Connecticut Department of Social Services Provider Bulletin Medical Assistance Program December 2012

Transcription

1 Connecticut Department of Social Services Provider Bulletin Medical Assistance Program December TO: RE: Pharmacy Providers, Physicians, Nurse Practitioners, Dental Providers, Physician Assistants, Optometrists, Long Term Care Providers, Clinics, and Hospitals January 2, 2013 Changes to the Connecticut Medicaid Preferred Drug List (PDL) The Pharmaceutical & Therapeutics (P&T) Committee has modified the list of preferred prescription products. The Committee has determined these preferred products as efficacious, safe and cost effective choices when prescribing for HUSKY A, HUSKY C, HUSKY D, Tuberculosis (TB), and Family Planning (FAMPL) members. Effective January 2, 2013, changes (additions or removals) have been made to the following drug classes (please note: the additions and removals listed refer to all strengths and dosage forms unless otherwise stated): Therapeutic Classes Additions (preferred) Removals (non-preferred) ANTICONVULSANTS CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL); CARBAMAZEPINE XR (ORAL); DIAZEPAM (RECTAL); DIVALPROEX SPRINKLE (ORAL); FELBAMATE SUSPENSION (ORAL) ANTIDEPRESSANTS, OTHER ANTIDEPRESSANTS, SSRIs ANTIHISTAMINES, MINIMALLY SEDATING ANTIPARKINSON'S AGENTS ANTIPSORIATICS, TOPICAL* ANTIPSYCHOTICS BOTULINUM TOXINS BRONCHODILATORS, BETA AGONIST COPD AGENTS CYTOKINE AND CAM ANTAGONISTS EMOLLIENTS GLUCOCORTICOIDS, INHALED VENLAFAXINE ER TABLETS (ORAL); VIIBRYD (ORAL); VIIBRYD TAB DS PK (ORAL); PRISTIQ (ORAL) CITALOPRAM SOLUTION (ORAL); ESCITALOPRAM TABLET (ORAL) FEXOFENADINE-D 12-HOUR OTC (ORAL); FEXOFENADINE-D 24-HOUR OTC (ORAL) CARBIDOPA/LEVODOPA/ENTACAPON E (ORAL) CALCIPOTRIENE CREAM (TOPICAL); CALCIPOTRIENE OINTMENT (TOPICAL); CALCIPOTRIENE SOLUTION (TOPICAL); CALCITRIOL OINTMENT (TOPICAL); DOVONEX CREAM (TOPICAL) ABILIFY (INTRAMUSC); HALOPERIDOL LACTATE (INJECTION); LOXAPINE (ORAL); OLANZAPINE/FLUOXETINE (ORAL) DYSPORT (INTRAMUSC) ALBUTEROL NEB SOLN 0.63MG, 1.25 MG (INHALATION); PULMICORT FLEXHALER (INHALATION) DEPAKOTE SPRINKLE (ORAL); DIASTAT (RECTAL); FELBATOL SUSPENSION (ORAL); TEGRETOL XR (ORAL) LEXAPRO TABLET (ORAL) STALEVO (ORAL) MAXAIR (INHALATION); VENTOLIN HFA (INHALATION) DALIRESP (ORAL) CIMZIA KIT (INJECTION); CIMZIA SYRINGE KIT (INJECTION) LAC-HYDRIN CREAM/LOTION (TOPICAL) INTRANASAL RHINITIS AGENTS LEUKOTRIENE MODIFIERS FLUNISOLIDE (NASAL); FLUTICASONE (NASAL) MONTELUKAST TAB CHEW (ORAL); MONTELUKAST TABLET (ORAL); MONTELUKAST GRAN PACK (ORAL) SINGULAIR GRAN PACK (ORAL); SINGULAIR TAB CHEW (ORAL); SINGULAIR TABLET (ORAL) Questions? Need assistance? Call the HP Provider Assistance Center Mon. Fri. 8:00 a.m. 5:00 p.m. Toll free at or write to HP, PO Box 2991, Hartford, CT Program information is available at

2 Provider Bulletin December 2012 page 2 Therapeutic Classes Additions (preferred) Removals (non-preferred) NON-STEROIDAL ANTI- MELOXICAM SUSPENSION (ORAL); INFLAMMATORY NAPROXEN SUSPENSION (ORAL) ONCOLOGY AGENTS, BREAST CANCER* ONCOLOGY AGENTS, ORAL* OPHTHALMIC ANTIBIOTICS OPHTHALMIC ANTIBIOTIC-STEROID COMBINATIONS OPHTHALMICS, ANTI- INFLAMMATORIES OTIC ANTIBIOTICS OTIC ANTI-INFECTIVES & ANESTHETICS SEDATIVE HYPNOTICS SMOKING CESSATION STEROIDS, TOPICAL HIGH STEROIDS, TOPICAL LOW STIMULANTS AND RELATED AGENTS ARIMIDEX (ORAL); EXEMESTANE (ORAL); LETROZOLE (ORAL); TAMOXIFEN CITRATE (ORAL) AFINITOR (ORAL); CAPRELSA (ORAL); ERIVEDGE (ORAL); GLEEVEC (ORAL); INLYTA (ORAL); JAKAFI (ORAL); NEXAVAR (ORAL); SPRYCEL (ORAL); SUTENT (ORAL); TARCEVA (ORAL); TASIGNA (ORAL); TYKERB (ORAL); VOTRIENT (ORAL); XALKORI (ORAL); XELODA (ORAL); ZELBORAF (ORAL); ZYTIGA (ORAL) BACITRACIN/POLYMYXIN B SULFATE OINT. (OPHTHALMIC); CIPROFLOXACIN SOLUTION (OPHTHALMIC); NEOMYCIN-POLYMYXIN-GRAMICIDIN (OPHTHALMIC) ALCLOMETASONE DIPROPIONATE CREAM (TOPICAL); ALCLOMETASONE DIPROPIONATE OINT. (TOPICAL); CAPEX SHAMPOO (TOPICAL); DERMA-SMOOTHE-FS (TOPICAL); DESOWEN LOTION (TOPICAL); HYDROCORTISONE ACETATE / UREA (TOPICAL); HYDROCORTISONE LOTION (TOPICAL); HYDROCORTISONE/ALOE GEL (TOPICAL) DEXMETHYLPHENIDATE (ORAL); MODAFINIL (ORAL) * New therapeutic class added to PDL effective 1/2/2013 ETODOLAC (ORAL); NAPROXEN EC (ORAL); OXAPROZIN (ORAL) BESIVANCE (OPHTHALMIC); BLEPH-10 (OPHTHALMIC); ILOTYCIN (OPHTHALMIC); ZYMAR (OPHTHALMIC) ZYLET (OPHTHALMIC) ACULAR (OPHTHALMIC) COLY-MYCIN S (OTIC) PINNACAINE (OTIC) SOMNOTE (ORAL) NICORETTE GUM OTC (BUCCAL) AMCINONIDE LOTION (TOPICAL) Questions? Need assistance? Call the HP Provider Assistance Center Mon. Fri. 8:00 a.m. 5:00 p.m. Toll free Or write to HP, PO Box 2991, Hartford, CT Program information is available at

3 Provider Bulletin December 2012 page 3 A new brand or generic entry into an existing PDL class will only appear if it is preferred. Preferred brand name products with a non-preferred generic equivalent will be designated in bold print. Prior Authorization (PA) is required when any new or refill prescription is filled for a non-preferred product for the first time. Providers are urged to be proactive in switching members to a preferred medication, or in obtaining PA, when appropriate. If a claim for a non-preferred medication is submitted and no PA is on file, the pharmacy will receive a message that they should contact the physician to obtain a PA. The pharmacist should consult with the prescriber to see if a preferred drug can be prescribed as an alternative, or explain that the prescriber must obtain PA from HP before a nonpreferred medication can be dispensed. Pharmacists will have the opportunity to dispense a one-time, 14-day supply of medication by entering in all 9 s in the Prior Authorization Number Submitted field, NCPDP 462- EV, and a numeric value of 1 in the Prior Authorization Type field, NCPDP 461-EU. Each time a 14-day supply of medication is dispensed the pharmacist should provide the client with a DSS authorized flier as described in Provider Bulletin PB The flier notifies clients that (1) PA is needed for the prescription to be fully filled, (2) the 14-day supply is a one-time supply, and (3) they must contact the prescriber as soon as possible to arrange for PA for a full prescription to be filled. PA forms can be found on the Web site. From the Home page, go to Information Publications PA forms Pharmacy Prior Authorization Form; or to Pharmacy Information Pharmacy Program Publications Pharmacy Prior Authorization Form. The full PDL is available on the Web site. From the Home page, go to Pharmacy Information > Preferred Drug List Information > Current Medicaid Preferred Drug List. In addition to the standard PDL, an alphabetical listing of all preferred medications is also available on the Pharmacy page of the Web site. From the Home page, go to Pharmacy Information Preferred Drug List Information PDL Alphabetized Medication List. The PDL formulary can also be downloaded and accessed for those providers who use e-prescribing. For more information, visit or contact Surescripts directly at Questions? Need assistance? Call the HP Provider Assistance Center Mon. Fri. 8:00 a.m. 5:00 p.m. Toll free Or write to HP, PO Box 2991, Hartford, CT Program information is available at

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5 CONNECTICUT MEDICAID Updated January 2, 2012 Preferred Drug List The Connecticut Medicaid Preferred Drug List (PDL) is a listing of prescription products selected by the Pharmaceutical and Therapeutics Committee as efficacious, safe and cost effective choices when prescribing for Medicaid patients Preferred or Non-preferred status only applies to those medications that fall within the drug classes listed on this PDL HIV medications are excluded from the PDL and do not require prior authorization All strengths and dosage forms of preferred agents are covered, unless otherwise stated The brand-name of a generically available medication will not be covered without a PA, unless the brand is listed on the PDL Preferred brand-name medications with nonpreferred generic equivalents are listed in bold ** New Therapeutic Class added to PDL effective 1/1/2013 Acne Agents, Topical Angiotensin Modulators (cont) Anticonvulsants (cont.) AZELEX (TOPICAL) MOEXIPRIL, MOEXIPRIL HCTZ (ORAL) PHENYTOIN, PHENYTOIN SOLUTION (ORAL) BENZACLIN, BENZACLIN W/PUMP (TOPICAL) QUINAPRIL, QUINIPRIL HCTZ (ORAL) PHENYTOIN EXT CAPSULE (GENERIC PHENYTEK) (ORAL) BENZOYL PEROXIDE CLEANSER, GEL, KIT, LOTION (TOPICAL) RAMIPRIL (ORAL) PRIMIDONE (ORAL) CLINDAMYCIN PHOSPHATE GEL, LOTION, MEDICATED TRANDOLAPRIL (ORAL) TOPIRAMATE SPRINKLE, TABLET (ORAL) SWAB, SOLUTION (TOPICAL) Angiotensin Modulators/CCB Comb. VALPROATE SYRUP (ORAL) DESQUAM-X (TOPICAL) AMLODIPINE / BENAZEPRIL (ORAL) VALPROIC ACID (ORAL) DIFFERIN CREAM, LOTION (TOPICAL) AZOR (ORAL) ZONISAMIDE (ORAL) ERYTHROMYCIN GEL, SOLUTION (TOPICAL) EXFORGE, EXFORGE HCT (ORAL) Antidepressants, Other RETIN-A MICRO (TOPICAL) (NOT PUMP) TRIBENZOR (ORAL) BUPROPION, BUPROPION SR, BUPROPION XL (ORAL) Alzheimer's Agents Antibiotics, GI MARPLAN (ORAL) DONEPEZIL TABLET, ODT (ORAL) ALINIA SUSPENSION, TABLET (ORAL) MIRTAZAPINE TABLET, ODT (ORAL) EXELON (TRANSDERMAL) METRONIDAZOLE TABLET (ORAL) NARDIL (ORAL) EXELON CAPSULES (ORAL) NEOMYCIN (ORAL) PARNATE (ORAL) NAMENDA SOLUTION, TABLET DS PAK, TABLET (ORAL) TINDAMAX (ORAL) PRISTIQ (ORAL) * Analgesics, Narcotic Long Antibiotics, Inhaled TRAZODONE (ORAL) FENTANYL (TRANSDERM) CAYSTON (INHALATION) VENLAFAXINE ER CASPULES, TABLETS * (ORAL) KADIAN (ORAL) TOBI (INHALATION) VIIBRYD, VIIBRYD DS PK (ORAL) * METHADONE CONC, SOL TABLET, SOLUTION, TABLET (ORAL) Antibiotics, Topical Antidepressants, SSRI MORPHINE ER (ORAL) GENTAMICIN CREAM, OINTMENT (TOPICAL) CITALOPRAM TABLET, SOLUTION * (ORAL) TRAMADOL ER (ORAL) MUPIROCIN OINTMENT (TOPICAL) ESCITALOPRAM TABLET (ORAL) Analgesics, Narcotic Short NEOMYCIN / POLYMYXIN / PRAMOXINE (TOPICAL) FLUOXETINE CAPSULE, SOLUTION, 10 MG TABLET (ORAL) APAP / CODEINE ELIXIR, TABLET (ORAL) Antibiotics, Vaginal FLUVOXAMINE (ORAL) BUTALBITAL COMPOUND W/CODEINE (ORAL) CLEOCIN OVULES (VAGINAL) LEXAPRO SOLUTION (ORAL) * BUTORPHANOL TARTRATE (NASAL) CLINDAMYCIN (VAGINAL) PAROXETINE TABLET (ORAL) * New Drug added to the PDL effective 1/1/2013 CODEINE (ORAL) METRONIDAZOLE (VAGINAL) SERTRALINE CONC, TABLET (ORAL) DIHYDROCODEINE / APAP / CAFFEINE (ORAL) VANDAZOLE (VAGINAL) Antiemetics HYDROCODONE / APAP CAPSULE, SOLUTION, TABLET (ORAL) Anticoagulants, Injectable EMEND, EMEND PACK (ORAL) PA Requirements HYDROCODONE / IBUPROFEN (ORAL) FRAGMIN DISP SYRIN, VIAL (SUBCUTANE.) MARINOL (ORAL) HYDROMORPHONE TABLET (ORAL) LOVENOX SYRINGE, VIAL (SUBCUTANE.) ONDANSETRON ODT, SOL, TAB (ORAL) Intolerance of the preferred agents MEPERIDINE SOLUTION, TABLET (ORAL) Anticoagulants, Oral Antifungals, Oral Adverse reaction to the preferred agents MORPHINE CONC, SOLUTION, MORPHINE IR TABLET (ORAL) PRADAXA (ORAL) CLOTRIMAZOLE (MUCOUS MEM) Inadequate response from the preferred agents MORPHINE SUPPOSITORIES (RECTAL) WARFARIN (ORAL) FLUCONAZOLE SUSPENSION, TABLET (ORAL) Determined medically necessary and medically OXYCODONE / APAP CAPSULE, TABLET (ORAL) XARELTO (ORAL) GRISEOFULVIN SUSPENSION (ORAL) appropriate OXYCODONE / ASA (ORAL) Anticonvulsants GRIS-PEG (ORAL) Absence of appropriate formulation of the preferred agents Important Connecticut Medicaid Phone Numbers OXYCODONE / IBUPROFEN (ORAL) CARBAMAZEPINE SUSPENSION, TAB CHEW, TABLET (ORAL) KETOCONAZOLE (ORAL) OXYCODONE CAPSULE, SOLUTION, TABLET (ORAL) CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL) * NYSTATIN SUSPENSION, TABLET (ORAL) PENTAZOCINE / APAP (ORAL) CARBAMAZEPINE XR (ORAL) * TERBINAFINE (ORAL) ROXICET SOLUTION (ORAL) CARBATROL (ORAL) Antifungals, Topical ROXICODONE TABLET (ORAL) CELONTIN (ORAL) CLOTRIMAZOLE CREAM RX, SOLUTION RX (TOPICAL) TRAMADOL, TRAMADOL / APAP (ORAL) CLONAZEPAM (ORAL) CLOTRIMAZOLE-BETAMETHASONE CREAM, LOTION (TOPICAL) HP Pharmacy Prior Authorization Center Androgenic Agents DIAZEPAM (RECTAL) * ECONAZOLE (TOPICAL) p (toll-free) ANDRODERM (TRANSDERM) DILANTIN INFATAB (ORAL) KETOCONAZOLE CREAM, SHAMPOO (TOPICAL) f (toll-free) ANDROGEL GEL PACKET, PUMP (TRANSDERM.) DIVALPROEX SPRINKLE (ORAL) * NYSTATIN CREAM, OINT, POWDER (TOPICAL) PA forms are only available on our website: Navigate to: Pharmacy Information or: information > publications > forms TESTIM (TRANSDERM.) DIVALPROEX TABLET, DIVALPROEX ER (ORAL) NYSTATIN-TRIAMCINOLONE CREAM, OINT (TOPICAL) Angiotensin Modulators ETHOSUXIMIDE SYRUP (ORAL) Antihistamines, Minimally Sedating BENAZEPRIL, BENAZEPRIL HCTZ (ORAL) FELBAMATE SUSPENSION (ORAL) * CETIRIZINE SOLUTION, CETIRIZINE SOLUTION OTC, CAPTOPRIL, CAPTOPRIL HCTZ (ORAL) GABITRIL (ORAL) CETIRIZINE-D OTC (ORAL) HP Provider Assistance Center DIOVAN, DIOVAN HCT (ORAL) LAMOTRIGINE, LAMOTRIGINE TAB DS PK (ORAL) FEXOFENADINE 60 MG OTC, 180 MG OTC (ORAL) ENALAPRIL, ENALAPRIL HCTZ (ORAL) LEVETIRACETAM SOLUTION, TABLETS (ORAL) FEXOFENADINE-D 12-HOUR OTC, 24-HOUR OTC (ORAL) * Dept of Social Services Rx Consultant FOSINOPRIL (ORAL) OXCARBAZEPINE SUSPENSION, TABLET (ORAL) LORATADINE ODT, SOLUTION, TABLET, LORATADINE-D OTC (ORAL) (860) LISINOPRIL, LISINOPRIL HCTZ (ORAL) PEGANONE (ORAL) Antihypertensives, Sympatholytics LOSARTAN, LOSARTAN HCTZ (ORAL) PHENOBARBITAL ELIXIR, TABLET (ORAL) CATAPRES-TTS (TRANSDERM)

6 Antihypertensives, Sympatholytics (cont.) Antipsychotics (cont.) Bladder Relaxants (cont.) Contraceptives, Oral (cont.) CLONIDINE (ORAL) LOXAPINE (ORAL) * VESICARE (ORAL) CRYSELLE (ORAL) GUANFACINE (ORAL) MOBAN (ORAL) Bone Resorption Inhibitors CYCLAFEM (ORAL) METHYLDOPA, METHYLDOPA HCTZ (ORAL) OLANZAPINE TABLET, ODT (ORAL) ALENDRONATE TABLETS (ORAL) DESOGEN (ORAL) Antihyperuricemics OLANZAPINE (INTRAMUSC) MIACALCIN (NASAL) ELLA (ORAL) ALLOPURINOL (ORAL) OLANZAPINE/FLUOXETINE (ORAL) * Botulinum Toxins, Injectable EMOQUETTE (ORAL) PROBENECID (ORAL) ORAP (ORAL) BOTOX (INTRAMUSC) ENPRESSE (ORAL) PROBENECID / COLCHICINE (ORAL) PERPHENAZINE (ORAL) DYSPORT (INTRAMUSC) * ERRIN (ORAL) Antimigraine Agents QUETIAPINE TABLET (ORAL) BPH Agents ESTROSTEP FE (ORAL) IMITREX (NASAL) RISPERDAL CONSTA (INTRAMUSC.) ALFUZOSIN (ORAL) FEMCON FE (ORAL) IMITREX KIT, VIAL (SUBCUTANE.) RISPERDAL ODT, SOLUTION, TABLET (ORAL) DOXAZOSIN (ORAL) GILDESS FE (ORAL) RELPAX (ORAL) RISPERIDONE TABLET, ODT, SOLUTION(ORAL) FINASTERIDE (ORAL) HEATHER (ORAL) SUMATRIPTAN (ORAL) SAPHRIS (SUBLINGUAL) TAMSULOSIN (ORAL) JUNEL, JUNEL FE (ORAL) SUMATRIPTAN PEN INJCTR (SUBCUTANE.) SEROQUEL (ORAL) TERAZOSIN (ORAL) KELNOR 1-35 (ORAL) Antiparasitics, Topical SEROQUEL XR (ORAL) Bronchodilators, Beta-Agonists LEENA (ORAL) EURAX CREAM (TOPICAL) SYMBYAX (ORAL) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) LESSINA (ORAL) PERMETHRIN (TOPICAL) THIORIDAZINE (ORAL) ALBUTEROL NEB SOLN 2.5 MG/3 ML (INHALATION) LEVONORGESTREL (ORAL) ULESFIA (TOPICAL) THIOTHIXENE (ORAL) ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION) * LEVORA-28 (ORAL) Antiparkinson's Agents TRIFLUOPERAZINE (ORAL) ALBUTEROL SYRUP, TABLET (ORAL) LOESTRIN, LOESTRIN FE (ORAL) BENZTROPINE (ORAL) ZIPRASIDONE CAPSULE (ORAL) PROAIR HFA (INHALATION) LOW-OGESTREL (ORAL) BROMOCRIPTINE (ORAL) ZYPREXA (ORAL) PROVENTIL HFA (INHALATION) LUTERA (ORAL) CARBIDOPA / LEVODOPA TABLET, ODT, CARBIDOPA / ZYPREXA RELPREVV (INTRAMUSC) TERBUTALINE (ORAL) MICROGESTIN, MICROGESTIN FE (ORAL) LEVODOPA ER (ORAL) ZYPREXA ZYDIS (ORAL) Calcium Channel Blockers MICRONOR (ORAL) CARBIDOPA / LEVODOPA / ENTACAPONE (ORAL) * Antivirals AMLODIPINE (ORAL) MIRCETTE (ORAL) PRAMIPEXOLE (ORAL) ACYCLOVIR CAPSULE, SUSPENSION, TABLET (ORAL) DILTIAZEM TABLET, DILTIAZEM CAPSULE ER (ORAL) MONONESSA (ORAL) ROPINIROLE (ORAL) AMANTADINE CAPSULE, SYRUP, TABLET (ORAL) FELODIPINE ER (ORAL) NATAZIA (ORAL) SELEGILINE CAPSULE, TABLET (ORAL) RELENZA (INHALATION) ISRADIPINE (ORAL) NECON (ORAL) TRIHEXYPHENIDYL ELIXIR, TABLET (ORAL) RIMANTADINE (ORAL) NICARDIPINE (ORAL) NORA-BE (ORAL) Antipsoriatics, Topical ** TAMIFLU CAPSULE, SUSPENSION (ORAL) NIFEDIPINE ER, NIFEDIPINE IR (ORAL) NORDETTE-28 (ORAL) CALCIPOTRIENE SOLUTION, OINTMENT, CREAM (TOPICAL) * VALACYCLOVIR (ORAL) VERAPAMIL CAPSULE, TABLET, VERAPAMIL TABLET ER NORETHINDRONE (ORAL) CALCITRIOL OINTMENT (TOPICAL) * Antivirals, Topical VERAPAMIL ER PM (ORAL) NORGESTIMATE-ETHINYL ESTRADIOL (ORAL) DOVONEX CREAM (TOPICAL) * DENAVIR (TOPICAL) Cephalosporins & Related Agents NORGESTREL-ETHINY ESTRA (ORAL) Antipsychotics ZOVIRAX OINTMENT (TOPICAL) AMOXICILLIN/CLAV CHEW TAB, SUSPENSION, TABLET (ORAL) NORINYL 1+50 (ORAL) ABILIFY DISCMELT, SOLUTION, TABLET (ORAL) Beta Blockers CEFACLOR CAPSULE, SUSPENSION, TABLET ER (ORAL) NOR-Q-D (ORAL) ABILIFY (INTRAMUSC) * ACEBUTOLOL (ORAL) CEFADROXIL CAPSULE, SUSPENSION, TABLET (ORAL) NORTREL (ORAL) AMITRIPTYLINE / PERPHENAZINE (ORAL) ATENOLOL, ATENOLOL / CHLORTHALIDONE (ORAL) CEFDINIR CAPSULE, SUSPENSION (ORAL) ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO (ORAL) CHLORPROMAZINE (ORAL) BETAXOLOL (ORAL) CEFPODOXIME SUSPENSION, TABLET (ORAL) ORTHO-CYCLEN (ORAL) CLOZAPINE (ORAL) BISOPROLOL, BISOPROLOL HCTZ (ORAL) CEFPROZIL SUSPENSION, TABLET (ORAL) ORTHO-NOVUM (ORAL) CLOZARIL (ORAL) BYSTOLIC (ORAL) CEFUROXIME SUSPENSION, TABLET (ORAL) OVCON-50 (ORAL) FANAPT TABLET, TITRATION PACK (ORAL) CARVEDILOL (ORAL) CEPHALEXIN CAPSULE, SUSPENSION, TABLET (ORAL) PORTIA (ORAL) FAZACLO (ORAL) LABETALOL (ORAL) SUPRAX SUSPENSION, TABLET (ORAL) PREVIFEM (ORAL) FLUPHENAZINE DECANOATE (INJECTION) METOPROLOL, METOPROLOL HCTZ, METOPROLOL XL (ORAL) Colony Stimulating Factors RECLIPSEN (ORAL) FLUPHENAZINE ELIXER/SOLN, TABLET (ORAL) NADOLOL, NADOLOL / BENDROFLUMETHIAZIDE (ORAL) LEUKINE (INJECTION) SAFYRAL (ORAL) GEODON (INTRAMUSC) PINDOLOL (ORAL) NEULASTA (INJECTION) SEASONALE (ORAL) GEODON (ORAL) PROPRANOLOL SOLUTION, TABLET, PROPRANOLOL HCTZ, NEUPOGEN DISP SYRIN, VIAL (INJECTION) SEASONIQUE (ORAL) HALDOL DECANOATE (INTRAMUSC) PROPRANOLOL ER (ORAL) Contraceptives, Oral SOLIA (ORAL) HALOPERIDOL (ORAL) SOTALOL (ORAL) ALTAVERA (ORAL) SPRINTEC (ORAL) HALOPERIDOL DECANOATE (INJECTION) TIMOLOL (ORAL) APRI (ORAL) SRONYX (ORAL) HALOPERIDOL LACTATE (INJECTION) * Bile Salts, Oral AVIANE (ORAL) TRI-NORINYL (ORAL) HALOPERIDOL LACTATE CONC (ORAL) URSODIOL CAPSULE (ORAL) BEYAZ (ORAL) TRI-SPRINTEC (ORAL) INVEGA (ORAL) Bladder Relaxants BRIELLYN (ORAL) TRIVORA-28 (ORAL) INVEGA SUSTENNA (INTRAMUSC) OXYBUTYNIN SYRUP, TABLET, OXYBUTYNIN ER (ORAL) CAMILA (ORAL) VELIVET (ORAL) LATUDA (ORAL) TOVIAZ (ORAL) CAZIANT (ORAL) YASMIN 28 (ORAL) Updated January 2, 2012

7 Updated January 2, 2012 Contraceptives, Oral (cont.) Hypoglycemics, Incretin Mimetics, Oral (cont.) Lipotropics, Statins Oncology Agents, Oral (cont.)** YAZ (ORAL) ONGLYZA (ORAL) ATORVASTATIN (ORAL) GLEEVEC (ORAL) * ZOVIA 1-35E, ZOVIA 1-50E (ORAL) TRADJENTA (ORAL) LESCOL, LESCOL XL (ORAL) INLYTA (ORAL) * COPD Agents Hypoglycemics, Insulin & Related LOVASTATIN (ORAL) JAKAFI (ORAL) * ATROVENT HFA (INHALATION) HUMALOG CARTRIDGE, PEN, VIAL (SUBCUTANE.) PRAVASTATIN (ORAL) NEXAVAR (ORAL) * COMBIVENT (INHALATION) HUMALOG MIX PEN, VIAL (SUBCUTANE.) SIMCOR (ORAL) SPRYCEL (ORAL) * DUONEB (INHALATION) HUMULIN VIAL (SUBCUTANE.) SIMVASTATIN (ORAL) SUTENT (ORAL) * IPRATROPIUM NEBULIZER (INHALATION) LANTUS CARTRIDGE, VIAL (SUBCUTANE.) Macrolides & Ketolides TARCEVA (ORAL) * SPIRIVA (INHALATION) LANTUS SOLOSTAR PEN (SUBCUTANE.) AZITHROMYCIN PACKET, SUSPENSION, TABLET (ORAL) TASIGNA (ORAL) * Cytokine & CAM Antagonists NOVOLOG CARTRIDGE, PEN, VIAL (SUBCUTANE.) CLARITHROMYCIN TABLET (ORAL) TYKERB (ORAL) * ENBREL DISP SYRINGE, KIT, PEN (INJECTION) NOVOLOG MIX 70/30 PEN, VIAL (SUBCUTANE.) E.E.S. 400 TABLET (ORAL) VOTRIENT (ORAL) * HUMIRA KIT, PEN INJ KIT (INJECTION) Hypoglycemics, Meglitinides ERY-TAB (ORAL) XALKORI (ORAL) * Emollients, Topical NATEGLINIDE (ORAL) ERYTHROCIN (ORAL) XELODA (ORAL) * AMMONIUM LACTATE CREAM/LOTION (TOPICAL) PRANDIN (ORAL) ERYTHROMYCIN BASE TABLET (ORAL) ZELBORAF (ORAL) * LACTIC ACID CREAM/LOTION (TOPICAL) Hypoglycemics, TZDs Multiple Sclerosis Agents ZYTIGA (ORAL) * Epinephrine, Self-Injected ACTOPLUS MET (ORAL) AVONEX (INTRAMUSC.) Ophthalmics, Allergic Conjunctivitis EPI-PEN, EPI-PEN JR. (INJECTION) ACTOS (ORAL) BETASERON (SUBCUTANE.) ALREX (OPHTHALMIC) Erythropoiesis Stimulating Proteins AVANDIA (ORAL) COPAXONE (SUBCUTANE.) CROMOLYN SODIUM (OPHTHALMIC) ARANESP DISP SYRIN, VIAL (INJECTION) DUETACT (ORAL) REBIF (SUBCUTANE.) PATADAY (OPHTHALMIC) PROCRIT (INJECTION) Immunomodulators, Atopic Dermatitis Neuropathic Pain ** PATANOL (OPHTHALMIC) * Fluoroquinolones, Oral ELIDEL (TOPICAL) CYMBALTA (ORAL) * Ophthalmics, Antibiotics CIPROFLOXACIN TABLET (ORAL) PROTOPIC (TOPICAL) GABAPENTIN CAPSULE, SOLUTION, TABLET (ORAL) * BACITRACIN / POLYMYXIN B SULFATE OINT. (OPTHALMIC) * LEVOFLOXACIN TABLET (ORAL) Immunosuppressives, Oral LIDODERM (TOPICAL) * CIPROFLOXACIN SOLUTION (OPTHALMIC) * Glucocorticoids, Inhaled AZATHIOPRINE (ORAL) LYRICA (ORAL) * ERYTHROMYCIN (OPHTHALMIC) ADVAIR DISKUS, ADVAIR HFA (INHALATION) CYCLOSPORINE CAPSULE, SOFTGEL, SOLUTION (ORAL) SAVELLA, SAVELLA DS PK (ORAL) * GENTAMICIN DROPS, OINTMENT (OPHTHALMIC) ASMANEX (INHALATION) CYCLOSPORINE, MODIFIED CAPSULE, SOLUTION (ORAL) Non-Steroidal Anti-Inflammatory LEVOFLOXACIN (OPHTHALMIC) DULERA (INHALATION) GENGRAF (ORAL) ETODOLAC TAB SR (ORAL) MOXEZA (OPHTHALMIC) FLOVENT DISKUS, FLOVENT HFA (INHALATION) MYCOPHENOLATE MOFETIL CAPSULE, TABLET (ORAL) FLECTOR (TOPICAL) NEOMYCIN-POLYMYXIN-GRAMICIDIN (OPTHALMIC) * PULMICORT 0.25, 0.5 MG RESPULES (INHALATION) NEORAL CAPSULE, SOLUTION (ORAL) FLURBIPROFEN (ORAL) OFLOXACIN (OPHTHALMIC) PULMICORT FLEXHALER (INHALATION) * RAPAMUNE SOLUTION, TABLET (ORAL) IBUPROFEN SUSPENSION, TABLET (ORAL) POLYMYXIN/TRIMETHOPRIM (OPHTHALMIC) QVAR (INHALATION) SANDIMMUNE CAPSULE, SOLUTION (ORAL) INDOCIN SUSPENSION (ORAL) SULFACETAMIDE SOLUTION (OPHTHALMIC) SYMBICORT (INHALATION) TACROLIMUS (ORAL) INDOMETHACIN (ORAL/RECTAL) TOBRAMYCIN (OPHTHALMIC) Growth Factors Intranasal Rhinitis Agents INDOMETHACIN CAPSULE (ORAL) TOBREX OINTMENT (OPHTHALMIC) EGRIFTA (SUB-Q) ASTELIN (NASAL) KETOPROFEN (ORAL) VIGAMOX (OPHTHALMIC) INCRELEX (SUB-Q) ASTEPRO (NASAL) KETOROLAC (ORAL) Ophthalmics, Antibiotic-Steroid Combinations Growth Hormones FLUNISOLIDE (NASAL) * MELOXICAM TABLET, SUSPENSION * (ORAL) BLEPHAMIDE, BLEPHAMIDE S.O.P. (OPHTHALMIC) GENOTROPIN CARTRIDGE, DSIP SYRIN (INJECTION) FLUTICASONE (NASAL) * MOBIC SUSPENSION (ORAL) NEOMYCIN/BACITRACIN/POLY/HC (OPHTHALMIC) NORDITROPIN PEN (INJECTION) IPRATROPIUM (NASAL) NABUMETONE (ORAL) NEOMYCIN/POLYMYXIN/DEXAMETHASONE (OPHTH.) NUTROPIN VIAL, NUTROPIN AQ CARTRIDGE, VIAL (INJECTION) NASACORT AQ (NASAL) NAPROXEN TABLET, SUSPENSION * (ORAL) PRED-G DROPS SUSP, OINTMENT (OPHTHALMIC) H. Pylori Agents NASONEX (NASAL) NAPROXEN SODIUM (ORAL) SULFACETAMIDE / PREDNISOLONE (OPHTHALMIC) NO PREFERRED AGENTS PATANASE (NASAL) PIROXICAM (ORAL) TOBRADEX OINTMENT, SUSPENSION (OPHTHALMIC) Hepatitis C Agents Leukotriene Modifiers SULINDAC (ORAL) Ophthalmic Anti-Inflammatories INCIVEK (ORAL) ACCOLATE (ORAL) VIMOVO (ORAL) DEXAMETHASONE (OPHTHALMIC) PEGASYS KIT, PROCLICK, SYRINGE, VIAL (SUBCUTANE.) MONTELUKAST SOD TABLET, TAB CHEW, GRAN PACK (ORAL) * VOLTAREN (TOPICAL) DICLOFENAC (OPHTHALMIC) RIBAVIRIN TABLET (ORAL) Lipotropics, Other Oncology Agents, Breast Cancer ** FLAREX (OPHTHALMIC) VICTRELIS (ORAL) CHOLESTYRAMINE/ASPARTAME (ORAL) ARIMIDEX (ORAL) * FLUOROMETHOLONE (OPHTHALMIC) Hypoglycemics, Incretin Mimetics, Injectable CHOLESTYRAMINE/SUCROSE (ORAL) EXEMESTANE (ORAL) * FLURBIPROFEN (OPHTHALMIC) NO PREFERRED AGENTS GEMFIBROZIL (ORAL) LETROZOLE (ORAL) * FML FORTE, FML S.O.P. (OPHTHALMIC) Hypoglycemics, Incretin Mimetics, Oral NIACOR (ORAL) TAMOXIFEN CITRATE (ORAL) * LOTEMAX DROPS (OPHTHALMIC) JANUMET (ORAL) NIASPAN (ORAL) Oncology Agents, Oral ** MAXIDEX (OPHTHALMIC) JANUVIA (ORAL) TRICOR (ORAL) AFINITOR (ORAL) * PRED MILD (OPHTHALMIC) JENTADUETO (ORAL) TRILIPIX (ORAL) CAPRELSA (ORAL) * PREDNISOLONE ACETATE (OPHTHALMIC) KOMBIGLYZE XR (ORAL) ERIVEDGE (ORAL) * PREDNISOLONE SOD PHOSPHATE (OPHTHALMIC)

8 Updated January 2, 2012 Ophthalmics, Glaucoma Agents Prenatal Vitamins (cont.) Prenatal Vitamins (cont.) Steroids, Topical-Low Potency ALPHAGAN P 0.15% (OPHTHALMIC) EDGE OB (ORAL) PV W-O VIT A/FE FUMARATE/FA (ORAL) ALCLOMETASONE DIPROPIONATE CREAM, OINT. (TOPICAL) * AZOPT (OPHTHALMIC) ELITE-OB (ORAL) PV W-O VIT A/FECBN-FEFM/FA (ORAL) CAPEX SHAMPOO (TOPICAL) * BETAXOLOL (OPHTHALMIC) EZFE FORTE (ORAL) ROVIN-A DHA (ORAL) DESONIDE CREAM, OINTMENT (TOPICAL) BETIMOL (OPHTHALMIC) FE C (ORAL) SELECT-OB, SELECT-OB + DHA (ORAL) DESOWEN LOTION (TOPICAL) * BETOPTIC S (OPHTHALMIC) FOLCAL DHA (ORAL) SE-NATAL 19 TAB CHEW, TABLET (ORAL) DERMA-SMOOTHE-FS (TOPICAL) * BRIMONIDINE (OPHTHALMIC) FOLCAPS OMEGA-3 (ORAL) SE-TAN DHA (ORAL) HYDROCORTISONE/ALOE GEL (TOPICAL) * CARTEOLOL (OPHTHALMIC) FOLIVANE-OB, FOLIVANE-PRX DHA NF (ORAL) SETONET, SETONET-EC (ORAL) HYDROCORTISONE ACETATE / UREA (TOPICAL) * COMBIGAN (OPHTHALMIC) ICAR-C PLUS (ORAL) TARON-BC, TARON-C DHA, TARON-DUE EC (ORAL) HYDROCORTISONE / MIN OIL / PET OINT. (TOPICAL) DORZOLAMIDE (OPHTHALMIC) INATAL GT (ORAL) TL-ASSURE + DHA (ORAL) HYDROCORTISONE CREAM, LOTION *, OINT. (TOPICAL) DORZOLAMIDE / TIMOLOL (OPHTHALMIC) LACTOCAL-F (ORAL) TRICARE (ORAL) Steroids, Topical-Medium Potency ISTALOL (OPHTHALMIC) LEVOMEFOLATE PNV (ORAL) TRINATAL GT (ORAL) FLUOCINOLONE ACETONIDE CREAM, OINT, SOLUTION (TOPICAL) LATANOPROST 2.5 ML (OPHTHALMIC) L-METHYLFOLATE PNV DHA (ORAL) TRINATE (ORAL) FLUTICASONE PROPIONATE CREAM, OINT (TOPICAL) LEVOBUNOLOL (OPHTHALMIC) MARNATAL-F (ORAL) TRIVEEN-DUO DHA, TRIVEEN-PRX RNF, TRIVEEN-U (ORAL) HYDROCORTISONE BUTYRATE CREAM, OINT, SOLUTION (TOPICAL) METIPRANOLOL (OPHTHALMIC) MATERNITY (ORAL) TRUST NATAL DHA (ORAL) HYDROCORTISONE VALERATE CREAM, OINT (TOPICAL) PILOCARPINE (OPHTHALMIC) MAXINATE (ORAL) ULTIMATE OB DHA (ORAL) MOMETASONE FUROATE CREAM, OINT, SOLUTION (TOPICAL) TIMOLOL (OPHTHALMIC) M-VIT (ORAL) ULTIMATECARE ONE NF (ORAL) PREDNICARBATE CREAM, OINT (TOPICAL) TRAVATAN / TRAVATAN Z 2.5 ML, 5 ML (OPHTHALMIC) NATAFORT (ORAL) VINATE AZ, VINATE CALCIUM, VINATE GT, VINATE IC Steroids, Topical-Very High Potency Opiate Dependence Treatments NATALVIT (ORAL) VINTATE II, VINATE PN CARE, VINATE-M (ORAL) CLOBETASOL EMOLLIENT (TOPICAL) SUBOXONE FILM, TABLETS (SUBLINGUAL) NESTABS, NESTABS DHA (ORAL) VITAFOL-OB, VITAFOL-OB+DHA, VITAFOL-ONE, CLOBETASOL PROPIONATE CREAM, GEL, OINT, SOLUTION (TOPICAL) Otic, Antibiotics NEXA SELECT (ORAL) VITAFOL-PN (ORAL) HALOBETASOL PROPIONATE CREAM, OINT (TOPICAL) CIPRODEX (OTIC) OB COMPLETE ONE, OB COMPLETE PREMIER, OB VITASPIRE (ORAL) Stimulants & Related Agents NEOMYCIN/POLYMYXIN/HC SOLUTION, SUSPENSION (OTIC) COMPLETE TABLET, OB COMPLETE WITH DHA (ORAL) VOL-NATE (ORAL) ADDERALL XR (ORAL) OFLOXACIN (OTIC) O-CAL FA, O-CAL PRENATAL (ORAL) VOL-TAB RX (ORAL) AMPHETAMINE SALT COMBO (ORAL) Otic, Anti-Infectives & Anesthetics PAIRE OB PLUS DHA (ORAL) ZATEAN-CH (ORAL) DAYTRANA (TRANSDERMAL) ACETIC ACID (OTIC) PN VIT.W-O CA NO.7, IRON,FA,DHA (ORAL) Proton Pump Inhibitors DEXMETHYLPHENIDATE (ORAL) * ACETIC ACID/ALUMINUM (OTIC) PNV #14/FERROUS FUM/FOLIC ACID (ORAL) OMEPRAZOLE (ORAL) DEXTROAMPHETAMINE TABLET (ORAL) ANTIPYRINE / BENZOCAINE (OTIC) PNV NO.22/IRON CBN&GLUC/FA/DSS (ORAL) PANTOPRAZOLE (ORAL) FOCALIN, FOCALIN XR (ORAL) PAH Agents, Oral & Inhaled PNV OB+DHA (ORAL) PROTONIX SUSPENSION (ORAL) INTUNIV (ORAL) ADCIRCA (ORAL) PNV W-CA NO.37/IRON/FA/OMEGA-3 (ORAL) Sedative Hypnotics METADATE CD (ORAL) LETAIRIS (ORAL) PNV WITH CA,NO.71/IRON/FA (ORAL) CHLORAL HYDRATE SYRUP (ORAL) METHYLIN SOLUTION, CHEWABLE TABLETS (ORAL) TRACLEER (ORAL) PNV WITH CA,NO.72/IRON/FA (ORAL) FLURAZEPAM (ORAL) METHYLPHENIDATE, METHYLPHENIDATE ER (METHLYN ) (ORAL) VENTAVIS (INHALATION) PNV WITH CA,NO.74/IRON/FA, BRAND (ORAL) TEMAZEPAM 15 MG, 30 MG (ORAL) METHYLPHENIDATE ER (CONCERTA) (ORAL) Pancreatic Enzymes PNV WITH CA8/IRON/FA/LMEFOLATE (ORAL) ZOLPIDEM TARTRATE (NOT ER) (ORAL) MODAFINIL (ORAL) * CREON (ORAL) PNV66/IRON FUMARATE/FA/DSS/DHA (ORAL) Skeletal Muscle Relaxants STRATTERA (ORAL) PANCRELIPASE (ORAL) PNV80/IRON FUMARATE/FA/DSS/DHA (ORAL) BACLOFEN (ORAL) VYVANSE (ORAL) ZENPEP (ORAL) PNV81/SOD IRON EDTA& PS/FA/OM3 (ORAL) CARISOPRODOL, CARISOPRODOL COMPOUND (ORAL) Tetracyclines, Oral Phosphate Binders POLY IRON PN, POLY IRON PN FORTE (ORAL) CHLORZOXAZONE (ORAL) DOXYCYCLINE HYCLATE CAPSULE, TABLET (ORAL) ELIPHOS (ORAL) PR NATAL 400, PR NATAL 400 EC (ORAL) CYCLOBENZAPRINE (ORAL) DOXYCYCLINE MONOHYDRATE 100 MG & 50 MG CAPSULE (ORAL) RENAGEL (ORAL) PR NATAL 430, PR NATAL 430 EC (ORAL) METHOCARBAMOL (ORAL) MINOCYCLINE CAPSULES (ORAL) Platelet Aggregation Inhibitors PREFERA OB, PREFERA OB ONE, PREFERA OB PLUS Smoking Cessations TETRACYCLINE (ORAL) AGGRENOX (ORAL) DHA (ORAL) BUPROPION SR (ORAL) Ulcerative Colitis Agents CLOPIDOGREL (ORAL) PRENAFIRST (ORAL) CHANTIX TAB DS PK, TABLET (ORAL) APRISO (ORAL) DIPYRIDAMOLE (ORAL) PRENATA (ORAL) NICOTINE GUM OTC, LOZENGE OTC (BUCCAL) ASACOL (ORAL) Prenatal Vitamins PRENATABS FA, PRENATABS RX (ORAL) NICOTINE LOZENGE OTC (MUCOUS MEM) CANASA (RECTAL) CAVAN-ALPHA KIT, CAVAN-EC SOD DHA, CAVAN-HEME PRENATAL 19 TAB CHEW, TABLET (ORAL) NICOTINE PATCH OTC (TRANSDERMAL) LIALDA (ORAL) OMEGA (ORAL) PRENATAL RX (ORAL) Steroids, Topical-High Potency PENTASA (ORAL) CITRANATAL RX (ORAL) PRENATAL VIT 15/IRON CB/FA/DSS (ORAL) BETAMETHASONE DIPROPIONATE CREAM, LOTION (TOPICAL) SULFASALAZINE (ORAL) COMPLETE NATAL DHA (ORAL) PRENATAL VIT 18/IRON CB/FA/DSS (ORAL) BETAMETHASONE VALERATE CREAM, LOTION, OINT (TOPICAL) COMPLETENATE (ORAL) PRENATAL VIT NO.78/IRON/FA (ORAL) BETA-VAL CREAM, LOTION (TOPICAL) COMPLETE-RF PRENATAL (ORAL) PRENATAL VIT27&CALCIUM/IRON/FA (ORAL) FLUOCINONIDE CREAM, EMOLLIENT, SOLUTION (TOPICAL) CONCEPT OB (ORAL) PRENEXA (ORAL) TRIAMCINOLONE ACETONIDE CREAM, LOTION, OINT (TOPICAL) DAILY PRENATAL (ORAL) PUREFE OB PLUS, PUREFE PLUS (ORAL)

9 Connecticut Medicaid Alphabetized Preferred Drug List (PDL) *** Available on *** (Navigate to Pharmacy Information > Preferred Drug List > PDL Alphabetical List ) Preferred Drug Brand Equivalent Preferred Drug Brand Equivalent ABILIFY DISCMELT, SOLUTION, TABLET (ORAL) BENAZEPRIL, BENAZEPRIL HCTZ (ORAL) LOTENSIN, LOTENSIN HCT ABILIFY (INTRAMUSC) BENZACLIN, BENZACLIN W/PUMP (TOPICAL) ACCOLATE (ORAL) BENZOYL PEROXIDE CLEANSER, GEL, KIT, LOTION (TOPICAL) ACEBUTOLOL (ORAL) SECTRAL BENZTROPINE (ORAL) COGENTIN ACETIC ACID (OTIC) VOSOL BETAMETHASONE DIPROPIONATE CREAM, LOTION (TOPICAL) DIPROSONE ACETIC ACID/ALUMINUM (OTIC) DOMEBORO BETAMETHASONE VALERATE CREAM, LOTION, OINT (TOPICAL) VALISONE ACTOPLUS MET (ORAL) BETASERON (SUBCUTANE.) ACTOS (ORAL) BETA-VAL CREAM, LOTION (TOPICAL) ACYCLOVIR CAPSULE, SUSPENSION, TABLET (ORAL) ZOVIRAX BETAXOLOL (OPHTHALMIC) BETOPIC ADCIRCA (ORAL) BETAXOLOL (ORAL) KERLONE ADDERALL XR (ORAL) BETIMOL (OPHTHALMIC) ADVAIR DISKUS, ADVAIR HFA (INHALATION) BETOPTIC S (OPHTHALMIC) AFINITOR (ORAL) BEYAZ (ORAL) AGGRENOX (ORAL) BISOPROLOL, BISOPROLOL HCTZ (ORAL) ZEBETA, ZIAC ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION) ACCUNEB BLEPHAMIDE, BLEPHAMIDE S.O.P. (OPHTHALMIC) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) BOTOX (INTRAMUSC) ALBUTEROL NEB SOLN 2.5 MG/3 ML (INHALATION) BRIELLYN (ORAL) ALBUTEROL SYRUP, TABLET (ORAL) VENTOLIN BRIMONIDINE (OPHTHALMIC) ALPHAGAN ALCLOMETASONE DIPROPIONATE CREAM, OINT. (TOPICAL) BROMOCRIPTINE (ORAL) PARLODEL ALENDRONATE TABLETS (ORAL) FOSAMAX BUPROPION, BUPROPION SR, BUPROPION XL (ORAL) WELLBUTRIN, ZYBAN ALFUZOSIN (ORAL) BUTALBITAL COMPOUND W/CODEINE (ORAL) FIORINAL Q/ CODEINE ALINIA SUSPENSION, TABLET (ORAL) BUTORPHANOL TARTRATE (NASAL) STADOL ALLOPURINOL (ORAL) ZYLOPRIM BYSTOLIC (ORAL) ALPHAGAN P 0.15% (OPHTHALMIC) CALCIPOTRIENE SOLUTION, OINTMENT, CREAM (TOPICAL) ALREX (OPHTHALMIC) CALCITRIOL OINTMENT (TOPICAL) ALTAVERA (ORAL) CAMILA (ORAL) AMANTADINE CAPSULE, SYRUP, TABLET (ORAL) SYMMETREL CANASA (RECTAL) AMITRIPTYLINE / PERPHENAZINE (ORAL) ETRAFON CAPEX SHAMPOO (TOPICAL) AMLODIPINE (ORAL) NORVASC CAPRELSA (ORAL) AMLODIPINE / BENAZEPRIL (ORAL) LOTREL CAPTOPRIL, CAPTOPRIL HCTZ (ORAL) CAPOTEN, CAPOZIDE AMMONIUM LACTATE CREAM/LOTION (TOPICAL) LAC-HYDRIN CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL) CARBATROL AMOXICILLIN/CLAV CHEW TAB, SUSPENSION, TABLET (ORAL) AUGMENTIN CARBAMAZEPINE SUSPENSION, TAB CHEW, TABLET (ORAL) TEGRETOL AMPHETAMINE SALT COMBO (ORAL) ADDERALL CARBAMAZEPINE XR (ORAL) TEGRETOL XR ANDRODERM (TRANSDERM) CARBATROL (ORAL) ANDROGEL GEL PACKET, PUMP (TRANSDERM.) CARBIDOPA / LEVODOPA / ENTACAPONE (ORAL) ANTIPYRINE / BENZOCAINE (OTIC) AURALGAN CARBIDOPA / LEVODOPA TABLET, ODT, CARBIDOPA / SINEMET APAP / CODEINE ELIXIR, TABLET (ORAL) TYLENOL W/ CODEINE LEVODOPA ER (ORAL) APRI (ORAL) CARISOPRODOL, CARISOPRODOL COMPOUND (ORAL) SOMA, SOMA COMPOUND APRISO (ORAL) CARTEOLOL (OPHTHALMIC) OCUPRESS ARANESP DISP SYRIN, VIAL (INJECTION) CARVEDILOL (ORAL) COREG ARIMIDEX (ORAL) CATAPRES-TTS (TRANSDERM) ASACOL (ORAL) CAVAN-ALPHA KIT, CAVAN-EC SOD DHA, CAVAN-HEME ASMANEX (INHALATION) OMEGA (ORAL) ASTELIN (NASAL) CAYSTON (INHALATION) ASTEPRO (NASAL) CAZIANT (ORAL) ATENOLOL, ATENOLOL / CHLORTHALIDONE (ORAL) TENORMIN, TENORETIC CEFACLOR CAPSULE, SUSPENSION, TABLET ER (ORAL) CECLOR ATORVASTATIN (ORAL) LIPITOR CEFADROXIL CAPSULE, SUSPENSION, TABLET (ORAL) DURICEF ATROVENT HFA (INHALATION) CEFDINIR CAPSULE, SUSPENSION (ORAL) OMNICEF AVANDIA (ORAL) CEFPODOXIME SUSPENSION, TABLET (ORAL) VANTIN AVIANE (ORAL) CEFPROZIL SUSPENSION, TABLET (ORAL) CEFZIL AVONEX (INTRAMUSC.) CEFUROXIME SUSPENSION, TABLET (ORAL) CEFTIN AZATHIOPRINE (ORAL) IMURAN CELONTIN (ORAL) AZELEX (TOPICAL) CEPHALEXIN CAPSULE, SUSPENSION, TABLET (ORAL) KEFLEX AZITHROMYCIN PACKET, SUSPENSION, TABLET (ORAL) ZITHROMAX CETIRIZINE SOLUTION, CETIRIZINE SOLUTION OTC, ZYRTEC, ZYRTEC-D AZOPT (OPHTHALMIC) CETIRIZINE-D OTC (ORAL) AZOR (ORAL) CHANTIX TAB DS PK, TABLET (ORAL) BACITRACIN / POLYMYXIN B SULFATE OINT. (OPTHALMIC) CHLORAL HYDRATE SYRUP (ORAL) NOCTEC BACLOFEN (ORAL) LIORESAL CHLORPROMAZINE (ORAL) THORAZINE Page 1 of 6 Updated: 1/2/2013 Preferred brand-name medications with non-preferred generic equivalents are listed in bold

10 Connecticut Medicaid Alphabetized Preferred Drug List (PDL) *** Available on *** (Navigate to Pharmacy Information > Preferred Drug List > PDL Alphabetical List ) Preferred Drug Brand Equivalent Preferred Drug Brand Equivalent CHLORZOXAZONE (ORAL) PARAFLEX DIVALPROEX SPRINKLE (ORAL) DEPAKOTE CHOLESTYRAMINE/ASPARTAME (ORAL) DIVALPROEX TABLET, DIVALPROEX ER (ORAL) DEPAKOTE CHOLESTYRAMINE/SUCROSE (ORAL) QUESTRAN DONEPEZIL TABLET, ODT (ORAL) ARICEPT CIPRODEX (OTIC) DORZOLAMIDE (OPHTHALMIC) TRUSOPT CIPROFLOXACIN SOLUTION (OPTHALMIC) DORZOLAMIDE / TIMOLOL (OPHTHALMIC) COSOPT CIPROFLOXACIN TABLET (ORAL) CIPRO DOVONEX CREAM (TOPICAL) CITALOPRAM TABLET, SOLUTION (ORAL) CELEXA DOXAZOSIN (ORAL) CARDURA CITRANATAL RX (ORAL) DOXYCYCLINE HYCLATE CAPSULE, TABLET (ORAL) VIBRAMYCIN CLARITHROMYCIN TABLET (ORAL) BIAXIN DOXYCYCLINE MONOHYDRATE 100 MG & 50 MG CAPSULE (ORAL) MONODOX CLEOCIN OVULES (VAGINAL) DUETACT (ORAL) CLINDAMYCIN (VAGINAL) CLINDAMAX DULERA (INHALATION) CLINDAMYCIN PHOSPHATE GEL, LOTION, MEDICATED CELOCIN-T DUONEB (INHALATION) SWAB, SOLUTION (TOPICAL) DYSPORT (INTRAMUSC) CLOBETASOL EMOLLIENT (TOPICAL) TEMOVATE EMOLLIENT E.E.S. 400 TABLET (ORAL) CLOBETASOL PROPIONATE CREAM, GEL, OINT, SOLUTION (TOPICAL) TEMOVATE ECONAZOLE (TOPICAL) SPECTAZOLE CLONAZEPAM (ORAL) KLONOPIN EDGE OB (ORAL) CLONIDINE (ORAL) CATAPRES EGRIFTA (SUB-Q) CLOPIDOGREL (ORAL) PLAVIX ELIDEL (TOPICAL) CLOTRIMAZOLE (MUCOUS MEM) MYCELEX TROCHE ELIPHOS (ORAL) CLOTRIMAZOLE CREAM RX, SOLUTION RX (TOPICAL) ELITE-OB (ORAL) CLOTRIMAZOLE-BETAMETHASONE CREAM, LOTION (TOPICAL) LOTRISONE ELLA (ORAL) CLOZAPINE (ORAL) CLOZARIL / FAZACLO EMEND, EMEND PACK (ORAL) CLOZARIL (ORAL) EMOQUETTE (ORAL) CODEINE (ORAL) ENALAPRIL, ENALAPRIL HCTZ (ORAL) VASOTEC, VASORETIC COMBIGAN (OPHTHALMIC) ENBREL DISP SYRINGE, KIT, PEN (INJECTION) COMBIVENT (INHALATION) ENPRESSE (ORAL) COMPLETE NATAL DHA (ORAL) EPI-PEN, EPI-PEN JR. (INJECTION) COMPLETENATE (ORAL) ERIVEDGE (ORAL) COMPLETE-RF PRENATAL (ORAL) ERRIN (ORAL) CONCEPT OB (ORAL) ERY-TAB (ORAL) COPAXONE (SUBCUTANE.) ERYTHROCIN (ORAL) E-MYCIN CREON (ORAL) ERYTHROMYCIN (OPHTHALMIC) ILOTYCIN CROMOLYN SODIUM (OPHTHALMIC) OPTICROM ERYTHROMYCIN BASE TABLET (ORAL) CRYSELLE (ORAL) ERYTHROMYCIN GEL, SOLUTION (TOPICAL) A/T/S CYCLAFEM (ORAL) ESCITALOPRAM TABLET (ORAL) LEXAPRO CYCLOBENZAPRINE (ORAL) FLEXERIL ESTROSTEP FE (ORAL) CYCLOSPORINE CAPSULE, SOFTGEL, SOLUTION (ORAL) SANDIMMUNE ETHOSUXIMIDE SYRUP (ORAL) ZARONTIN CYCLOSPORINE, MODIFIED CAPSULE, SOLUTION (ORAL) NEORAL ETODOLAC TAB SR (ORAL) LODINE, LODINE XL CYMBALTA (ORAL) EURAX CREAM (TOPICAL) DAILY PRENATAL (ORAL) EXELON (TRANSDERMAL) DAYTRANA (TRANSDERMAL) EXELON CAPSULES (ORAL) DENAVIR (TOPICAL) EXEMESTANE (ORAL) DERMA-SMOOTHE-FS (TOPICAL) EXFORGE, EXFORGE HCT (ORAL) DESOGEN (ORAL) EZFE FORTE (ORAL) DESONIDE CREAM, OINTMENT (TOPICAL) DESOWEN FANAPT TABLET, TITRATION PACK (ORAL) DESOWEN LOTION (TOPICAL) FAZACLO (ORAL) DESQUAM-X (TOPICAL) FE C (ORAL) DEXAMETHASONE (OPHTHALMIC) DEXASOL FELBAMATE SUSPENSION (ORAL) DEXMETHYLPHENIDATE (ORAL) FELODIPINE ER (ORAL) PLENDIL DEXTROAMPHETAMINE TABLET (ORAL) DEXEDRINE FEMCON FE (ORAL) DIAZEPAM (RECTAL) FENTANYL (TRANSDERM) DURAGESIC DICLOFENAC (OPHTHALMIC) VOLTAREN FEXOFENADINE 60 MG OTC, 180 MG OTC (ORAL) ALLEGRA DIFFERIN CREAM, LOTION (TOPICAL) FEXOFENADINE-D 12-HOUR OTC, 24-HOUR OTC (ORAL) ALLEGRA-D DIHYDROCODEINE / APAP / CAFFEINE (ORAL) PANLOR FINASTERIDE (ORAL) PROSCAR DILANTIN INFATAB (ORAL) FLAREX (OPHTHALMIC) DILTIAZEM TABLET, DILTIAZEM CAPSULE ER (ORAL) CARDIZEM FLECTOR (TOPICAL) DIOVAN, DIOVAN HCT (ORAL) FLOVENT DISKUS, FLOVENT HFA (INHALATION) DIPYRIDAMOLE (ORAL) PERSANTINE FLUCONAZOLE SUSPENSION, TABLET (ORAL) DIFLUCAN Page 2 of 6 Updated: 1/2/2013 Preferred brand-name medications with non-preferred generic equivalents are listed in bold

11 Connecticut Medicaid Alphabetized Preferred Drug List (PDL) *** Available on *** (Navigate to Pharmacy Information > Preferred Drug List > PDL Alphabetical List ) Preferred Drug Brand Equivalent Preferred Drug Brand Equivalent FLUNISOLIDE (NASAL) IMITREX KIT, VIAL (SUBCUTANE.) FLUOCINOLONE 0.01% OIL (TOPICAL) INATAL GT (ORAL) FLUOCINOLONE ACETONIDE CREAM, OINT, SOLUTION (TOPICAL) DERMA-SMOOTH INCIVEK (ORAL) FLUOCINONIDE CREAM, EMOLLIENT, SOLUTION (TOPICAL) LIDEX-E, SYNALAR INCRELEX (SUB-Q) FLUOROMETHOLONE (OPHTHALMIC) FML INDOCIN SUSPENSION (ORAL) FLUOXETINE CAPSULE, SOLUTION, 10 MG TABLET (ORAL) PROZAC INDOCMETHACIN (ORAL/RECTAL) FLUPHENAZINE DECANOATE (INJECTION) PROLIXIN INDOMETHACIN CAPSULE (ORAL) INDOCIN FLUPHENAZINE ELIXER/SOLN, TABLET (ORAL) PROLIXIN INLYTA (ORAL) FLURAZEPAM (ORAL) DALMANE INTUNIV (ORAL) FLURBIPROFEN (OPHTHALMIC) OCUFED INVEGA (ORAL) FLURBIPROFEN (ORAL) ANSAID INVEGA SUSTENNA (INTRAMUSC) FLUTICASONE (NASAL) FLONASE IPRATROPIUM (NASAL) ATROVENT FLUTICASONE PROPIONATE CREAM, OINT (TOPICAL) CUTIVATE IPRATROPIUM NEBULIZER (INHALATION) FLUVOXAMINE (ORAL) LUVOX ISRADIPINE (ORAL) FML FORTE, FML S.O.P. (OPHTHALMIC) ISTALOL (OPHTHALMIC) FOCALIN, FOCALIN XR (ORAL) JAKAFI (ORAL) FOLCAL DHA (ORAL) JANUMET (ORAL) FOLCAPS OMEGA-3 (ORAL) JANUVIA (ORAL) FOLIVANE-OB, FOLIVANE-PRX DHA NF (ORAL) JENTADUETO (ORAL) FOSINOPRIL (ORAL) MONOPRIL JUNEL, JUNEL FE (ORAL) FRAGMIN DISP SYRIN, VIAL (SUBCUTANE.) KADIAN (ORAL) GABAPENTIN CAPSULE, SOLUTION, TABLET (ORAL) NEURONTIN KELNOR 1-35 (ORAL) GABITRIL (ORAL) KETOCONAZOLE (ORAL) NIZORAL GEMFIBROZIL (ORAL) LOPID KETOCONAZOLE CREAM, SHAMPOO (TOPICAL) NIZORAL GENGRAF (ORAL) KETOPROFEN (ORAL) GENOTROPIN CARTRIDGE, DSIP SYRIN (INJECTION) KETOROLAC (ORAL) TORADOL GENTAMICIN CREAM, OINTMENT (TOPICAL) GARAMYCIN KOMBIGLYZE XR (ORAL) GENTAMICIN DROPS, OINTMENT (OPHTHALMIC) GENTAK LABETALOL (ORAL) NORMADYNE GEODON (INTRAMUSC) LACTIC ACID CREAM/LOTION (TOPICAL) LACTINOL GEODON (ORAL) LACTOCAL-F (ORAL) GILDESS FE (ORAL) LAMOTRIGINE, LAMOTRIGINE TAB DS PK (ORAL) LAMICTAL GLEEVEC (ORAL) LANTUS CARTRIDGE, VIAL (SUBCUTANE.) GRISEOFULVIN SUSPENSION (ORAL) LANTUS SOLOSTAR PEN (SUBCUTANE.) GRIS-PEG (ORAL) LATANOPROST 2.5 ML (OPHTHALMIC) XALATAN GUANFACINE (ORAL) TENEX LATUDA (ORAL) HALDOL DECANOATE (INTRAMUSC) LEENA (ORAL) HALOBETASOL PROPIONATE CREAM, OINT (TOPICAL) ULTRAVATE LESCOL, LESCOL XL (ORAL) HALOPERIDOL (ORAL) HALDOL LESSINA (ORAL) HALOPERIDOL DECANOATE (INJECTION) HALDOL LETAIRIS (ORAL) HALOPERIDOL LACTATE (INJECTION) LETROZOLE (ORAL) HALOPERIDOL LACTATE CONC (ORAL) HALDOL LEUKINE (INJECTION) HEATHER (ORAL) LEVETIRACETAM SOLUTION, TABLETS (ORAL) KEPPRA HUMALOG CARTRIDGE, PEN, VIAL (SUBCUTANE.) LEVOBUNOLOL (OPHTHALMIC) BETAGAN HUMALOG MIX PEN, VIAL (SUBCUTANE.) LEVOFLOXACIN (OPHTHALMIC) QUIXIN HUMIRA KIT, PEN INJ KIT (INJECTION) LEVOFLOXACIN TABLET (ORAL) LEVAQUIN HUMULIN VIAL (SUBCUTANE.) LEVOMEFOLATE PNV (ORAL) HYDROCODONE / APAP CAPSULE, SOLUTION, TABLET (ORAL) LORTAB, NORCO. VICODIN LEVONORGESTREL (ORAL) HYDROCODONE / IBUPROFEN (ORAL) VICOPROFEN LEVORA-28 (ORAL) HYDROCORTISONE / MIN OIL / PET OINT. (TOPICAL) LEXAPRO SOLUTION (ORAL) HYDROCORTISONE ACETATE / UREA (TOPICAL) LIALDA (ORAL) HYDROCORTISONE BUTYRATE CREAM, OINT, SOLUTION (TOPICAL) LOCOID LIDODERM (TOPICAL) HYDROCORTISONE CREAM, LOTION, OINT. (TOPICAL) HYTONE LISINOPRIL, LISINOPRIL HCTZ (ORAL) ZESTRIL, ZESTORETIC HYDROCORTISONE VALERATE CREAM, OINT (TOPICAL) WESTCORT L-METHYLFOLATE PNV DHA (ORAL) HYDROCORTISONE/ALOE GEL (TOPICAL) LOESTRIN, LOESTRIN FE (ORAL) HYDROMORPHONE TABLET (ORAL) DILAUDID LORATADINE ODT, SOLUTION, TABLET, LORATADINE-D OTC (ORAL) CLARITIN, CLARITIN-D IBUPROFEN SUSPENSION, TABLET (ORAL) MOTRIN LOSARTAN, LOSARTAN HCTZ (ORAL) COZAAR, HYZAAR ICAR-C PLUS (ORAL) LOTEMAX DROPS (OPHTHALMIC) IMITREX (NASAL) LOVASTATIN (ORAL) MEVACOR Page 3 of 6 Updated: 1/2/2013 Preferred brand-name medications with non-preferred generic equivalents are listed in bold

12 Connecticut Medicaid Alphabetized Preferred Drug List (PDL) *** Available on *** (Navigate to Pharmacy Information > Preferred Drug List > PDL Alphabetical List ) Preferred Drug Brand Equivalent Preferred Drug Brand Equivalent LOVENOX SYRINGE, VIAL (SUBCUTANE.) NEOMYCIN / POLYMYXIN / PRAMOXINE (TOPICAL) LOW-OGESTREL (ORAL) NEOMYCIN/BACITRACIN/POLY/HC (OPHTHALMIC) CORTISPORIN LOXAPINE (ORAL) NEOMYCIN/POLYMYXIN/DEXAMETHASONE (OPHTH.) MAXITROL LUTERA (ORAL) NEOMYCIN/POLYMYXIN/HC SOLUTION, SUSPENSION (OTIC) CORTISPORIN LYRICA (ORAL) NEOMYCIN-POLYMYXIN-GRAMICIDIN (OPTHALMIC) MARINOL (ORAL) NEORAL CAPSULE, SOLUTION (ORAL) MARNATAL-F (ORAL) NESTABS, NESTABS DHA (ORAL) MARPLAN (ORAL) NEULASTA (INJECTION) MATERNITY (ORAL) NEUPOGEN DISP SYRIN, VIAL (INJECTION) MAXIDEX (OPHTHALMIC) NEXA SELECT (ORAL) MAXINATE (ORAL) NEXAVAR (ORAL) MELOXICAM TABLET, SUSPENSION (ORAL) MOBIC NIACOR (ORAL) MEPERIDINE SOLUTION, TABLET (ORAL) DEMEROL NIASPAN (ORAL) METADATE CD (ORAL) NICARDIPINE (ORAL) CARDENE, CARDENE SR METHADONE CONC, SOL TABLET, SOLUTION, TABLET (ORAL) DOLOPHINE NICOTINE GUM OTC, LOZENGE OTC (BUCCAL) NICODERM, NICORETTE, COMMIT METHOCARBAMOL (ORAL) ROBAXIN NICOTINE LOZENGE OTC (MUCOUS MEM) METHYLDOPA, METHYLDOPA HCTZ (ORAL) ALDOMET, ALDORIL NICOTINE PATCH OTC (TRANSDERMAL) METHYLIN SOLUTION, CHEWABLE TABLETS (ORAL) NIFEDIPINE ER, NIFEDIPINE IR (ORAL) PROCARDIA, PROCARDIA XL METHYLPHENIDATE ER (CONCERTA) (ORAL) CONCERTA NO PREFERRED AGENTS METHYLPHENIDATE, METHYLPHENIDATE ER (METHLYN ) (ORAL) METHLYN NORA-BE (ORAL) METIPRANOLOL (OPHTHALMIC) OPTIPRANOLOL NORDETTE-28 (ORAL) METOPROLOL, METOPROLOL HCTZ, METOPROLOL XL (ORAL) LOPRESSOR, LOPRESSOR HCT NORDITROPIN PEN (INJECTION) METRONIDAZOLE (VAGINAL) VANDAZOLE NORETHINDRONE (ORAL) METRONIDAZOLE TABLET (ORAL) FLAGYL NORGESTIMATE-ETHINYL ESTRADIOL (ORAL) MIACALCIN (NASAL) NORGESTREL-ETHINY ESTRA (ORAL) MICROGESTIN, MICROGESTIN FE (ORAL) NORINYL 1+50 (ORAL) MICRONOR (ORAL) NOR-Q-D (ORAL) MINOCYCLINE CAPSULES (ORAL) MINOCIN NORTREL (ORAL) MIRCETTE (ORAL) NOVOLOG CARTRIDGE, PEN, VIAL (SUBCUTANE.) MIRTAZAPINE TABLET, ODT (ORAL) NOVOLOG MIX 70/30 PEN, VIAL (SUBCUTANE.) MOBAN (ORAL) NUTROPIN VIAL, NUTROPIN AQ CARTRIDGE, VIAL (INJECTION) MOBIC SUSPENSION (ORAL) NYSTATIN CREAM, OINT, POWDER (TOPICAL) MYCOSTATIN MODAFINIL (ORAL) NYSTATIN SUSPENSION, TABLET (ORAL) MYCOSTATIN MOEXIPRIL, MOEXIPRIL HCTZ (ORAL) UNIVASC, UNIRETIC NYSTATIN-TRIAMCINOLONE CREAM, OINT (TOPICAL) MYCOLOG MOMETASONE FUROATE CREAM, OINT, SOLUTION (TOPICAL) ELOCON OB COMPLETE ONE, OB COMPLETE PREMIER, OB MONONESSA (ORAL) COMPLETE TABLET, OB COMPLETE WITH DHA (ORAL) MONTELUKAST SOD TABLET, TAB CHEW, GRAN PACK (ORAL) SINGULAIR O-CAL FA, O-CAL PRENATAL (ORAL) MORPHINE CONC, SOLUTION, MORPHINE IR TABLET (ORAL) MSIR OFLOXACIN (OPHTHALMIC) FLOXIN MORPHINE ER (ORAL) OFLOXACIN (OTIC) FLOXIN MORPHINE SUPPOSITORIES (RECTAL) OLANZAPINE (INTRAMUSC) MOXEZA (OPHTHALMIC) OLANZAPINE TABLET, ODT (ORAL) ZYPREXA MUPIROCIN OINTMENT (TOPICAL) BACTROBAN OLANZAPINE/FLUOXETINE (ORAL) M-VIT (ORAL) OMEPRAZOLE (ORAL) PRILOSEC MYCOPHENOLATE MOFETIL CAPSULE, TABLET (ORAL) CELLCEPT ONDANSETRON ODT, SOL, TAB (ORAL) ZOFRAN NABUMETONE (ORAL) RELAFEN ONGLYZA (ORAL) NADOLOL, NADOLOL / BENDROFLUMETHIAZIDE (ORAL) CORGARD, CORZIDE ORAP (ORAL) NAMENDA SOLUTION, TABLET DS PAK, TABLET (ORAL) ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO (ORAL) NAPROXEN SODIUM (ORAL) NAPROSYN ORTHO-CYCLEN (ORAL) NAPROXEN TABLET, SUSPENSION (ORAL) ORTHO-NOVUM (ORAL) NARDIL (ORAL) OVCON-50 (ORAL) NASACORT AQ (NASAL) OXCARBAZEPINE SUSPENSION, TABLET (ORAL) TRILEPTAL NASONEX (NASAL) OXYBUTYNIN SYRUP, TABLET, OXYBUTYNIN ER (ORAL) DITROPAN, DITROPAN XL NATAFORT (ORAL) OXYCODONE / APAP CAPSULE, TABLET (ORAL) PERCOCET NATALVIT (ORAL) OXYCODONE / ASA (ORAL) PERCODAN NATAZIA (ORAL) OXYCODONE / IBUPROFEN (ORAL) COMBUNOX NATEGLINIDE (ORAL) STARLIX OXYCODONE CAPSULE, SOLUTION, TABLET (ORAL) OXYIR NECON (ORAL) PAIRE OB PLUS DHA (ORAL) NEOMYCIN (ORAL) PANCRELIPASE (ORAL) VIOKASE Page 4 of 6 Updated: 1/2/2013 Preferred brand-name medications with non-preferred generic equivalents are listed in bold

13 Connecticut Medicaid Alphabetized Preferred Drug List (PDL) *** Available on *** (Navigate to Pharmacy Information > Preferred Drug List > PDL Alphabetical List ) Preferred Drug Brand Equivalent Preferred Drug Brand Equivalent PANTOPRAZOLE (ORAL) PROTONIX PRISTIQ (ORAL) PARNATE (ORAL) PROAIR HFA (INHALATION) PAROXETINE TABLET (ORAL) PAXIL PROBENECID (ORAL) PATADAY (OPHTHALMIC) PROBENECID / COLCHICINE (ORAL) PATANASE (NASAL) PROCRIT (INJECTION) PATANOL (OPHTHALMIC) PROPRANOLOL SOLUTION, TABLET, PROPRANOLOL HCTZ, INDERAL, INDERIDE PEGANONE (ORAL) PROPRANOLOL ER (ORAL) PEGASYS KIT, PROCLICK, SYRINGE, VIAL (SUBCUTANE.) PROTONIX SUSPENSION (ORAL) PENTASA (ORAL) PROTOPIC (TOPICAL) PENTAZOCINE / APAP (ORAL) TALACEN PROVENTIL HFA (INHALATION) PERMETHRIN (TOPICAL) ELIMITE PULMICORT 0.25, 0.5 MG RESPULES (INHALATION) PERPHENAZINE (ORAL) TRILAFON PULMICORT FLEXHALER (INHALATION) PHENOBARBITAL ELIXIR, TABLET (ORAL) PUREFE OB PLUS, PUREFE PLUS (ORAL) PHENYTOIN, PHENYTOIN SOLUTION (ORAL) DILANTIN PV W-O VIT A/FE FUMARATE/FA (ORAL) PHENYTOIN EXT CAPSULE (ORAL) PHENYTEK PV W-O VIT A/FECBN-FEFM/FA (ORAL) PILOCARPINE (OPHTHALMIC) PILOCAR QUETIAPINE TABLET (ORAL) SEROQUEL PINDOLOL (ORAL) VISKIN QUINAPRIL, QUINIPRIL HCTZ (ORAL) ACCUPROL, ACCURETIC PIROXICAM (ORAL) FELDENE QVAR (INHALATION) PN VIT.W-O CA NO.7, IRON,FA,DHA (ORAL) RAMIPRIL (ORAL) PNV #14/FERROUS FUM/FOLIC ACID (ORAL) RAPAMUNE SOLUTION, TABLET (ORAL) PNV NO.22/IRON CBN&GLUC/FA/DSS (ORAL) REBIF (SUBCUTANE.) PNV OB+DHA (ORAL) RECLIPSEN (ORAL) PNV W-CA NO.37/IRON/FA/OMEGA-3 (ORAL) RELENZA (INHALATION) PNV WITH CA,NO.71/IRON/FA (ORAL) RELPAX (ORAL) PNV WITH CA,NO.72/IRON/FA (ORAL) RENAGEL (ORAL) PNV WITH CA,NO.74/IRON/FA, BRAND (ORAL) RETIN-A MICRO (TOPICAL) (NOT PUMP) PNV WITH CA8/IRON/FA/LMEFOLATE (ORAL) RIBAVIRIN TABLET (ORAL) COPEGUS, RIBASPHERE PNV66/IRON FUMARATE/FA/DSS/DHA (ORAL) RIMANTADINE (ORAL) FLUMANIDE PNV80/IRON FUMARATE/FA/DSS/DHA (ORAL) RISPERDAL CONSTA (INTRAMUSC.) PNV81/SOD IRON EDTA& PS/FA/OM3 (ORAL) RISPERDAL ODT, SOLUTION, TABLET (ORAL) POLY IRON PN, POLY IRON PN FORTE (ORAL) RISPERIDONE TABLET, ODT, SOLUTION(ORAL) RISPERDAL POLYMYXIN/TRIMETHOPRIM (OPHTHALMIC) POLYTRIM ROPINIROLE (ORAL) REQUIP PORTIA (ORAL) ROVIN-A DHA (ORAL) PR NATAL 400, PR NATAL 400 EC (ORAL) ROXICET SOLUTION (ORAL) PR NATAL 430, PR NATAL 430 EC (ORAL) ROXICODONE TABLET (ORAL) PRADAXA (ORAL) SAFYRAL (ORAL) PRAMIPEXOLE (ORAL) MIRAPEX SANDIMMUNE CAPSULE, SOLUTION (ORAL) PRANDIN (ORAL) SAPHRIS (SUBLINGUAL) PRAVASTATIN (ORAL) PRAVACHOL SAVELLA, SAVELLA DS PK (ORAL) PRED MILD (OPHTHALMIC) SEASONALE (ORAL) PRED-G DROPS SUSP, OINTMENT (OPHTHALMIC) SEASONIQUE (ORAL) PREDNICARBATE CREAM, OINT (TOPICAL) DERMATOP SELECT-OB, SELECT-OB + DHA (ORAL) PREDNISOLONE ACETATE (OPHTHALMIC) PRED FORTE SELEGILINE CAPSULE, TABLET (ORAL) ELDEPRYL PREDNISOLONE SOD PHOSPHATE (OPHTHALMIC) SE-NATAL 19 TAB CHEW, TABLET (ORAL) PREFERA OB, PREFERA OB ONE, PREFERA OB PLUS SEROQUEL (ORAL) DHA (ORAL) SEROQUEL XR (ORAL) PRENAFIRST (ORAL) SERTRALINE CONC, TABLET (ORAL) ZOLOFT PRENATA (ORAL) SE-TAN DHA (ORAL) PRENATABS FA, PRENATABS RX (ORAL) SETONET, SETONET-EC (ORAL) PRENATAL 19 TAB CHEW, TABLET (ORAL) SIMCOR (ORAL) PRENATAL RX (ORAL) SIMVASTATIN (ORAL) PRENATAL VIT 15/IRON CB/FA/DSS (ORAL) SOLIA (ORAL) PRENATAL VIT 18/IRON CB/FA/DSS (ORAL) SOTALOL (ORAL) BETAPACE PRENATAL VIT NO.78/IRON/FA (ORAL) SPIRIVA (INHALATION) PRENATAL VIT27&CALCIUM/IRON/FA (ORAL) SPRINTEC (ORAL) PRENEXA (ORAL) SPRYCEL (ORAL) PREVIFEM (ORAL) SRONYX (ORAL) PRIMIDONE (ORAL) MYSOLINE STRATTERA (ORAL) Page 5 of 6 Updated: 1/2/2013 Preferred brand-name medications with non-preferred generic equivalents are listed in bold

14 Connecticut Medicaid Alphabetized Preferred Drug List (PDL) *** Available on *** (Navigate to Pharmacy Information > Preferred Drug List > PDL Alphabetical List ) Preferred Drug Brand Equivalent Preferred Drug Brand Equivalent SUBOXONE FILM, TABLETS (SUBLINGUAL) ULESFIA (TOPICAL) SULFACETAMIDE (OPHTHALMIC) BELPH 10 ULTIMATE OB DHA (ORAL) SULFACETAMIDE / PREDNISOLONE (OPHTHALMIC) BLEPHAMIDE ULTIMATECARE ONE NF (ORAL) SULFASALAZINE (ORAL) AZULFIDINE URSODIOL CAPSULE (ORAL) ACTIGALL SULINDAC (ORAL) CLINORIL VALACYCLOVIR (ORAL) VALTREX SUMATRIPTAN (ORAL) IMITREX VALPROATE SYRUP (ORAL) DEPAKENE SUMATRIPTAN PEN INJCTR (SUBCUTANE.) IMITREX VALPROIC ACID (ORAL) DEPAKENE SUPRAX SUSPENSION, TABLET (ORAL) VANDAZOLE (VAGINAL) SUTENT (ORAL) VELIVET (ORAL) SYMBICORT (INHALATION) VENLAFAXINE ER CASPULES, TABLETS (ORAL) EFFEXOR XR SYMBYAX (ORAL) VENTAVIS (INHALATION) TACROLIMUS (ORAL) PROGRAF VERAPAMIL CAPSULE, TABLET, VERAPAMIL TABLET ER CALAN, CALAN SR, CALAN PM TAMIFLU CAPSULE, SUSPENSION (ORAL) VERAPAMIL ER PM (ORAL) TAMOXIFEN CITRATE (ORAL) VESICARE (ORAL) TAMSULOSIN (ORAL) FLOMAX VICTRELIS (ORAL) TARCEVA (ORAL) VIGAMOX (OPHTHALMIC) TARON-BC, TARON-C DHA, TARON-DUE EC (ORAL) VIIBRYD, VIIBRYD DS PK (ORAL) TASIGNA (ORAL) VIMOVO (ORAL) TEMAZEPAM 15 MG, 30 MG (ORAL) RESTORIL VINATE AZ, VINATE CALCIUM, VINATE GT, VINATE IC TERAZOSIN (ORAL) HYTRIN VINTATE II, VINATE PN CARE, VINATE-M (ORAL) TERBINAFINE (ORAL) LAMISIL VITAFOL-OB, VITAFOL-OB+DHA, VITAFOL-ONE, TERBUTALINE (ORAL) BRETHINE VITAFOL-PN (ORAL) TESTIM (TRANSDERM.) VITASPIRE (ORAL) TETRACYCLINE (ORAL) SUMYCIN VOL-NATE (ORAL) THIORIDAZINE (ORAL) MELLARIL VOL-TAB RX (ORAL) THIOTHIXENE (ORAL) NAVANE VOLTAREN (TOPICAL) TIMOLOL (OPHTHALMIC) TIMOPTIC VOTRIENT (ORAL) TIMOLOL (ORAL) BLOCADREN VYVANSE (ORAL) TINDAMAX (ORAL) WARFARIN (ORAL) COUMADIN TL-ASSURE + DHA (ORAL) XALKORI (ORAL) TOBI (INHALATION) XARELTO (ORAL) TOBRADEX OINTMENT, SUSPENSION (OPHTHALMIC) XELODA (ORAL) TOBRAMYCIN (OPHTHALMIC) TOBREX YASMIN 28 (ORAL) TOBREX OINTMENT (OPHTHALMIC) YAZ (ORAL) TOPIRAMATE SPRINKLE, TABLET (ORAL) TOPAMAX ZATEAN-CH (ORAL) TOVIAZ (ORAL) ZELBORAF (ORAL) TRACLEER (ORAL) ZENPEP (ORAL) TRADJENTA (ORAL) ZIPRASIDONE CAPSULE (ORAL) GEODON TRAMADOL ER (ORAL) ZOLPIDEM TARTRATE (NOT ER) (ORAL) AMBIEN TRAMADOL, TRAMADOL / APAP (ORAL) ULTRAM, ULTRACET ZONISAMIDE (ORAL) ZONEGRAN TRANDOLAPRIL (ORAL) MAVIK ZOVIA 1-35E, ZOVIA 1-50E (ORAL) TRAVATAN / TRAVATAN Z 2.5 ML, 5 ML (OPHTHALMIC) ZOVIRAX OINTMENT (TOPICAL) TRAZODONE (ORAL) DESYREL ZYPREXA (ORAL) TRIAMCINOLONE ACETONIDE CREAM, LOTION, OINT (TOPICAL) KENALOG ZYPREXA RELPREVV (INTRAMUSC) TRIBENZOR (ORAL) ZYPREXA ZYDIS (ORAL) TRICARE (ORAL) ZYTIGA (ORAL) TRICOR (ORAL) TRIFLUOPERAZINE (ORAL) STELAZINE TRIHEXYPHENIDYL ELIXIR, TABLET (ORAL) ARTANE TRILIPIX (ORAL) TRINATAL GT (ORAL) TRINATE (ORAL) TRI-NORINYL (ORAL) TRI-SPRINTEC (ORAL) TRIVEEN-DUO DHA, TRIVEEN-PRX RNF, TRIVEEN-U (ORAL) TRIVORA-28 (ORAL) TRUST NATAL DHA (ORAL) TYKERB (ORAL) Page 6 of 6 Updated: 1/2/2013 Preferred brand-name medications with non-preferred generic equivalents are listed in bold