| Document Date: 2014-04-17 16:00:00
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Company F MISSISSIPPI / EXELON / / MedicalCondition Diabetic Neuropathy / cardiac valve disease / MS / hypertension AND / cancer / Hepatic Encephalopathy / Herpetic Neuralgia OR / PA CRITERIA Acne / atrial fibrillation / / MedicalTreatment Antineoplastic therapy / ANTIBIOTICS / surgery / knee replacement / hip replacement / / Organization P&T Committee / MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST THERAPEUTIC DRUG CLASS ACNE AGENTS / / Product LOTREL / sulfanilamide / AVINZA / ZESTORETIC / LOVENOX / acetaminophen / valsartan / irbesartan / TAZORAC / DURAGESIC / ULTRAM / RETIN-A MICRO / BENZAMYCIN PAK / EVOCLIN / FIORINAL / CLEOCIN / ARIXTRA / VICOPROFEN / ZESTRIL / LOTENSIN / FLAGYL ER / AZOR / CLINDAGEL / FIORICET / ULTRAM ER / ANDROGEL / Subutex / TYLENOL / ALINIA / ACTIQ / mupirocin / OPANA / TARKA / RAZADYNE / VANDAZOLE / VASOTEC / RETIN-A / NORCO / METROGEL / TEVETEN / EXFORGE / TINDAMAX / CORTISPORIN / ANDRODERM / erythromycin / ACZONE / CLINDESSE / tretinoin / BENZACLIN / VICODIN / ATACAND / RAZADYNE ER / losartan / KADIAN / dapsone / rivastigmine / FINACEA / UNIVASC / AVAPRO / FENTORA / sodium sulfacetamide / KLARON / LORTAB / bacitracin / AZELEX / naloxone / Suboxone / telmisartan / DIOVAN / MS CONTIN / OPANA ER / LIDODERM / ramipril / VOLTAREN / COUMADIN / ZYDONE / lisinopril / ACCUPRIL / metronidazole / DUAC / ibuprofen / LOTENSIN HCT / PERCOCET / COZAAR / ATRALIN / PERCODAN / ACCURETIC / PRINIVIL / xylocaine / ZIANA / AKNE-MYCIN / ULTRACET / TESTIM / ROXICET / BENICAR / testosterone / NAMENDA / butalbital / quinapril / VASERETIC / UNIRETIC / donepezil / SYNALGOS-DC / lidocaine / ALTABAX / sulfacetamide sodium / diclofenac sodium / ARICEPT ODT / AVC / chlorthalidone / TYLOX / XIFAXAN / gentamicin sulfate / FRAGMIN / DIFFERIN / SYNERA / MAVIK / fentanyl / captopril / butorphanol tartrate / MICARDIS / Lactulose / BACTROBAN / TEKTURNA / ALTACE / EXELON / AVITA / trandolapril / OXYCONTIN / hydrocortisone / FLECTOR / HYZAAR / ARICEPT / AVALIDE / DEMEROL / DILAUDID / /
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MISSISSIPPI DIVISION OF MEDICAID PREFERRED DRUG LIST THERAPEUTIC DRUG CLASS ACNE AGENTS (Topical)