claim

44 Antineoplastics Antineoplastics, Antimetabolites DROXIA hydroxyurea NO NO NO 213282 8280303000

44 Antineoplastics Antineoplastics, Antimetabolites HYDROXYUREA HYDROXYUREA NO NO NO 197797 2170003000

HEMATOPOIETIC AGENTS Agents for Sickle Cell Anemia Hydrea Hydroxyurea Cap 200 MG NO NO NO 213282 8280303000



71 Anxiolytics Anxiolytics, Anxiolytics, Other hydroxyzine hydroxyzine NO NO NO 995232 5720004020

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines hydroxyzine hydroxyzine NO NO NO 995232 5720004020

OPHTHALMIC AGENTS Artificial Tears and Lubricants Genteal Hypromellose Ophth Soln 0.4% NO NO NO 966757 8620002500 Maximum Quantity 15 Claim

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents ibandronate ibandronate NO NO NO 904954 3004204810 0 0 1

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents BONIVA Ibandronate Sodium IV Soln NO NO NO 904954 3004204810 0 0 1

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs ibuprofen ibuprofen NO NO NO 206905 6610002000

Analgesics - Anti-Inflammatory NSAIDS Ibuprofen 200mg Tablet Ibuprofen 200mg Tablet 6610002000

Analgesics - Anti-Inflammatory NSAIDS Ibuprofen Children’s Susp. Ibuprofen Children’s Susp. 6610002000

45 Antineoplastics Antineoplastics, Antineoplastics, Other idarubicin idarubicin NO NO NO 996154 2120004510

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers ELAPRASE Idursulfase Soln NO NO NO 647118 3090685000

60 Antipsychotics Antipsychotics, 2nd Generation/Atypical FANAPT Iloperidone NO NO NO 848726 5907003500

151 Respiratory Tract Agents Respiratory Tract Agents, Pulmonary Antihypertensives VENTAVIS Iloprost Inhalation Solution NO NO NO 861966 4017006000

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors GLEEVEC Imatinib NO NO NO 404588 2153403510

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers CEREZYME Imiglucerase NO NO NO 605882 8270005000

11 Antibacterials Antibacterials, Beta-lactam, Other imipenem-cilastatin imipenem-cilastatin NO NO NO 998359 1615990240

28 Antidepressants Antidepressants, Tricyclics imipramine imipramine NO NO NO 835566 5820005010

105 Dermatological Agents Dermatological Agents, Dermatological Agents imiquimod imiquimod NO NO NO 310982 9077304000 Maximum Quantity 56 180 0

133 Immunological Agents Immunological Agents, Immunizing Agents, Passive CARIMUNE NF Immune Globulin (Human) IV or Subcutaneous Soln NO NO NO 606479 1910002010

133 Immunological Agents Immunological Agents, Immunizing Agents, Passive GAMMAKED Immune Globulin (Human) IV or Subcutaneous Soln NO NO NO 606479 1910002030

133 Immunological Agents Immunological Agents, Immunizing Agents, Passive GAMUNEX-C Immune Globulin (Human) IV or Subcutaneous Soln NO NO NO 606479 1910002030

133 Immunological Agents Immunological Agents, Immunizing Agents, Passive GAMMAGARD SD Immune Globulin (Human) IV or Subcutaneous Soln NO NO NO 606479 1910002010

133 Immunological Agents Immunological Agents, Immunizing Agents, Passive HIZENTRA Immune Globulin (IVIG) Subcutaneous NO NO NO 617621 1910002020

62 Antispasticity Agents Antispasticity Agents, Antispasticity Agents XEOMIN Incobutulinum toxin A NO NO NO 1000111 7440002020

93 Cardiovascular Agents Cardiovascular Agents, Diuretics, Thiazide indapamide indapamide NO NO NO 197816 3760005000

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors CRIXIVAN Indinavir Sulfate NO NO NO 153127 1210453020 0 0 6

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs indomethacin indomethacin NO NO NO 197817 6610003000

64 Antivirals Antivirals, Antihepatitis Agents INTRON-A Inerferon Alfa b NO NO NO 545293 2170006020

132 Immunological Agents Immunological Agents, Immune Suppressants REMICADE Infliximab For IV Inj NO NO NO 213361 5250504000

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins Humulin N Insulin (Human Isophane) NO NO NO 351926 2710400200 Maximum Quantity 30 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins Novolin N Insulin (Human Isophane) NO NO NO 351926 2710400200 Maximum Quantity 30 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins Novolin 70/30 Insulin (Human Regular and Isophane) NO NO NO 351926 2710400200 Maximum Quantity 30 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins HUMULIN Insulin (Human Regular) NO NO NO 847189 2710409000 Maximum Quantity 50 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins NOVOLIN R Insulin (Human Regular) NO NO NO 847205 2710401000 Maximum Quantity 50 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins NOVOLOG Insulin Aspart NO NO NO 351926 2710400200 Maximum Quantity 30 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins LEVEMIR Insulin Detemir NO NO NO 616238 2710400600 Maximum Quantity 30 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins LANTUS Insulin Glargine NO NO NO 285018 2710400300 Maximum Quantity 30 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins APIDRA Insulin Glulisine NO NO NO 803194 2710400400 Maximum Quantity 30 30 0

77 Blood Glucose Regulators Blood Glucose Regulators, Insulins HUMALOG Insulin Lispro (Human) NO NO NO 847209 2710400500 Maximum Quantity 50 30 0

MEDICAL DEVICES Parenteral Therapy Supplies Insulin Pen Needle 29 G X 12 MM (1/2") NO NO NO #N/A 9705105014 5

MEDICAL DEVICES Parenteral Therapy Supplies Insulin Pen Needle 29 G X 12.7 MM NO NO NO #N/A 9705105014 5


MEDICAL DEVICES Parenteral Therapy Supplies Insulin Pen Needle 30 G X 8 MM (1/3" or 5/16") NO NO NO #N/A 9705105014 5

MEDICAL DEVICES Parenteral Therapy Supplies Insulin Pen Needle 31 G X 5 MM NO NO NO #N/A 9705105014 5



MEDICAL DEVICES Parenteral Therapy Supplies Insulin Pen Needle 31 G X 8 MM NO NO NO #N/A 9705105014 5





MEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe (Disp) U-100 1 ML NO NO NO #N/A 9705103005 5

MEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe/Needle U-100 0.3 ML 28 x 1/2" NO NO NO #N/A 9705103090 5

MEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe/Needle U-100 0.3 ML 29 x 1" NO NO NO #N/A 9705103090 5



MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderMEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe/Needle U-100 0.3 ML 30 x 1/2" NO NO NO #N/A 9705103090 5





MEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe/Needle U-100 1 ML 25 x 1" NO NO NO #N/A 9705103090 5

MEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe/Needle U-100 1 ML 25 x 5/8" NO NO NO #N/A 9705103090 5














MEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe/Needle U-100 1/2 ML 27 x 1/2" NO NO NO #N/A 9705103090 5










MEDICAL DEVICES Parenteral Therapy Supplies Insulin Syringe/Needle U-100 2 ML 27.5 x 5/8" NO NO NO #N/A 9705103090 5


64 Antivirals Antivirals, Antihepatitis Agents INFERGEN Interferon Alfa NO NO NO 213084 1235304010

134 Immunological Agents Immunological Agents, Immunomodulators Intron-A Interferon Alfa-2b YES NO NO 213510 2170006020

134 Immunological Agents Immunological Agents, Immunomodulators Alferon Interferon Alfa-n3 NO NO NO 213377 2170006030 0 0 1

134 Immunological Agents Immunological Agents, Immunomodulators Avonex Interferon Beta -1A YES NO NO 213377 6240306045 0 0 1

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents REBIF Interferon Beta-1a NO NO NO 758032 6240306045

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents AVONEX Interferon Beta-1a NO NO NO 758032 6240306045

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents BETASERON Interferon Beta-1b NO NO NO 860244 6240306050

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents EXTAVIA Interferon Beta-1b NO NO NO 860244 6240306050

134 Immunological Agents Immunological Agents, Immunomodulators ACTIMMUNE Interferon Gamma-1B Inj 00 MCG/0.5ML NO NO NO 751970 2170006070

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral ionosol ionosol NO NO NO 800637 7999300262

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents IOPIDINE IOPIDINE NO NO NO 211020 8660201010

ANTIDOTES Antidotes Ipecac Syrup NO NO NO 756116 9300009200

Ipecac Syrup Ipecac Syrup 9300009200

148 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Anticholinergic ipratropium ipratropium NO NO NO 836358 4410003010 Maximum Quantity 375 30 0

148 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Anticholinergic ATROVENT Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) NO NO NO 836364 4230004010 Maximum Quantity 30 25 0

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists irbesartan irbesartan NO NO NO 200094 3615003000 0 0 1

ANTIHYPERTENSIVES Antihypertensive Combinations AVALIDE Irbesartan-Hydrochlorothiazide Tab 150-12.5 MG NO NO NO 823934 3699400230 1

ANTIHYPERTENSIVES Antihypertensive Combinations AVALIDE Irbesartan-Hydrochlorothiazide Tab 300-12.5 MG NO NO NO 823938 3699400230 1

45 Antineoplastics Antineoplastics, Antineoplastics, Other irinotecan irinotecan NO NO NO 904162 2155004010

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral PHYSIOLYTE Irrigation Solution, Physiological NO NO NO 827353 9975000000

26 Antidepressants Antidepressants, Monoamine Oxidase Inhibitors MARPLAN isocarboxazid NO NO NO 201708 5810001000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral isolyte isolyte NO NO NO #N/A 7999300290

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral isolyte-h isolyte-h NO NO NO 800687 7999300268

40 Antimycobacterials Antimycobacterials, Antituberculars isoniazid isoniazid NO NO NO 311166 0900006000

40 Antimycobacterials Antimycobacterials, Antituberculars RIFAMATE isoniazid; rifampin NO NO NO 206702 0999000210

40 Antimycobacterials Antimycobacterials, Antituberculars RIFATER isoniazid; rifampin; pyrazinamide NO NO NO 206698 0999000320

98 Cardiovascular Agents Cardiovascular Agents, Vasodilators, Direct-acting Arterial/Venous isosorbide isosorbide NO NO NO 808727 9658784575

105 Dermatological Agents Dermatological Agents, Dermatological Agents isotretinoin isotretinoin NO NO NO 600808 9658784600

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents isradipine isradipine NO NO NO 885735 3400001500

31 Antifungals Antifungals, Antifungals itraconazole itraconazole NO NO NO 833173 1140703500 0 0 1 13 thru 999

31 Antifungals Antifungals, Antifungals SPORANOX itraconazole NO NO NO 833173 1140703500 0 0 1 13 thru 999

152 Respiratory Tract Agents Respiratory Tract Agents, Respiratory Tract Agents, Other KALYDECO Ivacaftor Tab NO NO NO 1243052 4530203000

53 Antiparasitics Antiparasitics, Pediculicides/Scabicides SKLICE Ivermectin NO NO NO 1298427 9090001700

51 Antiparasitics Antiparasitics, Anthelmintics STROMECTOL Ivermectin NO NO NO 261314 1500000700

8 Antibacterials Antibacterials, Aminoglycosides KANAMYCIN kanamycin NO NO NO 311214 0700003010

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral kcl kcl NO NO NO 312515 7970003000

31 Antifungals Antifungals, Antifungals ketoconazole ketoconazole NO NO NO 206978 9015404500 Maximum Quantity 1 claim 0

DIAGNOSTIC PRODUCTS Diagnostic Tests Ketone Blood Test Strip NO NO NO #N/A 9410003800 Maximum Quantity 30 30

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs ketoprofen ketoprofen NO NO NO 197855 6610003500

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs ketorolac ketorolac NO NO NO 861844 6610003710 Maximum Quantity 20 30 0 0 thru 16

34 Anti-inflammatory Agents Anti-inflammatory, Nonsteroidal Anti-inflammatory Drugs ketorolac ketorolac NO NO NO 861844 6610003710 Maximum Quantity 20 30 0 0 thru 16

Opthalmic Agents Opthalmic - Misc. Ketotifen Fumerate 0.025% Eye Drops Ketotifen Fumerate 0.025% Eye Drops 8680204010 Package Limit 1 claim

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents labetalol labetalol NO NO NO 896777 3330001010 0 0 3

21 Anticonvulsants Anticonvulsants, Sodium Channel Agents VIMPAT lacosamide NO NO NO 809984 7260003600 0 0 2 22 thru 999

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral lactated ringer's lactated ringer's NO NO NO #N/A 9975001500

105 Dermatological Agents Dermatological Agents, Dermatological Agents lactic acid lactic acid NO NO NO 1328193 9610104000

Emollients Emollient Ammonium Lactate 12% Lotion Lactic Acid (Ammonium Lactate) Lotion 12% 9065001500 Package Limit 1 claim

111 Gastrointestinal Agents Gastrointestinal Agents, Laxatives lactulose lactulose NO NO NO 604797 9664421100

GASTROINTESTINAL AGENTS - MISC. Intestinal Acidifiers Enulose Lactulose (Encephalopathy) Solution 10 GM/15ML NO NO NO 755470 5240002000

LAXATIVES Laxatives - Miscellaneous Enulose Lactulose Solution 10 GM/15ML NO NO NO 544452 4660002000

64 Antivirals Antivirals, Antihepatitis Agents EPIVIR HBV Lamivudine NO NO NO 152932 1210606000 0 0 3 13 thru 999

67 Antivirals


Transcriptase Inhibitors lamivudine lamivudine NO NO NO 152932 1210606000 0 0 3 13 thru 999

67 Antivirals


Transcriptase Inhibitors lamivudine-zidovudine lamivudine-zidovudine NO NO NO 213088 1210990250 0 0 2

20 Anticonvulsants Anticonvulsants, Glutamate Reducing Agents lamotrigine lamotrigine NO NO NO 198427 7260004000 0 0 2 22 thru 999

73 Bipolar Agents Bipolar Agents, Other Lamotrigine lamotrigine NO NO NO 198427 7260004000 0 0 2 22 thru 999

MEDICAL DEVICES Diabetic Supplies Lancet Devices NO NO NO 310519 9720202700 Maximum Quantity 1 180

MEDICAL DEVICES Diabetic Supplies Lancets NO NO NO #N/A 9720202500 Maximum Quantity 200 30

PHARMACEUTICAL ADJUVANTS Semi Solid Vehicles Lanolor, HPA Lanolin Lanolin NO NO NO 608817 9860002020

129


(Pituitary) Hormonal Agents, Suppressant (Pituitary) SOMATULINE Lanreotide NO NO NO 749818 3017005010

113 Gastrointestinal Agents Gastrointestinal Agents, Proton Pump Inhibitors lansoprazole lansoprazole NO NO NO 967728 9664424300

117 Genitourinary Agents Genitourinary Agents, Phosphate Binders FOSRENOL Lanthanum Carbonate NO NO NO 603112 5280004520

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors TYKERB Lapatinib NO NO NO 672152 2153405010

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers ALDURAZYME Laronidase Soln NO NO NO 404492 3090655000



Analogs latanoprost latanoprost NO NO NO 542527 8633005000 Maximum Quantity 3 claim 0

42 Antineoplastics Antineoplastics, Antiangiogenic Agents REVLIMID lenalidomide NO NO NO 616114 9939405000

46 Antineoplastics Antineoplastics, Aromatase Inhibitors, 3rd Generation letrozole letrozole NO NO NO 200064 2140286000

45 Antineoplastics Antineoplastics, Antineoplastics, Other leucovorin leucovorin NO NO NO 197860 2175504010

129


(Pituitary) Hormonal Agents, Suppressant (Pituitary) LUPR DEP-PED leuprolide NO NO NO 1115456 3008005010

129


(Pituitary) Hormonal Agents, Suppressant (Pituitary) leuprolide leuprolide NO NO NO 825334 2140501010

129


(Pituitary) Hormonal Agents, Suppressant (Pituitary) LUPRON DEPOT Leuprolide Acetatate NO NO NO 825334 2140501010

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic levalbuterol levalbuterol NO NO NO #N/A 9664506560

17 Anticonvulsants Anticonvulsants, Anticonvulsants, Other levetiracetam levetiracetam NO NO NO 1150112 9664506600

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents levobunolol levobunolol NO NO NO 1150834 8625002010 Maximum Quantity 1 claim 0

ENDOCRINE AND METABOLIC AGENTS - MISC.Metabolic Modifiers CARNITOR Levocarnitine Oral Soln 1 GM/10ML (10%) NO NO NO 315134 3090304510 30

ENDOCRINE AND METABOLIC AGENTS - MISC.Metabolic Modifiers CARNITOR Levocarnitine Tab 330 MG NO NO NO 206346 3090304510 3

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines levocetirizine dihydrochloride levocetirizine dihydrochloride NO NO NO 855170 4155002710 0 0 1 13 thru 999

14 Antibacterials Antibacterials, Quinolones levofloxacin levofloxacin NO NO NO 284481 0500003400 0 0 1 13 thru 999

123

Hormonal Agents,


(Sex

Hormones/Modifiers), Estrogens Estrogens AVIANE Levonorgestrel & Ethinyl Estradiol NO NO NO 753533 2599000240 0 0 1 Female

124

Hormonal Agents,


(Sex

Hormones/Modifiers), Progestins Progestins levonorgestrel 0 Levonorgestrel Tab NO NO NO 854861 2540004000 Max Fills 4 365 0

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting levorphanol levorphanol NO NO NO 197873 6510004010

126

Hormonal Agents,


(Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine levothyroxine NO NO NO 892255 2810001010

4 Anesthetics Anesthetics, Local Anesthetics LIDODERM lidocaine NO NO NO 1543069 9085006000 Maximum Quantity 1 claim 0

4 Anesthetics Anesthetics, Local Anesthetics lidocaine lidocaine NO NO NO 1543069 9085006000 Maximum Quantity 1 claim 0

MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral Xylocaine Viscous Lidocaine HCl Viscous Soln 2% NO NO NO 1010740 8835006510 Maximum Quantity 100 Claim

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender4 Anesthetics Anesthetics, Local Anesthetics lidocaine-prilocaine lidocaine-prilocaine NO NO NO 206726 9085990290 Maximum Quantity 1 claim 0

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents TRADJENTA Linagliptin NO NO NO 1100706 2755005000 0 0 1

53 Antiparasitics Antiparasitics, Pediculicides/Scabicides lindane Lindane NO NO NO 141860 9090002000

9 Antibacterials Antibacterials, Antibacterials, Other ZYVOX linezolid NO NO NO 262091 1623004000 13 thru 999

126

Hormonal Agents,


(Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) liothyronine liothyronine NO NO NO #N/A 9664584700

126

Hormonal Agents,


(Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) THYROLAR Liotrix NO NO NO 903287 2810003000

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents VICTOZA Liraglutide NO NO NO 897126 2717005000 0 0 0.2



Disorder Agents, Amphetamines VYVANSE Lisdexamfetamine NO NO NO 854844 6110002510



Inhibitors lisinopril lisinopril NO NO NO 206771 3610003000 0 0 1

ANTIHYPERTENSIVES Antihypertensive Combinations PRINZIDE,ZESTORETIC Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG NO NO NO 823986 3699180255 2

ANTIHYPERTENSIVES Antihypertensive Combinations PRINZIDE,ZESTORETIC Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG NO NO NO 823982 3699180255 2

ANTIHYPERTENSIVES Antihypertensive Combinations PRINZIDE,ZESTORETIC Lisinopril & Hydrochlorothiazide Tab 20-25 MG NO NO NO 823971 3699180255 1

74 Bipolar Agents Bipolar Agents, Mood Stabilizers lithium lithium NO NO NO 756059 5950001000

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents ALOMIDE Lodoxamide Tromethamine Ophth Soln NO NO NO 206792 8680205020 Maximum Quantity 10 claim 0

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other loperamide loperamide NO NO NO 977986 4710002010 0 0 2

Antidiarrheals Antiperistaltic Agents Loperamide HCl 1mg/5mL Liquid Loperamide HCl 1mg/5mL Liquid 4710002010 Daily Dose 2

Antidiarrheals Loperamide HCL 2mg Capsules Loperamide HCL 2mg Capsules 4710002010 Daily Dose 2

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors KALETRA Lopinavir-Ritonavir NO NO NO 847741 1210990255 0 0 4 13 thru 999

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations CLARITIN-D Loratadine & Pseudoephedrine Tab SR 12HR 5-120 MG NO NO NO 1369753 4399300259 2

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations CLARITIN-D Loratadine & Pseudoephedrine Tab SR 24HR 10-240 MG NO NO NO 1369756 4399300259 2

ANTIHISTAMINES Antihistamines - Non-Sedating CLARITIN Loratadine Rapidly-Disintegrating Tab 10 MG NO NO NO 744830 4155003000

ANTIHISTAMINES Antihistamines - Non-Sedating CLARITIN Loratadine Rapidly-Disintegrating Tab 10 MG NO NO NO 744830 4155003000

ANTIHISTAMINES Antihistamines - Non-Sedating CLARITIN Loratadine Syrup 5 MG/5ML NO NO NO 755478 4155003000

ANTIHISTAMINES Antihistamines - Non-Sedating CLARITIN Loratadine Syrup 5 MG/5ML NO NO NO 755478 4155003000

ANTIHISTAMINES Antihistamines - Non-Sedating CLARITIN Loratadine Tab 10 MG NO NO NO 997953 4155003000

ANTIHISTAMINES Antihistamines - Non-Sedating CLARITIN Loratadine Tab 10 MG NO NO NO 997953 4155003000

71 Anxiolytics Anxiolytics, Anxiolytics, Other lorazepam lorazepam NO NO NO 197901 5710006000 0 0 4

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists losartan losartan NO NO NO 979482 3615004020 0 0 2

ANTIHYPERTENSIVES Antihypertensive Combinations HYZAAR Losartan Potassium & Hydrochlorothiazide Tab 100-12.5 MG NO NO NO 979466 3699400245 1

ANTIHYPERTENSIVES Antihypertensive Combinations HYZAAR Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG NO NO NO 979473 3699400245 1

ANTIHYPERTENSIVES Antihypertensive Combinations HYZAAR Losartan Potassium & Hydrochlorothiazide Tab 50-12.5 MG NO NO NO 979470 3699400245 1

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories ALREX Loteprednol Etabonate Ophth Susp NO NO NO 213262 8630003510

95 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors lovastatin lovastatin NO NO NO 206257 3940005000 0 0 1

59 Antipsychotics Antipsychotics, 1st Generation/Typical loxapine loxapine NO NO NO 311385 5915402020

110 Gastrointestinal Agents Gastrointestinal Agents, Irritable Bowel Syndrome Agents AMITIZA Lubiprostone NO NO NO 794641 5245004500 0 0 2

152 Respiratory Tract Agents Respiratory Tract Agents, Respiratory Tract Agents, Other SURFAXIN Lucinactant Intratracheal Susp NO NO NO 1293263 4500007000

41 Antineoplastics Antineoplastics, Alkylating Agents CEENU lumustine NO NO NO 206794 2110202000

155 Sleep Disorder Agents Sleep Disorder Agents, GABA Receptor Modulators LUNESTA LUNESTA NO NO NO #N/A 6020403500 0 0 1

132 Immunological Agents Immunological Agents, Immune Suppressants ATGAM Lymphocyte Immune Globulin Anti-Thymocyte G Inj NO NO NO 206289 9940254010

9 Antibacterials Antibacterials, Antibacterials, Other SULFAMYLON mafenide NO NO NO 251575 9045001010

Minerals & Electrolytes Magnesium Magnesium 64mg Tablet ER Magnesium 64mg Tablet ER 7940001000

Antacids Antacid Combinations Magnesium Carbonate/Aluminum Hydroxide/AAMagnesium Carbonate/Aluminum Hydroxide/AA 4899000215

LAXATIVES Saline Laxatives Magnesium Citrate Soln NO NO NO 1245168 4610002010

Minerals & Electrolytes Magnesium Magonate 1gm/5mL Syrup Magnesium Gluconate Liquid 1000 MG/5ML 7940001030

LAXATIVES Saline Laxatives Magnesium Hydroxide Susp 400 MG/5ML NO NO NO 282725 4610001010 Maximum Quantity 990 30

Antacids Antacid Combinations Magnesium Hydroxide/Aluminum HydroxideMagnesium Hydroxide/Aluminum Hydroxide 4899000210 Max DS/Dosage 496 30

Antacids Antacid Combinations Magnesium Hydroxide/Aluminum Hydroxide/SimethiconeMagnesium Hydroxide/Aluminum Hydroxide/Simethicone 4899100310 Max DS/Dosage 496 30

Antacids Antacid Combinations Magnesium Hydroxide/Aluminum Hydroxide/Simethicone EXMagnesium Hydroxide/Aluminum Hydroxide/Simethicone EX 4899100310 Max DS/Dosage 496 30

ANTACIDS Antacids - Magnesium Salts Magnesium Oxide Tab 400 MG NO NO NO 198741 4840002000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral magnesium sulfate magnesium sulfate NO NO NO 1053346 4610003010

53 Antiparasitics Antiparasitics, Pediculicides/Scabicides malathion malathion NO NO NO 261249 9090003000 Maximum Quantity 59 claim 0

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral mannitol irrigation mannitol irrigation NO NO NO 311451 5670008000

25 Antidepressants Antidepressants, Antidepressants, Other MAPROTILINE MAPROTILINE NO NO NO 1298857 5830001010

68 Antivirals Antivirals, Anti-HIV Agents, Other SELZENTRY Maraviroc NO NO NO 729201 1210206000 0 0 2

51 Antiparasitics Antiparasitics, Anthelmintics MEBENDAZOLE MEBENDAZOLE NO NO NO 105347 1500001000

119

Hormonal Agents,


(Pituitary), Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary), INCRELEX Mecasermin Inj 0 MG/4ML (10 MG/ML) NO NO NO 615882 3016004500

29 Antiemetics Antiemetics, Antiemetics, Other meclizine meclizine NO NO NO 995626 5020005000

Antiemetics Antiemetics - Anticholinergic Meclizine HCL 25mg Chew Tab Meclizine HCL 25mg Chew Tab 5020005000

Antiemetics Antiemetics - Anticholinergic Meclizine HCL 25mg Tablet Meclizine HCL 25mg Tablet 5020005000

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs meclofenamate meclofenamate NO NO NO 618557 6610004010

124

Hormonal Agents,


(Sex

Hormones/Modifiers), Progestins Progestins medroxyprogesterone medroxyprogesterone NO NO NO #N/A 9666501209

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs mefenamic acid mefenamic acid NO NO NO 829502 6610005000

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender52 Antiparasitics Antiparasitics, Antiprotozoals mefloquine mefloquine NO NO NO 835915 1300002510

124

Hormonal Agents,


(Sex

Hormones/Modifiers), Progestins Progestins megestrol megestrol NO NO NO 860215 2140402010

ALTERNATIVE MEDICINES Alternative Medicine - M's Melatonin Tab 3 MG NO NO NO 199163 9539153600 1

ALTERNATIVE MEDICINES Alternative Medicine - M's Melatonin Tab 5 MG NO NO NO 252732 9539153600 1

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs meloxicam meloxicam NO NO NO 152698 6610005200 0 0 1

41 Antineoplastics Antineoplastics, Alkylating Agents melphalan melphalan NO NO NO 105562 2110104000

24 Antidementia Agents Antidementia Agents, N-methyl-D-aspartate (NMDA) Receptor NAMENDA memantadine NO NO NO 996563 6205355010 0 0 2

Dermatologicals Emollients Menthol/Colloidal Oatmeal Lotion Menthol/Colloidal Oatmeal Lotion 9065000700

71 Anxiolytics Anxiolytics, Anxiolytics, Other meprobamate meprobamate NO NO NO 197928 5720005000

132 Immunological Agents Immunological Agents, Immune Suppressants mercaptopurine mercaptopurine NO NO NO #N/A 9666505390

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAntimetabolites PURINETHOL Mercaptopurine Tab 50 MG NO NO NO 206788 2130004000

11 Antibacterials Antibacterials, Beta-lactam, Other meropenem meropenem NO NO NO 211309 1615005000

135 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Aminosalicylates mesalamine mesalamine NO NO NO 238151 5250003020

135 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Aminosalicylates PENTASA mesalamine NO NO NO 104112 5250003000 0 0 8

135 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Aminosalicylates LIALDA Mesalamine Tab Delayed Release NO NO NO 104112 5250003000 0 0 8

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic metaproterenol metaproterenol NO NO NO 979409 4420105020 0 0 30 13 thru 999

154 Skeletal Muscle Relaxants Skeletal Muscle Relaxants, Skeletal Muscle Relaxants metaxalone metaxalone NO NO NO 351254 7510006000 0 0 4

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents metformin metformin NO NO NO 860977 2725005000 0 0 5 13 thru 999

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting methadone methadone NO NO NO #N/A 9666505585



Disorder Agents, Amphetamines methamphetamine methamphetamine NO NO NO 977860 6110003010

90 Cardiovascular Agents Cardiovascular Agents, Diuretics, Carbonic Anhydrase Inhibitors methazolamide methazolamide NO NO NO 206901 3710003000

9 Antibacterials Antibacterials, Antibacterials, Other methenamine methenamine NO NO NO #N/A 9630007300

131


(Thyroid), Antithyroid Agents Antithyroid Agents methimazole methimazole NO NO NO 207010 2830001000

154 Skeletal Muscle Relaxants Skeletal Muscle Relaxants, Skeletal Muscle Relaxants methocarbamol methocarbamol NO NO NO 197944 7510007000

132 Immunological Agents Immunological Agents, Immune Suppressants methotrexate methotrexate NO NO NO 600877 2130005000

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAntimetabolites Methotrexate Sodium Inj 25 MG/ML NO NO NO 311627 2130005010

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAntimetabolites Methotrexate Sodium Inj PF 25 MG/ML NO NO NO 311627 2130005010

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAntimetabolites Methotrexate Sodium Tab 10 MG (Base Equiv) NO NO NO 284593 2130005010


ANALGESICS - ANTI-INFLAMMATORY Antirheumatic Antimetabolites Methotrexate Sodium Tab 2.5 MG (Antirheumatic) NO NO NO 1541224 6625005010

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAntimetabolites Methotrexate Sodium Tab 2.5 MG (Base Equiv) NO NO NO 105585 2130005010


ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESAntimetabolites Methotrexate Sodium Tab 7.5 MG (Base Equiv) NO NO NO 284594 2130005010

105 Dermatological Agents Dermatological Agents, Dermatological Agents UVADEX Methoxsalen (Photopheresis) NO NO NO 352083 2170705000

107 Gastrointestinal Agents Gastrointestinal Agents, Antispasmodics, Gastrointestinal methscopolamine bromide methscopolamine bromide NO NO NO 314088 4910206010

18 Anticonvulsants Anticonvulsants, Calcium Channel Modifying Agents CELONTIN methsuximide NO NO NO 207088 7240002000

93 Cardiovascular Agents Cardiovascular Agents, Diuretics, Thiazide methyclothiazide methyclothiazide NO NO NO 197951 3760005500

82 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Agonists METHYLDOPATE Methyldopa NO NO NO 204452 3620103010

82 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Agonists methyldopa methyldopa NO NO NO 197956 3620103000

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other RELISTOR Methylnaltrexone NO NO NO 979115 5258005010



Disorder Agents, Non-amphetamines methylphenidate methylphenidate NO NO NO 753443 6140002000

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSStimulants - Misc. METADATECD Methylphenidate HCl Cap CR 10 MG NO NO NO 1091139 6140002010 1 0-5






ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSStimulants - Misc. METADATECD Methylphenidate HCl Tab 10 MG NO NO NO 1091379 6140002010 3 0-2



ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSStimulants - Misc. METADATECD Methylphenidate HCl Tab CR 10 MG NO NO NO 1091147 6140002010 2 0-5

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSStimulants - Misc. METADATECD Methylphenidate HCl Tab CR 20 MG NO NO NO 1091495 6140002010 1 0-5

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSStimulants - Misc. METADATECD Methylphenidate HCl Tab SA OSM 18 MG NO NO NO 1091157 6140002010 1 0-5




MHS Indiana

Preferred Drug List

HIP State


118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids DEPO-MEDROL methylprednisolone NO NO NO 1358512 2210003010

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids methylprednisolone methylprednisolone NO NO NO 207137 2210003000

136 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Glucocorticoids methylprednisolone methylprednisolone NO NO NO 207137 2210003000

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids SOLU-MEDROL Methylprednisolone Sodium Succinate NO NO NO 207193 2210003020

136 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Glucocorticoids MEDROL Methylprednisolone Tab NO NO NO 207137 2210003000

122

Hormonal Agents,


(Sex

Hormones/Modifiers), Androgens Androgens METHITEST Methyltestosterone NO NO NO 541524 2310002000

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents metipranolol metipranolol NO NO NO 311665 8625001510

29 Antiemetics Antiemetics, Antiemetics, Other metoclopramide metoclopramide NO NO NO 104884 5230002010

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other metoclopramide metoclopramide NO NO NO 104884 5230002010

93 Cardiovascular Agents Cardiovascular Agents, Diuretics, Thiazide metolazone metolazone NO NO NO 197978 3760006000

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents metoprolol metoprolol NO NO NO 866513 3320003010 0 0 2

ANTIHYPERTENSIVES Antihypertensive Combinations LOPRESSHCT Metoprolol & Hydrochlorothiazide Tab 100-25 MG NO NO NO 866498 3699200220 2



ANTIHYPERTENSIVES Antihypertensive Combinations LOPRESSHCT Metoprolol & Hydrochlorothiazide Tab SR 24HR 100-12.5 MG NO NO NO 866455 3699200220 1



9 Antibacterials Antibacterials, Antibacterials, Other metronidazole metronidazole NO NO NO 261119 9006004000 Maximum Quantity 45 claim 0

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics mexiletine mexiletine NO NO NO 1362706 3520002510

31 Antifungals Antifungals, Antifungals MYCAMINE micafungin NO NO NO 861385 1150005010

31 Antifungals Antifungals, Antifungals MICONAZOLE miconazole NO NO NO 992770 5510405010 Maximum Quantity 45 claim 0

Vaginal Products Vaginal Anti-Infectives Miconazole Nitrate 2% Cream Miconazole Nitrate 2% Cream 5510405010 Max DS/Dosage 45 claim 0

Vaginal Products Vaginal Anti-Infectives Miconazole Nitrate Dual Pak Miconazole Nitrate Dual Pak 5510405010 Max DS/Dosage 45 claim

Vaginal Products Vaginal Anti-Infectives Miconazole Suppository Miconazole Suppository 5510405010 Max DS/Dosage 45 claim

82 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Agonists midodrine midodrine NO NO NO 993464 3800008310

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents GLYSET Miglitol NO NO NO 213486 2750005000 0 0 3

Laxatives Laxative Combination Milk of Magnesia Suspension Milk of Magnesia Suspension 4699000223

102 Central Nervous System Agents Central Nervous System Agents, Fibromyalgia Agents SAVELLA Milnacipran NO NO NO 833139 6250405010 0 0 2

16 Antibacterials Antibacterials, Tetracyclines minocycline minocycline NO NO NO 197985 0400004010

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents ARESTIN Minocycline HCl Subgingival NO NO NO 351974 8845205010

97 Cardiovascular Agents Cardiovascular Agents, Vasodilators, Direct-acting Arterial minoxidil minoxidil NO NO NO 197986 3640002000

25 Antidepressants Antidepressants, Antidepressants, Other mirtazapine mirtazapine NO NO NO 311725 5803005000

112 Gastrointestinal Agents Gastrointestinal Agents, Protectants misoprostol misoprostol NO NO NO 311727 4925003000 0 0 4

120 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins) misoprostol misoprostol NO NO NO #N/A 4925003000

45 Antineoplastics Antineoplastics, Antineoplastics, Other mitomycin mitomycin NO NO NO 359796 9666586045

127


(Adrenal), Hormonal Agents,

Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal), Hormonal Agents,

Suppressant (Adrenal) LYSODREN Mitotane Tab NO NO NO 207373 2140225000

45 Antineoplastics Antineoplastics, Antineoplastics, Other mitoxantrone mitoxantrone NO NO NO 197989 2120005500

156 Sleep Disorder Agents Sleep Disorder Agents, Sleep Disorders, Other modafinil modafinil NO NO NO 260218 6140002400 0 0 1



Inhibitors moexipril moexipril NO NO NO 1299897 3610003310 0 0 2



Corticosteroids ASMANEX Mometasone NO NO NO 746815 4440003620 Maximum Quantity 1 30 0

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids mometasone mometasone NO NO NO 92583 9055008210 Maximum Quantity 1 claim 0



Corticosteroids NASONEX Mometasone Furoate Nasal Susp NO NO NO 746201 4220004510 Maximum Quantity 34 30 0 0 thru 1

147 Respiratory Tract Agents Respiratory Tract Agents, Antileukotrienes montelukast montelukast NO NO NO 200224 4450505010 0 0 1 15 thru 999

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting morphine sulfate morphine sulfate NO NO NO 892516 6510005510 0 0 6

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting morphine sulfate morphine sulfate NO NO NO 892516 6510005510 0 0 6

14 Antibacterials Antibacterials, Quinolones AVELOX moxifloxacin NO NO NO 860777 0500003712

MULTIVITAMINS Multivitamins CARDENZ, LYSIPLEX, ONE-A-DAY, THERAGRANMultiple Vitamin Tab NO NO NO 212033 7820000000 1

MULTIVITAMINS Multiple Vitamins w/ Iron GERITOL EXT Multiple Vitamins w/ Iron Tab NO NO NO 261037 7821000000 1

MULTIVITAMINS Multiple Vitamins w/ Minerals CAROMEGA, CENTRUM, CENTRUM SILV, FOSFREE, ONE-A-DAY...Multiple Vitamins w/ Minerals Tab NO NO NO 891815 7831000000 1 14-999

Multiple Vitamins w/Minerals Multiple Vitamins w/Minerals Aquadek Pediatric Liquid Multivitamin with Minerals Liquid 7831000000 Daily Dose 1

Multivitamins Multivitamins Multivitamins w/o Iron, with other Minerals CapsuleMultivitamins w/o Iron, with other Minerals Capsule 7820000000 Daily Dose 1

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderMultivitamins Multivitamins Multivitamins w/o Iron, with other Minerals LiquidMultivitamins w/o Iron, with other Minerals Liquid 7820000000 Daily Dose 1

Multivitamins Multivitamins Multivitamins w/o Iron, with other Minerals TabletMultivitamins w/o Iron, with other Minerals Tablet 7820000000 Daily Dose 1

Multivitamins Multivitamins Multivitamins with Iron, with other Minerals LiquidMultivitamins with Iron, with other Minerals Liquid 7821000000 Daily Dose 1

9 Antibacterials Antibacterials, Antibacterials, Other mupirocin mupirocin NO NO NO 311877 9010006520 Maximum Quantity 1 claim 0

NASAL AGENTS - SYSTEMIC AND TOPICALNasal Anti-infectives Bactroban Mupirocin Calcium Nasal Oint 2% NO NO NO 108758 4225105010

132 Immunological Agents Immunological Agents, Immune Suppressants mycophenolate mycophenolate NO NO NO 616435 9940303010 0 0 2

ASSORTED CLASSES Immunosuppressive Agents CELLCEPT Mycophenolate Mofetil Cap 250 MG NO NO NO 616447 9940303010 2

ASSORTED CLASSES Immunosuppressive Agents CELLCEPT Mycophenolate Mofetil For Oral Susp 200 MG/ML NO NO NO 616444 9940303010 15

ASSORTED CLASSES Immunosuppressive Agents CELLCEPT Mycophenolate Mofetil Tab 500 MG NO NO NO 616435 9940303010 4

132 Immunological Agents Immunological Agents, Immune Suppressants MYFORTIC Mycophenolate Sodium Tab DR NO NO NO 616449 9940303030 0 0 2

ASSORTED CLASSES Immunosuppressive Agents MYFORTIC Mycophenolate Sodium Tab DR 180 MG (Mycophenolic Acid Equiv) NO NO NO 616450 9940303030 2

ASSORTED CLASSES Immunosuppressive Agents MYFORTIC Mycophenolate Sodium Tab DR 360 MG (Mycophenolic Acid Equiv) NO NO NO 616449 9940303030 4

30 Antiemetics Antiemetics, Emetogenic Therapy Adjuncts CESAMET nabilone NO NO NO 104885 5030004000 Maximum Quantity 30 claim 0

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs nabumetone nabumetone NO NO NO 311892 6610005500

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents nadolol nadolol NO NO NO 201337 3310001000 0 0 2

129


(Pituitary) Hormonal Agents, Suppressant (Pituitary) SYNAREL Nafarelin NO NO NO 853486 3008005510

12 Antibacterials Antibacterials, Beta-lactam, Penicillins nafcillin nafcillin NO NO NO 311896 0130004010

31 Antifungals Antifungals, Antifungals NAFTIN naftifine NO NO NO 896112 9015007800

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting nalbuphine nalbuphine NO NO NO 904440 6520003010



Antagonists naloxone naloxone NO NO NO 1191234 9340002010



Deterrents/Anti-craving naltrexone naltrexone NO NO NO 633137 9668423990

ANTIDOTES Opioid Antagonists REVIA Naltrexone HCl Tab 50 MG NO NO NO 1483767 9340003010

140 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Agents, Other naphazoline naphazoline NO NO NO 1046613 8640003010 0 0 0 0

Opthalmic Agents Opthalmic Decongestant Naphazoline 0.012% Eye Drops Naphazoline 0.012% Eye Drops 8640003010 Max DS/Dosage 15 claim

Opthalmic Agents Opthalmic Decongestant Combination Naphazoline/Pheniramine 0.025%/0.3% Eye DropsNaphazoline/Pheniramine 0.025%/0.3% Eye Drops 8640990214 Max Fills 1 30

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs naproxen naproxen NO NO NO 198012 6610006000 0 0 2

Analgesics - Anti-Inflammatory NSAIDS Naproxen 220mg Tablet Naproxen 220mg Tablet 6610006010 Daily Dose 2

37 Antimigraine Agents Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan naratriptan NO NO NO 311918 6740605010 Maximum Quantity 9 30 0

103 Central Nervous System Agents Central Nervous System Agents, Multiple Sclerosis Agents TYSABRI Natalizumab NO NO NO 603541 6240505000

31 Antifungals Antifungals, Antifungals NATACYN natamycin NO NO NO 207100 8610401000

52 Antiparasitics Antiparasitics, Antiprotozoals ALINIA Natazoxanide NO NO NO 404419 1640006000 13 thru 999

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents nateglinide nateglinide NO NO NO 284529 2728004000 0 0 3

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents BYSTOLIC Nebivolol NO NO NO 827075 3320004010

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents ALOCRIL Nedocromil Sodium Ophth Soln NO NO NO 897294 8680206010 Maximum Quantity 5 claim 0

25 Antidepressants Antidepressants, Antidepressants, Other NEFAZODONE NEFAZODONE NO NO NO 1098651 5812005010

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors VIRACEPT Nelfinavir Mesylate NO NO NO 212118 1210454520 0 0 10

8 Antibacterials Antibacterials, Aminoglycosides neomycin neomycin NO NO NO 866042 0700004010

9 Antibacterials Antibacterials, Antibacterials, Other neomycin-bacitrac zn-polymyx neomycin-bacitrac zn-polymyx NO NO NO 308493 8610990310

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories neomycin-polymyxin-dexamethasone neomycin-polymyxin-dexamethasone NO NO NO 309679 8630990332 Maximum Quantity 5 claim 0

144 Otic Agents Otic Agents, Otic Agents neomycin-polymyxin-hc neomycin-polymyxin-hc NO NO NO 206400 9010990310

144 Otic Agents Otic Agents, Otic Agents CORTISPORIN Neomycin-Polymyxin-HC Ophth Susp NO NO NO 204874 8630990334 Maximum Quantity 8 claim 0

66 Antivirals


Inhibitors nevirapine nevirapine NO NO NO 211327 1210905000 0 0 2 13 thru 999

66 Antivirals


Inhibitors VIRAMUNE XR Nevirapine Tab NO NO NO 211327 1210905000 0 0 2 13 thru 999

Vitamins Water Soluable Vitamins Niacin 100mg Tablet Niacin 100mg Tablet 7710301000

Vitamins Water Soluable Vitamins Niacin 50mg Tablet Niacin 50mg Tablet 7710301000

VITAMINS Water Soluble Vitamins Niacin Cap CR 250 MG NO NO NO 314131 7710301000

VITAMINS Water Soluble Vitamins Niacin Cap CR 500 MG NO NO NO 311959 7710301000

96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other NIASPAN ER Niacin ER NO NO NO 311944 3945005000 0 0 1

VITAMINS Water Soluble Vitamins Niacin Tab 500 MG NO NO NO 198024 7710301000

VITAMINS Water Soluble Vitamins Niaspan Niacin Tab CR 1000 MG NO NO NO 311949 7710301000




96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other ADVICOR Niacin-Lovastatin NO NO NO 791842 3940990245 0 0 1

96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other SIMCOR Niacin-Simvastatin NO NO NO 763228 3940990270 0 0 1

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents nicardipine nicardipine NO NO NO 858613 3400001810



Cessation Agents COMMIT 0 nicotine NO NO NO 605818 6210001000



Cessation Agents NICOTINE nicotine NO NO NO 351427 6210000500 0 0 1

Psychotherapeutic and Neurological

Agents - Misc. Smoking Deterrents Nicorette Chewing Gum 2mg Nicotine Polacrilex Gum 2 MG 6210001000


Agents - Misc. Smoking Deterrents Nicorette Chewing Gum 4mg Nicotine Polacrilex Gum 4 MG 6210001000


Agents - Misc. Smoking Deterrents Nicorette Lozenge 2mg Nicotine Polacrilex Lozenge 2 MG 6210001000


Agents - Misc. Smoking Deterrents Nicorette Lozenge 4mg Nicotine Polacrilex Lozenge 4 MG 6210001000


Agents - Misc. Smoking Deterrents Nicoderm Topical Patch 14mg/24hr Nicotine TD Patch 24HR 14 MG/24HR 6210000500 Daily Dose 1

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderPsychotherapeutic and Neurological




88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents nifedipine nifedipine NO NO NO 198033 3400002000 0 0 4

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors TASIGNA Nilotinib NO NO NO #N/A 2153406020

130



Antiandrogens Antiandrogens NILANDRON Nilutamide NO NO NO 284551 2140246000

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents nimodipine nimodipine NO NO NO 198037 3400002200

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents nisoldipine sr nisoldipine sr NO NO NO 763589 3400002400

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers ORFADIN Nitisinone NO NO NO 352121 3090404500

9 Antibacterials Antibacterials, Antibacterials, Other nitrofurantoin nitrofurantoin NO NO NO 311989 5300005000 0 0 40 13 thru 999

98 Cardiovascular Agents Cardiovascular Agents, Vasodilators, Direct-acting Arterial/Venous nitroglycerin nitroglycerin NO NO NO 207273 3210003000

98 Cardiovascular Agents Cardiovascular Agents, Vasodilators, Direct-acting Arterial/Venous NITROSTAT nitroglycerin NO NO NO 207273 3210003000

97 Cardiovascular Agents Cardiovascular Agents, Vasodilators, Direct-acting Arterial RECTIV nitroglycerin NO NO NO 1114470 8925406000

109 Gastrointestinal Agents Gastrointestinal Agents, Histamine2 (H2) receptor Antagonists nizatidine nizatidine NO NO NO 211821 4920004000 0 0 2 13 thru 999

Ulcer Drugs H-2 Antagonists Nizatidine 75mg Tablet Nizatidine 75mg Tablet 4920004000 Daily Dose 2 13 thru 999

VAGINAL PRODUCTS Spermicides Nonoxynol-9 Film 28% NO NO NO #N/A 5530001000 Package Limit 1 Claim

VAGINAL PRODUCTS Spermicides Nonoxynol-9 Gel 2% NO NO NO 809441 5530001000 Package Limit 1 Claim

VAGINAL PRODUCTS Spermicides Nonoxynol-9 Gel 3% NO NO NO 809441 5530001000 Maximum Quantity 86 Claim

VAGINAL PRODUCTS Spermicides Nonoxynol-9 Gel 4% NO NO NO 845305 5530001000

VAGINAL PRODUCTS Spermicides Nonoxynol-9 Vaginal Insert 150 MG NO NO NO #N/A 5530001000 Maximum Quantity 10 Claim

VAGINAL PRODUCTS Spermicides Nonoxynol-9 Vaginal Suppos 100 MG NO NO NO 884378 5530001000 Package Limit 1 Claim

124

Hormonal Agents,


(Sex

Hormones/Modifiers), Progestins Progestins NORETHIN ACE 0 Norethindrone Acetate NO NO NO #N/A 2600003010

124

Hormonal Agents,


(Sex

Hormones/Modifiers), Progestins Progestins CAMILA 0 Norethindrone Tab NO NO NO 977836 2510001000 0 0 1

14 Antibacterials Antibacterials, Quinolones NOROXIN norfloxacin NO NO NO 209288 0500004000

123

Hormonal Agents,


(Sex

Hormones/Modifiers), Estrogens Estrogens TRI-SPRINTEC 0 Norgestimate-Eth Estrad Tab NO NO NO 762333 2599200230 0 0 1

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral normosol normosol NO NO NO #N/A 7999200170

28 Antidepressants Antidepressants, Tricyclics nortriptyline nortriptyline NO NO NO 209329 5820006010

156 Sleep Disorder Agents Sleep Disorder Agents, Sleep Disorders, Other NUVIGIL NUVIGIL NO NO NO 805661 6140001000 0 0 1

31 Antifungals Antifungals, Antifungals NYSTATIN Nystatin NO NO NO 724568 5510005000

MOUTH/THROAT/DENTAL AGENTS Anti-infectives - Throat Mycostatin Nystatin Susp 100000 Unit/ML NO NO NO 312055 8810001000 Maximum Quantity 120 Claim

ANTIFUNGALS Antifungals Mycostatin Nystatin Tab 500000 Unit NO NO NO 312059 1100006000 6

105 Dermatological Agents Dermatological Agents, Dermatological Agents nystatin-triamcinolone nystatin-triamcinolone NO NO NO 1053697 9015990225 Maximum Quantity 1 claim 0

129


(Pituitary) Hormonal Agents, Suppressant (Pituitary) octreotide octreotide NO NO NO 898607 3017007010

14 Antibacterials Antibacterials, Quinolones ofloxacin ofloxacin NO NO NO 198049 0500005000 Maximum Quantity 56 claim 0

OTIC AGENTS Otic Anti-infectives Floxin Otic Ofloxacin Otic Soln 0.3% NO NO NO 876425 8710006000 Package Limit 1 Claim

60 Antipsychotics Antipsychotics, 2nd Generation/Atypical olanzapine olanzapine NO NO NO 212405 5915706000

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists BENICAR Olmesartan NO NO NO 352200 3615005520 0 0 2

145 Respiratory Tract Agents Respiratory Tract Agents, Antihistamines PATANASE Olopatadine HCl Nasal Soln 0.6% NO NO NO 1111337 4240106010

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents PATANOL Olopatadine HCl Ophth Soln 0.1% NO NO NO 1111345 8680206510

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents PATADAY Olopatadine HCl Ophth Soln 0.2% NO NO NO 1111345 8680206510

135 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Aminosalicylates DIPENTUM Olsalazine Sodium Cap NO NO NO 905164 5250004010

152 Respiratory Tract Agents Respiratory Tract Agents, Respiratory Tract Agents, Other XOLAIR Omalizumab For Inj NO NO NO 404574 4460306000

NUTRIENTS Misc. Nutritional Substances Lovaza Omega-3 Fatty Acids Cap 1000 MG NO NO NO 849080 8050003000 6

NUTRIENTS Misc. Nutritional Substances Lovaza Omega-3 Fatty Acids Cap 1200 MG NO NO NO #N/A 8050003000 6

96 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, Other LOVAZA Omega-3-acid NO NO NO 607044 3950004520 0 0 4

113 Gastrointestinal Agents Gastrointestinal Agents, Proton Pump Inhibitors omeprazole omeprazole NO NO NO 1336037 9670661500

30 Antiemetics Antiemetics, Emetogenic Therapy Adjuncts ondansetron ondansetron NO NO NO 876690 5025006500 0 0 2

134 Immunological Agents Immunological Agents, Immunomodulators Neumega Oprelvekin YES NO NO 213377 8240306000 0 0 1

MINERALS & ELECTROLYTES Electrolyte Mixtures EQUALYTE,PEDIALYTE,PEDIALYTEST Oral Electrolyte Solution NO NO NO 596843 7999100000

154 Skeletal Muscle Relaxants Skeletal Muscle Relaxants, Skeletal Muscle Relaxants orphenadrine citrate sr orphenadrine citrate sr NO NO NO 994521 7510008010 0 0 2

70 Antivirals Antivirals, Anti-influenza Agents TAMIFLU Oseltamivir NO NO NO 261315 1250406020 Maximum Quantity 20 30 0 13 thru 999

12 Antibacterials Antibacterials, Beta-lactam, Penicillins oxacillin oxacillin NO NO NO 312127 0130005010

45 Antineoplastics Antineoplastics, Antineoplastics, Other oxaliplatin oxaliplatin NO NO NO 352269 2110002800

121

Hormonal Agents,


(Sex

Hormones/Modifiers), Anabolic

Steroids Anabolic Steroids oxandrolone oxandrolone NO NO NO #N/A 9670870342

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs oxaprozin oxaprozin NO NO NO 312132 6610006500

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender21 Anticonvulsants Anticonvulsants, Sodium Channel Agents oxcarbazepine oxcarbazepine NO NO NO 312136 7260004600 0 0 4 22 thru 999

74 Bipolar Agents Bipolar Agents, Mood Stabilizers Oxcarbazepine oxcarbazepine NO NO NO 672908 5940001500

31 Antifungals Antifungals, Antifungals OXISTAT oxiconazole NO NO NO 207248 9015406500

114 Genitourinary Agents Genitourinary Agents, Antispasmodics, Urinary oxybutynin oxybutynin NO NO NO 404448 5410004500

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting oxycodone oxycodone NO NO NO 1049504 6510007510 0 0 6

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting OXYCONTIN oxycodone ER NO NO NO 1049504 6510007510 0 0 6

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting oxycodone w/ acetaminophen oxycodone w/ acetaminophen NO NO NO 1049582 6599000220 0 0 8

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs oxycodone-ibuprofen oxycodone-ibuprofen NO NO NO 1049589 6599000226 0 0 4

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting OXYMORPHONE ER OXYMORPHONE ER NO NO NO 977939 6510008010 0 0 6

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting oxymorphone sr oxymorphone sr NO NO NO 977939 6510008010 0 0 6

45 Antineoplastics Antineoplastics, Antineoplastics, Other paclitaxel paclitaxel NO NO NO 312199 2150001200

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents KEPIVANCE Palifermin NO NO NO 545357 2176506000

60 Antipsychotics Antipsychotics, 2nd Generation/Atypical INVEGA Paliperidone NO NO NO 686443 5907005000

30 Antiemetics Antiemetics, Emetogenic Therapy Adjuncts ALOXI palonosetron NO NO NO 404606 5025007010

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents PAMIDRONATE Pamidronate NO NO NO 904919 3004206010

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers CREON Pancrelipase (Lip-Prot-Amyl) DR NO NO NO 861830 5120002400

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers ZENPEP Pancrelipase (Lip-Prot-Amyl) DR NO NO NO 861830 5120002400

113 Gastrointestinal Agents Gastrointestinal Agents, Proton Pump Inhibitors Protonix pantoprazole NO NO NO 885257 4927007010 0 0 1 13 thru 999

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral PHYSIOSOL Parenteral Nutrition Base NO NO NO 827353 9975000000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral PLASMALYTE-M Parenteral Nutrition Base NO NO NO 800790 7999300275

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents ZEMPLAR Paricalcitol IV Soln NO NO NO 213298 3090507000

8 Antibacterials Antibacterials, Aminoglycosides paromomycin paromomycin NO NO NO 239204 0700002010

72 Anxiolytics Anxiolytics, SSRI/SNRI paroxetine paroxetine NO NO NO 213291 5816006000

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors VOTRIENT Pazopanib NO NO NO 867506 2153407010

MULTIVITAMINS Pediatric Multiple Vitamins VITACRAVES Pediatric Multiple Vitamin w/ C & FA Chew Tab NO NO NO 260698 7841200000 1

MULTIVITAMINS Pediatric Multiple Vitamins POLY-VI-SOL Pediatric Multiple Vitamin w/ C Soln 35 MG/ML NO NO NO 876861 7841100000 Maximum Quantity 50 Claim

MULTIVITAMINS Ped Multi Vitamins w/Fl & FE Pediatric Multiple Vitamins w/ Fl-Fe Chew Tab 1-12 MG NO NO NO 260146 7845000000 1 14-999

MULTIVITAMINS Ped Multi Vitamins w/Fl & FE Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.25-10 MG/ML NO NO NO 260146 7845000000 Maximum Quantity 50 Claim 14-999

MULTIVITAMINS Ped Multi Vitamins w/Fl & FE Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.5-10 MG/ML NO NO NO 260146 7845000000 Maximum Quantity 50 Claim 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.25 MG NO NO NO 1486772 7844100000 1 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.5 MG NO NO NO 1486774 7844100000 1 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Multiple Vitamins w/ Fluoride Chew Tab 1 MG NO NO NO 1486776 7844100000 Maximum Quantity 30 30 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Multiple Vitamins w/ Fluoride Soln 0.25 MG/ML NO NO NO 1234482 7844100000 Maximum Quantity 50 Claim 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Multiple Vitamins w/ Fluoride Soln 0.5 MG/ML NO NO NO 1234482 7844100000 Maximum Quantity 50 Claim 14-999

MULTIVITAMINS Ped MV w/ Iron POLY-VI-SOL Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML NO NO NO 876866 7843000000 Maximum Quantity 60 Claim

MULTIVITAMINS Ped Multi Vitamins w/Fl & FE Pediatric Vitamins ACD Fluoride & Fe Drops 0.25-10 MG/ML NO NO NO 1244008 7845200000 Maximum Quantity 50 Claim 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Vitamins ACD w/ Fluoride Chew Tab 1 MG NO NO NO 1365984 7844050000 1 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Vitamins ACD w/ Fluoride Soln 0.25 MG/ML NO NO NO 313599 7844050000 1 14-999

MULTIVITAMINS Ped MV w/ Fluoride Pediatric Vitamins ACD w/ Fluoride Soln 0.5 MG/ML NO NO NO 1365984 7844050000 Maximum Quantity 50 Claim 14-999

MULTIVITAMINS Ped MV w/ Iron Pediatric Vitamins ACD w/ Iron Drops 10 MG/ML NO NO NO 876852 7843151000 Maximum Quantity 50 Claim

MULTIVITAMINS Pediatric Vitamins Pediatric Vitamins ADC Drops 1500 Unit-400 Unit-35 MG/ML NO NO NO 313599 7840150300 Maximum Quantity 50 Claim

MULTIVITAMINS Pediatric Vitamins Pediatric Vitamins ADC Drops 1500IU-400IU-35 MG/ML NO NO NO #N/A 7840150300 Maximum Quantity 50 Claim

LAXATIVES Laxative Combinations GOLYTELY PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM NO NO NO 967012 4699200530 Package Limit 1 Claim

LAXATIVES Laxative Combinations GOLYTELY PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 240 GM NO NO NO 967023 4699200530 Package Limit 1 Claim

LAXATIVES Laxative Combinations NULYTELY PEG 3350-KCl-Sod Bicarb-NaCl For Soln 420 GM NO NO NO 979099 4699200430 Package Limit 1 Claim

111 Gastrointestinal Agents Gastrointestinal Agents, Laxatives MOVIPREP PEG 350-KCl-NaCl-Na Sulfate-Na Ascorbate-C NO NO NO 800918 4699200630

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers ADAGEN Pegademase Bovine NO NO NO 207351 2000005000

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents OMONTYS Peginesatide Acetate Soln Inj NO NO NO 1248813 8240106010

64 Antivirals Antivirals, Antihepatitis Agents PEGASYS Peginterferon alfa-2A NO NO NO 352297 1235306005 Maximum Quantity 4 28 0

64 Antivirals Antivirals, Antihepatitis Agents PEG-INTRON Peginterferon alfa-2B NO NO NO 805007 1235306010 Maximum Quantity 4 28 0

64 Antivirals Antivirals, Antihepatitis Agents SYLATRON Peginterferon alfa-2B NO NO NO 1099056 2170007520

129


(Pituitary) Hormonal Agents, Suppressant (Pituitary) SOMAVERT Pegvisomant NO NO NO 404458 3018006000

141 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-Allergy Agents ALAMAST Pemirolast Potassium Ophth Soln NO NO NO #N/A 8680207010

12 Antibacterials Antibacterials, Beta-lactam, Penicillins PEN G PROC PEN G PROC NO NO NO 745560 0110003000

12 Antibacterials Antibacterials, Beta-lactam, Penicillins PEN G SOD PEN G SOD NO NO NO 745302 0110001020

52 Antiparasitics Antiparasitics, Antiprotozoals NEBUPENT Penamidine NO NO NO 861604 1600004500

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents LEVATOL Penbutolol NO NO NO 1191187 3310002510

116 Genitourinary Agents Genitourinary Agents, Genitourinary Agents, Other CUPRIMINE Penicillamine NO NO NO 207369 9920003000

ASSORTED CLASSES Chelating Agents Artamin Penicillamine Cap 250 MG NO NO NO 207369 9920003000

12 Antibacterials Antibacterials, Beta-lactam, Penicillins penicillin g potassium penicillin g potassium NO NO NO 995906 0110001010

12 Antibacterials Antibacterials, Beta-lactam, Penicillins penicillin v potassium penicillin v potassium NO NO NO 834061 0110004010

52 Antiparasitics Antiparasitics, Antiprotozoals PENTAM 00 PENTAM 00 NO NO NO #N/A 1600004500

116 Genitourinary Agents Genitourinary Agents, Genitourinary Agents, Other ELMIRON Pentosan NO NO NO 211140 5650006010 0 0 3

45 Antineoplastics Antineoplastics, Antineoplastics, Other pentostatin pentostatin NO NO NO 105607 2170004500

89 Cardiovascular Agents Cardiovascular Agents, Cardiovascular Agents, Other pentoxifylline pentoxifylline NO NO NO 792133 9672504245

HEMATOLOGICAL AGENTS - MISC. Hematorheologic Agents TRENTAL Pentoxifylline Tab CR 400 MG NO NO NO 847469 8520001000

MHS Indiana

Preferred Drug List

HIP State




Inhibitors perindopril erbumine perindopril erbumine NO NO NO 854986 3610003510 0 0 2

53 Antiparasitics Antiparasitics, Pediculicides/Scabicides permethrin permethrin NO NO NO 207485 9090003500 Maximum Quantity 1 claim 0

Dermatologicals Scabicides & Pediculicides Permethrin 1% Liquid Permethrin 1% Liquid 9090003500 Package Limit 1 claim

29 Antiemetics Antiemetics, Antiemetics, Other perphenazine perphenazine NO NO NO 198075 5920004500

28 Antidepressants Antidepressants, Tricyclics perphenazine-amitriptyline perphenazine-amitriptyline NO NO NO 856706 6299400260 0 0 4

Genitourinary Agents - Misc. Urinary Analgesics Phenazopyridine 95mg Tablet Phenazopyridine 95mg Tablet 5630001010

GENITOURINARY AGENTS - MISCELLANEOUSUrinary Analgesics PYRIDIUM Phenazopyridine HCl Tab 100 MG NO NO NO 1094109 5630001010

GENITOURINARY AGENTS - MISCELLANEOUSUrinary Analgesics PYRIDIUM Phenazopyridine HCl Tab 200 MG NO NO NO 1094122 5630001010

26 Antidepressants Antidepressants, Monoamine Oxidase Inhibitors phenelzine sulfate phenelzine sulfate NO NO NO #N/A 9672561475

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations SCOT-TUSSIN Phenir-PE w/ Sod Salicyl & Caff Cit Liq 13-4-83-25 MG/5ML NO NO NO 754869 4399400454 0-9

156 Sleep Disorder Agents Sleep Disorder Agents, Sleep Disorders, Other phenobarbital phenobarbital NO NO NO 198083 6010006000

LAXATIVES Laxative Combinations Phenolphthalein-DSS Tab 65-100 MG NO NO NO #N/A 4699100260

83 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Blocking Agents DIBENZYLINE Phenoxybenzamine NO NO NO #N/A 3630001010

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Phenyleph-Chlorphen w/ Hydrocodone Syrup 5-2-1.67 MG/5ML NO NO NO #N/A 4399530350 Maximum Quantity 240 Claim

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Phenyleph-Chlorphen w/ Hydrocodone Syrup 5-2-2.5 MG/5ML NO NO NO 857851 4399530350 Maximum Quantity 240 Claim

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Phenyleph-Pyrilamine w/ Hydrocodone Syrup 5-8.33-1.66 MG/5ML NO NO NO #N/A 4399530352 Maximum Quantity 240 Claim

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFED PE Phenylephrine HCl Soln 2.5 MG/5ML NO NO NO 827706 4210104010 Maximum Quantity 24 Claim

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFED PE Phenylephrine HCl Tab 10 MG NO NO NO 1090087 4210104010 Maximum Quantity 24 Claim

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Phenylephrine-APAP-Caffeine Tab 5-500-75 MG NO NO NO #N/A 4399100310 Maximum Quantity 120 30

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Phenylephrine-DM Soln 2.5-5 MG/5ML NO NO NO 827703 4399560215 Maximum Quantity 240 Claim

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations NUMONYL NR Phenylephrine-Potassium Guaiacolsulfonate Liqd 5-75 MG/5ML NO NO NO #N/A 4399620212

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Phenylephrine-Promethazine w/ Codeine Syrup 5-6.25-10 MG/5ML NO NO NO 996757 4399530310 Maximum Quantity 240 Claim 0-1

ANORECTAL AGENTS Rectal Combinations PREPARATION Phenylephrine-Shark Liver Oil-MO-Pet Oint 0.25-3-14-71.9% NO NO NO 249465 8999400460 Package Limit 1 Claim

ANORECTAL AGENTS Rectal Combinations PREPARATION Phenyleph-Shark Liver Oil-Cocoa Butter Suppos 0.25-3-85.5% NO NO NO 312398 8999400325 Maximum Quantity 12 Claim

21 Anticonvulsants Anticonvulsants, Sodium Channel Agents DILANTIN phenytoin NO NO NO 855673 7220003020

21 Anticonvulsants Anticonvulsants, Sodium Channel Agents PHENYTEK phenytoin NO NO NO 855673 7220003020

21 Anticonvulsants Anticonvulsants, Sodium Channel Agents phenytoin phenytoin NO NO NO 1313884 7220003000

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents PHOSPHOLINE PHOSPHOLINE NO NO NO 205739 8650202010

VITAMINS Oil Soluble Vitamins Mephyton Phytonadione Tab 5 MG NO NO NO 207839 7720403000

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents pilocarpine pilocarpine NO NO NO #N/A 9630007500

142 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Antiglaucoma Agents pilocarpine pilocarpine NO NO NO #N/A 8650103010

MOUTH/THROAT/DENTAL AGENTS Throat Products - Misc. SALAGEN Pilocarpine HCl Tab 5 MG NO NO NO 1000915 8850156010 6

132 Immunological Agents Immunological Agents, Immune Suppressants ELIDEL Pimecrolimus Cream NO NO NO 352085 9078406000 Maximum Quantity 30 30 0

59 Antipsychotics Antipsychotics, 1st Generation/Typical ORAP Pimozide NO NO NO 262226 6200003000

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents pindolol pindolol NO NO NO 198104 3310003000

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents ACTOS Pioglitazone NO NO NO 312440 2760705010 0 0 1

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents ACTOPLUS MET Pioglitazone-Metformin NO NO NO 861785 2799800240 0 0 2

12 Antibacterials Antibacterials, Beta-lactam, Penicillins piperacillin piperacillin NO NO NO 312444 0140004010

12 Antibacterials Antibacterials, Beta-lactam, Penicillins piperacillin sodium-tazobactam piperacillin sodium-tazobactam NO NO NO 884254 0199000270

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs piroxicam piroxicam NO NO NO 198107 6610007000

95 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors LIVALO Pitavastatin NO NO NO 861646 3940005810 0 0 1

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral plasma-lyte plasma-lyte NO NO NO #N/A 7999300000



Modifiers MOZOBIL Plerixafor Subcutaneous NO NO NO 828703 8250206000

105 Dermatological Agents Dermatological Agents, Dermatological Agents podofilox podofilox NO NO NO #N/A 9672701350

LAXATIVES Laxatives - Miscellaneous MIRALAX Polyethylene Glycol 3350 Oral Packet NO NO NO 880407 4660003300 34

LAXATIVES Laxatives - Miscellaneous MIRALAX Polyethylene Glycol 3350 Oral Powder NO NO NO 900963 4660003300 34

OPHTHALMIC AGENTS Artificial Tears and Lubricants Hypo Tears Opthalmic Drops Polyethylene Glycol-Polyvinyl Alcohol Ophth Soln 1-1% NO NO NO 1099494 8620990245 Package Limit 1 Claim

9 Antibacterials Antibacterials, Antibacterials, Other polymyxin b sulfate polymyxin b sulfate NO NO NO 204509 1610001010

9 Antibacterials Antibacterials, Antibacterials, Other polymyxin b-trimethoprim polymyxin b-trimethoprim NO NO NO 244967 8610990260 Maximum Quantity 10 claim 0

Hematopoietic Agents Iron Polysaccharide Iron 150mg Capsule/Caplet/TabletPolysaccharide Iron 150mg Capsule/Caplet/Tablet 8230005000 Daily Dose 1

HEMATOPOIETIC AGENTS Iron Poly-Iron 15 Polysaccharide Iron Complex Cap 150 MG (Iron Equivalent) NO NO NO 404280 8230005000 1

OPHTHALMIC AGENTS Artificial Tears and Lubricants PREMIERVALU Polyvinyl Alcohol Ophth Soln 1.4% NO NO NO 142004 8620005000 Maximum Quantity 15 Claim

31 Antifungals Antifungals, Antifungals NOXAFIL posaconazole NO NO NO 665022 1140706000 13 thru 999

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral pot bicarbonate & chloride effer pot bicarbonate & chloride effer NO NO NO 1537086 7970002000

MINERALS & ELECTROLYTES Phosphate K-PHOS Pot Phos Monobasic w/Sod Phos Di & Monobas Tab 155-852-130MG NO NO NO 656742 7960003010 8

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral potassium acetate potassium acetate NO NO NO 237383 9672707920

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral potassium bicarbonate potassium bicarbonate NO NO NO 1537086 7970002000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral potassium chloride potassium chloride NO NO NO 312515 7970003000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral potassium citrate potassium citrate NO NO NO 603281 5620201020

MINERALS & ELECTROLYTES Iodine Products SSKI Potassium Iodide Soln 1 GM/ML NO NO NO 544597 7935001000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral potassium phosphate potassium phosphate NO NO NO 1148124 7960001001

56 Antiparkinson Agents Antiparkinson Agents, Dopamine Agonists pramipexole dihydrochloride pramipexole dihydrochloride NO NO NO 858625 7320306010

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents SYMLIN PEN Pramlintide NO NO NO 861041 2715005010 Maximum Quantity 6 30 0

ANORECTAL AGENTS Rectal Local Anesthetics PROCTOFOAM Pramoxine HCl Rectal Foam 1% NO NO NO 828367 8920003010 Maximum Quantity 15 Claim

MHS Indiana

Preferred Drug List

HIP State


81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying EFFIENT Prasugrel NO NO NO 855816 8515806010 0 0 1

95 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors pravastatin pravastatin NO NO NO 904467 3940006510 0 0 1

51 Antiparasitics Antiparasitics, Anthelmintics BILTRICIDE Praziquantel NO NO NO 208975 1500005000

83 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Blocking Agents prazosin prazosin NO NO NO 208981 3620203010

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents prazosin prazosin NO NO NO 208981 3620203010

105 Dermatological Agents Dermatological Agents, Dermatological Agents prednicarbate prednicarbate NO NO NO 208982 9055008300 Maximum Quantity 1 claim 0

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids prednicarbate prednicarbate NO NO NO 208982 9055008300 Maximum Quantity 1 claim 0

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories prednisolone prednisolone NO NO NO 755702 2210004000

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories PRED SOD PHO Prednisolone Sodium Phosphate NO NO NO 284516 2210004020 Maximum Quantity 240 claim 0

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids prednisone prednisone NO NO NO 198144 2210004500

102 Central Nervous System Agents Central Nervous System Agents, Fibromyalgia Agents Lyrica Pregabalin NO NO NO 833139 6250405010 0 0 2

18 Anticonvulsants Anticonvulsants, Calcium Channel Modifying Agents LYRICA pregabalin NO NO NO 607018 7260005700 0 0 3

MULTIVITAMINS Prenatal Vitamins Prenatal Multivitamins & Minerals w/ Fe & FA Tab 0.25 MG NO NO NO #N/A 7851200000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Multivitamins & Minerals w/ Iron & FA Cap 1 MG NO NO NO #N/A 7851200000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Multivitamins & Minerals w/ Iron & FA Tab 0.1MG NO NO NO #N/A 7851200000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Multivitamins & Minerals w/ Iron & FA Tab 0.8MG NO NO NO #N/A 7851200000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.1 MG NO NO NO #N/A 7851200000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Multivitamins & Minerals w/Iron & FA Tab 0.8 MG NO NO NO #N/A 7851200000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG NO NO NO 1313925 7851207000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ DSS-Fe Fumarate-FA Tab CR 90-1 MG NO NO NO 855382 7851207000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG NO NO NO 1248142 7851206500 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Fe Fumarate-FA Cap 13.5-0.4 MG NO NO NO #N/A 7851201500 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG NO NO NO #N/A 7851201500 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Fe Fumarate-FA Tab 15-1 MG NO NO NO #N/A 7851201500 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG NO NO NO 802795 7851201500 1 46-999


MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG NO NO NO #N/A 7851201500 1 46-999





MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Fe Gluconate-FA Tab 30-0.4 MG NO NO NO 603209 7851202000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG NO NO NO 603316 7851201000 1 46-999

MULTIVITAMINS Prenatal Vitamins CITRANATAL Prenatal Vit w/ Iron Carbonyl-Fe Gluc-FA Tab 27-1 MG NO NO NO 794165 7851204500 1 46-999

MULTIVITAMINS Prenatal Vitamins CITRANATAL Prenatal Vit w/ Iron Carbonyl-Fe Gluc-FA Tab 27-1MG NO NO NO 794165 7851204500 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vit w/ Sel-Fe Fumarate-FA Tab 27-1 MG NO NO NO #N/A 7851206000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal Vitamin Fast Dissolving Tab NO NO NO #N/A 7851000000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal w/FE Polys Cmplx-FA-Ca Tab & Omega 3 Cap Pack NO NO NO #N/A 7851503000 1 46-999

MULTIVITAMINS Prenatal Vitamins Prenatal w/o A Vit w/ Fe Carbonyl-FA Tab 29-1 MG NO NO NO 848400 7851205200 1 46-999

52 Antiparasitics Antiparasitics, Antiprotozoals PRIMAQUINE PRIMAQUINE NO NO NO 904170 1300003010

19 Anticonvulsants


Agents primidone primidone NO NO NO #N/A 9672762739

32 Antigout Agents Antigout Agents, Antigout Agents probenecid probenecid NO NO NO 198152 6810001000

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics procainamide procainamide NO NO NO 857886 3510002010

41 Antineoplastics Antineoplastics, Alkylating Agents MATULANE procarbazine NO NO NO 207588 2170005010

59 Antipsychotics Antipsychotics, 1st Generation/Typical prochlorperazine prochlorperazine NO NO NO 284254 5920005500

124

Hormonal Agents,


(Sex

Hormones/Modifiers), Progestins Progestins progesterone progesterone NO NO NO 262080 2600004010 0 0 1

29 Antiemetics Antiemetics, Antiemetics, Other promethazine promethazine NO NO NO 992432 4140002010 Maximum Quantity 240 claim 0

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Promethazine VC Plain Promethazine & Phenylephrine Syrup 6.25-5 MG/5ML NO NO NO 1248057 4399300270 Maximum Quantity 240 Claim 0-1

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Phenergan w/ Codeine Promethazine w/ Codeine Syrup 6.25-10 MG/5ML NO NO NO 991486 4399520234 Maximum Quantity 240 Claim 0-1

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics propafenone propafenone NO NO NO 861426 3530005000

140 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Agents, Other proparacaine proparacaine NO NO NO 1191026 8675002010

36 Antimigraine Agents Antimigraine Agents, Prophylactic Propranolol propranolol NO NO NO 845478 7260007500 0 0 4 22 thru 999

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents propranolol propranolol NO NO NO 856448 3310004010 0 0 2

ANTIHYPERTENSIVES Antihypertensive Combinations Inderide Propranolol & Hydrochlorothiazide Tab 40-25 MG NO NO NO 856422 3699200240

ANTIHYPERTENSIVES Antihypertensive Combinations Inderide Propranolol & Hydrochlorothiazide Tab 80-25 MG NO NO NO 856429 3699200240

131


(Thyroid), Antithyroid Agents Antithyroid Agents propylthiouracil propylthiouracil NO NO NO 198175 2830002000

28 Antidepressants Antidepressants, Tricyclics protriptyline protriptyline NO NO NO 905168 5820007010

Nasal Agents - Systemic and Topical Sympathomimetic Decogestants Pseudoephedrine HCL 15mg/5mL Elixir Pseudoephedrine HCL 15mg/5mL Elixir 4210102010 Daily Dose 2

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFD NASAL, SUDAFED, SUDAFED CONGPseudoephedrine HCl Liq 15 MG/5ML NO NO NO 1089106 4210102010

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFD NASAL, SUDAFED, SUDAFED CONGPseudoephedrine HCl Liq 30 MG/5ML NO NO NO 1049163 4210102010

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age GenderNASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFD NASAL, SUDAFED, SUDAFED CONGPseudoephedrine HCl Syrup 30 MG/5ML NO NO NO 1049163 4210102010

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFD NASAL, SUDAFED, SUDAFED CONGPseudoephedrine HCl Tab 30 MG NO NO NO 1049551 4210102010

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFD NASAL, SUDAFED, SUDAFED CONGPseudoephedrine HCl Tab 60 MG NO NO NO 1049169 4210102010

NASAL AGENTS - SYSTEMIC AND TOPICALSympathomimetic Decongestants SUDAFD NASAL, SUDAFED, SUDAFED CONGPseudoephedrine HCl Tab SR 12HR 120 MG NO NO NO 1367228 4210102010

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations CEPACOL CHLD Pseudoephedrine w/ Acetaminophen Liquid 15-160 MG/5ML NO NO NO 1366838 4399100230

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations Guaifenesin DAC Pseudoephedrine w/ COD-GG Soln 30-10-100 MG/5ML NO NO NO 996273 4399730330 Maximum Quantity 240 Claim

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations ADVIL COLD/ Pseudoephedrine-Ibuprofen Susp 15-100 MG/5ML NO NO NO 1310494 4399100231

COUGH/COLD/ALLERGY Cough/Cold/Allergy Combinations ADVIL COLD/ Pseudoephedrine-Ibuprofen Tab 30-200 MG NO NO NO 313884 4399100231

LAXATIVES Bulk Laxatives METAMUCIL Psyllium Cap 0.52 GM NO NO NO 581417 4630003010

LAXATIVES Bulk Laxatives METAMUCIL Psyllium Powder 100% NO NO NO 824586 4630003010


LAXATIVES Bulk Laxatives METAMUCIL Psyllium Powder 28.3% NO NO NO 824586 4630003010








40 Antimycobacterials Antimycobacterials, Antituberculars pyrazinamide pyrazinamide NO NO NO #N/A 9672884290

Dermatologicals Scabicide Combinations Pyrethrin Liquid Pyrethrin Liquid 9090990210 Package Limit 1 claim

Dermatologicals Scabicide Combinations Pyrethrin Shampoo Pyrethrin Shampoo 9090990210 Package Limit 1 claim

Dermatologicals Scabicide Combinations Pyrethrin Spray Pyrethrin Spray 9090990210 Package Limit 1 claim

38 Antimyasthenic Agents Antimyasthenic Agents, Parasympathomimetics pyridostigmine bromide pyridostigmine bromide NO NO NO 903849 7600005010

Vitamins Water Soluable Vitamins Pyridoxine HCL 250mg Tablet Pyridoxine HCL 250mg Tablet 7710501000

Vitamins Water Soluable Vitamins Pyridoxine HCL 500mg Tablet Pyridoxine HCL 500mg Tablet 7710501000

VITAMINS Water Soluble Vitamins Vitamin B6 Pyridoxine HCl Tab 100 MG NO NO NO 639566 7710501000



52 Antiparasitics Antiparasitics, Antiprotozoals DARAPRIM Pyrimethamine NO NO NO 201912 1300004000

25 Antidepressants Antidepressants, Antidepressants, Other SEROQUEL XR quetiapine NO NO NO 312743 5915307010

60 Antipsychotics Antipsychotics, 2nd Generation/Atypical quetiapine quetiapine NO NO NO 312743 5915307010

73 Bipolar Agents Bipolar Agents, Other quetiapine quetiapine NO NO NO 312743 5915307010



Inhibitors quinapril quinapril NO NO NO 312748 3610004010 0 0 2

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics quinidine quinidine NO NO NO 852920 3510003010

52 Antiparasitics Antiparasitics, Antiprotozoals quinine quinine NO NO NO 997010 1300006010 Maximum Quantity 84 365 0

113 Gastrointestinal Agents Gastrointestinal Agents, Proton Pump Inhibitors ACIPHEX Rabeprazole Sodium NO NO NO 854870 4927007610 0 0 1

125

Hormonal Agents,


(Sex

Hormones/Modifiers), Selective

Estrogen Receptor Modifying Agents Selective Estrogen Receptor Modifying Agents EVISTA Raloxifene NO NO NO 1490067 3005306010 0 0 1

68 Antivirals Antivirals, Anti-HIV Agents, Other ISENTRESS Raltegravir Potassium NO NO NO 744846 1210306010 0 0 2

156 Sleep Disorder Agents Sleep Disorder Agents, Sleep Disorders, Other ROZEREM Ramelteon Tab NO NO NO 603162 6025006000 0 0 1



Inhibitors ramipril ramipril NO NO NO 198188 3610005000 0 0 2

109 Gastrointestinal Agents Gastrointestinal Agents, Histamine2 (H2) receptor Antagonists ranitidine ranitidine NO NO NO 198190 4920002010 0 0 2 13 thru 999

Ulcer Drugs H-2 Antagonists Ranitidine 75mg Tablet Ranitidine 75mg Tablet 4920002010 Daily Dose 2 13 thru 999

89 Cardiovascular Agents Cardiovascular Agents, Cardiovascular Agents, Other RANEXA Ranolaxine NO NO NO 860737 3220004000 0 0 3

58 Antiparkinson Agents Antiparkinson Agents, Monomine Oxidase B (MAO-B) Inhibitors AZILECT Rasagiline NO NO NO 637185 7330002520 0 0 1

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents PRANDIN Repaglinide NO NO NO 213219 2728006000 0 0 4

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents PRANDIMET Repaglinide-Metformin NO NO NO 861792 2799500270 0 0 2

MEDICAL DEVICES Respiratory Therapy Supplies Respiratory Therapy Supplies - Misc NO NO NO #N/A 9710000000 Maximum Quantity 1 360

9 Antibacterials Antibacterials, Antibacterials, Other ALTABAX Retapamulin NO NO NO 704858 9010009500

64 Antivirals Antivirals, Antihepatitis Agents REBETOL ribavirin NO NO NO 352337 1235307000 0 0 7 13 thru 999

64 Antivirals Antivirals, Antihepatitis Agents ribavirin ribavirin NO NO NO 352337 1235307000 0 0 7 13 thru 999

VITAMINS Water Soluble Vitamins Vitamin B2 Riboflavin Tab 100 MG NO NO NO 204625 7710201000 Maximum Quantity 100 34



39 Antimycobacterials Antimycobacterials, Antimycobacterials, Other MYCOBUTIN rifabutin NO NO NO 103899 0900007500

40 Antimycobacterials Antimycobacterials, Antituberculars rifampin rifampin NO NO NO 312821 0900008000

40 Antimycobacterials Antimycobacterials, Antituberculars PRIFTIN rifapentine NO NO NO 261101 0900008500

9 Antibacterials Antibacterials, Antibacterials, Other XIFAXAN rifaximin NO NO NO 856666 1600004900

134 Immunological Agents Immunological Agents, Immunomodulators ARCALYST Rilonacept For Inj NO NO NO 763457 6645006000

66 Antivirals


Inhibitors EDURANT Rilpivirine NO NO NO 1102277 1210908010 0 0 1

101 Central Nervous System Agents Central Nervous System Agents, Central Nervous System, Other RILUTEK Riluzole NO NO NO 152915 7450307000

70 Antivirals Antivirals, Anti-influenza Agents rimantadine hydrochloride rimantadine hydrochloride NO NO NO 856605 1250007010 0 0 2

143 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Anti-inflammatories VEXOL Rimexolone Ophth Susp NO NO NO 207446 8630007000 Maximum Quantity 1 claim 0

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral ringer's ringer's NO NO NO #N/A 9975002000

MHS Indiana

Preferred Drug List

HIP State


138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents ACTONEL Risedronate Sodium Tab NO NO NO 905034 3004206510 0 0 1

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents ATELVIA Risedronate Sodium Tab Delayed Release NO NO NO 905034 3004206510 0 0 1

60 Antipsychotics Antipsychotics, 2nd Generation/Atypical RISPERDAL risperidone NO NO NO 211489 5907007000

73 Bipolar Agents Bipolar Agents, Other risperidone risperidone NO NO NO 211489 5907007000

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors NORVIR Ritonavir Tab NO NO NO 152970 1210456000 0 0 12 13 thru 999

49 Antineoplastics Antineoplastics, Monoclonal Antibodies RITUXAN Rituximab NO NO NO 213126 2135306000

78 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Anticoagulants XARELTO Rivarixaban NO NO NO 1114202 8337006000 0 0 1

23 Antidementia Agents Antidementia Agents, Cholinesterase Inhibitors rivastigmine rivastigmine NO NO NO 725105 6205104000

37 Antimigraine Agents Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists rizatriptan benzoate rizatriptan benzoate NO NO NO 213321 6740606010 Maximum Quantity 12 30 0



Modifiers NPLATE Romiplostim NO NO NO 805459 8240506000

56 Antiparkinson Agents Antiparkinson Agents, Dopamine Agonists ropinirole hydrochloride ropinirole hydrochloride NO NO NO 312845 7320307010 0 0 6

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents AVANDIA Rosiglitazone Maleate NO NO NO 261241 2760706010 0 0 1

95 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors CRESTOR Rosuvastatin NO NO NO 859421 3940006010 0 0 1

56 Antiparkinson Agents Antiparkinson Agents, Dopamine Agonists NEUPRO Rotigotine NO NO NO 1251914 7320307500

21 Anticonvulsants Anticonvulsants, Sodium Channel Agents BANZEL rufinamide NO NO NO 1092360 7260006500 0 0 2 22 thru 999

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers SUCRAID Sacrosidase NO NO NO 213337 5120006000

NASAL AGENTS - SYSTEMIC AND TOPICALNasal Agents - Misc. OCEAN NASAL Saline Nasal Spray 0.65% NO NO NO 707544 4250001000 Package Limit 1 Claim

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic SEREVENT Salmeterol NO NO NO 866049 4420105810 0 0 2

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers KUVAN Sapropterin Dihydrochloride NO NO NO 1111020 3090856510

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors INVIRASE Saquinavir Mesylate NO NO NO 859861 1210458020 0 0 10



Modifiers LEUKINE Sargramostim NO NO NO #N/A 8240205000

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents ONGLYZA Saxagliptin NO NO NO 858040 2755006510 0 0 1 0 thru 17

29 Antiemetics Antiemetics, Antiemetics, Other Scopolamine Scopolamine NO NO NO #N/A 5020006000

107 Gastrointestinal Agents Gastrointestinal Agents, Antispasmodics, Gastrointestinal TRANSDERM-SC Scopolamine NO NO NO 351875 5020006000

58 Antiparkinson Agents Antiparkinson Agents, Monomine Oxidase B (MAO-B) Inhibitors selegiline selegiline NO NO NO 865212 5810002700

ANTIPARKINSON AGENTS Antiparkinson Monoamine Oxidase Inhibitors ELDEPRYL Selegiline HCl Cap 5 MG NO NO NO 859193 7330003010

ANTIPARKINSON AGENTS Antiparkinson Monoamine Oxidase Inhibitors ELDEPRYL Selegiline HCl Tab 5 MG NO NO NO 859193 7330003010

26 Antidepressants Antidepressants, Monoamine Oxidase Inhibitors EMSAM selegiline, transdermal NO NO NO 865212 5810002700

105 Dermatological Agents Dermatological Agents, Dermatological Agents selenium sulfide selenium sulfide NO NO NO 210208 9030005000 Maximum Quantity 240 claim 0

Dermatologicals Antiseborrheic Products Selenium Sulfide Shampoo Selenium Sulfide Shampoo 9030005000 Max DS/Dosage 240 claim

LAXATIVES Stimulant Laxatives Senna Senna Powder NO NO NO 883726 4620006010

Laxatives Stimulant Laxatives Senna Syrup Senna Syrup 4620006010

LAXATIVES Stimulant Laxatives Senokot Senna Tab 187 MG NO NO NO 312935 4620006010

LAXATIVES Stimulant Laxatives SENOKOT, SENOKOT 2GO Sennosides Tab 8.6 MG NO NO NO 404186 4620006020

LAXATIVES Laxative Combinations SENOKOT S Sennosides-Docusate Sodium Tab 8.6-50 MG NO NO NO 998740 4699100277 4

72 Anxiolytics Anxiolytics, SSRI/SNRI sertraline sertraline NO NO NO 312938 5816007010

117 Genitourinary Agents Genitourinary Agents, Phosphate Binders RENAGEL Sevelamer HCl NO NO NO 857226 5280007010

151 Respiratory Tract Agents Respiratory Tract Agents, Pulmonary Antihypertensives sildenafil sildenafil NO NO NO 581645 4014306010

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents RAPAFLO Silodosin NO NO NO 809481 5685206000

15 Antibacterials Antibacterials, Sulfonamides silver sulfadiazine silver sulfadiazine NO NO NO #N/A 9678583660

Gatrointestinal Agents - Misc. Antiflatulents Simethicone 40mg/0.6mL Drops Simethicone 40mg/0.6mL Drops 5220002000 Package Limit 1 claim

95 Cardiovascular Agents Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors simvastatin simvastatin NO NO NO 672886 9678583966

105 Dermatological Agents Dermatological Agents, Dermatological Agents VEREGEN Sinecatechins NO NO NO 795918 9076007000

132 Immunological Agents Immunological Agents, Immune Suppressants RAPAMUNE Sirolimus Oral Soln NO NO NO 351901 9940407000 0 0 6

ASSORTED CLASSES Immunosuppressive Agents RAPAMUNE Sirolimus Oral Soln 1 MG/ML NO NO NO 351901 9940407000

ASSORTED CLASSES Immunosuppressive Agents RAPAMUNE Sirolimus Tab 0.5 MG NO NO NO 905160 9940407000

ASSORTED CLASSES Immunosuppressive Agents RAPAMUNE Sirolimus Tab 1 MG NO NO NO 351989 9940407000

ASSORTED CLASSES Immunosuppressive Agents RAPAMUNE Sirolimus Tab 2 MG NO NO NO 404432 9940407000

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents JANUVIA Sitagliptin NO NO NO 665036 2755007010 0 0 1

111 Gastrointestinal Agents Gastrointestinal Agents, Laxatives OSMOPREP Sod Phos Mono-Sod Phos Di Tabs NO NO NO 636141 4610990212

111 Gastrointestinal Agents Gastrointestinal Agents, Laxatives PREPOPIK Sod Picosulfate-Mg Oxide-Citric Acid NO NO NO 1305810 4699200345

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral sodium acetate sodium acetate NO NO NO 237371 7905001000

ANTACIDS Antacids - Bicarbonate Sodium Bicarbonate Tab 325 MG NO NO NO 198859 4820001000 Maximum Quantity 496 30

ANTACIDS Antacids - Bicarbonate Sodium Bicarbonate Tab 650 MG NO NO NO 198861 4820001000 Maximum Quantity 496 30

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral sodium chloride sodium chloride NO NO NO 486515 5670006000

Nasal Agents - Systemic and Topical Nasal Agents - Misc. Sodium Chloride 0.65% Spray/Drops Sodium Chloride 0.65% Spray/Drops 4250001000 Package Limit 1 claim

COUGH/COLD/ALLERGY Misc. Respiratory Inhalants Sodium Chloride Aero Soln 0.9% NO NO NO 312984 4340001000

COUGH/COLD/ALLERGY Misc. Respiratory Inhalants Sodium Chloride Soln Nebu 0.45% NO NO NO 312997 4340001000

COUGH/COLD/ALLERGY Misc. Respiratory Inhalants Sodium Chloride Soln Nebu 0.9% NO NO NO 312997 4340001000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral sodium citrate & citric acid sodium citrate & citric acid NO NO NO 543018 5620202000 Maximum Quantity 500 30 0

MHS Indiana

Preferred Drug List

HIP State


158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral sodium fluoride sodium fluoride NO NO NO 315102 7930002000

MOUTH/THROAT/DENTAL AGENTS Dental Products PREVIDENT Sodium Fluoride Cream 1.1% NO NO NO 895464 8840202000

MOUTH/THROAT/DENTAL AGENTS Dental Products PREVIDENT Sodium Fluoride Gel 1.1% (0.5% F) NO NO NO 630194 8840202000

MOUTH/THROAT/DENTAL AGENTS Dental Products PREVIDENT Sodium Fluoride Rinse 0.2% NO NO NO 645459 8840202000

156 Sleep Disorder Agents Sleep Disorder Agents, Sleep Disorders, Other XYREM Sodium Oxybate Oral Solution NO NO NO 352257 6245006020

106 Enzyme Replacement Modifiers Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers BUPHENYL Sodium Phenylbutyrate NO NO NO 984105 3090806000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral sodium phosphate sodium phosphate NO NO NO 318209 7960002000

Laxatives Saline Laxative Mixtures Sodium Phosphate/NA Biphos Adult/Pediatric EnemaSodium Phosphate/NA Biphos Adult/Pediatric Enema 4610990212

Laxatives Saline Laxative Mixtures Sodium Phosphate/NA Biphos Pediatric EnemaSodium Phosphate/NA Biphos Pediatric Enema 4610990312

LAXATIVES Saline Laxatives FLEET Sodium Phosphates - Enema NO NO NO 283100 4610990210



Modifiers sodium polystyrene sulfonate sodium polystyrene sulfonate NO NO NO 793741 9945001000 Maximum Quantity 454 claim 0



Modifiers KIONEX Sodium Polystyrene Sulfonate Oral Susp NO NO NO 793741 9945001000 Maximum Quantity 454 claim 0

ASSORTED CLASSES Potassium Removing Resins SPS Sodium Polystyrene Sulfonate Oral Susp 15 GM/60ML NO NO NO 793741 9945001000

ASSORTED CLASSES Potassium Removing Resins SPS Sodium Polystyrene Sulfonate Powder NO NO NO 793741 9945001000

114 Genitourinary Agents Genitourinary Agents, Antispasmodics, Urinary VESICARE Solifenacin NO NO NO 539815 5410005520

119

Hormonal Agents,


(Pituitary), Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary), NORDITROPIN Somatropin NO NO NO 763489 3010002000

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors NEXAVAR Sorafenib NO NO NO 615979 2153306040

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral sorbitol sorbitol NO NO NO 313091 5670008200

LAXATIVES Laxatives - Miscellaneous Ora-Sweet SF Sorbitol Oral Solution 70% NO NO NO 313092 4660007000

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral sorbitol-mannitol sorbitol-mannitol NO NO NO 311446 5670008400

86 Cardiovascular Agents Cardiovascular Agents, Antiarrhythmics sotalol sotalol NO NO NO 904571 3310004510 0 0 2

MEDICAL DEVICES Respiratory Therapy Supplies Spacer/Aerosol-Holding Chamber Supplies - Bags NO NO NO #N/A 9710055010 Maximum Quantity 3 180

MEDICAL DEVICES Respiratory Therapy Supplies Spacer/Aerosol-Holding Chamber Supplies - Mouthpieces NO NO NO #N/A 9710055015 Maximum Quantity 1 180

MEDICAL DEVICES Respiratory Therapy Supplies Spacer/Aerosol-Holding Chambers - Device NO NO NO #N/A 9710055000 Maximum Quantity 2 360

105 Dermatological Agents Dermatological Agents, Dermatological Agents spinosad spinosad NO NO NO 1085816 9090004800

92 Cardiovascular Agents Cardiovascular Agents, Diuretics, Potassium-sparing spironolactone spironolactone NO NO NO 200817 3750002000

DIURETICS Diuretic Combinations ALDACTAZIDE Spironolactone & Hydrochlorothiazide Tab 25-25 MG NO NO NO 208112 3799000220

MOUTH/THROAT/DENTAL AGENTS Dental Products GEL-KAM Stannous Fluoride Conc 0.63% NO NO NO 750104 8840203000

67 Antivirals


Transcriptase Inhibitors stavudine stavudine NO NO NO 313107 1210807000 0 0 2 13 thru 999

8 Antibacterials Antibacterials, Aminoglycosides STREPTOMYCIN STREPTOMYCIN NO NO NO 239204 0700002010



Modifiers CHEMET Succimer Cap NO NO NO 207949 9310008000

ANTIDOTES Antidotes - Chelating Agents Chemet Succimer Cap 100 MG NO NO NO 207949 9310008000

112 Gastrointestinal Agents Gastrointestinal Agents, Protectants sucralfate sucralfate NO NO NO 313123 4930001000 0 0 4 13 thru 999

31 Antifungals Antifungals, Antifungals EXELDERM sulconazole NO NO NO 208117 9015407500

15 Antibacterials Antibacterials, Sulfonamides sulfacetamide sulfacetamide NO NO NO 360152 9678823500

105 Dermatological Agents Dermatological Agents, Dermatological Agents sulfacetamide sulfacetamide NO NO NO 360152 9678823500

15 Antibacterials Antibacterials, Sulfonamides sulfadiazine sulfadiazine NO NO NO 198228 0800002000

15 Antibacterials Antibacterials, Sulfonamides sulfamethoxazole-trimethoprim sulfamethoxazole-trimethoprim NO NO NO 208416 1699000230 13 thru 999

137 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Sulfonamides sulfasalazine sulfasalazine NO NO NO 208437 5250006000

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs sulindac sulindac NO NO NO 198238 6610008000

37 Antimigraine Agents Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists sumatriptan sumatriptan NO NO NO 582328 6740607000 Maximum Quantity 6 30 0

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors SUTENT Sunitinib NO NO NO 616283 2153307030



Modifiers SYPRINE SYPRINE NO NO NO 208720 9920002010

105 Dermatological Agents Dermatological Agents, Dermatological Agents PROTOPIC tacrolimus NO NO NO 284521 9078407500 Maximum Quantity 30 30 0

132 Immunological Agents Immunological Agents, Immune Suppressants tacrolimus Tacrolimus Cap NO NO NO 198377 9940408000 0 0 6

132 Immunological Agents Immunological Agents, Immune Suppressants PROGRAF Tacrolimus Cap NO NO NO 198377 9940408000 0 0 6

ASSORTED CLASSES Immunosuppressive Agents PROGRAF Tacrolimus Cap 0.5 MG NO NO NO 313190 9940408000 3

ASSORTED CLASSES Immunosuppressive Agents PROGRAF Tacrolimus Cap 1 MG NO NO NO 198377 9940408000 3

ASSORTED CLASSES Immunosuppressive Agents PROGRAF Tacrolimus Cap 5 MG NO NO NO 198378 9940408000 3

132 Immunological Agents Immunological Agents, Immune Suppressants ASTRAGRAF XR Tacrolimus Extended release NO NO NO 206289 9940254010

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents CIALIS Tadalafil NO NO NO 404711 4030408000

151 Respiratory Tract Agents Respiratory Tract Agents, Pulmonary Antihypertensives ADCIRCA Tadalafil Tab NO NO NO 849866 4014308000

43 Antineoplastics Antineoplastics, Antiestrogens/Modifiers SOLTAMOX tamoxifen NO NO NO 198240 2140268010

43 Antineoplastics Antineoplastics, Antiestrogens/Modifiers tamoxifen citrate tamoxifen citrate NO NO NO 284141 9680423910

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents tamsulosin tamsulosin NO NO NO 863671 5685207010 0 0 2

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting NUCYNTA tapentadol NO NO NO 854140 6510009110 0 0 6

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting NUCYNTA ER tapentadol ER NO NO NO 854140 6510009110 0 0 6

105 Dermatological Agents Dermatological Agents, Dermatological Agents TAZORAC Tazaratene NO NO NO 212437 9025007000 Maximum Quantity 1 claim 0

9 Antibacterials Antibacterials, Antibacterials, Other VIBATIV telavancin NO NO NO 864631 1600005210

64 Antivirals Antivirals, Antihepatitis Agents TYZEKA Telbivudine NO NO NO 668691 1235208000 0 0 1

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists MICARDIS Telmisartan NO NO NO 284531 3615007000 0 0 1

132 Immunological Agents Immunological Agents, Immune Suppressants TORISEL Temsirolimus Soln For IV Infusion NO NO NO 725108 2153257000

64 Antivirals Antivirals, Antihepatitis Agents VIREAD Tenofovir NO NO NO 352050 1210857010 0 0 1

MHS Indiana

Preferred Drug List

HIP State


67 Antivirals


Transcriptase Inhibitors VIREAD Tenofovir Disoproxil Fumarate NO NO NO 352050 1210857010 0 0 1

83 Cardiovascular Agents Cardiovascular Agents, Alpha-adrenergic Blocking Agents terazosin terazosin NO NO NO 260376 3620204010

115 Genitourinary Agents Genitourinary Agents, Benign Prostatic Hypertrophy Agents terazosin terazosin NO NO NO 260376 3620204010

31 Antifungals Antifungals, Antifungals terbinafine terbinafine NO NO NO 901800 9015008700

ANTIFUNGALS Antifungals LAMISIL Terbinafine HCl Tab 250 MG NO NO NO 313222 1100008010 Maximum Quantity 90 120 1

150 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Sympathomimetic terbutaline terbutaline NO NO NO 857679 4420106020

31 Antifungals Antifungals, Antifungals terconazole terconazole NO NO NO 543835 5510407000 Maximum Quantity 45 claim 0

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents FORTEO Teriparatide (Recombinant) Inj NO NO NO 1435117 3004407000 Maximum Quantity 1 28 0

122

Hormonal Agents,


(Sex

Hormones/Modifiers), Androgens Androgens ANDRODERM Testosterone TD tch NO NO NO 1190955 2310003000 Maximum Quantity 180 30 0

101 Central Nervous System Agents Central Nervous System Agents, Central Nervous System, Other XENAZINE Tetrabenazine NO NO NO 805462 6238007000

16 Antibacterials Antibacterials, Tetracyclines tetracycline tetracycline NO NO NO 360174 9680508000

152 Respiratory Tract Agents Respiratory Tract Agents, Respiratory Tract Agents, Other TYZINE Tetrahydrozoline HCl Nasal Soln 0.1% NO NO NO 1232720 4210206010

42 Antineoplastics Antineoplastics, Antiangiogenic Agents THALOMID thalidomide NO NO NO 213360 9939207000

149 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Phosphodiesterase theophylline theophylline NO NO NO 237178 4430004000

VITAMINS Water Soluble Vitamins Vitamin B1 Thiamine HCl Tab 100 MG NO NO NO 313323 7710101010 Maximum Quantity 100 34




VITAMINS Water Soluble Vitamins Vitamin B1 Thiamine Mononitrate Tab 100 MG NO NO NO 313323 7710101020 Maximum Quantity 100 34

44 Antineoplastics Antineoplastics, Antimetabolites TABLOID thioguanine NO NO NO 105590 2130006000

59 Antipsychotics Antipsychotics, 1st Generation/Typical thioridazine thioridazine NO NO NO 198270 5920008010

45 Antineoplastics Antineoplastics, Antineoplastics, Other Thiotepa Thiotepa NO NO NO 313360 2110004000

59 Antipsychotics Antipsychotics, 1st Generation/Typical thiothixene thiothixene NO NO NO 313361 5930002010

19 Anticonvulsants


Agents tiagabine tiagabine NO NO NO 1299967 7217007010

81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying BRILINTA Ticagrelor NO NO NO 1116639 8515847000

81 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Platelet Modifying ticlopidine ticlopidine NO NO NO 313406 8515808010

9 Antibacterials Antibacterials, Antibacterials, Other TYGACIL tigecycline NO NO NO 584201 1629007000

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents SKELID Tiludronate Disodium Tab NO NO NO 905011 3004207010

87 Cardiovascular Agents Cardiovascular Agents, Beta-adrenergic Blocking Agents timolol timolol NO NO NO 208561 8625003000

Vaginal Products Imidazole - Related Antifungals Tioconazole 6.5% Ointment Tioconazole 6.5% Ointment 5510407500 Max DS/Dosage 5 claim

148 Respiratory Tract Agents Respiratory Tract Agents, Bronchodilators, Anticholinergic SPIRIVA Tiotropium NO NO NO 580261 4410008010 0 0 1

69 Antivirals Antivirals, Anti-HIV Agents, Protease Inhibitors APTIVUS Tipranavir NO NO NO 603378 1210458500 0 0 4 13 thru 999

62 Antispasticity Agents Antispasticity Agents, Antispasticity Agents tizanidine tizanidine NO NO NO 313412 7510009010 0 0 9

8 Antibacterials Antibacterials, Aminoglycosides TOBI tobramycin NO NO NO 1374574 0700007000

8 Antibacterials Antibacterials, Aminoglycosides tobramycin tobramycin NO NO NO 1041828 9680700654

8 Antibacterials Antibacterials, Aminoglycosides TOBRADEX tobramycin; dexamethasone NO NO NO 208821 8630990280 Maximum Quantity 1 claim 0

134 Immunological Agents Immunological Agents, Immunomodulators ACTEMRA Tocilizumab IV Inj NO NO NO 895764 6650007000

134 Immunological Agents Immunological Agents, Immunomodulators XELJANZ Tofacitinib Citrate Tab NO NO NO 1357547 6660306510

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents tolazamide tolazamide NO NO NO 198293 2720005000

75 Blood Glucose Regulators Blood Glucose Regulators, Antidiabetic Agents tolbutamide tolbutamide NO NO NO 198294 2720006000

55 Antiparkinson Agents Antiparkinson Agents, Antiparkinson Agents, Other TASMAR Tolcapone NO NO NO 153655 7315207000

1 Analgesics Analgesics, Nonsteroidal Anti-inflammatory Drugs tolmetin tolmetin NO NO NO 861844 6610003710 Maximum Quantity 20 30 0 0 thru 16

114 Genitourinary Agents Genitourinary Agents, Antispasmodics, Urinary DETROL LA tolterodine NO NO NO #N/A 5400007020

114 Genitourinary Agents Genitourinary Agents, Antispasmodics, Urinary tolterodine tolterodine NO NO NO 855180 5410006020



Modifiers SAMSCA Tolvaptan Tab NO NO NO 849831 3045406000

20 Anticonvulsants Anticonvulsants, Glutamate Reducing Agents topiramate topiramate NO NO NO 845478 7260007500 0 0 4 22 thru 999

47 Antineoplastics Antineoplastics, Enzyme Inhibitors topotecan topotecan NO NO NO 748738 2155008010

43 Antineoplastics Antineoplastics, Antiestrogens/Modifiers FARESTON toremifene NO NO NO 152880 2140268510

91 Cardiovascular Agents Cardiovascular Agents, Diuretics, Loop torsemide torsemide NO NO NO 208076 3720008000 0 0 1

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral TPN ELECTROL Total renteral Nutrician with Electrolytees NO NO NO 643282 7999200000

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting tramadol tramadol NO NO NO 835605 6510009510

2 Analgesics Analgesics, Opioid Analgesics, Long-Acting tramadol sr tramadol sr NO NO NO 835605 6510009510

3 Analgesics Analgesics, Opiod Analgesics, Short-Acting tramadol-acetaminophen tramadol-acetaminophen NO NO NO 836397 6599500220 0 0 8



Inhibitors trandolapril trandolapril NO NO NO 210671 3610006000 0 0 1

80 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Coagulants tranexamic acid tranexamic acid NO NO NO 1316794 9680760500

HEMOSTATICS Hemostatics - Systemic LYSTEDA Tranexamic Acid Tab 650 MG NO NO NO 883830 8410004000 Maximum Quantity 30 5 0-11

26 Antidepressants Antidepressants, Monoamine Oxidase Inhibitors tranylcypromine sulfate tranylcypromine sulfate NO NO NO 313447 5810003010

49 Antineoplastics Antineoplastics, Monoclonal Antibodies HERCEPTIN Trastuzumab NO NO NO 806575 2135307000



Analogs TRAVATAN Z Travoprost Ophth Soln NO NO NO 285032 8633007000

25 Antidepressants Antidepressants, Antidepressants, Other OLEPTRO trazodone NO NO NO 856366 5812008010

25 Antidepressants Antidepressants, Antidepressants, Other trazodone trazodone NO NO NO 856366 5812008010

151 Respiratory Tract Agents Respiratory Tract Agents, Pulmonary Antihypertensives REMODULIN Treprostinil Sodium Inj NO NO NO 352211 4017008010

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender50 Antineoplastics Antineoplastics, Retinoids tretinoin tretinoin NO NO NO 208328 9005003000 Maximum Quantity 1 claim 0

105 Dermatological Agents Dermatological Agents, Dermatological Agents tretinoin tretinoin NO NO NO 208328 9005003000 Maximum Quantity 1 claim 0

104 Dental and Oral Agents Dental and Oral Agents, Dental and Oral Agents triamcinolone triamcinolone NO NO NO 360187 9680762703

118

Hormonal Agents,


(Adrenal),

Glucocorticoids/Mineralocorticoids Glucocorticoids/Mineralocorticoids triamcinolone triamcinolone NO NO NO 360187 9680762703

MOUTH/THROAT/DENTAL AGENTS Steroids - Mouth/Throat Kenalog Triamcinolone Acetonide Dental Paste 0.1% NO NO NO 1085767 8825002010 Maximum Quantity 5 Claim

MOUTH/THROAT/DENTAL AGENTS Steroids - Mouth/Throat Kenalog Orabase Triamcinolone Acetonide in Orabase 0.1% NO NO NO 1085728 8825002010 Maximum Quantity 5 Claim

136 Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents, Glucocorticoids KENALOG-40 Triamcinolone Acetonide Inj Susp NO NO NO 1085756 2210005010

92 Cardiovascular Agents Cardiovascular Agents, Diuretics, Potassium-sparing DYRENIUM Triamterene NO NO NO #N/A 3750003000

DIURETICS Diuretic Combinations DYAZIDE Triamterene & Hydrochlorothiazide Cap 37.5-25 MG NO NO NO 208124 3799000230 1

DIURETICS Diuretic Combinations DYAZIDE Triamterene & Hydrochlorothiazide Cap 50-25 MG NO NO NO 198314 3799000230 1

DIURETICS Diuretic Combinations DYAZIDE Triamterene & Hydrochlorothiazide Tab 75-50 MG NO NO NO 93252 3799000230 1

59 Antipsychotics Antipsychotics, 1st Generation/Typical trifluoperazine trifluoperazine NO NO NO 198322 5920008510

65 Antivirals Antivirals, Antiherpetic Agents trifluridine trifluridine NO NO NO 313477 8610302000 Maximum Quantity 8 claim 0

54 Antiparkinson Agents Antiparkinson Agents, Anticholinergics trihexyphenidyl trihexyphenidyl NO NO NO 905269 7310007010 Maximum Quantity 500 30 0

29 Antiemetics Antiemetics, Antiemetics, Other trimethobenzamide trimethobenzamide NO NO NO 860749 5020007010

9 Antibacterials Antibacterials, Antibacterials, Other trimethoprim trimethoprim NO NO NO 198332 1600005500

28 Antidepressants Antidepressants, Tricyclics trimipramine trimipramine NO NO NO 313498 5820008010

Antibiotics - Topical Antibiotic Mixtures Topical Triple Antibiotic – Neo/Poly/Bac Triple Antibiotic – Neo/Poly/Bac 9010980310 Package Limit 1 claim

140 Ophthalmic Agents Ophthalmic Agents, Ophthalmic Agents, Other tropicamide tropicamide NO NO NO 313521 8635005000 Maximum Quantity 15 claim 0

114 Genitourinary Agents Genitourinary Agents, Antispasmodics, Urinary trospium trospium NO NO NO 857562 5410006520

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral ultrabag ultrabag NO NO NO #N/A 9970000000

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other ursodiol ursodiol NO NO NO 858749 5210004000 0 0 3

108 Gastrointestinal Agents Gastrointestinal Agents, Gastrointestinal Agents, Other XIFAXAN Usrsodiol NO NO NO 856666 1600004900

105 Dermatological Agents Dermatological Agents, Dermatological Agents STELARA Ustekinumab NO NO NO 853356 9025058500

65 Antivirals Antivirals, Antiherpetic Agents valacyclovir valacyclovir NO NO NO 313564 1240508510 0 0 2

63 Antivirals Antivirals, Anti-cytomegalovirus (CMV) Agents VALCYTE Valganciclovir NO NO NO 284587 1220006610 0 0 4 13 thru 999

19 Anticonvulsants


Agents valproate valproate NO NO NO 1099689 7250002010

19 Anticonvulsants


Agents valproic acid valproic acid NO NO NO 1099683 7250003000

74 Bipolar Agents Bipolar Agents, Mood Stabilizers Valproic acid Valproic acid NO NO NO 672908 5940001500

84 Cardiovascular Agents Cardiovascular Agents, Angiotensin II Receptor Antagonists DIOVAN Valsartan NO NO NO 351761 3615008000 0 0 1

ANTIHYPERTENSIVES Antihypertensive Combinations DIOVANHCT Valsartan-Hydrochlorothiazide Tab 160-12.5 MG NO NO NO 809018 3699400270 1

ANTIHYPERTENSIVES Antihypertensive Combinations DIOVANHCT Valsartan-Hydrochlorothiazide Tab 160-25 MG NO NO NO 809022 3699400270 1


ANTIHYPERTENSIVES Antihypertensive Combinations DIOVANHCT Valsartan-Hydrochlorothiazide Tab 320-25 MG NO NO NO 809030 3699400270 1


9 Antibacterials Antibacterials, Antibacterials, Other vancomycin vancomycin NO NO NO 313574 1600006010 Maximum Quantity 14 30 0

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors CAPRELSA Vandetanib NO NO NO 1114074 2153408500



Cessation Agents CHANTIX 0 varenicline NO NO NO 637188 6210008020 0 0 2

48 Antineoplastics Antineoplastics, Molecular Target Inhibitors ZELBORAF Vemurafenib NO NO NO 1147228 2153208000

27 Antidepressants Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors venlafaxine venlafaxine NO NO NO 313580 5818009010

72 Anxiolytics Anxiolytics, SSRI/SNRI venlafaxine venlafaxine NO NO NO 313580 5818009010

88 Cardiovascular Agents Cardiovascular Agents, Calcium Channel Blocking Agents verapamil verapamil NO NO NO 897614 3400003010 0 0 3

19 Anticonvulsants


Agents SABRIL vigabatrin NO NO NO 860895 7217008500 0 0 6

25 Antidepressants Antidepressants, Antidepressants, Other VIIBRYD vilazodone NO NO NO 1086776 5812008810

45 Antineoplastics Antineoplastics, Antineoplastics, Other Vinblastine Vinblastine NO NO NO 239178 2150003010

45 Antineoplastics Antineoplastics, Antineoplastics, Other vincristine vincristine NO NO NO 894896 2150002010

45 Antineoplastics Antineoplastics, Antineoplastics, Other vinorelbine vinorelbine NO NO NO 894896 2150002010

Oil Soluable Vitamins Vitamin D Vitamin D 400 IU Softgel Vitamin D 400 IU Softgel 7720203200

Oil Soluable Vitamins Vitamin D Vitamin D 400 IU Tab Chew Vitamin D 400 IU Tab Chew 7720203200

Oil Soluable Vitamins Vitamin D Vitamin D 400 IU Tablet Vitamin D 400 IU Tablet 7720203200

Oil Soluable Vitamins Vitamin D Vitamin D drops (ergocalciferol) 8,000units/mL DropsVitamin D drops (ergocalciferol) 8,000units/mL Drops 7720203000

Oil Soluable Vitamins Vitamin E Vitamin E 400 IU Liquid Vitamin E 400 IU Liquid 7720305000 Daily Dose 2

VITAMINS Oil Soluble Vitamins Vitamin E Cap 100 Unit NO NO NO 210467 7720305000 2


VITAMINS Oil Soluble Vitamins Vitamin E Cap 400 IU NO NO NO 237735 7720305000 2


VITAMINS Oil Soluble Vitamins Vitamin E Chew Tab 400 Unit NO NO NO 210467 7720305000 2

Emollients Emollient Aqua E Liquid Vitamin E Liquid 9065003000

MULTIVITAMINS Vitamins w/ Lipotropics Vitamins w/ Lipotropics Cap NO NO NO 262008 7852000000 1

31 Antifungals Antifungals, Antifungals voriconazole voriconazole NO NO NO 352220 1140708000 13 thru 999

78 Blood Product/Modifiers/Volume ExpandersBlood Products/Modifiers/Volume Expanders, Anticoagulants warfarin warfarin NO NO NO 855306 8320003020

158 Therapeutic Nutrients/Minerals/ElectrolytesTherapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral water for irrigation water for irrigation NO NO NO #N/A 9840101000

OPHTHALMIC AGENTS Artificial Tears and Lubricants TEARSNATURA White Petrolatum-Mineral Oil Ophth Ointment NO NO NO 827713 8620990290 Package Limit 1 Claim

PHARMACEUTICAL ADJUVANTS Internal Vehicle Ingredients/Agents Xanthan Gum Oral Thickening Gel NO NO NO #N/A 9836508500

147 Respiratory Tract Agents Respiratory Tract Agents, Antileukotrienes zafirlukast zafirlukast NO NO NO 261313 4450508000 0 0 2

MHS Indiana

Preferred Drug List

HIP State

Class ID Therapeutic Category Therapeutic Class Brand Trade Name Generic Name/Ingredient Name PA Step QLL RXCUI GPI_10 QL Type Dosage Units or Max/Package #Period Daily Dose Age Gender155 Sleep Disorder Agents Sleep Disorder Agents, GABA Receptor Modulators zaleplon zaleplon NO NO NO 313761 6020407000 0 0 1

70 Antivirals Antivirals, Anti-influenza Agents RELENZA Zanamivir NO NO NO 759473 1250408000 Maximum Quantity 20 30 0

67 Antivirals


Transcriptase Inhibitors zidovudine zidovudine NO NO NO 199663 1210808500 0 0 6 13 thru 999

147 Respiratory Tract Agents Respiratory Tract Agents, Antileukotrienes ZYFLO CR Zileuton Tab SR HR NO NO NO 211777 4450408500 0 0 4

MOUTH/THROAT/DENTAL AGENTS Lozenges Cold-EEZE Zinc Lozenge 15 MG NO NO NO #N/A 8820007800

MINERALS & ELECTROLYTES Zinc OraZinc, Zincate Zinc Sulfate Cap 220 MG (50 MG Elemental Zn) NO NO NO 313773 7980001000

60 Antipsychotics Antipsychotics, 2nd Generation/Atypical ziprasidone ziprasidone NO NO NO 313776 5940008510

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents ZOMETA Zoledronic Acid IV Soln NO NO NO 1114087 3004209000

138 Metabolic Bone Disease Agents Metabolic Bone Disease Agents, Metabolic Bone Disease Agents RECLAST Zoledronic Acid IV Soln NO NO NO 1114087 3004209000

37 Antimigraine Agents Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists ZOMIG zolmatriptan NO Yes NO 200193 6740608000 Maximum Quantity 6 30 0

155 Sleep Disorder Agents Sleep Disorder Agents, GABA Receptor Modulators zolpidem zolpidem NO NO NO 854875 6020408010 0 0 1

18 Anticonvulsants Anticonvulsants, Calcium Channel Modifying Agents zonisamide zonisamide NO NO NO 314285 7260009000 0 0 6

MHS Indiana Preferred Drug List HIP State - c.ymcdn.com · MHS Indiana Preferred Drug List HIP...

Documents

Transcript of MHS Indiana Preferred Drug List HIP State - c.ymcdn.com · MHS Indiana Preferred Drug List HIP...