drug list reflects utilization items only mainecare pdl ......retin-a cre 0.1% brand preferred 4...

MaineCare PDL

PROVIDER Drug Reference

DRUG Classification Listing *

Most listed drugs are associated with one preferred status for all strengths. However, there may be instances where a drug name may be

subject to more than one preference based on strength, brand indicator or specified NDC. Any drug subject to more than one indicator will

be highlighted below the drug name with its appropriate status.

11/01/2003

All drugs are given step orders within Drug Categories identifying step therapy requirements.

The instructional sequences of prescribing are outlined as such:

Preferred Step Order (4) is the labeled default for step therapy unless preceded by primary step orders.

Non-Preferred Step Order (8) is the labeled default for step therapy unless preceded by primary step orders.

If Step Order is accompanied by an alpha (M), that drug must be used AND a choice of any other

drug in the specified step order before advancing to the next level of step therapies.

* Listed drugs are based on MaineCare Utilization 7/1/2002 to present.

Drug List reflects utilization items only

Drug Name

Brand

Indicator

Pref /

Non-Pref Status

Step Order CAT Applicable NDC

5-HT3 RECEPTOR ANTAGONISTS/SUBSTANCE P NEUROKININ

MARINOL PreferredBrand 4

ZOFRAN PreferredBrand 4

EMEND Non-PreferredBrand 8

KYTRIL Non-PreferredBrand 8

ZOFRAN ODT Non-PreferredBrand 8

5-Lipoxygenase Inhibitors

ZYFLO Non-PreferredBrand 8

ACE AND THIAZIDE COMBOS

CAPTOPRIL/HYDROCHLOROTHIA PreferredGeneric 4

ENALAPRIL MALEATE/HCTZ PreferredGeneric 4

LISINOPRIL/HCTZ PreferredGeneric 4

UNIRETIC PreferredBrand 4

ACCURETIC Non-PreferredBrand 8

LOTENSIN HCT Non-PreferredBrand 8

MONOPRIL HCT Non-PreferredBrand 8

PRINZIDE Non-PreferredBrand 8

VASERETIC Non-PreferredBrand 8

Copyright GHS Data Management, 2003 of 142

MaineCare PDL

PROVIDER Drug Reference : Drug Classification Listing


Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ACE AND THIAZIDE COMBOS

ZESTORETIC Non-PreferredBrand 8

ACE INHIBITORS

CAPTOPRIL PreferredGeneric 4

ENALAPRIL MALEATE PreferredGeneric 4

LISINOPRIL PreferredBrand/Generic 4

UNIVASC PreferredBrand 4

LOTENSIN Non-PreferredBrand 5

MAVIK Non-PreferredBrand 5

ACCUPRIL Non-PreferredBrand 8

ACEON Non-PreferredBrand 8

ALTACE Non-PreferredBrand 8

CAPOTEN Non-PreferredBrand 8

ENALAPRIL MALEATE Non-PreferredBrand 8

MOEXIPRIL HCL Non-PreferredGeneric 8

MONOPRIL Non-PreferredBrand 8

PRINIVIL Non-PreferredBrand 8

VASOTEC Non-PreferredBrand 8

ZESTRIL Non-PreferredBrand 8

ACE INHIBITORS AND CA CHANNEL BLOCKERS

LEXXEL Non-PreferredBrand 8

LOTREL Non-PreferredBrand 8

TARKA Non-PreferredBrand 8

ACNE PREPARATIONS

ACCUTANE PreferredBrand 4

AKNE-MYCIN PreferredBrand/Generic 4

AMNESTEEM

AMNESTEEM CAP 40MG Generic Preferred 62794061488

4

AZELEX PreferredBrand 4

BENZOYL PEROXIDE

BENZOYL PER GEL 10% Generic Preferred 00603771082

4

OTC -

BENZOYL PER GEL 2.5% Generic Preferred 00603771382

4


4


4

BENZOYL PER LIQ 10% Generic Preferred 49158017634

4

BENZOYL PER LIQ 5% Generic Preferred 54868445000

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ACNE PREPARATIONS

BENZOYL PER SHA 10% Brand Preferred 00814115376

4

OTC -

BENZOYL PEROXIDE WASH PreferredGeneric 4

CLEOCIN-T PreferredBrand 4

DESQUAM-E PreferredGeneric 4

DESQUAM-X PreferredGeneric 4

DIFFERIN PreferredBrand 4

EMGEL PreferredGeneric 4

ERYTHROMYCIN PreferredGeneric 4

ERYTHROMYCIN-BENZOYL PERO PreferredGeneric 4

METROCREAM PreferredBrand 4

METROGEL PreferredBrand 4

METROLOTION PreferredBrand 4

RETIN-A

RETIN-A CRE 0.025% Brand Preferred 00062016501

4


4


4

RETIN-A GEL 0.01% Brand Preferred 00062057544

4

RETIN-A GEL 0.025% Brand Preferred 00062047542

4

RETIN-A LIQ 0.05% Brand Preferred 00062007507

4

SODIUM SULFACETAMIDE/SULF

SOD SUL/SULF LOT 10%-5% Generic Preferred 00182512534

4

TRETINOIN

TRETINOIN LIQ 0.05% Generic Preferred 00093965531

4

AMNESTEEM

AMNESTEEM CAP 10MG Generic Non-Preferred 62794061188

8

AMNESTEEM CAP 20MG Generic Non-Preferred 62794061288

8

BENZAC AC Non-PreferredBrand 8

BENZAC AC WASH Non-PreferredBrand 8

BENZAC W Non-PreferredBrand 8

BENZAC W WASH Non-PreferredBrand 8

BENZACLIN Non-PreferredBrand 8

BENZAGEL-10 Non-PreferredBrand 8

BENZAMYCIN Non-PreferredBrand 8

BENZAMYCINPAK Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ACNE PREPARATIONS

BENZOYL PEROXIDE

BENZOYL PER CRE 10% Generic Non-Preferred 00304059773

8

BENZOYL PER LOT 10% Generic Non-Preferred 55175501503

8

OTC -

BENZOYL PER LOT 5% Generic Non-Preferred 00223425230

8

OTC -

BENZOYL PER POW 70% Brand Non-Preferred 62991164601

8

BREVOXYL Non-PreferredBrand 8

BREVOXYL-4 CREAMY WASH Non-PreferredBrand 8

BREVOXYL-8 CREAMY WASH Non-PreferredBrand 8

CLINDAGEL Non-PreferredBrand 8

CLINDAMYCIN PHOSPHATE Non-PreferredGeneric 8

CLINDETS Non-PreferredGeneric 8

DESQUAM-E Non-PreferredBrand 8

DESQUAM-X Non-PreferredBrand 8

DUAC Non-PreferredBrand 8

FINACEA Non-PreferredBrand 8

FINEVIN Non-PreferredGeneric 8

KLARON Non-PreferredBrand 8

NORITATE Non-PreferredBrand 8

PLEXION Non-PreferredBrand 8

PLEXION TS Non-PreferredBrand 8

RETIN-A

RETIN-A KIT 0.01% Brand Non-Preferred 00062057644

8


8


8


8

RETIN-A MICRO Non-PreferredBrand 8

ROSANIL CLEANSER Non-PreferredGeneric 8

SODIUM SULFACETAMIDE/SULF

SOD SUL/SULF LOT 10%-5% Generic Non-Preferred 60258003301

8

SOD SUL/SULF SUS 10-5% Generic Non-Preferred 59366272405

8

SULFACET-R Non-PreferredBrand 8

TRETINOIN

TRETINOIN CRE 0.025% Generic Non-Preferred 00472011720

8


8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ACNE PREPARATIONS


8

TRETINOIN GEL 0.01% Generic Non-Preferred 66530024515

8

TRETINOIN GEL 0.025% Generic Non-Preferred 00781706119

8

TRIAZ Non-PreferredBrand/Generic 8

TRIAZ CLEANSER Non-PreferredBrand/Generic 8

TRIAZ GEL Non-PreferredBrand 8

ADRENERGIC AGENTS

DIPIVEFRIN HCL PreferredGeneric 4

ADRENERGIC COMBINATIONS

ADVAIR DISKUS PreferredBrand 4

COMBIVENT PreferredBrand 4

DUONEB Non-PreferredBrand 8

ALCOHOL DETERRENTS

DISULFIRAM PreferredGeneric 4

ANTABUSE Non-PreferredBrand 8

ALPHA-PROTEINASE INHIBITOR

PROLASTIN Non-PreferredBrand 8

ALS DRUG

RILUTEK PreferredBrand 4

ALTERNATIVE MEDICINES

MELATONIN

MELATONIN CAP 1MG Brand Preferred 53191022601

4

OTC -

MELATONIN CAP 3MG Generic Preferred 53191022701

4

OTC -

MELATONIN LOZ 3MG Brand Preferred 47469000456

4

OTC -

MELATONIN SUB 5MG Brand Preferred 54629061500

4

OTC -

MELATONIN TAB 200MCG Brand Preferred 74312007900

4

OTC -

MELATONIN TAB 300MCG Generic Preferred 00122137512

4

OTC -

MELATONIN TAB 500MCG Brand Preferred 51991002190

4

OTC -

COENZYME Q10 Non-PreferredBrand/Generic 8OTC

CO-ENZYME Q-10 Non-PreferredBrand/Generic 8OTC

CO-ENZYME Q10/VITAMIN E Non-PreferredBrand 8OTC

FLEXAGEN Non-PreferredBrand 8OTC

GLUCOSAMINE SULFATE Non-PreferredBrand/Generic 8OTC

GLUCOSAMINE-CHONDROITIN Non-PreferredGeneric 8OTC

HM GINKGO BILOBA Non-PreferredGeneric 8OTC

MELATONIN


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ALTERNATIVE MEDICINES

MELATONIN CAP 2.5MG Brand Non-Preferred 53335031012

8

OTC -

MELATONIN CAP 5MG Brand Non-Preferred 53191021401

8

OTC -

MELATONIN TAB 1.5MG Generic Non-Preferred 49884047802

8

OTC -

MELATONIN TAB 2.5MG Brand Non-Preferred 11845111505

8

OTC -

MELATONIN TAB 3-2MG Generic Non-Preferred 48107004967

8

OTC -

MELATONIN TAB 3MG Generic Non-Preferred 00536641208

8

OTC -

MELATONIN TAB 500MCG Generic Non-Preferred 49884047902

8

OTC -

MELATONIN TAB 5MG Brand Non-Preferred 11845111405

8

OTC -

MELATONIN TAB Brand Non-Preferred 47469000510

8

OTC -

V-R COENZYME Q-10 Non-PreferredGeneric 8OTC

AMINO GLYCOSIDES

GENTAMICIN SULFATE PreferredGeneric 4

NEOMYCIN SULFATE PreferredGeneric 4

TOBI PreferredBrand 4

TOBRAMYCIN SULFATE

TOBRA/NACL INJ 80/0.9 Brand Preferred 00074347023

4

TORBA/NACL INJ 60/0.9 Brand Preferred 00074346913

4

TOBRAMYCIN SULFATE

TOBRAMYCIN POW SULFATE Brand Non-Preferred 38779031901

8

AMLODIPINES

NORVASC PreferredBrand 4

ANAPHYLAXIS THERAPY

EPIPEN PreferredBrand 4

EPIPEN-JR PreferredBrand 4

ANDROGENS / ANABOLICS

ANDRODERM

ANDRODERM DIS 5MG/24HR Brand Preferred 00007315613

4

ANDROID

ANDROID CAP 10MG Brand Preferred 00187090201

4

DANAZOL PreferredGeneric 4

DELATESTRYL

DELATESTRYL INJ 200MG/ML Generic Preferred 00003032840

4

DEPO-TESTOSTERONE PreferredBrand 4

FLUOXYMESTERONE PreferredBrand/Generic 4

OXANDRIN PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANDROGENS / ANABOLICS

TESTODERM PreferredBrand 4

TESTOSTERONE PROPIONATE

TESTOST PROP POW MICRONIZ Brand Preferred 17317056802

4

TESTOST PROP POW Brand Preferred 00574046101

4

TESTOST PROP POW Generic Preferred 00802395717

4

TESTRED PreferredBrand 4

WINSTROL PreferredBrand 4

ANDRODERM

ANDRODERM DIS 2.5MG/24 Brand Non-Preferred 00007315518

8

ANDROGEL Non-PreferredBrand 8

ANDROID

ANDROID 25 TAB 25MG Brand Non-Preferred 00187049906

8

ANDROID-10 TAB 10MG Brand Non-Preferred 00187031106

8

DANAZOL Non-PreferredBrand 8

DELATESTRYL Non-PreferredBrand/Generic 8

DELATESTRYL INJ 200MG/ML Generic Non-Preferred 00003032816

8

HALOTESTIN Non-PreferredBrand 8

TESTOSTERONE PROPIONATE

TESTOST PROP INJ 100MG/ML Brand Non-Preferred 00314077270

8

TESTOST PROP INJ 100MG/ML Generic Non-Preferred 00143616870

8

TESTOST PROP INJ 25MG/ML Brand Non-Preferred 00536850070

8


8


8

TESTRED Non-PreferredGeneric 8

ANGIOTENSIN RECEPTOR BLOCKER

BENICAR Non-PreferredBrand 5

COZAAR Non-PreferredBrand 5

MICARDIS Non-PreferredBrand 5

TEVETEN Non-PreferredBrand 5

ATACAND Non-PreferredBrand 8

AVAPRO Non-PreferredBrand 8

DIOVAN Non-PreferredBrand 8

ANTHELMINTICS

ALBENZA PreferredBrand 4

MEBENDAZOLE PreferredGeneric 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTHELMINTICS

STROMECTOL PreferredBrand 4

MEBENDAZOLE Non-PreferredBrand 8

VERMOX Non-PreferredBrand 8

ANTI-ALLERGICS

ALAMAST PreferredBrand 4

ALOCRIL PreferredBrand 4

ALOMIDE PreferredBrand 4

EMADINE PreferredBrand 4

LIVOSTIN PreferredBrand 4

PATANOL PreferredBrand 4

CROLOM Non-PreferredBrand 8

CROMOLYN SODIUM Non-PreferredGeneric 8

OPTIVAR Non-PreferredBrand 8

ZADITOR Non-PreferredBrand 8

ANTIARRHYTHMICS

AMIODARONE HCL PreferredGeneric 4

CORDARONE PreferredBrand 4

DISOPYRAMIDE PHOSPHATE PreferredBrand/Generic 4

DISOPYRAMIDE PHOSPHATE ER PreferredGeneric 4

MEXILETINE HCL PreferredGeneric 4

PROCANBID PreferredBrand 4

QUINIDINE GLUCONATE CR PreferredGeneric 4

QUINIDINE GLUCONATE ER PreferredGeneric 4

QUINIDINE GLUCONATE SA PreferredGeneric 4

QUINIDINE SULFATE PreferredBrand/Generic 4

RYTHMOL PreferredBrand 4

TAMBOCOR PreferredBrand 4

FLECAINIDE ACETATE Non-PreferredGeneric 8

NORPACE Non-PreferredBrand 8

NORPACE CR Non-PreferredBrand 8

PACERONE Non-PreferredBrand/Generic 8

PROPAFENONE HCL Non-PreferredGeneric 8

QUINIDINE SULFATE ER Non-PreferredBrand/Generic 8

ANTIASTHMATIC - ANTI-CHOLINERGICS


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTIASTHMATIC - ANTI-CHOLINERGICS

ATROVENT

ATROVENT INH AER 18MCG/AC Brand Preferred 00597008214

4

ATROVENT REF AER 18MCG/AC Brand Preferred 00597008218

4

IPRATROPIUM BROMIDE PreferredBrand/Generic 4

ATROVENT

ATROVENT SOL INHAL Brand Non-Preferred 00403064518

8

ANTIBIOTIC TOPICALS

BACITRACIN PreferredGeneric 4OTC

BACITRACIN/NEOMYCIN/POLYM PreferredGeneric 4OTC

BACTROBAN PreferredBrand 4

GENTAMICIN SULFATE PreferredGeneric 4

TRIPLE ANTIBIOTIC

TRIPLE ANTIB OIN Generic Preferred 54868058201

4

OTC -

BACITRACIN Non-PreferredBrand 8

CORTISPORIN Non-PreferredBrand 8

GENTAMICIN SULFATE Non-PreferredBrand 8

TRIPLE ANTIBIOTIC

TRIPLE ANTI OIN Generic Non-Preferred 58659322101

8

OTC -

TRIPLE ANTI- OIN BIOTIC Generic Non-Preferred 52959001403

8

OTC -

TRIPLE ANTIB OIN Generic Non-Preferred 55045143605

8

OTC -

TRPL ANTIBIO OIN Generic Non-Preferred 51672201601

8

OTC -

ANTI-CHOLINERGIC / DOPAMINERGIC

MECLIZINE HCL PreferredGeneric 4OTC

PHENERGAN

PHENERGAN SUP 12.5MG Brand Preferred 00008049801

4

PHENERGAN SUP 25MG Brand Preferred 52246091704

4

PHENERGAN SUP 50MG Brand Preferred 54124091606

4

PHENERGAN SYP 6.25/5ML Brand Preferred 54569178801

4

PHENERGAN TAB 12.5MG Brand Preferred 49999026906

4

PROMETHAZINE HCL

PROMETHAZINE INJ 25MG/ML Generic Preferred 00364657025

4

PROMETHAZINE INJ 50MG/ML Generic Preferred 00402025981

4

PROMETHAZINE SUP 12.5MG Generic Preferred 00904564412

4

PROMETHAZINE SUP 25MG Generic Preferred 00472009612

4

PROMETHAZINE SUP 50MG Generic Preferred 00102393512

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTI-CHOLINERGIC / DOPAMINERGIC

PROMETHAZINE SYP 25MG/5ML Generic Preferred 00223634401

4

PROMETHAZINE SYP 6.25/5ML Generic Preferred 00005319224

4

PROMETHAZINE TAB 12.5MG Generic Preferred 00527111501

4

PROMETHAZINE TAB 25MG Generic Preferred 00102161501

4

PROMETHAZINE TAB 50MG Generic Preferred 00339582912

4

PROMETHAZINE HCL PLAIN PreferredBrand/Generic 4

TIGAN

TIGAN CAP 100MG Brand Preferred 00029408230

4


4


4

TIGAN INJ 100MG/ML Brand Preferred 00029408522

4

TIGAN SUP 100MG Brand Preferred 49999014610

4

TIGAN SUP 200MG Brand Preferred 49999014510

4

TRANSDERM-SCOP PreferredBrand 4

MECLIZINE HCL Non-PreferredBrand 8

PHENERGAN

PHENERGAN INJ 25MG/ML Brand Non-Preferred 00008006301

8

PHENERGAN INJ 50MG/ML Brand Non-Preferred 00008045501

8

PHENERGAN TAB 12.5MG Brand Non-Preferred 00008001901

8

PHENERGAN TAB 25MG Brand Non-Preferred 00008002702

8

PHENERGAN TAB 50MG Brand Non-Preferred 00008022701

8

PROMETHAZINE HCL

PROMETHAZINE SUP 25MG Generic Non-Preferred 54868060101

8

PROMETHEGAN Non-PreferredGeneric 8

TIGAN

TIGAN SUP 200MG Brand Non-Preferred 00029408438

8

TIGAN PEDIAT SUP 100MG Brand Non-Preferred 00029408838

8

TORECAN Non-PreferredBrand 8

ANTICOAGULANTS

FRAGMIN PreferredBrand 4

HEPARIN LOCK PreferredGeneric 4

HEPARIN LOCK FLUSH PreferredGeneric 4

HEPARIN SODIUM PreferredBrand/Generic 4

HEPARIN SODIUM LOCK FLUSH PreferredBrand/Generic 4

HEPARIN LOCK INJ 100U/ML Generic Preferred 08290037002

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTICOAGULANTS

HEPARIN LOCK INJ 10U/ML Generic Preferred 00338810669

4

HEP-LOCK PreferredGeneric 4

LOVENOX PreferredBrand 4

WARFARIN SODIUM PreferredGeneric 4

COUMADIN Non-PreferredBrand 8

HEPARIN SODIUM LOCK FLUSH

HEPARIN COMB KIT 100U/ML Generic Non-Preferred 64054300003

8

HEPARIN COMB KIT 10U/ML Generic Non-Preferred 64054300103

8

HEPARIN LOCK KIT 100U/ML Generic Non-Preferred 08290041003

8

HEPARIN LOCK KIT 10U/ML Generic Non-Preferred 00008252801

8

WARFARIN SODIUM Non-PreferredBrand 8

ANTI-FLATULENTS / GI STIMULANTS

CALULOSE PreferredGeneric 4

CONSTULOSE PreferredGeneric 4

ENULOSE PreferredGeneric 4

GASTROCROM PreferredBrand 4

GENERLAC PreferredGeneric 4

GLYCERIN ADULT PreferredGeneric 4OTC

GLYCERIN INFANT PreferredGeneric 4OTC

LACTULOSE PreferredGeneric 4

METOCLOPRAMIDE HCL PreferredGeneric 4

MIRALAX

MIRALAX POW 3350 NF Brand Preferred 52268080002

4

SIMETHICONE

SIMETHICONE CHW 125MG Generic Preferred 00536453408

4

OTC -

SIMETHICONE CHW 80MG Generic Preferred 00349849201

4

OTC -

SIMETHICONE DRO 40/0.6ML Generic Preferred 70030011910

4

OTC -

COLYTE Non-PreferredGeneric 8

COLYTE-FLAVORED Non-PreferredGeneric 8

GENASYME Non-PreferredGeneric 8OTC

GOLYTELY Non-PreferredBrand 8

INFANTS GAS RELIEF Non-PreferredGeneric 8OTC

KRISTALOSE Non-PreferredBrand 8

METOCLOPRAMIDE HCL Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTI-FLATULENTS / GI STIMULANTS

MIRALAX

MIRALAX PKG 3350 Brand Non-Preferred 52268080005

8

NULYTELY Non-PreferredBrand 8

PEG 3350/ELECTROLYTES Non-PreferredGeneric 8

REGLAN Non-PreferredBrand 8

SIMETHICONE Non-PreferredBrand/Generic 8OTC

SIMETHICONE TAB 80MG Generic Non-Preferred 00302635001

8

OTC -

ANTI-HEMOPHILIC AGENTS

BENEFIX PreferredBrand 4

HELIXATE FS PreferredBrand 4

NOVOSEVEN PreferredBrand 4

RECOMBINATE PreferredBrand 4

ANTIHYPERTENSIVE COMBOS

METHYLDOPA/HYDROCHLOROTHI

METHYLD/HCTZ TAB 250/15 Generic Preferred 00003063050

4

CLORPRES Non-PreferredBrand 8

METHYLDOPA/HYDROCHLOROTHI

METHYLD/HCTZ TAB 250/25 Generic Non-Preferred 00003064550

8


8


8

ANTI-INFLAMMATORY / STEROIDS OPHTH.

ALREX PreferredBrand 4

BAC/POLY/NEOMY/HC

BAC/POLY/NEO OIN /HC OP Generic Preferred 54977057301

4

BAC/POLY/NEO OIN /HC Generic Preferred 52959023803

4

BLEPHAMIDE PreferredBrand 4

CORTISPORIN PreferredBrand 4

DEXAMETHASONE SODIUM PHOS

DEXAMETH PHO DRO 0.1% OP Generic Preferred 55045175505

4

DEXAMETH PHO SOL 0.1% OP Generic Preferred 00058074805

4

FLAREX PreferredBrand 4

FLUOROMETHOLONE PreferredGeneric 4

FML LIQUIFILM PreferredBrand 4

FML S.O.P. PreferredBrand 4

FML-S LIQUIFILM PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTI-INFLAMMATORY / STEROIDS OPHTH.

LOTEMAX PreferredBrand 4

NEO/POLY/BAC/HC

NEO/POLY/BAC OIN /HC OP Generic Preferred 00182155231

4

NEOMYCIN/POLYMIXIN/DEXAME PreferredGeneric 4

NEOMYCIN/POLYMYXIN/DEXAME PreferredGeneric 4

NEOMYCIN/POLYMYXIN/HYDRO- PreferredGeneric 4

NEOMYCIN-POLYMYXIN-DEXAME PreferredGeneric 4

PRED FORTE PreferredBrand 4

PRED MILD PreferredBrand 4

PREDNISOLONE ACETATE PreferredGeneric 4

PREDNISOLONE SODIUM PHOSP PreferredGeneric 4

TOBRADEX PreferredBrand 4

BAC/POLY/NEOMY/HC

BAC/POLY/NEO OIN /HC OP Generic Non-Preferred 52959134903

8

BAC/POLY/NEO OIN /HC Generic Non-Preferred 54569538900

8

BLEPHAMIDE S.O.P. Non-PreferredBrand 8

DEXAMETHASONE SODIUM PHOS Non-PreferredBrand/Generic 8

DEXAMETH PHO OIN 0.05% OP Generic Non-Preferred 54569311900

8

ECONOPRED Non-PreferredBrand 8

ECONOPRED PLUS Non-PreferredBrand 8

EFLONE Non-PreferredBrand 8

MAXIDEX Non-PreferredBrand/Generic 8

NEO/POLY/BAC/HC

NEO/POLY/BAC OIN /HC OP Generic Non-Preferred 24208078555

8

PRED-G S.O.P. Non-PreferredBrand 8

SULFACETAMIDE SODIUM/PRED Non-PreferredGeneric 8

VEXOL Non-PreferredBrand 8

ANTI-INFLAMMATORY AGENTS

CROMOLYN SODIUM PreferredGeneric 4

INTAL

INTAL AER 800MCG Brand Preferred 54868282200

4

INTAL INH AER 800MCG Brand Preferred 00585067501

4

TILADE PreferredBrand 4

CROMOLYN SODIUM Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTI-INFLAMMATORY AGENTS

INTAL

INTAL CAP 20MG Brand Non-Preferred 00585067012

8

INTAL NEB 20MG/2ML Brand Non-Preferred 00585067302

8

ANTILEPROTIC

THALOMID Non-PreferredBrand 8

ANTI-MALARIAL AGENTS

CHLOROQUINE PHOSPHATE

CHLOROQUINE TAB 250MG Brand Preferred 00115279001

4

DARAPRIM PreferredBrand 4

HYDROXYCHLOROQUINE SULFAT PreferredGeneric 4

LARIAM PreferredBrand 4

MALARONE PreferredBrand 4

MEFLOQUINE HCL PreferredGeneric 4

QUININE SULFATE

QUININE SULF CAP 130MG Brand Preferred 00002062602

4

OTC -


4


4


4

OTC -

CHLOROQUINE PHOSPHATE

CHLOROQUINE POW PHOSPHAT Brand Non-Preferred 38779011504

8

PLAQUENIL Non-PreferredBrand 8

QUININE SULFATE

QUININE SULF POW Brand Non-Preferred 00395240188

8

OTC -

ANTI-MYCOBACTERIALS / ANTI-TUBERCULOSIS

ETHAMBUTOL HCL PreferredGeneric 4

ISONIAZID

ISONIAZID SYP 50MG/5ML Brand Preferred 46287000901

4

ISONIAZID SYP 50MG/5ML Generic Preferred 00223653016

4

ISONIAZID TAB 100MG Generic Preferred 00002209302

4

ISONIAZID TAB 300MG Generic Preferred 00002212302

4

MYAMBUTOL PreferredBrand 4

RIFAMPIN PreferredGeneric 4

ETHAMBUTOL HCL Non-PreferredBrand 8

ISONIAZID

ISONIAZID INJ 100MG/ML Generic Non-Preferred 51309094710

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTI-MYCOBACTERIALS / ANTI-TUBERCULOSIS

ISONIAZID POW Brand Non-Preferred 38779012004

8

RIFAMPIN Non-PreferredBrand 8

RIMACTANE Non-PreferredGeneric 8

ANTI-NEOPLASTICS

EFUDEX PreferredBrand 4

FLUOROPLEX

FLUOROPLEX CRE 1% Brand Preferred 00023081230

4

CARAC Non-PreferredBrand 8

FLUOROPLEX

FLUOROPLEX SOL 1% Brand Non-Preferred 00023081030

8

ANTIPARKINSONIAN - ANTI-CHOLINERGICS

AKINETON PreferredBrand 4

BENZTROPINE MESYLATE PreferredBrand/Generic 4

KEMADRIN PreferredBrand 4

TRIHEXYPHENIDYL HCL PreferredGeneric 4

ANTI-PERISTALTIC AGENTS

ANTI-DIARRHEAL

ANIT-DIARRHE TAB 2MG Generic Preferred 19458918104

4

OTC -

ANTI-DIARRHE LIQ 1MG/5ML Generic Preferred 00113037726

4

OTC -

DIPHENOXYLATE HYDROCHLORI PreferredGeneric 4

DIPHENOXYLATE/ATROPINE PreferredGeneric 4

LOFENE PreferredGeneric 4

LONOX

LONOX TAB 2.5MG Generic Preferred 00781126213

4

LOPERAMIDE HCL

LOPERAMIDE CAP 2MG Generic Preferred 00054253725

4

LOPERAMIDE LIQ 1MG/5ML Generic Preferred 37205037716

4

OTC -

LOPERAMIDE LIQ 4MG/20ML Generic Preferred 00054853616

4

OTC -

LOPERAMIDE TAB 2MG Generic Preferred 50844028902

4

OTC -

OPIUM TINCTURE PreferredBrand/Generic 4

PAREGORIC PreferredGeneric 4

ANTI-DIARRHEAL

ANIT-DIARRHE TAB 2MG Generic Non-Preferred 19458918101

8

OTC -

ANTI-DIARRHE TAB 2MG Generic Non-Preferred 24385055462

8

OTC -

LONOX


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTI-PERISTALTIC AGENTS

LONOX TAB 2.5MG Generic Non-Preferred 00781126201

8

LOPERAMIDE HCL Non-PreferredBrand/Generic 8

LOPERAMIDE TAB 2MG Generic Non-Preferred 37205055453

8

OTC -

MOTOFEN Non-PreferredBrand 8

ANTI-PRURITICS

ZONALON PreferredBrand 4

PRUDOXIN Non-PreferredGeneric 8

ANTI-PSORIATICS

DOVONEX PreferredBrand 4

OXSORALEN ULTRA PreferredBrand 4

TAZORAC PreferredBrand 4

PSORIATEC Non-PreferredBrand 8

SORIATANE Non-PreferredBrand 8

ANTI-PSYCHOTICS ATYPICALS

RISPERDAL

RISPERDAL SOL 1MG/ML Brand Preferred 50458030503

1

RISPERDAL TAB 0.25MG Brand Preferred 50458030104

1

RISPERDAL TAB 0.5MG Brand Preferred 50458030206

1

RISPERDAL TAB 1MG Brand Preferred 50458030006

1


1


1


1

RISPERDAL M-TAB PreferredBrand 1

GEODON PreferredBrand 2

SEROQUEL PreferredBrand 2

LITHIUM CARBONATE ER PreferredGeneric 4

ABILIFY Non-PreferredBrand 8

LITHIUM CARBONATE Non-PreferredBrand 8

RISPERDAL

RISPERDAL TAB 0.25MG Brand Non-Preferred 50458030101

8

RISPERDAL TAB 0.5MG Brand Non-Preferred 50458030201

8

ZYPREXA Non-PreferredBrand 8

ZYPREXA ZYDIS Non-PreferredBrand 8

ANTI-PSYCHOTICS TYPICAL


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



CHLORPROMAZINE HCL PreferredBrand/Generic 4

CHLORPROMAZ CON 30MG/ML Brand Preferred 00054314450

4

COMPAZINE PreferredGeneric 4

COMPRO PreferredGeneric 4

FLUPHENAZINE DECANOATE PreferredGeneric 4

FLUPHENAZINE HCL PreferredBrand/Generic 4

HALDOL

HALDOL INJ 5MG/ML Brand Preferred 00045025501

4

HALOPERIDOL PreferredBrand/Generic 4

HALOPERIDOL SOL 10MG/10 Brand Preferred 51079079810

4


4


4

HALOPERIDOL SOL 5MG/5ML Brand Preferred 51079079710

4

HALOPERIDOL TAB 10MG Brand Preferred 00781139713

4

HALOPERIDOL TAB 20MG Brand Preferred 00781139801

4

HALOPERIDOL DECANOATE PreferredGeneric 4

HALOPERIDOL LACTATE PreferredBrand/Generic 4

LOXAPINE SUCCINATE PreferredGeneric 4

LOXITANE

LOXITANE CAP 10MG Brand Preferred 00005536023

4


4


4


4

LOXITANE INJ 50MG/ML Brand Preferred 00205538555

4

LOXITANE-C CON 25MG/ML Brand Preferred 00005538758

4

MELLARIL

MELLARIL TAB 150MG Brand Preferred 00078000605

4

MOBAN

MOBAN SOL 20MG/ML Brand Preferred 00056046004

4

MOBAN TAB 100MG Brand Preferred 00056007770

4


4


4


4


4

NAVANE


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



NAVANE CON 5MG/ML Brand Preferred 00049575047

4

PERPHENAZINE PreferredBrand/Generic 4

PROCHLORPERAZINE PreferredGeneric 4

PROCHLORPERAZINE MALEATE PreferredGeneric 4

SERENTIL PreferredBrand 4

THIORIDAZINE HCL PreferredBrand/Generic 4

THIOTHIXENE PreferredGeneric 4

THORAZINE

THORAZINE CON 30MG/ML Brand Preferred 00007504744

4

THORAZINE SUP 100MG Brand Preferred 00007507103

4

THORAZINE SUP 25MG Brand Preferred 00007507003

4

TRIFLUOPERAZINE HCL

TRIFLUOPERAZ TAB 10MG Generic Preferred 00047075624

4


4


4


4

CHLORPROMAZINE HCL

CHLORPROMAZ CRY Brand Non-Preferred 51552013901

8

CHLORPROMAZ POW USP NF Brand Non-Preferred 49452199001

8

CHLORPROMAZ POW USP Brand Non-Preferred 62991142501

8

CHLORPROMAZ POW Brand Non-Preferred 38779042301

8

COMPAZINE Non-PreferredBrand 8

HALDOL

HALDOL CON 2MG/ML Brand Non-Preferred 00045025004

8

HALDOL TAB 0.5MG Brand Non-Preferred 00045024060

8

HALDOL TAB 10MG Brand Non-Preferred 00045024610

8


8


8


8


8

HALDOL DECANOATE-100 Non-PreferredBrand 8

HALDOL DECANOATE-50 Non-PreferredBrand 8

HALOPERIDOL

HALOPERIDOL POW USP/NF Brand Non-Preferred 49452344601

8

HALOPERIDOL POW USP Brand Non-Preferred 51552051901

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



HALOPERIDOL POW Brand Non-Preferred 38779033001

8

LOXITANE

LOXITANE CAP 10MG Brand Non-Preferred 52544049501

8


8


8


8

LOXITANE INJ 50MG/ML Brand Non-Preferred 00205538534

8

MELLARIL

MELLARIL CON 100MG/ML Brand Non-Preferred 00078000931

8

MELLARIL CON 30MG/ML Brand Non-Preferred 00078000131

8

MELLARIL TAB 100MG Brand Non-Preferred 00078000505

8


8


8


8


8


8


8

MELLARIL-S SUS 100/5ML Brand Non-Preferred 00078006933

8

MELLARIL-S SUS 25MG/5ML Brand Non-Preferred 00078006833

8

MOBAN

MOBAN SOL 20MG/ML Brand Non-Preferred 63481046004

8

NAVANE

NAVANE CAP 10MG Brand Non-Preferred 00049574066

8


8


8


8


8

NAVANE INJ 5MG/ML Brand Non-Preferred 00049576583

8

NAVANE IM INJ 2MG/ML Brand Non-Preferred 00049576083

8

PROCHLORPERAZINE MALEATE Non-PreferredBrand 8

PROLIXIN Non-PreferredBrand 8

PROLIXIN DECANOATE Non-PreferredBrand 8

THORAZINE

THORAZINE CAP 150MG CR Brand Non-Preferred 00007506615

8


8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status




8


8


8

THORAZINE CON 100MG/ML Brand Non-Preferred 00007504948

8

THORAZINE INJ 25MG/ML Brand Non-Preferred 00007506011

8

THORAZINE SYP 10MG/5ML Brand Non-Preferred 00007507244

8

THORAZINE TAB 100MG Brand Non-Preferred 00007507720

8


8


8


8


8

TRIFLUOPERAZINE HCL

TRIFLUOPERAZ CON 10MG/ML Generic Non-Preferred 00047293535

8

TRIFLUOPERAZ INJ 2MG/ML Generic Non-Preferred 51309095110

8

ANTI-RETROVIRALS

AGENERASE PreferredBrand 4

COMBIVIR PreferredBrand 4

CRIXIVAN PreferredBrand 4

EPIVIR PreferredBrand 4

EPIVIR HBV PreferredBrand 4

FORTOVASE PreferredBrand 4

INVIRASE PreferredBrand 4

KALETRA PreferredBrand 4

NORVIR PreferredBrand 4

RESCRIPTOR PreferredBrand 4

RETROVIR PreferredBrand 4

REYATAZ PreferredBrand 4

SUSTIVA PreferredBrand 4

TRIZIVIR PreferredBrand 4

VIDEX

VIDEX CHW 100MG Brand Preferred 00087662743

4


4


4


4

VIDEX SOL 2GM Brand Preferred 00087663241

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTI-RETROVIRALS

VIDEX SOL 4GM Brand Preferred 00087663341

4

VIDEX BUFFER CHW 100MG Brand Preferred 00087665201

4


4


4


4


4

VIDEX EC PreferredBrand 4

VIRACEPT

VIRACEPT TAB 250MG Brand Preferred 54569454300

4

VIRAMUNE PreferredBrand 4

VIREAD PreferredBrand 4

ZERIT PreferredBrand 4

ZIAGEN PreferredBrand 4

FUZEON Non-PreferredBrand 8

VIDEX

VIDEX POW 100MG Brand Non-Preferred 00087661443

8


8


8


8

VIRACEPT

VIRACEPT POW 50MG/GM Brand Non-Preferred 63010001190

8

ANTI-SEBORRHEICS

CAPITROL PreferredBrand 4

SELENIUM SULFIDE PreferredGeneric 4OTC

ANTISEPTICS / DISINFECTANTS

PHISOHEX PreferredBrand 4

POVIDONE-IODINE

POVIDONE-IOD OIN 10% Generic Preferred 00182133945

4

OTC -

POVIDONE-IOD SOL 1% Generic Preferred 00147022601

4

OTC -

POVIDONE-IOD SOL 10% Generic Preferred 00223654101

4

OTC -

POVIDONE-IOD SOL 7.5% Generic Preferred 17236082916

4

OTC -

IODOSORB Non-PreferredBrand 8

LAZERFORMALYDE SOLUTION Non-PreferredBrand 8

POVIDONE-IODINE

POVIDONE-IOD OIN 10% Generic Non-Preferred 00182133989

8

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANTISEPTICS / DISINFECTANTS

POVIDONE-IOD SHA 7.5% Generic Non-Preferred 53258019930

8

OTC -

ANTI-SPASMODICS

OXYBUTYNIN CHLORIDE PreferredBrand/Generic 4

URISPAS PreferredBrand 4

DETROL Non-PreferredBrand 8

DITROPAN Non-PreferredBrand 8

OXYTROL Non-PreferredBrand 8

ANTI-SPASMODICS - LONG ACTING

DETROL LA PreferredBrand 4

DITROPAN XL Non-PreferredBrand 8

ANTI-THYROID THERAPIES

METHIMAZOLE PreferredBrand/Generic 4

METHIMAZOLE TAB 20MG Brand Preferred 49884068955

4

PROPYLTHIOURACIL PreferredGeneric 4

METHIMAZOLE

METHIMAZOLE POW USP/NF Brand Non-Preferred 49452457301

8

METHIMAZOLE POW USP Brand Non-Preferred 62991151501

8

METHIMAZOLE POW Brand Non-Preferred 38779036003

8

TAPAZOLE Non-PreferredBrand 8

ANTI-VIRALS

DENAVIR PreferredBrand 4

ZOVIRAX PreferredBrand 4

ANXIOLYTIC - BENZODIAZEPINES

ALPRAZOLAM PreferredGeneric 4

CHLORDIAZEPOXIDE HCL PreferredGeneric 4

CLORAZEPATE DIPOTASSIUM PreferredGeneric 4

DIAZEPAM PreferredBrand/Generic 4

DIAZEPAM INTENSOL PreferredBrand 4

LORAZEPAM PreferredGeneric 4

LORAZEPAM INTENSOL PreferredBrand 4

OXAZEPAM PreferredGeneric 4

ATIVAN Non-PreferredBrand 8

SERAX Non-PreferredBrand 8

TRANXENE-SD Non-PreferredBrand 8

TRANXENE-T Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ANXIOLYTIC - BENZODIAZEPINES

XANAX Non-PreferredBrand 8

ARBS AND DIURETICS

HYZAAR Non-PreferredBrand 5

MICARDIS HCT Non-PreferredBrand 5

TEVETEN HCT Non-PreferredBrand 5

ATACAND HCT Non-PreferredBrand 8

AVALIDE Non-PreferredBrand 8

BENICAR HCT Non-PreferredBrand 8

DIOVAN HCT Non-PreferredBrand 8

ARTIFICIAL SALIVA/STIMULANTS

EVOXAC PreferredBrand 4

SALIVA SUBSTITUTE PreferredBrand 4OTC

SALAGEN Non-PreferredBrand 8

ARTIFICIAL TEARS AND LUBRICANTS

AKWA TEARS PreferredBrand/Generic 4OTC

ARTIFICIAL TEARS

ARTICI TEARS SOL OP Generic Preferred 54274092412

4

OTC -

ARTIF TEARS SOL OP Generic Preferred 12333945001

4

OTC -

ARTIFI TEARS DRO OP Generic Preferred 36800003642

4

OTC -

ARTIFI TEARS DRO Generic Preferred 49614031866

4

OTC -

ARTIFI TEARS OIN OP Generic Preferred 00536655091

4

OTC -

ARTIFI TEARS SOL OP Generic Preferred 58016620101

4

OTC -

ARTIFIC TEAR DRO Generic Preferred 49614030505

4

OTC -

ARTIFIC TEAR SOL OP Generic Preferred 49614030205

4

OTC -

ARTIFICIAL SOL TEARS OP Generic Preferred 59690000715

4

OTC -

ARTIFICIAL SOL TEARS Generic Preferred 37205013705

4

OTC -

BION TEARS PreferredGeneric 4OTC

CELLUVISC PreferredBrand 4OTC

DRY EYES PreferredGeneric 4OTC

GENTEAL PreferredBrand/Generic 4OTC

GENTEAL MILD PreferredBrand 4OTC

HYPOTEARS PreferredGeneric 4OTC

LACRI-LUBE S.O.P. PreferredBrand 4OTC

LUBRIFRESH P.M. PreferredGeneric 4OTC

NATURAL BALANCE PreferredGeneric 4OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ARTIFICIAL TEARS AND LUBRICANTS

NATURE'S TEARS PreferredGeneric 4OTC

PURALUBE PreferredGeneric 4OTC

PURALUBE TEARS PreferredGeneric 4OTC

REFRESH PreferredBrand 4OTC

REFRESH ENDURA PreferredBrand 4OTC

REFRESH PLUS PreferredBrand 4OTC

REFRESH TEARS PreferredGeneric 4OTC

REFRESH-PM

REFRESH-PM OIN OP Brand Preferred 00023066704

4

OTC -

TEARS NATURALE

TEARS NATURA SOL FREE OP Generic Preferred 00065041624

4

OTC -

TEARS NATURA SOL FREE Generic Preferred 54569330500

4

OTC -

TEARS NATURA SOL OP Generic Preferred 58016209801

4

OTC -

TEARS NATURALE FORTE PreferredGeneric 4OTC

TEARS NATURALE II PreferredGeneric 4OTC

TEARS PURE PreferredGeneric 4OTC

TEARS RENEWED PreferredGeneric 4OTC

V-R ARTIFICIAL TEARS PreferredGeneric 4OTC

ARTIFICIAL TEARS

ARTIFICIAL SOL TEARS OP Generic Non-Preferred 50383002615

8

OTC -

HYPO TEARS PF Non-PreferredBrand 8OTC

HYPOTEARS Non-PreferredBrand 8OTC

ISOPTO TEARS Non-PreferredBrand/Generic 8OTC

MUROCEL Non-PreferredBrand/Generic 8OTC

REFRESH-PM

REFRESH-PM OIN OP Brand Non-Preferred 54569251900

8

OTC -

SYSTANE Non-PreferredBrand 8OTC

TEARISOL Non-PreferredBrand 8OTC

TEARS NATURALE

TEARS NATURA SOL FREE OP Generic Non-Preferred 00065041631

8

OTC -

THERATEARS Non-PreferredBrand 8OTC

ASSORTED ANTI-FUNGALS

DIFLUCAN PreferredBrand 4

GRIFULVIN PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ASSORTED ANTI-FUNGALS

GRIS-PEG PreferredBrand 4

KETOCONAZOLE PreferredGeneric 4

NYSTATIN PreferredBrand/Generic 4

VFEND PreferredBrand 4

LAMISIL Non-PreferredBrand 5

SPORANOX Non-PreferredBrand 5

SPORANOX PULSEPAK Non-PreferredBrand 5



ASTRINGENTS / PROTECTANTS

ALUMINUM CHLORIDE HEXAHYD PreferredGeneric 4

CRITIC-AID PreferredBrand 4OTC

DRYSOL PreferredBrand 4

XERAC AC PreferredBrand 4

ALUMINUM CHLORIDE HEXAHYD Non-PreferredBrand 8OTC

BARBITURATE

CHLORAL HYDRATE

CHLORAL HYDR CAP 250MG Generic Preferred 00157082001

4

CHLORAL HYDR CAP 500MG Generic Preferred 00182032401

4

PHENOBARBITAL

PHENOBARB TAB 15MG Generic Preferred 00002103102

4

PHENOBARB TAB 16.2MG Generic Preferred 00252671201

4

PHENOBARBITA TAB 15MG Generic Preferred 57866417001

4

CHLORAL HYDRATE

CHLORAL HYDR SYP 500/10ML Generic Non-Preferred 00054813904

7

CHLORAL HYDR SYP 500/5ML Generic Non-Preferred 00121053204

7

MEBARAL Non-PreferredBrand 7

PHENOBARBITAL Non-PreferredBrand/Generic 7

PHENOBARB ELX 20MG/5ML Generic Non-Preferred 00002243805

7

PHENOBARB ELX 4MG/ML Generic Non-Preferred 00349403516

7

PHENOBARB TAB 100MG Generic Non-Preferred 00002103302

7


7

PHENOBARB TAB 16.2MG Generic Non-Preferred 00254501128

7

PHENOBARB TAB 1GR Generic Non-Preferred 61392039230

7


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


BARBITURATE


7


7


7


7


7


7


7

PHENOBARBITA TAB 100MG Generic Non-Preferred 00143145801

7

PHENOBARBITA TAB 16.2MG Generic Non-Preferred 54569545500

7

CHLORAL HYDRATE Non-PreferredBrand/Generic 8

CHLORAL HYDR SUP 500MG Generic Non-Preferred 00223530000

8

LUMINAL Non-PreferredBrand 8

PHENOBARBITAL Non-PreferredBrand/Generic 8

SOMNOTE Non-PreferredBrand 8

BETA - ADRENERGICS

ALBUTEROL PreferredGeneric 4

ALBUTEROL SULFATE PreferredGeneric 4

FORADIL AEROLIZER PreferredBrand 4

MAXAIR PreferredBrand 4

METAPROTERENOL SULFATE PreferredBrand/Generic 4

METAPROTEREN TAB 10MG Brand Preferred 58016040200

4

METAPROTEREN TAB 20MG Brand Preferred 00247035030

4

SEREVENT PreferredBrand 4

SEREVENT DISKUS PreferredBrand 4

TERBUTALINE SULFATE

TERBUTALINE TAB 2.5MG Generic Preferred 00115261101

4

TERBUTALINE TAB 5MG Generic Preferred 00115262201

4

ACCUNEB Non-PreferredBrand 8

ALBUTEROL Non-PreferredBrand 8

ALBUTEROL SULFATE Non-PreferredBrand 8

ALUPENT Non-PreferredBrand 8

BRETHINE Non-PreferredBrand 8

METAPROTERENOL SULFATE

METAPROTEREN AER .65/ACT Brand Non-Preferred 40893080715

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


BETA - ADRENERGICS

METAPROTEREN POW SULFATE Brand Non-Preferred 38779017100

8

PROVENTIL Non-PreferredBrand 8

PROVENTIL HFA Non-PreferredBrand 8

TERBUTALINE SULFATE

TERBUTALINE AER 0.2MG Generic Non-Preferred 40893081308

8

VENTOLIN Non-PreferredBrand 8

VENTOLIN HFA Non-PreferredBrand 8

VOLMAX Non-PreferredBrand 8

VOSPIRE ER Non-PreferredGeneric 8

XOPENEX Non-PreferredBrand 8

BETA - BLOCKERS - OPHTHALMIC

BETIMOL PreferredBrand 4

BETOPTIC-S PreferredBrand 4

CARTEOLOL HCL PreferredGeneric 4

LEVOBUNOLOL HCL PreferredGeneric 4

TIMOLOL MALEATE PreferredGeneric 4

TIMOLOL MALEATE OPHTHALMI PreferredGeneric 4

BETAGAN Non-PreferredBrand 8

BETAXOLOL HCL Non-PreferredGeneric 8

OCUPRESS Non-PreferredBrand 8

TIMOPTIC Non-PreferredBrand 8

TIMOPTIC-XE Non-PreferredBrand 8

BETA BLOCKERS - ALPHA / BETA

LABETALOL HCL PreferredGeneric 4

LABETALOL HCL Non-PreferredBrand 8

BETA BLOCKERS - CARDIO SELECTIVE

ACEBUTOLOL HCL PreferredGeneric 4

ATENOLOL PreferredBrand/Generic 4

BETAXOLOL HCL PreferredGeneric 4

BISOPROLOL FUMARATE PreferredGeneric 4

METOPROLOL TARTRATE PreferredBrand/Generic 4

TOPROL XL PreferredBrand 4

ACEBUTOLOL HCL Non-PreferredBrand 8

KERLONE Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


BETA BLOCKERS - CARDIO SELECTIVE

LOPRESSOR Non-PreferredBrand 8

TENORMIN Non-PreferredBrand 8

ZEBETA Non-PreferredBrand 8

BETA BLOCKERS - NON SELECTIVE

INDERAL LA

INDERAL LA CAP 120MG Brand Preferred 00046047381

4


4


4


4

NADOLOL PreferredBrand/Generic 4

PINDOLOL PreferredBrand/Generic 4

PROPRANOLOL HCL PreferredBrand/Generic 4

PROPRANOLOL POW USP NF Brand Preferred 51552091004

4

PROPRANOLOL SOL 20MG/5ML Brand Preferred 00054372763

4

PROPRANOLOL SOL 40MG/5ML Brand Preferred 00054373063

4

PROPRANOLOL TAB 90MG Brand Preferred 00904041940

4

PROPRANOLOL HCL LA

PROPRANOLOL CAP 80MG LA Brand Preferred 00615133243

4

SOTALOL HCL PreferredGeneric 4

TIMOLOL MALEATE PreferredGeneric 4

BETAPACE Non-PreferredBrand 8

BETAPACE AF Non-PreferredBrand 8

COREG Non-PreferredBrand 8

CORGARD Non-PreferredBrand 8

INDERAL Non-PreferredBrand 8

INDERAL LA

INDERAL LA CAP 120MG Brand Non-Preferred 57866491301

8


8


8


8

PROPRANOLOL HCL

PROPRANOLOL POW USP NF Brand Non-Preferred 49452608901

8

PROPRANOLOL POW Brand Non-Preferred 38779018303

8

PROPRANOLOL HCL LA Non-PreferredBrand/Generic 8

PROPRANOLOL CAP 80MG LA Brand Non-Preferred 00615133229

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


BETA BLOCKERS - NON SELECTIVE

TIMOLOL MALEATE Non-PreferredBrand 8

BETA BLOCKERS AND DIURETIC COMBOS

ATENOLOL/CHLORTHALIDONE PreferredGeneric 4

BISOPROLOL FUMARATE/HCTZ PreferredGeneric 4

PROPRANOLOL/HYDROCHLOROT

H

PreferredGeneric 4

CORZIDE Non-PreferredBrand 8

LOPRESSOR HCT Non-PreferredBrand 8

TENORETIC 100 Non-PreferredBrand 8

TENORETIC 50 Non-PreferredBrand 8

TIMOLIDE 10/25 Non-PreferredBrand 8

ZIAC Non-PreferredBrand 8

BETA-LACTAMS / CLAVULANATE COMBOS

AMOXICILLIN PreferredGeneric 4

AMOXIL PreferredBrand/Generic 4

AMOXIL CHW 125MG Brand Preferred 00029600439

4


4


4


4

AMOXIL DRO 50MG/ML Brand Preferred 00029603520

4

AMOXIL SUS 200/5ML Brand Preferred 00029604818

4

AMOXIL SUS 400/5ML Brand Preferred 00029604918

4

AMOXIL TAB 875MG Brand Preferred 00029604712

4

AMPICILLIN PreferredGeneric 4

AMPICILLIN SODIUM PreferredBrand/Generic 4

AUGMENTIN PreferredBrand 4

AUGMENTIN ES-600 PreferredBrand 4

AUGMENTIN XR PreferredBrand 4

BEEPEN PreferredGeneric 4

DICLOXACILLIN SODIUM PreferredGeneric 4

OXACILLIN SODIUM PreferredBrand/Generic 4

OXACILLIN INJ 10GM Generic Preferred 00003271525

4


4


4

OXACILLIN INJ 500MG Generic Preferred 00003271110

4

OXACILLIN SOL 250/5ML Generic Preferred 00093415773

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


BETA-LACTAMS / CLAVULANATE COMBOS

PENICILLIN V POTASSIUM PreferredGeneric 4

PRINCIPEN

PRINCIPEN CAP 250MG Generic Preferred 00003012251

4

TRIMOX PreferredGeneric 4

UNASYN PreferredBrand 4

VEETIDS PreferredGeneric 4

ZOSYN PreferredBrand 4

AMOXICILLIN Non-PreferredBrand 8

AMOXICILLIN/POTASSIUM CLA Non-PreferredGeneric 8

AMOXIL

AMOXIL TAB 500MG Brand Non-Preferred 00029604612

8

OXACILLIN SODIUM

OXACILLIN CAP 250MG Generic Non-Preferred 00093311501

8

OXACILLIN CAP 500MG Generic Non-Preferred 00093311701

8

PRINCIPEN Non-PreferredBrand/Generic 8

PRINCIPEN CAP 500MG Generic Non-Preferred 66116024928

8

PRINCIPEN SUS 125/5ML Generic Non-Preferred 00003096915

8

PRINCIPEN SUS 250/5ML Generic Non-Preferred 00003097220

8

BI-PHASIC COMBINATIONS

ORTHO-NOVUM 10/11-28 PreferredBrand 4

NECON 10/11-28 Non-PreferredGeneric 8

BPH

DOXAZOSIN MESYLATE PreferredGeneric 4

TERAZOSIN HCL PreferredBrand/Generic 4

FLOMAX Non-PreferredBrand 5

AVODART Non-PreferredBrand 8

CARDURA Non-PreferredBrand 8

HYTRIN Non-PreferredBrand 8

PROSCAR Non-PreferredBrand 8

BURN PRODUCTS

SILVER SULFADIAZINE

SILVER SULFA CRE 1% Generic Preferred 49999018550

4

SSD

SSD CRE 1% Generic Preferred 49884060057

4

THERMAZENE PreferredGeneric 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


BURN PRODUCTS

SILVADENE Non-PreferredBrand 8

SILVER SULFADIAZINE

SILVER SULFA CRE 1% Generic Non-Preferred 00591081083

8

SSD

SSD AF CRE 1% Generic Non-Preferred 49884060139

8

SSD AF Non-PreferredGeneric 8

CARBONIC ANHYDRASE INHIBITORS/COMBO

AZOPT PreferredBrand 4

COSOPT PreferredBrand 4

TRUSOPT PreferredBrand 4

CARBOXYLIC ACID DERIVATIVES

DEPAKOTE ER

DEPAKOTE ER TAB 250 MG Brand Preferred 00074382613

4

DEPAKOTE ER TAB 500MG Brand Preferred 00074712613

4

DEPAKOTE ER

DEPAKOTE ER TAB 250 MG Brand Non-Preferred 00074382611

8

CARDIAC GLYCOSIDES

DIGITEK PreferredGeneric 4

DIGOXIN

DIGOXIN TAB 0.125MG Generic Preferred 66116042930

4


4


4

DIGOXIN PEDIATRIC PreferredGeneric 4

LANOXICAPS PreferredBrand 4

LANOXIN

LANOXIN TAB 0.125MG Brand Preferred 00081024230

4


4


4

LANOXIN PED DRO 0.05/ML Brand Preferred 00081026427

4

LANOXIN PED ELX 0.05/ML Brand Preferred 00173026427

4

DIGOXIN

DIGOXIN INJ .1MG/ML Generic Non-Preferred 00074216701

8

DIGOXIN INJ .25MG/ML Generic Non-Preferred 00641141035

8

LANOXIN

LANOXIN INJ .1MG/ML Brand Non-Preferred 00081026210

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


CARDIAC GLYCOSIDES

LANOXIN INJ .25MG/ML Brand Non-Preferred 00081026010

8

CENTRALLY ACTING

BACLOFEN PreferredGeneric 4

CHLORZOXAZONE PreferredGeneric 4

CYCLOBENZAPRINE HCL PreferredGeneric 4

LIORESAL INTRATHECAL PreferredBrand 4

METHOCARBAMOL

METHOCARBAM TAB 500MG Generic Preferred 00005356223

4

METHOCARBAM TAB 750MG Generic Preferred 00005356323

4

ORPHENADRINE CITRATE CR Non-PreferredGeneric 7

ORPHENADRINE CITRATE ER Non-PreferredGeneric 7

TIZANIDINE HCL Non-PreferredGeneric 7

BACLOFEN Non-PreferredBrand 8

CARISOPRODOL Non-PreferredBrand/Generic 8

CHLORZOXAZONE Non-PreferredBrand 8

CYCLOBENZAPRINE HCL Non-PreferredBrand 8

DANTRIUM Non-PreferredBrand 8

FLEXERIL Non-PreferredBrand 8

METHOCARBAMOL

METHOCARBAM INJ 100MG/ML Generic Non-Preferred 00182306263

8

NORFLEX Non-PreferredBrand/Generic 8

SKELAXIN Non-PreferredBrand 8

SOMA Non-PreferredBrand 8

ZANAFLEX Non-PreferredBrand 8

CEPHALOSPORINS

CEFADROXIL HEMIHYDRATE

CEFADROXIL CAP 500MG Generic Preferred 63304058201

4

CEFADROXIL MONOHYDRATE

CEFADROXIL CAP 500MG Generic Preferred 54569439100

4

CEFADROXIL SUS 125/5ML Generic Preferred 00047252817

4

CEFADROXIL SUS 250/5ML Generic Preferred 00047253815

4

CEFAZOLIN SODIUM PreferredBrand/Generic 4

CEFUROXIME AXETIL PreferredGeneric 4

CEFZIL PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


CEPHALOSPORINS

CEPHALEXIN MONOHYDRATE PreferredBrand/Generic 4

CEPHALEXIN TAB 250MG Brand Preferred 00093223801

4

CEPHALEXIN TAB 500MG Brand Preferred 00093224001

4

DURICEF

DURICEF SUS 125/5ML Brand Preferred 00087078641

4


4


4

FORTAZ

FORTAZ INJ 1GM Brand Preferred 00173037835

4


4

FORTAZ INJ 500MG Brand Preferred 00173037731

4


4

KEFLEX PreferredGeneric 4

OMNICEF PreferredBrand 4

ROCEPHIN PreferredBrand 4

SUPRAX PreferredBrand 4

VANTIN PreferredBrand 4

CECLOR CD Non-PreferredBrand 8

CEDAX Non-PreferredBrand 8

CEFACLOR Non-PreferredBrand/Generic 8

CEFACLOR ER Non-PreferredBrand/Generic 8

CEFADROXIL HEMIHYDRATE

CEFADROXIL TAB 1GM Generic Non-Preferred 55175510201

8

CEFADROXIL MONOHYDRATE Non-PreferredBrand/Generic 8

CEFADROXIL SUS 500/5ML Generic Non-Preferred 00182701870

8

CEFADROXIL TAB 1000MG Generic Non-Preferred 00093079624

8

CEFADROXIL TAB 1GM Generic Non-Preferred 00364241124

8

CEFTIN Non-PreferredBrand 8

CEPHALEXIN MONOHYDRATE

CEPHALEXIN POW MONOHYDR Brand Non-Preferred 38779034410

8

DURICEF

DURICEF CAP 500MG Brand Non-Preferred 00087078407

8

DURICEF TAB 1GM Brand Non-Preferred 00087078541

8

FORTAZ


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


CEPHALOSPORINS

FORTAZ INJ 1GM Brand Non-Preferred 00173041200

8

FORTAZ INJ 2GM Brand Non-Preferred 00173041300

8

KEFLEX Non-PreferredBrand 8

CHELATING AGENTS

CUPRIMINE PreferredBrand 4

DEPEN TITRATABS Non-PreferredBrand 8

CHOLESTEROL - BILE SEQUESTRANTS

CHOLESTYRAMINE PreferredGeneric 4

CHOLESTYRAMINE LIGHT PreferredGeneric 4

COLESTID PreferredBrand 4

PREVALITE Non-PreferredGeneric 8

QUESTRAN Non-PreferredBrand 8

QUESTRAN LIGHT Non-PreferredBrand 8

WELCHOL Non-PreferredBrand 8

CHOLESTEROL - FIBRIC ACID DERIVATIVES

GEMFIBROZIL PreferredBrand/Generic 4

TRICOR PreferredBrand/Generic 4

LOPID Non-PreferredBrand 8

CHOLESTEROL - HGM COA + ABSORB INHIBITORS

ADVICOR PreferredBrand 4

ALTOCOR PreferredBrand 4

CRESTOR PreferredBrand 4

LESCOL PreferredBrand 4

LESCOL XL PreferredBrand 4

LIPITOR PreferredBrand 4

LOVASTATIN PreferredGeneric 4

ZOCOR PreferredBrand 4

MEVACOR Non-PreferredBrand 8

PRAVACHOL Non-PreferredBrand 8

ZETIA Non-PreferredBrand 8

Cholinomimetics - ACHE Inhibitors

REMINYL Non-PreferredBrand 5

ARICEPT Non-PreferredBrand 8

COGNEX Non-PreferredBrand 8

EXELON Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


COMBO PSYCHOTHERAPEUTICS

CHLORDIAZEPOXIDE/AMITRIPT PreferredGeneric 4

PERPHENAZINE/AMITRIPTYLIN PreferredBrand/Generic 4

COMT INHIBITORS

COMTAN PreferredBrand 4

TASMAR Non-PreferredBrand 8

COUGH/COLD

DECOFED PreferredGeneric 4OTC

GUAIFENESIN DM

GUAIFENESIN SYP DM Generic Preferred 52959075004

4

OTC -

GUAIFENESIN/DEXTROMETHORP

GG/DM SYP 100-10/5 Generic Preferred 00536097047

4

OTC -

GG/DM SYP 100-15/5 Generic Preferred 47679041611

4

OTC -

GUIATUSS DM

GUIATUSS DM SYP 100-10/5 Generic Preferred 11845013504

4

OTC -

GUIATUSS DM SYP 100-15/5 Generic Preferred 00182073537

4

OTC -

GUIATUSS DM SYP 10-100 Generic Preferred 49999018804

4

OTC -

PSEUDO PreferredGeneric 4OTC

PSEUDOEPHEDRINE HCL

PSEUDOEPHEDR SYP 30MG/5ML Generic Preferred 00005349524

4

PSEUDOEPHEDR TAB 30MG Generic Preferred 17236026324

4

OTC -

PSEUDOEPHEDR TAB 60MG Generic Preferred 00005313457

4

PSEUDOEPHEDRINE HCL CR

PSEUDOEPHEDR CAP 120MG CR Generic Preferred 00349824801

4

PSEUDOEPHEDR TAB 120MG CR Generic Preferred 00814649014

4

OTC -

ROBAFEN DM PreferredGeneric 4OTC

ROBITUSSIN

ROBITUSSIN SYP DM Brand Preferred 00031868529

4

OTC -

ROBITUSSIN DM PreferredBrand 4OTC

ROBITUSSIN SUGAR FREE PreferredBrand 4OTC

SUDOGEST PreferredGeneric 4OTC

TUSSIN DM

TUSSIN DM LIQ 100-10/5 Generic Preferred 36800016259

4

OTC -

TUSSIN DM SYP 100-10/5 Generic Preferred 00113035926

4

OTC -


4

OTC -


4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


COUGH/COLD

TUSSIN DM SYP Generic Preferred 36800013442

4

OTC -

AH-CHEW Non-PreferredGeneric 8

AMIBID DM Non-PreferredGeneric 8

AMIBID LA Non-PreferredGeneric 8

AMI-TEX LA Non-PreferredGeneric 8

AMITEX PSE Non-PreferredGeneric 8

ANDEHIST DM NR Non-PreferredGeneric 8

ANDEHIST NR Non-PreferredGeneric 8

BENZONATATE Non-PreferredGeneric 8

BROMATANE DX Non-PreferredGeneric 8

BROMAXEFED DM RF Non-PreferredGeneric 8

BROMETANE DX Non-PreferredGeneric 8

BROMFED Non-PreferredBrand/Generic 8

BROMFENEX Non-PreferredGeneric 8

BROMFENEX PD Non-PreferredGeneric 8

CARBAXEFED DM RF Non-PreferredGeneric 8

CARBINOXAMINE COMPOUND Non-PreferredGeneric 8

CHERATUSSIN AC Non-PreferredGeneric 8

CHERATUSSIN DAC Non-PreferredGeneric 8OTC

CHILDRENS PSEUPHEDRIN Non-PreferredGeneric 8OTC

CHLORPHENIRAMINE/PSEUDOEP Non-PreferredGeneric 8

CODAL-DH Non-PreferredGeneric 8

CODEINE/GUAIFENESIN Non-PreferredGeneric 8

C-PHED DM TANNATE Non-PreferredGeneric 8

C-PHED TANNATE Non-PreferredGeneric 8

CRANTEX LA Non-PreferredGeneric 8

DELSYM Non-PreferredBrand 8OTC

DEXALONE Non-PreferredBrand 8OTC

DIABETIC TUSSIN EX Non-PreferredGeneric 8OTC

DIHISTINE DH Non-PreferredBrand/Generic 8OTC

DIMETAPP DM Non-PreferredBrand/Generic 8OTC

DRITUSS G Non-PreferredGeneric 8

DRITUSS HD Non-PreferredGeneric 8

DRIXORAL COLD/ALLERGY Non-PreferredBrand 8OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


COUGH/COLD

DURATUSS AM/PM Non-PreferredBrand 8

DURATUSS GP Non-PreferredBrand 8

DURATUSS HD Non-PreferredBrand 8

ENTEX PSE Non-PreferredGeneric 8

EXTENDRYL Non-PreferredBrand 8

EXTENDRYL JR Non-PreferredBrand 8

EXTENDRYL SR Non-PreferredBrand 8

GFN/PSE Non-PreferredGeneric 8

GUAIBID LA Non-PreferredGeneric 8

GUAIFED-PD Non-PreferredBrand/Generic 8

GUAIFEN PSE Non-PreferredGeneric 8

GUAIFENESIN Non-PreferredBrand/Generic 8OTC

GUAIFENESIN 1200 Non-PreferredGeneric 8

GUAIFENESIN AC Non-PreferredGeneric 8OTC

GUAIFENESIN CR Non-PreferredGeneric 8

GUAIFENESIN DM

GUAIFEN DM LIQ 100-10/5 Generic Non-Preferred 55370090524

8

OTC -

GUAIFEN DM TAB 30-600ER Generic Non-Preferred 66993031002

8

GUAIFEN DM TAB 30-600SR Generic Non-Preferred 52544043301

8

GUAIFEN DM TAB 600-30CR Generic Non-Preferred 55289062520

8

GUAIFENESIN LIQ DM Generic Non-Preferred 60432004816

8

GUAIFENESIN TAB DM Generic Non-Preferred 54868317500

8

GUAIFENESIN ER Non-PreferredGeneric 8

GUAIFENESIN LA Non-PreferredGeneric 8

GUAIFENESIN/DEXTROMETHORP

GG/DM LIQ 100-10/5 Generic Non-Preferred 54569104800

8

OTC -

GG/DM LIQ 100-15/5 Generic Non-Preferred 54569358200

8

OTC -

GG/DM CR TAB 600-30MG Generic Non-Preferred 57664035508

8

GG/DM LA TAB Generic Non-Preferred 00677182901

8

GG/DM SR TAB 600-30MG Generic Non-Preferred 52959044414

8

GG/DM/PSE TAB 12HR Generic Non-Preferred 00677184601

8

GUA/DEX/PSEU TAB Generic Non-Preferred 00677187501

8

GUAIFENESIN TAB W/DM ER Generic Non-Preferred 52152024602

8

GUAIFENESIN/PSEUDOEPHEDRI Non-PreferredGeneric 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


COUGH/COLD

GUAIFENESIN-DM NR Non-PreferredGeneric 8OTC

GUAIFENEX DM Non-PreferredGeneric 8

GUAIFENEX G Non-PreferredGeneric 8

GUAIFENEX GP Non-PreferredGeneric 8

GUAIFENEX LA Non-PreferredGeneric 8

GUAIFENEX PSE 120 Non-PreferredGeneric 8

GUAIFENEX PSE 60 Non-PreferredGeneric 8

GUIATUSS Non-PreferredGeneric 8OTC

GUIATUSS AC Non-PreferredGeneric 8OTC

GUIATUSS DAC Non-PreferredGeneric 8OTC

GUIATUSS DM

GUIATUSS DM LIQ 100-10/5 Generic Non-Preferred 58016401801

8

OTC -

GUIATUSS DM SYP 100-10/5 Generic Non-Preferred 54274077014

8

OTC -

GUIATUSS DM SYP 100-15/5 Generic Non-Preferred 00839538969

8

OTC -

HALOTUSSIN-AC Non-PreferredGeneric 8OTC

HISTA-VENT DA Non-PreferredGeneric 8

HISTINEX HC Non-PreferredGeneric 8

HT-TUSS DM Non-PreferredGeneric 8

HUMIBID LA Non-PreferredBrand 8

HUMIBID PEDIATRIC Non-PreferredBrand 8

HYCOTUSS EXPECTORANT Non-PreferredBrand 8

HYDROCODONE BITARTRATE/HO Non-PreferredGeneric 8

HYDROCODONE/GUAIFENESIN Non-PreferredGeneric 8

HYDROCODONE/HOMATROPINE Non-PreferredGeneric 8

HYDROMET Non-PreferredGeneric 8

HYDRO-TUSSIN HD Non-PreferredGeneric 8

KRONOFED-A-JR Non-PreferredGeneric 8

KWELCOF Non-PreferredBrand/Generic 8

MESCOLOR Non-PreferredBrand 8

MIRAPHEN PSE Non-PreferredGeneric 8

MYTUSSIN AC Non-PreferredGeneric 8OTC

MYTUSSIN DAC Non-PreferredGeneric 8OTC

P-EPD TAN/CHLOR-TAN Non-PreferredGeneric 8

PHENCLOR TANNATE PEDIATRI Non-PreferredGeneric 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


COUGH/COLD

PROMETHAZINE PLAIN/CODEIN Non-PreferredGeneric 8

PROMETHAZINE VC Non-PreferredBrand/Generic 8

PROMETHAZINE VC/CODEINE Non-PreferredBrand/Generic 8

PROMETHAZINE/CODEINE Non-PreferredGeneric 8

PROMETHAZINE/DEXTROMETHOR Non-PreferredGeneric 8

PROTUSS Non-PreferredGeneric 8

PSEUDOEPHEDRINE HCL Non-PreferredBrand/Generic 8

PSEUDOEPHEDR LIQ 30MG/5ML Generic Non-Preferred 50383068004

8

OTC -

PSEUDOEPHEDR TAB 30MG Generic Non-Preferred 20254021024

8

OTC -

PSEUDOEPHEDR TAB 60MG Generic Non-Preferred 20254021224

8

OTC -

PSEUDOEPHEDRINE HCL CR

PSEUDOEPHEDR CAP 120MG CR Generic Non-Preferred 37205044652

8

OTC -

PSEUDOEPHEDRINE/GUAIFENES Non-PreferredBrand/Generic 8

PSEUDOVENT Non-PreferredGeneric 8

PSEUDOVENT PED Non-PreferredGeneric 8

Q-BID-DM Non-PreferredGeneric 8

Q-BID-LA Non-PreferredGeneric 8

RI-TUSSIN Non-PreferredGeneric 8OTC

ROBAFEN AC Non-PreferredGeneric 8

ROBITUSSIN

ROBITUSSIN SOL DAC Brand Non-Preferred 00031868012

8

OTC -

ROBITUSSIN SYP 100/5ML Brand Non-Preferred 00031862412

8

OTC -

ROBITUSSIN SYP CF Brand Non-Preferred 00031867712

8

OTC -

ROBITUSSIN SYP NIGHT Brand Non-Preferred 00031864012

8

OTC -

ROBITUSSIN SYP PE Brand Non-Preferred 00031869525

8

OTC -

ROBITUSSIN PE Non-PreferredBrand 8OTC

RONDEC Non-PreferredBrand/Generic 8

RONDEC DM Non-PreferredBrand 8

RYNATAN Non-PreferredBrand 8

RYNATAN PEDIATRIC Non-PreferredBrand 8

RYNATUSS PEDIATRIC Non-PreferredBrand 8

SEMPREX-D Non-PreferredBrand 8

SUDAFED 12 HOUR Non-PreferredGeneric 8OTC

SU-TUSS DM Non-PreferredGeneric 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


COUGH/COLD

SU-TUSS HD Non-PreferredGeneric 8

TANAFED Non-PreferredBrand 8

TANAFED DM Non-PreferredBrand/Generic 8

TANAFED DMX Non-PreferredBrand 8

TANAFED DP Non-PreferredBrand 8

TANNIHIST-12 RF Non-PreferredGeneric 8

TESSALON Non-PreferredBrand 8

TETRA TANNATE PEDIATRIC Non-PreferredGeneric 8

TRINALIN REPETABS Non-PreferredBrand 8

TRIPLE TANNATE PEDIATRIC Non-PreferredGeneric 8

TUSSI-12D S Non-PreferredBrand 8

TUSSIN Non-PreferredGeneric 8OTC

TUSSIN DM

TUSSIN DM LIQ 100-10/5 Generic Non-Preferred 11161098112

8

OTC -

TUSSIONEX Non-PreferredBrand 8

COX 2 INHIBITORS

BEXTRA Non-PreferredBrand 8

CELEBREX Non-PreferredBrand 8

VIOXX Non-PreferredBrand 8

CYCLOPLEGICS

AK-PENTOLATE PreferredGeneric 4

ATROPINE SULFATE PreferredBrand/Generic 4

CYCLOPENTOLATE HCL PreferredGeneric 4

HOMATROPINE HBR PreferredGeneric 4

ISOPTO HYOSCINE PreferredBrand 4

TROPICAMIDE

TROPICAMIDE SOL 0.5% OP Generic Preferred 00302749015

4

TROPICAMIDE SOL 1% OP Generic Preferred 00302749315

4

CYCLOGYL Non-PreferredBrand 8

ISOPTO HOMATROPINE Non-PreferredBrand 8

TROPICAMIDE Non-PreferredBrand/Generic 8

TROPICAMIDE SOL 1% OP Generic Non-Preferred 24208058559

8

CYTO-MEGALOVIRUS AGENTS

VALCYTE PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


CYTO-MEGALOVIRUS AGENTS

CYTOVENE Non-PreferredBrand 8

DENTAL PRODUCTS

ETHEDENT PreferredGeneric 4

GEL-KAM PreferredBrand 4

PREVIDENT PreferredBrand 4

PREVIDENT 5000 PLUS PreferredBrand 4

SF PreferredGeneric 4

APF GEL Non-PreferredGeneric 8

SF 5000 PLUS Non-PreferredGeneric 8

DE-PIGMENTING AGENTS

GLYQUIN Non-PreferredGeneric 8

HYDROQUINONE Non-PreferredBrand/Generic 8OTC

HYDROQUINONE/SUNSCREENS Non-PreferredGeneric 8

TRI-LUMA Non-PreferredBrand 8

Diabetic - Alpha-Glucosidase Inhibitors

GLYSET PreferredBrand 4

PRECOSE Non-PreferredBrand 8

Diabetic - Biguanides

GLUCOPHAGE PreferredGeneric 4

METFORMIN HCL PreferredGeneric 4

GLUCOPHAGE Non-PreferredBrand 8

GLUCOPHAGE XR Non-PreferredBrand 8

Diabetic - Insulin

ILETIN II NPH/PORK PreferredBrand 4OTC

ILETIN II REGULAR/PORK PreferredBrand 4OTC

LANTUS PreferredBrand 4

NOVOLIN 70/30 PreferredBrand 4OTC

NOVOLIN L PreferredBrand 4OTC

NOVOLIN N PreferredBrand 4OTC

NOVOLIN R PreferredBrand 4OTC

NOVOLOG PreferredBrand 4

RELION 70/30 PreferredBrand 4OTC

RELION N PreferredBrand 4OTC

RELION R PreferredBrand 4OTC

VELOSULIN BR PreferredBrand 4OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


Diabetic - Insulin

HUMALOG Non-PreferredBrand 8

HUMALOG MIX 75/25 Non-PreferredBrand 8

HUMULIN 50/50 Non-PreferredBrand 8OTC

HUMULIN 70/30 Non-PreferredBrand 8OTC

HUMULIN L Non-PreferredBrand 8OTC

HUMULIN N Non-PreferredBrand 8OTC

HUMULIN R Non-PreferredBrand 8OTC

HUMULIN U Non-PreferredBrand 8OTC

Diabetic - Meglitinides

PRANDIN Non-PreferredBrand 8

Diabetic - Penfills

NOVOLIN 70/30 Non-PreferredBrand 5OTC

NOVOLIN 70/30 INNOLET Non-PreferredBrand 5OTC

NOVOLIN 70/30 PENFILL Non-PreferredBrand 5OTC

NOVOLIN N Non-PreferredBrand 5OTC

NOVOLIN N INNOLET Non-PreferredBrand 5OTC

NOVOLIN N U-100 PENFILL Non-PreferredBrand 5OTC

NOVOLIN R Non-PreferredBrand 5OTC

NOVOLIN R INNOLET Non-PreferredBrand 5OTC

NOVOLIN R U-100 PENFILL Non-PreferredBrand 5OTC

NOVOLOG Non-PreferredBrand 5

NOVOLOG MIX 70/30 PENFILL Non-PreferredBrand 5

NOVOLOG MIX 70/30 PREFILL Non-PreferredBrand 5

NOVOLOG PENFILL Non-PreferredBrand 5

HUMALOG Non-PreferredBrand 8

HUMALOG MIX 75/25 PEN Non-PreferredBrand 8

HUMALOG PEN Non-PreferredBrand 8

HUMULIN 70/30 PEN Non-PreferredBrand 8OTC

HUMULIN N U-100 PEN Non-PreferredBrand 8OTC

Diabetic - Sulfonylurea-Biguanide Combinations

GLUCOVANCE Non-PreferredBrand 8

METAGLIP Non-PreferredBrand 8

Diabetic - Sulfonylureas

CHLORPROPAMIDE PreferredGeneric 4

GLIPIZIDE PreferredBrand/Generic 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


Diabetic - Sulfonylureas

GLYBURIDE PreferredBrand/Generic 4

GLYBURIDE MICRONIZED PreferredGeneric 4

STARLIX PreferredBrand 4

TOLAZAMIDE PreferredGeneric 4

TOLBUTAMIDE PreferredBrand/Generic 4

AMARYL Non-PreferredBrand 8

DIABETA Non-PreferredBrand 8

GLUCOTROL Non-PreferredBrand 8

GLUCOTROL XL Non-PreferredBrand 8

GLYNASE Non-PreferredBrand 8

MICRONASE Non-PreferredBrand 8

Diabetic - Thiazol/Biquanide combo

AVANDAMET

AVANDAMET TAB 1-500MG Brand Preferred 00007316618

4


4


4

AVANDAMET

AVANDAMET TAB 2-1000MG Brand Non-Preferred 00007316318

8

AVANDAMET TAB 4-1000MG Brand Non-Preferred 00007316418

8

Diabetic - Thiazolidinediones

AVANDIA Non-PreferredBrand 5

ACTOS Non-PreferredBrand 8

DIGESTIVE ENZYMES

LACTAID ULTRA PreferredBrand 4OTC

LACTRASE PreferredBrand 4OTC

LIPRAM 4500 Non-PreferredGeneric 7

LIPRAM-PN16 Non-PreferredGeneric 7

LIPRAM-UL20 Non-PreferredGeneric 7

PANCREASE Non-PreferredBrand 7

PANCRELIPASE Non-PreferredBrand/Generic 7

PANGESTYME CN 20 Non-PreferredGeneric 7

PANGESTYME EC Non-PreferredGeneric 7

PANGESTYME MT 16 Non-PreferredGeneric 7

PANOKASE Non-PreferredGeneric 7

PLARETASE 8000 Non-PreferredGeneric 7


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


DIGESTIVE ENZYMES

ULTRASE Non-PreferredGeneric 7

CREON 5 Non-PreferredBrand 8



KUTRASE Non-PreferredBrand 8

LIPRAM CR 10000 Non-PreferredGeneric 8

LIPRAM-CR20 Non-PreferredGeneric 8

LIPRAM-CR5 Non-PreferredGeneric 8



PANCREASE Non-PreferredBrand 8

PANCREASE MT 10 Non-PreferredBrand 8




PANCRECARB MS-8 Non-PreferredBrand 8

PANCRELIPASE Non-PreferredBrand/Generic 8

ULTRASE MT 12 Non-PreferredBrand 8



VIOKASE 16 Non-PreferredBrand 8

VIOKASE 8 Non-PreferredBrand 8

DILTIAZEMS

CARDIZEM LA PreferredBrand 1

DILTIA XT PreferredGeneric 1

DILTIAZEM CD PreferredGeneric 1

DILTIAZEM HCL

DILTIAZEM CAP 300MG Generic Preferred 00258369090

1


1

DILTIAZEM HCL ER

DILTIAZEM ER CAP 120MG/24 Generic Preferred 51079094701

1

DILTIAZEM ER CAP 120MG Generic Preferred 54868310300

1


1


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


DILTIAZEMS

DILTIAZEM ER CAP 180MG Generic Preferred 66116043230

1


1


1

DILTIAZEM HC CAP 180MG ER Generic Preferred 54868418600

1

DILTIAZEM HC CAP 240MG ER Generic Preferred 54868418400

1

DILTIAZEM XR PreferredGeneric 1

CARTIA XT PreferredGeneric 4

DILTIAZEM CD PreferredGeneric 4

DILTIAZEM HCL


4

DILTIAZEM CAP 240MG/24 Generic Preferred 57866612701

4

DILTIAZEM HCL ER


4


4


4

DILTIAZEM XR PreferredGeneric 4

DILTIAZEM HCL

DILTIAZEM CAP 120MG Generic Non-Preferred 00258368790

6


6


6

TAZTIA XT Non-PreferredGeneric 6

TIAZAC Non-PreferredBrand 7

CARDIZEM Non-PreferredBrand 8

CARDIZEM CD Non-PreferredBrand 8

CARDIZEM SR Non-PreferredBrand 8

DILTIAZEM HCL

DILTIAZEM INJ 5MG/ML Generic Non-Preferred 00548580000

8

DILTIAZEM SOL 5MG/ML Generic Non-Preferred 00074117101

8

DILTIAZEM TAB 120MG Generic Non-Preferred 00003585002

8


8


8


8

DILTIAZEM HCL ER

DILTIAZEM CAP 120MG ER Generic Non-Preferred 00093002301

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


DILTIAZEMS


8


8

DIURETICS

ACETAZOLAMIDE PreferredBrand/Generic 4

AMILORIDE HCL PreferredBrand/Generic 4

AMILORIDE/HYDROCHLOROTHIA PreferredGeneric 4

BUMETANIDE PreferredBrand/Generic 4

CHLOROTHIAZIDE PreferredGeneric 4

CHLORTHALIDONE PreferredBrand/Generic 4

FUROSEMIDE PreferredBrand/Generic 4

HYDROCHLOROTHIAZIDE

HCTZ POW USP NF Brand Preferred 49452357501

4

HCTZ POW USP Brand Preferred 62991107701

4

HCTZ POW Brand Preferred 38779031400

4

HYDROCHLOROT SOL 100MG/ML Brand Preferred 00054338244

4

HYDROCHLOROT SOL 50MG/5ML Brand Preferred 00054338363

4

HYDROCHLOROT TAB 100MG Brand Preferred 00172248560

4

HYDROCHLOROT TAB 25MG Brand Preferred 40893063001

4

INDAPAMIDE PreferredBrand/Generic 4

METHAZOLAMIDE PreferredGeneric 4

METHYCLOTHIAZIDE PreferredBrand/Generic 4

METOLAZONE PreferredGeneric 4

SPIRONOLACTONE PreferredBrand/Generic 4

SPIRONOLACTONE/HYDRO PreferredGeneric 4

SPIRONOLACTONE/HYDROCHLOR PreferredGeneric 4

TORSEMIDE PreferredGeneric 4

TRIAMTERENE/HYDROCHLOROTH PreferredGeneric 4

ZAROXOLYN PreferredBrand 4

ALDACTAZIDE Non-PreferredBrand 8

ALDACTONE Non-PreferredBrand 8

BUMEX Non-PreferredBrand 8

DEMADEX Non-PreferredBrand 8

DIAMOX Non-PreferredBrand 8

DIURIL Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


DIURETICS

DYAZIDE Non-PreferredBrand 8

HYDROCHLOROTHIAZIDE

HCTZ POW USP Brand Non-Preferred 51552101204

8

LASIX Non-PreferredBrand 8

LOZOL Non-PreferredBrand 8

MAXZIDE-25 Non-PreferredBrand 8

METHAZOLAMIDE Non-PreferredBrand 8

MICROZIDE Non-PreferredBrand 8

MIDAMOR Non-PreferredBrand 8

EMERGENCY CONTRACEPTIVE

PREVEN PreferredBrand 4

EMOLLIENTS

A & D ZINC OXIDE PreferredBrand 4OTC

LAC-HYDRIN PreferredBrand 4

UREACIN-20 PreferredGeneric 4OTC

AMMONIUM LACTATE Non-PreferredGeneric 8

LACLOTION Non-PreferredGeneric 8

LACTINOL Non-PreferredBrand 8

RENOVA Non-PreferredBrand 8

VANAMIDE Non-PreferredBrand 8

ENZYMES / KERATOLYTICS / UREA

GRANUL-DERM PreferredGeneric 4

GRANULEX PreferredBrand 4

PANAFIL

PANAFIL OIN Brand Preferred 00064341007

4

XENADERM PreferredBrand 4

CARMOL 40 Non-PreferredBrand 8

PANAFIL

PANAFIL OIN Brand Non-Preferred 00263514516

8

SANTYL Non-PreferredBrand 8

ERGOTAMINE DERIVATIVES

MIGRANAL PreferredBrand 4

D.H.E. 45 Non-PreferredBrand 8

ERYTHROPOEITINS

PROCRIT Non-PreferredBrand 5


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ERYTHROPOEITINS

EPOGEN Non-PreferredBrand 6

ARANESP Non-PreferredBrand 8

ESTROGEN COMBOS

ESTRATEST PreferredBrand 4

ESTRATEST H.S. PreferredBrand 4

PREMPHASE PreferredBrand 4

PREMPRO PreferredBrand 4

PREMPRO LOW DOSE PreferredBrand 4

ACTIVELLA Non-PreferredBrand 8

COMBIPATCH Non-PreferredBrand 8

FEMHRT 1/5 Non-PreferredBrand 8

ORTHO-PREFEST Non-PreferredBrand 8

SYNTEST D.S. Non-PreferredGeneric 8

SYNTEST H.S. Non-PreferredGeneric 8

ESTROGENS - PATCHES

ALORA Non-PreferredBrand 5

ESCLIM Non-PreferredBrand 5

ESTRADERM Non-PreferredBrand 5

ESTRADIOL Non-PreferredGeneric 5

VIVELLE Non-PreferredBrand 5

VIVELLE-DOT Non-PreferredBrand 5

ALORA Non-PreferredBrand 8

CLIMARA Non-PreferredBrand 8

ESCLIM Non-PreferredBrand 8

VIVELLE Non-PreferredBrand 8

VIVELLE-DOT Non-PreferredBrand 8

ESTROGENS - TABS

CENESTIN PreferredBrand 4

DELESTROGEN PreferredBrand 4

ESTRADIOL PreferredBrand/Generic 4

ESTROPIPATE PreferredGeneric 4

MENEST PreferredBrand/Generic 4

PREMARIN

PREMARIN INJ 25MG Brand Preferred 00046055205

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ESTROGENS - TABS

PREMARIN TAB 0.3MG Brand Preferred 00440817290

4


4


4


4


4

PREMARIN LOW DOSE PreferredBrand 4

ESTRACE Non-PreferredBrand 8

OGEN Non-PreferredBrand 8

ORTHO-EST Non-PreferredGeneric 8

PREMARIN

PREMARIN/MT TAB .625/5MG Brand Non-Preferred 00046087881

8

PREMARIN/MT TAB 1.25/10 Brand Non-Preferred 00046087981

8

FELODIPINES

PLENDIL Non-PreferredBrand 8

FERTILITY REGULATORS

CLOMIPHENE CITRATE Non-PreferredBrand/Generic 8

FLUOROQUINOLONES

AVELOX PreferredBrand 4

CIPRO PreferredBrand 4

CIPRO CYSTITIS PreferredBrand 4

CIPRO I.V. PreferredBrand 4

CIPRO XR

CIPRO XR TAB 500MG Brand Preferred 00026888950

4

CIPROFLOXACIN HCL PreferredBrand 4

NOROXIN PreferredBrand 4

AVELOX ABC PACK Non-PreferredBrand 8

CIPRO XR

CIPRO XR TAB 1000MG Brand Non-Preferred 00026889750

8

FLOXIN Non-PreferredBrand 8

LEVAQUIN Non-PreferredBrand 8

TEQUIN Non-PreferredBrand 8

G/M CSF

NEUPOGEN PreferredBrand 4

GENITAL WARTS

ALDARA PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


GENITAL WARTS

PODOFILOX Non-PreferredGeneric 5

CONDYLOX Non-PreferredBrand 8

GLUCOCORTICOIDS / MINERALOCORTICOIDS

CORTEF

CORTEF TAB 5MG Brand Preferred 00009001201

4

CORTISONE ACETATE

CORTISONE AC TAB 10MG Brand Preferred 00009002301

4


4

CORTISONE AC TAB 25MG Generic Preferred 00102107001

4


4

DELTASONE PreferredBrand/Generic 4

DEPO-MEDROL PreferredBrand 4

DEXAMETHASONE PreferredBrand/Generic 4

DEXAMETHASON SOL 0.5/5ML Brand Preferred 00054317763

4

DEXAMETHASON TAB 0.25MG Brand Preferred 49884008301

4

DEXAMETHASON TAB 1MG Brand Preferred 00054418125

4

DEXAMETHASON TAB 2MG Brand Preferred 00054418325

4

DEXAMETHASONE INTENSOL PreferredBrand 4

DEXAMETHASONE SODIUM PHOS PreferredBrand/Generic 4

ENTOCORT EC PreferredBrand 4

FLUDROCORTISONE ACETATE PreferredGeneric 4

HYDROCORTISONE

HYDROCORT TAB 10MG Generic Preferred 00157060801

4

HYDROCORT TAB 20MG Generic Preferred 00115368501

4

HYDROCORTONE

HYDROCORTONE TAB 10MG Brand Preferred 00006061968

4

HYDROCORTONE TAB 20MG Brand Preferred 00006062568

4

KENALOG-40 PreferredBrand 4

METHYLPREDNISOLONE PreferredGeneric 4

ORAPRED PreferredBrand 4

PREDNISOLONE PreferredBrand/Generic 4

PREDNISOLONE TAB 5MG Brand Preferred 00364021701

4

PREDNISOLONE SODIUM PHOSP PreferredGeneric 4

PREDNISONE

PREDNISONE PAK 10MG Brand Preferred 00659250321

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



PREDNISONE PAK 10MG Generic Preferred 00254509313

4

PREDNISONE PAK 5MG Generic Preferred 00254509413

4

PREDNISONE SOL 10/10ML Brand Preferred 00054873604

4

PREDNISONE SOL 20/20ML Brand Preferred 00054873004

4

PREDNISONE SOL 5MG/5ML Brand Preferred 00054372250

4

PREDNISONE SOL 5MG/5ML Generic Preferred 00304209374

4

PREDNISONE TAB 10MG Generic Preferred 00054473025

4

PREDNISONE TAB 1MG Brand Preferred 00054474125

4


4

PREDNISONE TAB 2.5MG Brand Preferred 00054474225

4

PREDNISONE TAB 2.5MG Generic Preferred 00157092601

4


4


4

PREDNISONE TAB 50MG Brand Preferred 00054473325

4


4


4

SOLU-CORTEF PreferredBrand 4

SOLU-MEDROL PreferredBrand 4

CORTEF

CORTEF SUS 10MG/5ML Brand Non-Preferred 00009014201

8

CORTEF TAB 10MG Brand Non-Preferred 00009003101

8

CORTEF TAB 20MG Brand Non-Preferred 00009004401

8

CORTISONE ACETATE

CORTISONE AC INJ 25MG/ML Generic Non-Preferred 00385102970

8

CORTISONE AC INJ 50MG/ML Generic Non-Preferred 00191008901

8

CORTISONE AC POW MICRO Brand Non-Preferred 51552003501

8

CORTISONE AC POW MICRONIZ Brand Non-Preferred 49452000101

8

CORTISONE AC POW USP Brand Non-Preferred 38779011703

8

CORTISONE AC POW Brand Non-Preferred 38779048203

8

DEXAMETHASONE

DEXAMETHASON POW MICRONIZ Brand Non-Preferred 38779040501

8

FLORINEF Non-PreferredBrand 8

FLUDROCORTISONE ACETATE Non-PreferredBrand 8

HYDROCORTISONE

HYDROCORT INJ 25MG/ML Generic Non-Preferred 00537235070

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



HYDROCORT INJ 50MG/ML Generic Non-Preferred 00364662554

8

HYDROCORTONE

HYDROCORTONE INJ 25MG/ML Brand Non-Preferred 00006750103

8

HYDROCORTONE INJ 50MG/ML Brand Non-Preferred 00006751903

8

MEDROL Non-PreferredBrand 8

METHYLPREDNISOLONE Non-PreferredBrand 8

PEDIAPRED Non-PreferredBrand 8

PREDNISOLONE

PREDNISOLONE POW USP NF Brand Non-Preferred 49452598001

8

PREDNISOLONE POW USP/NF Brand Non-Preferred 49452000401

8

PREDNISOLONE POW Brand Non-Preferred 00574047001

8

PREDNISOLONE SODIUM PHOSP Non-PreferredBrand 8

PREDNISONE

PREDNISONE POW MICRONIZ Brand Non-Preferred 38779015400

8

PREDNISONE POW USP NF Brand Non-Preferred 49452600001

8

PREDNISONE POW USP/NF Brand Non-Preferred 49452000901

8

PREDNISONE POW USP Brand Non-Preferred 17317066301

8

PREDNISONE POW Brand Non-Preferred 00574047501

8

PREDNISONE POW Generic Non-Preferred 39822520005

8

PRELONE Non-PreferredBrand 8

GOUT

ALLOPURINOL PreferredGeneric 4

COLCHICINE

COLCHICINE TAB 0.5MG Generic Preferred 00074007402

4

COLCHICINE TAB 0.6MG Brand Preferred 00074378101

4

COLCHICINE TAB 0.6MG Generic Preferred 00002101302

4

PROBENECID PreferredGeneric 4

PROBENECID/COLCHICINE PreferredGeneric 4

SULFINPYRAZONE PreferredBrand/Generic 4

COLCHICINE

COLCHICINE INJ 1MG/2ML Brand Non-Preferred 00002144316

8

COLCHICINE INJ 1MG/2ML Generic Non-Preferred 54569243500

8

COLCHICINE POW USP Brand Non-Preferred 62991122901

8

COLCHICINE POW Brand Non-Preferred 38779040703

8

ZYLOPRIM Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


GROWTH HORMONE

GENOTROPIN Non-PreferredBrand 5

GENOTROPIN MINIQUICK Non-PreferredBrand 5

NUTROPIN Non-PreferredBrand 6

NUTROPIN AQ Non-PreferredBrand 6

NUTROPIN AQ PEN Non-PreferredBrand 6

NUTROPIN DEPOT Non-PreferredBrand 6

HUMATROPE Non-PreferredBrand 8

NORDITROPIN CARTRIDGE Non-PreferredBrand 8

SAIZEN Non-PreferredBrand 8

H2-ANTAGONISTS

CIMETIDINE PreferredGeneric 4OTC

CIMETIDINE HCL PreferredBrand/Generic 4

CIMETIDINE SOL 300/5ML Brand Preferred 50962020005

4

FAMOTIDINE PreferredBrand/Generic 4

FAMOTIDINE TAB 20MG Brand Preferred 54348012160

4

PEPCID

PEPCID TAB 20MG Brand Preferred 54569235200

4

PEPCID AC PreferredGeneric 4OTC

RANITIDINE HCL PreferredGeneric 4

TAGAMET

TAGAMET LIQ 300/5ML Brand Preferred 00108501410

4

TAGAMET LIQ 400/6.67 Brand Preferred 00108502810

4

TAGAMET SUS 200/20ML Brand Preferred 00766501512

4

OTC -

TAGAMET/NACL INJ 300/50ML Brand Preferred 00108502904

4

AXID Non-PreferredBrand 8

CIMETIDINE Non-PreferredBrand 8

CIMETIDINE HCL

CIMETIDINE INJ 150MG/ML Brand Non-Preferred 00074744602

8

FAMOTIDINE

FAMOTIDINE POW USP Brand Non-Preferred 38779065504

8

NIZATIDINE Non-PreferredGeneric 8

PEPCID

PEPCID SUS 40MG/5ML Brand Non-Preferred 00006353892

8

PEPCID TAB 20MG Brand Non-Preferred 00006096328

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


H2-ANTAGONISTS

PEPCID TAB 40MG Brand Non-Preferred 00006096430

8

PEPCID I.V. INJ 10MG/ML Brand Non-Preferred 00006354114

8

PEPCID I.V. INJ 20MG/2ML Brand Non-Preferred 00006353904

8

PEPCID AC Non-PreferredBrand 8OTC

RANITIDINE HCL Non-PreferredBrand 8

TAGAMET

TAGAMET INJ 300/2ML Brand Non-Preferred 00108502001

8

TAGAMET LIQ 300/5ML Brand Non-Preferred 00108501448

8

TAGAMET TAB 200MG Brand Non-Preferred 00108501220

8


8


8


8

ZANTAC Non-PreferredBrand 8

HEMOSTATIC

AMICAR PreferredBrand 4

AMINOCAPROIC ACID PreferredGeneric 4

HEPATITIS B

HEPSERA PreferredBrand 4

HEPATITIS C

PEG-INTRON PreferredBrand 1

REBETOL PreferredBrand 1

PEGASYS Non-PreferredBrand 5

COPEGUS Non-PreferredBrand 8

HERPES AGENTS

ACYCLOVIR PreferredGeneric 4

VALTREX PreferredBrand 4

FAMVIR Non-PreferredBrand 8

ZOVIRAX Non-PreferredBrand 8

HYDRO-LYTIC ENZYMES

PULMOZYME Non-PreferredBrand 8

IMMUNOMODULATORS

ELIDEL Non-PreferredBrand 8

PROTOPIC Non-PreferredBrand 8

IMMUNOSUPPRESSANTS

CELLCEPT PreferredBrand 4

CYCLOSPORINE MODIFIED


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


IMMUNOSUPPRESSANTS

CYCLOSPORINE CAP MD 100MG Generic Preferred 00185093330

4

CYCLOSPORINE CAP MOD 25MG Generic Preferred 00185093230

4

GENGRAF

GENGRAF CAP 100MG Generic Preferred 00074647932

4

GENGRAF CAP 25MG Generic Preferred 00074646332

4

NEORAL PreferredBrand 4

PROGRAF

PROGRAF CAP 0.5MG Brand Preferred 00469060767

4

PROGRAF CAP 1MG Brand Preferred 00469061771

4

PROGRAF CAP 5MG Brand Preferred 00469065771

4

RAPAMUNE PreferredBrand 4

SANDIMMUNE PreferredBrand 4

CYCLOSPORINE Non-PreferredGeneric 8

CYCLOSPORINE MODIFIED

CYCLOSPORINE SOL MODIFIED Generic Non-Preferred 50111088542

8

GENGRAF

GENGRAF SOL 100MG/ML Generic Non-Preferred 00074726950

8

PROGRAF

PROGRAF INJ 5MG/ML Brand Non-Preferred 00469301601

8

IMPOTENCE AGENTS

CAVERJECT Non-PreferredBrand 8

CAVERJECT IMPULSE Non-PreferredBrand 8

LEVITRA Non-PreferredBrand 8

MUSE Non-PreferredBrand 8

VIAGRA Non-PreferredBrand 8

INFLAMMATORY BOWEL AGENTS

ASACOL PreferredBrand 4

AZULFIDINE EN-TABS PreferredBrand 4

CANASA PreferredBrand 4

COLAZAL PreferredBrand 4

DIPENTUM PreferredBrand 4

PENTASA PreferredBrand 4

ROWASA PreferredBrand 4

SULFASALAZINE PreferredGeneric 4

SULFASALAZINE Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


INFLAMMATORY BOWEL AGENTS

SULFAZINE EC Non-PreferredGeneric 8

INFLUENZA AGENTS

RIMANTADINE HCL PreferredGeneric 4

TAMIFLU PreferredBrand 4

FLUMADINE Non-PreferredBrand 8

INJECTIBLES

DEPO-PROVERA PreferredBrand 4

LUNELLE Non-PreferredBrand 8

IRRITABLE BOWEL SYNDROME AGENTS

LOTRONEX Non-PreferredBrand 8

ZELNORM Non-PreferredBrand 8

ISOSORBIDE DI-NITRATE

ISOSORBIDE DINITRATE

ISOSORB DIN CAP 40MG Generic Preferred 00157049401

4

ISOSORB DIN SUB 10MG Generic Preferred 00536395001

4

ISOSORB DIN SUB 2.5MG Generic Preferred 00143176525

4

ISOSORB DIN TAB 10MG Generic Preferred 61392030560

4


4


4


4


4

ISOSORBIDE DINITRATE ER PreferredGeneric 4

ISOSORBIDE MONONITRATE ER PreferredGeneric 4

DILATRATE SR Non-PreferredBrand/Generic 8

ISORDIL Non-PreferredBrand 8

ISOSORBIDE DINITRATE

ISOSORB DIN SUB 2.5MG Generic Non-Preferred 00005359234

8

ISOSORB DIN SUB 5MG Generic Non-Preferred 00102161201

8

ISOSORBIDE MONONITRATE

ISOSORBIDE MONONITRATE PreferredGeneric 4

ISOSORBIDE MONONITRATE ER PreferredGeneric 4

IMDUR Non-PreferredBrand 8

ISMO Non-PreferredBrand 8

MONOKET Non-PreferredBrand 8

ISRADIPINES

DYNACIRC CR PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


ISRADIPINES

DYNACIRC-CR PreferredBrand 4

DYNACIRC Non-PreferredBrand 8

K REMOVING RESINS

KAYEXALATE PreferredBrand 4

SODIUM POLYSTYRENE SULFON PreferredGeneric 4

SPS PreferredGeneric 4

LEUKOTRIENE RECEPTOR ANTAGONISTS

SINGULAIR Non-PreferredBrand 5

ACCOLATE Non-PreferredBrand 8

LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS

CLEOCIN

CLEOCIN INJ 300MG Brand Preferred 00009087021

4

CLEOCIN INJ 600/4ML Brand Preferred 54868415400

4


4


4

CLEOCIN INJ 9GM Brand Preferred 00009072805

4

CLEOCIN PED SUS 75MG/5ML Brand Preferred 00009076004

4

CLINDAMYCIN HCL

CLINDAMYCIN CAP 150MG Generic Preferred 00093317101

4

CLINDAMYCIN CAP 75MG Generic Preferred 00185075401

4

DAPSONE PreferredBrand 4

CLEOCIN

CLEOCIN CAP 150MG Brand Non-Preferred 53506037224

8


8


8

CLINDAMYCIN HCL

CLINDAMYCIN CAP 300MG Generic Non-Preferred 00591312001

8

ZYVOX Non-PreferredBrand 8

LITHIUM

ESKALITH PreferredBrand 4

ESKALITH CR PreferredBrand 4

LITHIUM CARBONATE

LITHIUM CARB CAP 150MG Brand Preferred 00054252625

4

LITHIUM CARB CAP 600MG Brand Preferred 00054253125

4

LITHIUM CARB TAB 300MG Brand Preferred 00054452725

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


LITHIUM

LITHIUM CARBONATE CR PreferredGeneric 4

LITHIUM CARBONATE ER PreferredGeneric 4

LITHIUM CITRATE PreferredGeneric 4

LITHOBID PreferredBrand 4

LITHIUM CARBONATE

LITHIUM CARB POW Brand Non-Preferred 10106236201

8

LOCAL ANESTHETICS

CAPSAICIN

CAPSAICIN CRE 0.025% Generic Preferred 00182507652

4

OTC -

CAPSAICIN CRE 0.075% Generic Preferred 00182507852

4

OTC -

LIDOCAINE/PRILOCAINE PreferredGeneric 4

MARCAINE

MARCAINE INJ 0.25% Brand Preferred 00024121202

4


4


4

MARCIANE INJ 0.5% Brand Preferred 54569229800

4

XYLOCAINE

XYLOCAINE GEL 2% Brand Preferred 54569226300

4

XYLOCAINE INJ 0.5% Brand Preferred 00186013501

4

XYLOCAINE INJ 1% Brand Preferred 00186011001

4

XYLOCAINE INJ 2% Brand Preferred 00186017014

4

XYLOCAINE INJ MPF 0.5% Brand Preferred 00186013701

4

XYLOCAINE INJ -MPF 1% Brand Preferred 00186021003

4

XYLOCAINE INJ MPF 1.5% Brand Preferred 00186024502

4


4


4

XYLOCAINE OIN 2.5% Brand Preferred 00186033501

4

OTC -

XYLOCAINE OIN 5% Brand Preferred 00186031521

4

XYLOCAINE SOL 4% Brand Preferred 00186032001

4

XYLOCAINE SOL 5% Brand Preferred 00186032501

4

CAPSAICIN

CAPSAICIN LOT 0.025% Generic Non-Preferred 24385067746

8

OTC -

ELA-MAX Non-PreferredBrand 8OTC

ELA-MAX PLUS Non-PreferredBrand 8OTC

EMLA Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


LOCAL ANESTHETICS

EMLA/TEGADERM Non-PreferredBrand 8

LIDA MANTLE Non-PreferredBrand 8

LIDOCAINE HCL Non-PreferredBrand/Generic 8

LIDODERM Non-PreferredBrand 8

MARCAINE

MARCAINE INJ SPINAL Brand Non-Preferred 00024122910

8

MARCAINE/ INJ EPI .25% Brand Non-Preferred 00024122202

8

MARCAINE/ INJ EPI .75% Brand Non-Preferred 00024122402

8

MARCAINE/ INJ EPI 0.5% Brand Non-Preferred 00024122302

8

XYLOCAINE

XYLO/DEXTROS INJ 1.5-7.5% Brand Non-Preferred 00186021203

8

XYLO/GLUCOSE INJ 5-7.5% Brand Non-Preferred 00186022503

8

XYLOCAINE AER 10% Brand Non-Preferred 00186035501

8

XYLOCAINE KIT DUO-TRAC Brand Non-Preferred 00186023572

8

ZOSTRIX-HP Non-PreferredBrand 8OTC

LONG ACTING ANXIOLYTICS

XANAX XR Non-PreferredBrand 8

LONG ACTING NARCOTICS

AVINZA PreferredBrand 4

KADIAN PreferredBrand 4

METHADONE HCL

METHADONE CON 10MG/ML Generic Preferred 51079069439

4

METHADONE TAB 10MG Generic Preferred 66689081010

4


4


4

METHADOSE PreferredGeneric 4

MOPRHINE SULFATE ER

MORPHINE SUL TAB 100MG ER Generic Preferred 00406839062

4

MORPHINE SULFATE

MORPHINE SUL INJ 0.5MG/ML Generic Preferred 00074405701

4

MORPHINE SUL INJ 10MG/ML Generic Preferred 00186115603

4


4


4


4


4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


LONG ACTING NARCOTICS


4


4


4


4

MORPHINE SULFATE ER


4


4


4

RMS

RMS SUP 10MG Brand Preferred 00245016112

4


4


4

DURAGESIC Non-PreferredBrand 7

METHADONE HCL

METHADONE TAB 10MG Generic Non-Preferred 00054855411

8

METHADONE TAB 5MG Generic Non-Preferred 00054855311

8

MOPRHINE SULFATE ER

MORPHINE SUL TAB 100MG ER Generic Non-Preferred 00406839001

8

MORPHINE SULFATE

MORPHINE SUL INJ 10MG/ML Generic Non-Preferred 54868475200

8


8


8


8


8

MORPHINE SUL SUP 10MG Generic Non-Preferred 00574711212

8


8

MORPHINE SULFATE ER

MORPHINE SUL TAB 100MG ER Generic Non-Preferred 60951065870

8

MS CONTIN Non-PreferredBrand 8

ORAMORPH SR Non-PreferredBrand 8

OXYCONTIN Non-PreferredBrand 8

RMS

RMS SUP 30MG Brand Non-Preferred 00245016312

8

MACROLIDES / ERYTHROMYCINS

E.E.S. 200 PreferredGeneric 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



E.E.S. 400 PreferredGeneric 4

E.E.S. GRANULES PreferredBrand 4

ERYPED

ERYPED DRO 100/2.5 Brand Preferred 00074630350

4

ERYPED 400 SUS 400/5ML Brand Preferred 00074630560

4

ERYPED 200 PreferredBrand 4

ERYPED 400 PreferredBrand 4

ERY-TAB PreferredBrand/Generic 4

ERYTHROCIN STEARATE PreferredGeneric 4

ERYTHROMYCIN PreferredBrand/Generic 4

ERYTHROMYCIN BASE PreferredBrand/Generic 4

ERYTHROMYCIN ESTOLATE

ERYTHROM EST SUS 125/5ML Brand Preferred 00472097716

4

ERYTHROM EST SUS 125/5ML Generic Preferred 00005311965

4

ERYTHROM EST SUS 250/5ML Brand Preferred 00472097916

4

ERYTHROM EST SUS 250/5ML Generic Preferred 00005312065

4

ERYTHROMYCIN ETHYLSUCCINA PreferredGeneric 4

ERYTHROMYCIN STEARATE PreferredBrand/Generic 4

ZITHROMAX

ZITHROMAX CAP 250MG Brand Preferred 00069305030

4

ZITHROMAX POW 1GM PAK Brand Preferred 00069305107

4

ZITHROMAX SUS 100/5ML Brand Preferred 00069311019

4

ZITHROMAX SUS 200/5ML Brand Preferred 00069312019

4

ZITHROMAX SUS 200MG/5 Brand Preferred 55045237305

4

ZITHROMAX TAB 250MG Brand Preferred 58016039101

4


4


4

ZITHROMAX TAB Z-PAK Brand Preferred 52959050506

4

ZITHROMAX TRI-PAK PreferredBrand 4

ZITHROMAX Z-PAK PreferredBrand 4

BIAXIN Non-PreferredBrand 8

BIAXIN XL Non-PreferredBrand 8

BIAXIN XL PAC Non-PreferredBrand 8

DYNABAC D5-PAK Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



E.E.S. 200 Non-PreferredBrand 8

ERYPED

ERYPED CHW 200MG Brand Non-Preferred 00074631440

8

ERYTHROMYCIN ESTOLATE

ERYTHROM EST CAP 250MG Generic Non-Preferred 00228219710

8

ERYTHROM EST TAB 250MG Brand Non-Preferred 51432017103

8

ERYTHROMYCIN ETHYLSUCCINA Non-PreferredBrand 8

PCE Non-PreferredBrand 8

ZITHROMAX

ZITHROMAX INJ 500MG Brand Non-Preferred 00069315014

8

MAO INHIBITORS

NARDIL PreferredBrand 4

PARNATE PreferredBrand 4

MIGRAINE MISCELLANEOUS MIXTURE THERAPIES

CAFERGOT PreferredBrand 4

MIGRAZONE Non-PreferredGeneric 8

MIOTICS - DIRECT ACTING

ISOPTO CARBACHOL PreferredBrand 4

ISOPTO CARPINE PreferredBrand 4

PILOCARPINE HCL PreferredBrand/Generic 4

PILOPINE HS PreferredBrand 4

MISC - ANTI-CONVULSANTS

CARBAMAZEPINE PreferredBrand/Generic 4

CARBAMAZEPIN SUS 100/5ML Brand Preferred 50962022705

4

CARBATROL PreferredBrand 4

CELONTIN PreferredBrand 4

CLONAZEPAM PreferredGeneric 4

DEPAKOTE PreferredBrand 4

DEPAKOTE SPRINKLES PreferredBrand 4

DIASTAT PreferredBrand 4

DIASTAT ADULT PreferredBrand 4

DIASTAT PEDIATRIC PreferredBrand 4

DIASTAT UNIVERSAL PreferredBrand 4

DILANTIN PreferredBrand 4

DILANTIN INFATABS PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISC - ANTI-CONVULSANTS

EPITOL PreferredGeneric 4

ETHOSUXIMIDE PreferredGeneric 4

FELBATOL PreferredBrand 4

MYSOLINE

MYSOLINE TAB 250MG Brand Preferred 00046043081

4

MYSOLINE TAB 50MG Brand Preferred 00046043181

4

PHENYTOIN PreferredBrand/Generic 4

PHENYTOIN SODIUM EXTENDED PreferredGeneric 4

PHENYTOIN SODIUM PROMPT PreferredBrand/Generic 4

TEGRETOL PreferredBrand 4

TEGRETOL-XR PreferredBrand 4

VALPROIC ACID PreferredGeneric 4

ZARONTIN

ZARONTIN CAP 250MG Brand Preferred 00071023724

4

CARBAMAZEPINE

CARBAMAZEPIN POW USP NF Brand Non-Preferred 49452170501

8

CARBAMAZEPIN POW USP Brand Non-Preferred 51552065325

8

CARBAMAZEPIN POW Brand Non-Preferred 38779011404

8

DEPAKENE Non-PreferredBrand 8

GABITRIL Non-PreferredBrand 8

KEPPRA Non-PreferredBrand 8

KLONOPIN Non-PreferredBrand 8

LAMICTAL Non-PreferredBrand 8

MYSOLINE

MYSOLINE SUS 250/5ML Brand Non-Preferred 00046385008

8

NEURONTIN Non-PreferredBrand 8

PHENYTEK Non-PreferredBrand 8

PRIMIDONE Non-PreferredGeneric 8

TOPAMAX Non-PreferredBrand 8

TRILEPTAL Non-PreferredBrand 8

ZARONTIN

ZARONTIN SYP 250/5ML Brand Non-Preferred 00071241823

8

ZONEGRAN Non-PreferredBrand 8

MISC - ANTIDEPRESSANTS--Join with SSRI class


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



BUPROPION HCL PreferredGeneric 4

CELEXA PreferredBrand 4

FLUOXETINE HCL

FLUOXETINE CAP 10MG Generic Preferred 63739029515

4

FLUOXETINE CAP 20MG Generic Preferred 00172435660

4

FLUOXETINE LIQ 20MG/5ML Generic Preferred 00093610812

4

FLUOXETINE PAK 20MG Generic Preferred 49999012814

4

FLUOXETINE TAB 10MG Generic Preferred 00093718810

4

FLUOXETINE TAB 20MG Generic Preferred 49884073501

4

FLUVOXAMINE MALEATE PreferredGeneric 4

LEXAPRO PreferredBrand 4

MIRTAZAPINE PreferredGeneric 4

NEFAZODONE HCL PreferredGeneric 4

PAROXETINE HCL

PAROXETINE TAB 10MG Generic Preferred 00904567661

4


4


4


4

PAXIL PreferredBrand 4

PAXIL CR PreferredBrand 4

SERZONE PreferredBrand 4

TRAZODONE HCL PreferredBrand/Generic 4

TRAZODONE TAB 100MG Generic Preferred 00003096350

4


4


4

WELLBUTRIN SR PreferredBrand 4

ZOLOFT PreferredBrand 4

EFFEXOR Non-PreferredBrand 5

EFFEXOR XR Non-PreferredBrand 5

DESYREL Non-PreferredBrand 8

FLUOXETINE HCL

FLUOXETINE CAP 40MG Generic Non-Preferred 00093719856

8

LUVOX Non-PreferredBrand 8

MAPROTILINE HCL Non-PreferredBrand/Generic 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



PAROXETINE HCL

PAROXETINE TAB 10MG Generic Non-Preferred 49884087611

8


8


8


8

PROZAC Non-PreferredBrand 8

PROZAC WEEKLY Non-PreferredBrand 8

REMERON Non-PreferredBrand 8

REMERON SOLTAB Non-PreferredBrand 8

SARAFEM Non-PreferredBrand 8

TRAZODONE HCL

TRAZODONE TAB 300MG Generic Non-Preferred 00555073302

8

WELLBUTRIN Non-PreferredBrand 8

WELLBUTRIN XL Non-PreferredBrand 8

MISC - ANXIOLYTICS

BUSPIRONE HCL PreferredGeneric 4

HYDROXYZINE HCL

HYDROXYZ HCL INJ 100/2ML Generic Preferred 00641043425

4

HYDROXYZ HCL INJ 25MG/ML Generic Preferred 00223788501

4

HYDROXYZ HCL INJ 50MG/ML Generic Preferred 00074570901

4

HYDROXYZ HCL SYP 10MG/5ML Generic Preferred 00047290223

4

HYDROXYZ HCL TAB 10MG Generic Preferred 00005379223

4

HYDROXYZINE PAMOATE

HYDROXYZ PAM CAP 25MG Generic Preferred 00102294501

4

HYDROXYZ PAM CAP 50MG Generic Preferred 00102295001

4

MEPROBAMATE PreferredGeneric 4

BUSPAR Non-PreferredBrand 8

DROPERIDOL Non-PreferredBrand/Generic 8

HYDROXYZINE HCL

HYDROXYZ HCL TAB 100MG Generic Non-Preferred 00555030002

8


8


8

HYDROXYZINE PAMOATE

HYDROXYZ PAM CAP 100MG Generic Non-Preferred 00182110001

8

VISTARIL Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISC - STIMULANTS

ADDERALL PreferredBrand 4

ADDERALL XR PreferredBrand 4

AMPHETAMINE SALT COMBO PreferredGeneric 4

AMPHETAMINE SALTS COMBO PreferredGeneric 4

CONCERTA PreferredBrand 4

DEXEDRINE

DEXEDRINE CAP 10MG CR Brand Preferred 54868381100

4

DEXEDRINE CAP 10MG Brand Preferred 00007351315

4


4


4

DEXEDRINE TAB 5MG Brand Preferred 00007351920

4

DEXTROAMPHETAMINE SULFATE

DEXTROAMPHET CAP 15MG Generic Preferred 00537613210

4

DEXTROAMPHET TAB 10MG Generic Preferred 00364009205

4

DEXTROAMPHET TAB 5MG Generic Preferred 00406895801

4

DEXTROSTAT PreferredBrand/Generic 4

FOCALIN PreferredBrand 4

METADATE CD

METADATE CD CAP 20MG Brand Preferred 53014057507

4

METADATE ER PreferredBrand/Generic 4

METHYLIN PreferredGeneric 4

METHYLIN ER

METHYLIN ER TAB 20MG Generic Preferred 00406145101

4

METHYLPHENIDATE HCL PreferredGeneric 4

METHYLPHENIDATE HCL ER PreferredGeneric 4

METHYLPHENIDATE HCL SR PreferredGeneric 4

CYLERT Non-PreferredBrand 8

DESOXYN Non-PreferredBrand 8

DEXEDRINE

DEXEDRINE ELX 5MG/5ML Brand Non-Preferred 00007351156

8

DEXTROAMPHETAMINE SULFATE

DEXTROAMPHET CAP 10MG CR Generic Non-Preferred 00406896101

8


8


8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISC - STIMULANTS

METADATE CD

METADATE CD CAP 10MG Brand Non-Preferred 53014057407

8

METADATE CD CAP 30MG Brand Non-Preferred 53014057607

8

METHYLIN ER

METHYLIN ER TAB 10MG Generic Non-Preferred 00406142301

8

PEMOLINE Non-PreferredGeneric 8

PROVIGIL Non-PreferredBrand 8

RITALIN Non-PreferredBrand 8

RITALIN LA Non-PreferredBrand 8

RITALIN SR Non-PreferredBrand 8

STRATTERA Non-PreferredBrand 8

MISC. ANTI INFECTIVE COMBOS

ERYTHROMYCIN/SULFISOXAZOL PreferredGeneric 4

MEPRON PreferredBrand 4

SEPTRA

SEPTRA SUS 200-40/5 Brand Preferred 00081085496

4

SEPTRA TAB 400-80MG Brand Preferred 00081085255

4

SEPTRA DS TAB 800-160 Brand Preferred 00081085356

4

SEPTRA DS PreferredBrand 4

SULFAMETHOXAZOLE/TRIMETHO PreferredBrand/Generic 4

SULFATRIM PreferredGeneric 4

BACTRIM DS Non-PreferredBrand 8

PRIMAXIN IV Non-PreferredBrand 8

SEPTRA

SEPTRA IV INJ 400-80/5 Brand Non-Preferred 00081085610

8

MISC. ANTI-BIOTICS

GANTRISIN

GANTRIS PED SUS 500/5ML Brand Preferred 00004100328

4

GANTRISIN SYP 500/5ML Brand Preferred 00004100428

4

METRONIDAZOLE

METRON/NACL INJ 500MG PB Generic Preferred 00338105548

4

METRON/NACL INJ 500MG Generic Preferred 00074781124

4

METRONIDAZOL TAB 250MG Generic Preferred 00003048850

4

METRONIDAZOL TAB 500MG Generic Preferred 00003057240

4

PRIMSOL PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISC. ANTI-BIOTICS

SULFADIAZINE

SULFADIAZINE TAB 500MG Brand Preferred 00002205402

4

SULFADIAZINE TAB 500MG Generic Preferred 00115471401

4

SULFISOXAZOLE

SULFISOXAZOL TAB 0.5GM Generic Preferred 00102230501

4

SULFISOXAZOL TAB 500MG Generic Preferred 54569023100

4

TRIMETHOPRIM PreferredBrand/Generic 4

TRIMETHOPRIM TAB 200MG Brand Preferred 00093215901

4

VANCOCIN HCL PreferredBrand 4

VANCOMYCIN HCL PreferredBrand/Generic 4

VANCOMYCIN INJ 5000MG Brand Preferred 00205315405

4

FLAGYL Non-PreferredBrand 8

FLAGYL ER Non-PreferredBrand 8

GANTRISIN

GANTRISIN TAB 500MG Brand Non-Preferred 00004000901

8

LORABID Non-PreferredBrand 8

METRONIDAZOLE

METRONIDAZOL INJ 5MG/ML Generic Non-Preferred 00641720097

8

NEBUPENT Non-PreferredBrand 8

PROLOPRIM Non-PreferredBrand 8

SULFADIAZINE

SULFADIAZINE POW USP NF Brand Non-Preferred 49452746001

8

SULFADIAZINE POW USP Brand Non-Preferred 38779055005

8

SULFADIAZINE POW Brand Non-Preferred 51552030516

8

SULFADIAZINE TAB 500MG Generic Non-Preferred 51079084020

8

SULFISOXAZOLE Non-PreferredBrand/Generic 8

SULFISOXAZOL TAB 0.5GM Generic Non-Preferred 00143168325

8

TRIMETHOPRIM

TRIMETHOPRIM POW MICRONIZ Brand Non-Preferred 38779077004

8

TRIMETHOPRIM POW USP Brand Non-Preferred 62991207301

8

TRIMETHOPRIM POW Brand Non-Preferred 38779027000

8

VANCOMYCIN HCL

VANCOMYCIN POW POWDER Brand Non-Preferred 51552103601

8

VANCOMYCIN POW Brand Non-Preferred 38779027403

8

MISC. ANTI-DIARRHEAL / ANTACID


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



ALUMINUM HYDROXIDE

ALUM HYDROX SUS 320/5ML Generic Preferred 00121023406

4

OTC -

ALUM HYDROX SUS 600/5ML Generic Preferred 00121054330

4

OTC -

ANTACID

ANTACID CHW 420MG Generic Preferred 47682080213

4

OTC -


4

OTC -


4

OTC -


4

OTC -

ANTACID SUS LEMON CM Generic Preferred 00603069457

4

OTC -

ANTACID SUS MINT Generic Preferred 19458356401

4

OTC -

ANTACID SUS Generic Preferred 51017010212

4

OTC -

ANTACID EXTRA STRENGTH

ANTACID CHW 750MG XS Generic Preferred 49348036234

4

OTC -

ANTACID E/S CHW 750MG Generic Preferred 19458953001

4

OTC -

ANTACID X-ST CHW 750MG Generic Preferred 37205020580

4

OTC -

ANTACID X-ST CHW ASSORTED Generic Preferred 24385047680

4

OTC -

ANTACID XTRA CHW 750MG Generic Preferred 37205070680

4

OTC -

BENTYL

BENTYL SYP 10MG/5ML Brand Preferred 00068012516

4

BISMATROL PreferredGeneric 4OTC

CALCIUM ANTACID

CAL ANTACID CHW 1000MG Generic Preferred 38726059523

4

OTC -

CAL ANTACID CHW 750MG XS Generic Preferred 00113017980

4

OTC -

CAL ANTACID CHW 750MG Generic Preferred 38726017980

4

OTC -

CALC ANTACID CHW 500MG Generic Preferred 49614048547

4

OTC -

CALCIUM ANTA CHW 500MG Generic Preferred 36800099331

4

OTC -

CALCIUM ANTACID EXTRA STR PreferredGeneric 4OTC

CALCIUM CARBONATE PreferredBrand/Generic 4OTC

CAL-GEST ANTACID PreferredGeneric 4OTC

CHEWABLE ANTACID


4

OTC -

DICYCLOMINE HCL

DICYCLOMINE CAP 10MG Generic Preferred 00005332434

4

DICYCLOMINE CAP 20MG Generic Preferred 00659161202

4

DICYCLOMINE TAB 20MG Generic Preferred 00005332334

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



HYOSCYAMINE SULFATE PreferredGeneric 4

HYOSCYAMINE SULFATE ER PreferredGeneric 4

HYOSCYAMINE SULFATE SR PreferredGeneric 4

MAALOX

MAALOX SUS MINT CRM Brand Preferred 54569398800

4

OTC -

MAALOX SUS Brand Preferred 00067022244

4

OTC -

MAGNESIUM OXIDE PreferredBrand/Generic 4OTC

MAG OXIDE TAB 420MG Brand Preferred 10706083701

4

OTC -

MAG-OX 400 PreferredBrand 4OTC

PAMINE PreferredBrand 4

PINK BISMUTH

PINK BISMUTH CHW 262MG Generic Preferred 00182109117

4

OTC -

PINK BISMUTH CHW 300MG Generic Preferred 12333931901

4

OTC -

PINK BISMUTH SUS 262/15ML Generic Preferred 63868030234

4

OTC -

PINK BISMUTH SUS 262MG/15 Generic Preferred 65504014012

4

OTC -


4

OTC -


4

OTC -

PINK BISMUTH TAB 262MG Generic Preferred 24385001758

4

OTC -

PROPANTHELINE BROMIDE

PROPANTHELIN TAB 15MG Brand Preferred 00054472125

4

ROBINUL

ROBINUL TAB 1MG Brand Preferred 00031782463

4

ROBINUL FORTE PreferredBrand 4

SAL-TROPINE PreferredBrand 4

SODIUM BICARBONATE

SODIUM BICAR TAB 10GR Generic Preferred 52152010302

4

OTC -

SODIUM BICAR TAB 300MG Generic Preferred 00527106710

4

OTC -


4

OTC -


4

OTC -


4

OTC -


4

OTC -


4

OTC -

TUMS PreferredBrand 4OTC

TUMS CALCIUM FOR LIFE BON PreferredBrand 4OTC

TUMS E-X PreferredBrand 4OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



TUMS E-X SUGAR FREE PreferredBrand 4OTC

TUMS ULTRA PreferredBrand 4OTC

V-R ANTACID

V-R ANTACID CHW 500MG Generic Preferred 49348016921

4

OTC -

V-R ANTACID SUS Generic Preferred 49348001938

4

OTC -

X-STR CHEW ANTACID PreferredGeneric 4OTC

ALUMINUM HYDROXIDE Non-PreferredBrand/Generic 8OTC

ALUM HYDROX SUS 320/5ML Generic Non-Preferred 00121023415

8

OTC -


8

OTC -


8

OTC -


8

OTC -

ALUM HYDROX TAB 300MG Generic Non-Preferred 00615258801

8

OTC -

ALUM HYDROX TAB 500MG Generic Non-Preferred 00054407025

8

OTC -

ANTACID

ANTACID CAP Generic Non-Preferred 11161098381

8

OTC -

ANTACID CHW 80-20MG Generic Non-Preferred 54569278200

8

OTC -

ANTACID CHW FRUIT Generic Non-Preferred 37205012347

8

OTC -

ANTACID CHW ORIGINAL Generic Non-Preferred 30142052747

8

OTC -

ANTACID CHW Generic Non-Preferred 17236023501

8

OTC -

ANTACID SUS 400/135 Generic Non-Preferred 19458976501

8

OTC -

ANTACID SUS Generic Non-Preferred 00719600781

8

OTC -

ANTACID TAB 311-232 Generic Non-Preferred 50844028615

8

OTC -

ANTACID TAB Generic Non-Preferred 00182100316

8

OTC -

ANTACID EXTRA STRENGTH

ANTACID CHW EX-STR Generic Non-Preferred 19458920001

8

OTC -

B & O 15-A SUPPRETTE Non-PreferredBrand 8

BENTYL

BENTYL CAP 10MG Brand Non-Preferred 00068012061

8

BENTYL INJ 10MG/ML Brand Non-Preferred 00068080923

8

BENTYL TAB 20MG Brand Non-Preferred 00068012361

8

CALCIUM ANTACID

CALC ANTACID CHW 500MG Generic Non-Preferred 12333909602

8

OTC -

CHEWABLE ANTACID

ANTACID CHW Generic Non-Preferred 11845085101

8

OTC -

DICYCLOMINE HCL


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



DICYCLOMINE INJ 10MG/ML Generic Non-Preferred 00182070863

8

DICYCLOMINE SYP 10MG/5ML Generic Non-Preferred 00182116040

8

HYOSCYAMINE SULFATE Non-PreferredBrand 8

LEVBID Non-PreferredBrand 8

LEVSIN Non-PreferredBrand 8

LEVSIN/SL Non-PreferredBrand 8

MAALOX

MAALOX AER WHIP Brand Non-Preferred 00067037066

8

OTC -

MAALOX DS CHW Brand Non-Preferred 00067034024

8

OTC -

MAALOX HRF SUS Brand Non-Preferred 00067035071

8

OTC -

MAALOX TC SUS Brand Non-Preferred 00067033459

8

OTC -

MAALOX-CONC CHW THERAP Brand Non-Preferred 00067034448

8

OTC -

MAGNESIUM OXIDE

MAG OXIDE CAP 400MG Brand Non-Preferred 27434001021

8

OTC -

NULEV Non-PreferredBrand 8

PINK BISMUTH

PINK BISMUTH SUS 525/15ML Generic Non-Preferred 00364239976

8

OTC -

PROPANTHELINE BROMIDE

PROPANTHELIN POW BROMIDE Brand Non-Preferred 38779030404

8

ROBINUL

ROBINUL INJ 0.2MG/ML Brand Non-Preferred 00031789006

8

SODIUM BICARBONATE Non-PreferredBrand/Generic 8OTC

SODIUM BICAR POW Generic Non-Preferred 00223174904

8

OTC -

URO-MAG Non-PreferredGeneric 8OTC

V-R ANTACID

V-R ANTACID CHW EX-STR Generic Non-Preferred 49348019410

8

OTC -

V-R ANTACID TAB 311-232 Generic Non-Preferred 49348081009

8

OTC -

MISC. ELECTROLYTES/NUTRITIONALS

DEXTROSE 5% PreferredGeneric 4

FISH OIL PreferredGeneric 4OTC

INTRALIPID PreferredBrand/Generic 4

MCT OIL PreferredBrand 4OTC

PEDIALYTE PreferredBrand 4OTC

ALIMENTUM Non-PreferredBrand 8OTC

BOOST Non-PreferredBrand 8OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



BOOST BREEZE Non-PreferredBrand 8OTC

BOOST HIGH PROTEIN Non-PreferredBrand 8OTC

BOOST PLUS Non-PreferredBrand 8OTC

BOOST PUDDING Non-PreferredBrand 8OTC

CHOICE DM Non-PreferredBrand 8OTC

DELIVER 2.0 Non-PreferredBrand 8OTC

DUOCAL Non-PreferredBrand 8OTC

ELECARE Non-PreferredBrand 8OTC

ENSURE Non-PreferredBrand 8OTC

ENSURE ENLIVE Non-PreferredBrand 8OTC

ENSURE HIGH PROTEIN Non-PreferredBrand 8OTC

ENSURE LIGHT Non-PreferredBrand 8OTC

ENSURE PLUS Non-PreferredBrand 8OTC

ENSURE PLUS HN Non-PreferredBrand 8OTC

ENSURE PUDDING Non-PreferredBrand 8OTC

GLUCERNA Non-PreferredBrand 8OTC

GLUCERNA SHAKE Non-PreferredBrand 8OTC

I-VALEX-1 Non-PreferredBrand 8OTC

JEVITY 1 CAL Non-PreferredBrand 8OTC

JEVITY 1.2 CAL Non-PreferredBrand 8OTC

KINDERCAL TF Non-PreferredBrand 8OTC

L-CARNITINE Non-PreferredBrand/Generic 8OTC

LIPISORB Non-PreferredBrand 8OTC

NEOCATE INFANT FORMULA Non-PreferredBrand 8OTC

NEOCATE ONE + Non-PreferredBrand 8OTC

NEPRO Non-PreferredBrand 8OTC

NUTRAMIGEN Non-PreferredBrand 8OTC

NUTREN 1.0/FIBER Non-PreferredBrand 8OTC

NUTREN 1.5 Non-PreferredBrand 8OTC

NUTRIVENT 1.5 Non-PreferredBrand 8OTC

PEDIASURE Non-PreferredBrand 8OTC

PEDIASURE PEDIATRIC Non-PreferredBrand 8OTC

PEDIASURE WITH FIBER Non-PreferredBrand 8OTC

PEDIATRIC EO28 Non-PreferredBrand 8OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



PEPTAMEN Non-PreferredBrand 8OTC

PEPTAMEN 1.5 Non-PreferredBrand 8OTC

PEPTAMEN JUNIOR Non-PreferredBrand 8OTC

PHENEX-2 Non-PreferredBrand 8OTC

PHENYLADE MTE Non-PreferredGeneric 8OTC

PHENYL-FREE 2 Non-PreferredBrand 8OTC

PHENYL-FREE 2HP Non-PreferredBrand 8OTC

PHLEXY-10 Non-PreferredBrand/Generic 8OTC

PKU 3 Non-PreferredBrand 8OTC

POLYCOSE Non-PreferredBrand 8OTC

PREGESTIMIL Non-PreferredBrand 8OTC

PROMOD Non-PreferredBrand 8OTC

PROMOTE WITH FIBER Non-PreferredBrand 8OTC

PROSOBEE Non-PreferredBrand 8OTC

PROSURE Non-PreferredBrand 8OTC

SCANDISHAKE Non-PreferredBrand 8OTC

SIMILAC PM 60/40 Non-PreferredBrand 8OTC

TWOCAL HN Non-PreferredBrand 8OTC

VIVONEX PLUS Non-PreferredBrand 8OTC

XP MAXAMAID Non-PreferredBrand 8OTC

MISC. MULTI-VITAMINS

ANTIOXIDANT FORMULA

ANTIOXIDANT CAP FORMULA Generic Preferred 31604001671

4

OTC -

ANTIOXIDANT CAP Generic Preferred 00536558806

4

OTC -

ANTIOXIDANT TAB FORMULA Generic Preferred 30768000452

4

OTC -

CENTRUM PreferredGeneric 4OTC

CENTRUM JR/EXTRA C PreferredGeneric 4OTC

CENTRUM JR/IRON PreferredBrand 4OTC

CENTRUM SILVER

CENTRUM TAB SILVER Brand Preferred 00005417719

4

OTC -

CENTRUM-LUTEIN PreferredGeneric 4OTC

CHEWABLE MULTIVITAMINS/FL PreferredGeneric 4

DUET

DUET TAB Brand Preferred 64731082001

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



FOLGARD RX 2.2 PreferredBrand 4

FOLTX PreferredBrand 4

MULTI VITA-BETS/FLUORIDE PreferredGeneric 4

MULTI-DAY

MULTI-DAY TAB /IRON Generic Preferred 74312001580

4

OTC -

MULTI-DAY TAB MINERALS Generic Preferred 74312004130

4

OTC -

MULTI-DAY TAB Generic Preferred 74312001570

4

OTC -

MULTIVITAMINS PreferredGeneric 4OTC

MULTIVITAMINS/FLUORIDE

MULTIVIT/FL CHW 0.5/FE12 Generic Preferred 38245019710

4

MULTIVIT/FL CHW 0.5MG Generic Preferred 00093915801

4

MULTIVIT/FL CHW 1MG Generic Preferred 54979040101

4

MULTIVIT/FL DRO 0.25MG Generic Preferred 47202130905

4

MULTIVIT/FL SOL 0.5MG/ML Generic Preferred 47202130705

4

MULTIVITS/FL CHW 0.5MG Generic Preferred 00349204401

4

NATACHEW PreferredBrand 4

NATALCARE RX PreferredGeneric 4

NEPHPLEX RX PreferredBrand 4

NEPHRO-VITE

NEPHRO-VITE TAB Brand Preferred 54391000201

4

OTC -

OCUVITE

OCUVITE TAB Generic Preferred 54569286900

4

OTC -

OCUVITE PRESERVISION PreferredBrand/Generic 4OTC

ONE DAILY

ONE DAILY TAB MINERALS Generic Preferred 74980007985

4

OTC -

ONE DAILY TAB Generic Preferred 74980007800

4

OTC -

ONE-DAILY MULTIVITAMINS PreferredGeneric 4OTC

ONE-TABLET-DAILY NF PreferredGeneric 4OTC

ONE-TABLET-DAILY W/MINERA PreferredGeneric 4OTC

POLY-VI-FLOR

POLY-VI-FLOR CHW 0.5MG Brand Preferred 00087046841

4

POLY-VI-FLOR DRO FE 0.5MG Brand Preferred 00087046901

4

POLY-VI-SOL/IRON

POLY-VI-SOL/ CHW IRON Brand Preferred 00087045602

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



POLY-VITAMIN/FLUORIDE PreferredGeneric 4

POLY-VITAMIN/IRON/FLUORID PreferredGeneric 4

PRENATAL 1 PLUS 1 PreferredGeneric 4

PRENATAL LOW IRON PreferredGeneric 4

PRENATAL PLUS

PRENATAL TAB PLUS Generic Preferred 59879010301

4

PRENATAL PLS TAB Generic Preferred 49999008530

4

PRENATAL PLUS NF PreferredGeneric 4

PRENATAL PLUS/27MG IRON PreferredGeneric 4

PRENATAL RX/BETA-CAROTENE

PRENATAL RX TAB BETA-CAR Generic Preferred 00093916505

4

PRENATAL RX/ TAB BETA CAR Generic Preferred 38245016955

4

RENAL

RENAL TAB Generic Preferred 10974090000

4

OTC -

THERA-PLUS PreferredGeneric 4OTC

THERAVITE

THERAVITE LIQ Generic Preferred 54274077307

4

OTC -

TRI-VITAMIN/FLUORIDE

TRI-VIT/FL DRO 0.5MG Generic Preferred 54838051650

4

TRI-VIT/FLUO DRO 0.25MG Generic Preferred 00302747050

4

TRI-VIT/FLUO DRO 0.5MG Generic Preferred 00302746050

4

VITAPLEX PLUS PreferredGeneric 4

ADEKS Non-PreferredBrand 8OTC

ADEKS PEDIATRIC Non-PreferredBrand 8OTC

ADVANCED NATALCARE Non-PreferredGeneric 8

ANEMAGEN Non-PreferredGeneric 8

ANEMAGEN FA Non-PreferredGeneric 8

ANTIOXIDANT FORMULA

ANTIOXIDANT CAP Generic Non-Preferred 25077004150

8

OTC -

CENTRUM Non-PreferredBrand 8OTC

CENTRUM PERFORMANCE Non-PreferredBrand 8OTC

CENTRUM SILVER

CENTRUM TAB SILVER Brand Non-Preferred 00005417723

8

OTC -

CHROMAGEN Non-PreferredBrand/Generic 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



DUET

DUET CHW Brand Non-Preferred 64731083090

8

EMBREX 600 Non-PreferredBrand 8

FERREX 150 FORTE Non-PreferredGeneric 8

FERRO-SEQUELS Non-PreferredBrand 8OTC

FE-TINIC 150 FORTE Non-PreferredGeneric 8

IBERET Non-PreferredBrand 8OTC

IBERET-FOLIC-500 Non-PreferredBrand 8

MATERNA Non-PreferredBrand 8

MULTI-DAY

MULTI-DAY TAB /CA/IRON Generic Non-Preferred 74312004240

8

OTC -

MULTIRET FOLIC-500 Non-PreferredGeneric 8

MULTIVITAMINS/FLUORIDE

MULTIVIT/FL TAB Generic Non-Preferred 51432029303

8

MULTIVITS/FL CHW 0.25MG Generic Non-Preferred 00839809806

8

NATAFORT Non-PreferredBrand/Generic 8

NATALCARE CFE 60 Non-PreferredGeneric 8

NATALCARE GLOSS Non-PreferredGeneric 8

NATALCARE PIC FORTE Non-PreferredGeneric 8

NATALCARE PLUS Non-PreferredGeneric 8

NATATAB RX Non-PreferredGeneric 8

NEPHROCAPS Non-PreferredBrand 8

NEPHRO-VITE

NEPHRO-VITE TAB RX Brand Non-Preferred 54391100201

8

NIFEREX-150 FORTE Non-PreferredBrand 8

NIFEREX-PN FORTE Non-PreferredGeneric 8

NUTRINATE Non-PreferredGeneric 8

OCUVITE

OCUVITE TAB Generic Non-Preferred 00005455019

8

OTC -

ONE DAILY

ONE DAILY TAB CAL/IRON Generic Non-Preferred 74980007875

8

OTC -

POLY-VI-FLOR

POLY-VI-FLOR CHW 0.25MG Brand Non-Preferred 54569127900

8

POLY-VI-FLOR CHW 0.5MG Brand Non-Preferred 54569126100

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



POLY-VI-FLOR CHW 1MG Brand Non-Preferred 00087047402

8

POLY-VI-FLOR CHW FE .25MG Brand Non-Preferred 00087048801

8

POLY-VI-FLOR CHW FE 0.5MG Brand Non-Preferred 00087048201

8

POLY-VI-FLOR CHW FE 1MG Brand Non-Preferred 00087047602

8

POLY-VI-FLOR DRO /FE 0.25 Brand Non-Preferred 00087048301

8

POLY-VI-FLOR DRO 0.25MG Brand Non-Preferred 00087045101

8

POLY-VI-FLOR DRO 0.5MG/ML Brand Non-Preferred 00087047202

8

POLY-VI-SOL Non-PreferredBrand 8OTC

POLY-VI-SOL/IRON

POLY-VI-SOL DRO /IRON Brand Non-Preferred 00087040501

8

OTC -

POLY-VI-SOL/ CHW /IRON Brand Non-Preferred 54569311600

8

OTC -

POLY-VI-SOL/ CHW IRON Brand Non-Preferred 00087045502

8

OTC -

PRECARE Non-PreferredBrand 8

PRECARE PRENATAL Non-PreferredBrand 8

PREMESIS RX Non-PreferredBrand 8

PRENATAL 19 Non-PreferredGeneric 8

PRENATAL MR 90 Non-PreferredGeneric 8

PRENATAL MTR/SELENIUM Non-PreferredGeneric 8

PRENATAL OPTIMA ADVANCE Non-PreferredGeneric 8

PRENATAL PLUS

PRENATAL TAB PLUS Generic Non-Preferred 00182446401

8

PRENATAL RX Non-PreferredGeneric 8

PRENATAL RX/BETA-CAROTENE

PRENATAL RX/ TAB BETA CAR Generic Non-Preferred 38245016910

8

PRENATE ADVANCE Non-PreferredBrand 8

PRENATE GT Non-PreferredBrand 8

PRIMACARE Non-PreferredBrand 8

RENAL

RENAL CAP SOFTGEL Generic Non-Preferred 60258016201

8

RENAPHRO Non-PreferredGeneric 8

RENA-VITE RX Non-PreferredGeneric 8

STUARTNATAL PLUS 3 Non-PreferredBrand/Generic 8

THERAVITE

THERAVITE LIQ Generic Non-Preferred 11845044704

8

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



THERAVITE SOL Generic Non-Preferred 00839732565

8

OTC -

TRI-VITAMIN/FLUORIDE

TRI-VIT/FL DRO 0.25MG Generic Non-Preferred 54838051550

8

TRI-VIT/FLUO DRO 0.25MG Generic Non-Preferred 00364078357

8

TRI-VIT/FLUO DRO 0.5MG Generic Non-Preferred 50383063650

8

ULTRA NATALCARE Non-PreferredGeneric 8

VICON FORTE Non-PreferredBrand 8

VINATAL FORTE Non-PreferredGeneric 8

VINATE ADVANCED Non-PreferredGeneric 8

VINATE GT Non-PreferredGeneric 8

MISC. NEUROLOGICS

MESTINON PreferredBrand 4

MESTINON TIMESPAN PreferredBrand 4

ORAP PreferredBrand 4

PYRIDOSTIGMINE BROMIDE Non-PreferredGeneric 8

MISC. OPHTHALMICS OF INTEREST

ENUCLENE PreferredBrand 4OTC

BOTOX Non-PreferredBrand 8

MISC. PLATELET AGGR. INHIBITORS / COMBOS

AGGRENOX PreferredBrand 4

PENTOXIFYLLINE ER PreferredGeneric 4

PLETAL PreferredBrand 4

AGRYLIN Non-PreferredBrand 8

TRENTAL Non-PreferredBrand 8

MISC. UROLOGICAL

ACETIC ACID 0.25% PreferredGeneric 4

BICITRA PreferredBrand 4

CINOBAC PreferredBrand 4

FURADANTIN

FURADANTIN SUS 25MG/5ML Brand Preferred 00149073515

4

HIPREX PreferredBrand 4

MACRODANTIN PreferredBrand 4

METHENAMINE MANDELATE

METHENAM MAN SUS 500/5ML Generic Preferred 00005328765

4

METHENAM MAN TAB 0.5GM Generic Preferred 00115397601

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISC. UROLOGICAL

METHENAM MAN TAB 1GM Generic Preferred 00115397701

4

METHENAMINE SUS 500/5ML Generic Preferred 00677053633

4

METHENAMINE TAB 250MG Brand Preferred 00223104201

4

MONUROL PreferredBrand 4

NEOSPORIN GU IRRIGANT PreferredBrand 4

PHENAZOPYRIDINE HCL PreferredGeneric 4

PHOSLO PreferredBrand 4

POLYCITRA PreferredBrand 4

POLYCITRA-K

POLYCITRA-K SOL Brand Preferred 11414020901

4

POLYCITRA-LC PreferredBrand 4

PROSED/DS PreferredBrand 4

PYRIDIUM PLUS PreferredBrand 4

RENACIDIN

RENACIDIN SOL IRR Brand Preferred 00327001105

4

SODIUM CHLORIDE 0.9% PreferredGeneric 4

UREX PreferredBrand 4

URISED PreferredBrand 4

UROCIT-K 10 PreferredBrand 4

UROCIT-K 5 PreferredBrand 4

UROQID #2 PreferredBrand 4

CYTRA-2 Non-PreferredGeneric 8

ELMIRON Non-PreferredBrand 8

FURADANTIN Non-PreferredBrand/Generic 8

FURADANTIN TAB 100MG Brand Non-Preferred 00149003705

8

FURADANTIN TAB 50MG Brand Non-Preferred 00149003605

8

MACROBID Non-PreferredBrand 8

MANDELAMINE Non-PreferredBrand 8

METHENAMINE MANDELATE

METHENAM MAN SUS 500/5ML Brand Non-Preferred 46672062116

8

METHENAMINE TAB 0.5GM EC Generic Non-Preferred 00781173001

8

METHENAMINE TAB 1GM EC Generic Non-Preferred 00223104401

8

NITROFURANTOIN MACROCRYST Non-PreferredBrand/Generic 8

PHENAZOPYRIDINE HCL Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISC. UROLOGICAL

POLYCITRA-K

POLYCITRA-K POW CRYSTALS Brand Non-Preferred 11414021501

8

RENACIDIN

RENACIDIN POW Brand Non-Preferred 00327000703

8

RENAGEL Non-PreferredBrand 8

MISCELLANEOUS ANALGESICS

ACEPHEN PreferredGeneric 4OTC

ACETAMINOPHEN

ACETAMIN CAP 500MG Generic Preferred 00157076401

4

OTC -

ACETAMIN CHW 160MG Generic Preferred 20254021401

4

OTC -

ACETAMIN CHW 80MG FRT Generic Preferred 11845008498

4

OTC -

ACETAMIN CHW 80MG GRP Generic Preferred 00536323407

4

OTC -

ACETAMIN CHW 80MG GUM Generic Preferred 50844031801

4

OTC -

ACETAMIN CHW 80MG Generic Preferred 00254002128

4

OTC -

ACETAMIN DRO 100MG/ML Generic Preferred 00223640401

4

OTC -

ACETAMIN DRO 500/5ML Generic Preferred 00405203877

4

OTC -

ACETAMIN DRO 80/0.8ML Generic Preferred 61073002215

4

OTC -

ACETAMIN ELX 120/5ML Generic Preferred 00295132616

4

OTC -

ACETAMIN ELX 160/5ML Generic Preferred 11845090304

4

OTC -

ACETAMIN ELX 80MG/5ML Generic Preferred 00304204074

4

OTC -

ACETAMIN LIQ 160/5ML Generic Preferred 00005319324

4

OTC -

ACETAMIN LIQ 500/15ML Generic Preferred 00182617744

4

OTC -

ACETAMIN SOL 120/3.75 Generic Preferred 51079082706

4

OTC -

ACETAMIN SOL 160/5ML Generic Preferred 00121065705

4

OTC -

ACETAMIN SOL 240/7.5 Generic Preferred 51079082906

4

OTC -

ACETAMIN SOL 80/2.5ML Generic Preferred 51079082606

4

OTC -

ACETAMIN SUP 120MG Generic Preferred 54977062212

4

OTC -


4

OTC -


4

OTC -


4

OTC -

ACETAMIN TAB 325MG Generic Preferred 58016026524

4

OTC -


4

OTC -


4

OTC -

ACETAMINOPHE DRO 100MG/ML Generic Preferred 55045128904

4

OTC -

ACETAMINOPHE TAB 325MG Generic Preferred 54738054813

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



ACETAMINOPHE TAB 500MG Generic Preferred 54738054013

4

OTC -

ACETAMINOPHN SOL 130/5ML Brand Preferred 51079066030

4

OTC -

ACETAMINOPHEN JR PreferredGeneric 4OTC

APAP PreferredGeneric 4OTC

APAP DROPS PreferredGeneric 4OTC

ASPIR-81 PreferredGeneric 4OTC

ASPIRIN

ASPIRIN CHW 60MG Brand Preferred 00527102110

4

OTC -

ASPIRIN CHW 75MG Generic Preferred 00304000900

4

OTC -


4

OTC -


4

OTC -

ASPIRIN TAB 10GR EC Generic Preferred 00084008910

4

OTC -

ASPIRIN TAB 162MG EC Generic Preferred 49483004001

4

OTC -

ASPIRIN TAB 300MG Generic Preferred 00008031302

4

OTC -


4

OTC -


4

OTC -


4

OTC -

ASPIRIN TAB 487.5MG Brand Preferred 49483000501

4

OTC -


4

OTC -


4

OTC -

ASPIRIN TAB 5GR Generic Preferred 00677001710

4

OTC -


4

OTC -

ASPIRIN TAB 650MG Brand Preferred 00182044901

4

OTC -


4

OTC -

ASPIRIN TAB 65MG Brand Preferred 00377002810

4

OTC -

ASPIRIN TAB 81MG E/C Generic Preferred 49483005410

4

OTC -


4

OTC -


4

ASPIRIN ADLT TAB 81MG Generic Preferred 43292055805

4

OTC -

ASPIRIN EC TAB 81MG Generic Preferred 00440713590

4

OTC -

ASPIRIN EC PreferredGeneric 4OTC

ASPIRIN EC LO-DOSE PreferredGeneric 4OTC

ASPIRIN EC LOW DOSE PreferredGeneric 4OTC

ASPIR-LOW PreferredGeneric 4OTC

AXOCET


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



AXOCET CAP Generic Preferred 00281019817

4

BAYER LOW STRENGTH PreferredGeneric 4OTC

BUFFERED ASPIRIN

ASPIRIN BUFF TAB 325MG Generic Preferred 41280022038

4

OTC -

BUFF ASPIRIN TAB 325MG Generic Preferred 00349835001

4

OTC -

BUFFERED ASA TAB 325MG Generic Preferred 00182190901

4

OTC -

BUTAL/ASA/CAFF PreferredGeneric 4

BUTALBITAL COMPOUND PreferredGeneric 4

BUTALBITAL/ACETAMINOPHEN PreferredGeneric 4

BUTALBITAL/ACETAMINOPHEN/ PreferredGeneric 4

BUTALBITAL/APAP/CAFFEINE PreferredGeneric 4

CHILDRENS ASPIRIN PreferredGeneric 4OTC

CHILDRENS PAIN RELIEVER PreferredGeneric 4OTC

CHOLINE MAGNESIUM TRISALI PreferredGeneric 4

DIFLUNISAL

DIFLUNISAL TAB 250MG Brand Preferred 54868305100

4

ECOTRIN LOW STRENGTH PreferredGeneric 4OTC

FIORICET PreferredGeneric 4

FORTABS PreferredGeneric 4

FP ASPRIN LOW STRENGTH PreferredGeneric 4OTC

GENAPAP PreferredGeneric 4OTC

GENEBS PreferredGeneric 4OTC

INFANTAIRE PreferredGeneric 4OTC

INFANTS APAP PreferredGeneric 4OTC

MAPAP PreferredGeneric 4OTC

NON-ASPIRIN PAIN RELIEF PreferredGeneric 4OTC

PAIN RELIEVER PreferredGeneric 4OTC

PAIN RELIEVER EXTRA STREN PreferredGeneric 4OTC

Q-NOL PreferredGeneric 4OTC

Q-PAP CHILDRENS PreferredGeneric 4OTC

SALSALATE PreferredGeneric 4

ST JOSEPH ASPIRIN PreferredGeneric 4OTC

TACTINAL EXTRA STRENGTH PreferredGeneric 4OTC

TYLENOL


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



TYLENOL DRO 80/0.8ML Brand Preferred 00045018615

4

OTC -

TYLENOL LIQ 167/5ML Brand Preferred 50580011108

4

OTC -

TYLENOL LIQ 167MG/5 Brand Preferred 00045050008

4

OTC -

TYLENOL TAB 325MG Brand Preferred 00045045224

4

OTC -

TYLENOL TAB 500MG Brand Preferred 00045044924

4

OTC -

TYLENOL CHLD CHW 80MG Brand Preferred 00045048532

4

OTC -

TYLENOL CHLD ELX 160/5ML Brand Preferred 00045018702

4

OTC -

TYLENOL CHLD SUS 160/5ML Brand Preferred 00045012302

4

OTC -

TYLENOL INF DRO 80/0.8ML Brand Preferred 00045012201

4

OTC -

TYLENOL JR TAB 160MG Brand Preferred 00045047001

4

OTC -

TYLENOL ARTHRITIS EXTENDE PreferredBrand 4OTC

TYLENOL ARTHRITIS PAIN PreferredBrand 4OTC

TYLENOL EXTRA STRENGTH PreferredBrand 4OTC

V-R NON-ASPIRIN PreferredGeneric 4OTC

V-R NON-ASPIRIN EXTRA STR PreferredGeneric 4OTC

ACETAMINOPHEN

ACETAMIN POW USP/NF Brand Non-Preferred 49452001001

8

OTC -

ACETAMIN POW USP Brand Non-Preferred 63370000345

8

OTC -

ACETAMIN POW Brand Non-Preferred 38779040950

8

OTC -

ACETAMIN TAB 650MG CR Generic Non-Preferred 62584059901

8

OTC -

ASPIRIN

ASPIRIN POW USP/NF Brand Non-Preferred 49452076001

8

OTC -

ASPIRIN POW Brand Non-Preferred 00406200403

8

OTC -

ASPIRIN SUP 1200MG Brand Non-Preferred 45802070614

8

OTC -

ASPIRIN SUP 1200MG Generic Non-Preferred 00223503701

8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status




8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -


8

OTC -

ASPIRIN TAB 800MG CR Generic Non-Preferred 00304171101

8

ASPIRIN BUFF TAB 325MG Generic Non-Preferred 00536330001

8

OTC -

AXOCET

AXOCET TAB 650-50MG Generic Non-Preferred 00281038953

8

BUFFERED ASPIRIN Non-PreferredBrand/Generic 8OTC

ASPIRIN BUFF TAB 325MG Generic Non-Preferred 00615052310

8

OTC -

BUFFERED ASA TAB 324MG Generic Non-Preferred 50844015812

8

OTC -

BUFFERED ASA TAB 325MG Generic Non-Preferred 30142064281

8

OTC -

BUFFERED ASA TAB X-ST 500 Generic Non-Preferred 25077015601

8

OTC -

BUFFERED ASA TAB Generic Non-Preferred 55175077702

8

OTC -

DIFLUNISAL

DIFLUNISAL POW USP/NF Brand Non-Preferred 49452259701

8

DIFLUNISAL POW Brand Non-Preferred 38779043304

8

DOLOBID Non-PreferredBrand 8

EASPRIN Non-PreferredBrand 8

EQUAGESIC Non-PreferredBrand 8

ESGIC-PLUS Non-PreferredBrand 8

FIORICET Non-PreferredBrand 8

FIORINAL Non-PreferredBrand 8

PHRENILIN Non-PreferredBrand 8

PHRENILIN FORTE Non-PreferredBrand 8

TRILISATE Non-PreferredBrand 8

TYLENOL

TYLENOL SOL 160/5ML Brand Non-Preferred 54569100001

8

OTC -

TYLENOL SOL 500/15ML Brand Non-Preferred 00045050080

8

OTC -

ZEBUTAL Non-PreferredGeneric 8

ZORPRIN Non-PreferredBrand 8

MISCELLANEOUS ANARECTAL

ANALPRAM-HC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISCELLANEOUS ANARECTAL

ANALPRAM-HC CRE 1% Brand Preferred 00496077804

4

ANALPRAM-HC CRE 1-1% Brand Preferred 52959050001

4

ANALPRAM-HC CRE 2.5% Brand Preferred 00496080004

4

COLOCORT PreferredGeneric 4

ELA-MAX 5 PreferredBrand 4OTC

HEMORRHOIDAL-HC

HEMORRHOIDAL CRE HC 2.5% Generic Preferred 58016300501

4

HYDROCORTISONE PreferredGeneric 4

PROCTOCREAM-HC PreferredBrand 4

PROCTOZONE-HC PreferredGeneric 4

ANALPRAM-HC

ANALPRAM-HC LOT 2.5% Brand Non-Preferred 00496082904

8

ANUSOL-HC Non-PreferredBrand 8

CORTIFOAM Non-PreferredBrand 8

HEMORRHOIDAL-HC

HEMORRHOIDAL SUP -HC 10MG Generic Non-Preferred 00102233004

8

HEMORRHOIDAL SUP -HC 25MG Generic Non-Preferred 00182703811

8

HEMORRHOIDAL SUP Generic Non-Preferred 00143702012

8

PROCTOCREAM-HC Non-PreferredGeneric 8

PROCTOFOAM HC Non-PreferredBrand 8

PROCTO-KIT Non-PreferredGeneric 8

PROCTOSERT HC Non-PreferredGeneric 8

PROCTOSOL HC Non-PreferredGeneric 8

MISCELLANEOUS ARTHRITIS

RIDAURA PreferredBrand 4

ARTHROTEC 50 Non-PreferredBrand 8

ARTHROTEC 75 Non-PreferredBrand 8

MISCELLANEOUS EAR

A/B OTIC PreferredGeneric 4

ACETASOL PreferredGeneric 4

ACETASOL HC PreferredGeneric 4

ACETIC ACID PreferredGeneric 4

ACETIC ACID/ALUMINUM ACET PreferredGeneric 4

ACETIC ACID/HYDROCORTISON PreferredGeneric 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISCELLANEOUS EAR

ALLERGEN PreferredGeneric 4

ANTIBIOTIC EAR PreferredGeneric 4

ANTIPYRINE/BENZOCAINE PreferredGeneric 4

AURODEX PreferredGeneric 4

AUROTO OTIC PreferredGeneric 4

CERUMENEX PreferredBrand 4

CIPRODEX PreferredBrand 4

CORTISPORIN

CORTISPORIN SOL 1% OTIC Brand Preferred 00081019992

4

CORTOMYCIN PreferredGeneric 4

EAR DROPS RX PreferredGeneric 4

EAR WAX REMOVAL DROPS PreferredGeneric 4OTC

FLOXIN OTIC PreferredBrand 4

NEOMYCIN/POLYMYXIN/HC PreferredGeneric 4

NEOMYCIN/POLYMYXIN/HYDROC PreferredGeneric 4

OTICAINE OTIC PreferredGeneric 4

CIPRO HC Non-PreferredBrand 8

COLY-MYCIN-S Non-PreferredBrand 8

CORTISPORIN

CORTISPORIN SUS 1% OTIC Brand Non-Preferred 58016601701

8

CORTISPORIN SUS OTIC 1% Brand Non-Preferred 54569089100

8

CORTISPORIN-TC Non-PreferredBrand 8

DEBROX Non-PreferredBrand 8OTC

PEDIOTIC Non-PreferredBrand 8

ZOTANE HC Non-PreferredGeneric 8

ZOTO-HC Non-PreferredGeneric 8

MISCELLANEOUS EYE

SODIUM CHLORIDE PreferredGeneric 4OTC

LENS PLUS REWETTING DROPS Non-PreferredBrand 8OTC

MURO 128 Non-PreferredBrand 8OTC

RESTASIS Non-PreferredBrand 8

MISCELLANEOUS GI

BISAC-EVAC PreferredGeneric 4OTC

BISACODYL


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISCELLANEOUS GI

BISACODYL SUP 10MG Generic Preferred 00719765010

4

OTC -

BISACODYL SUP 5MG Generic Preferred 00223516100

4

BISACODYL EC PreferredGeneric 4OTC

CITRATE OF MAGNESIA PreferredGeneric 4OTC

CITRUCEL PreferredBrand 4OTC

CITRUCEL FIBER LAXATIVE PreferredBrand 4OTC

COLACE

COLACE CAP 50MG Brand Preferred 67618010010

4

OTC -

CVS MILK OF MAGNESIA PreferredGeneric 4OTC

CVS SENNA-C PreferredGeneric 4OTC

CVS STOOL SOFTENER PreferredGeneric 4OTC

D.O.S. PreferredGeneric 4OTC

DIOCTO PreferredGeneric 4OTC

DIOCTO-C

DIOCTO-C CAP 100-30 Generic Preferred 54569327400

4

OTC -

DIOCTYN PreferredGeneric 4OTC

DOC-Q-LACE PreferredGeneric 4OTC

DOCU PreferredGeneric 4OTC

DOCUSATE SODIUM

DOCUSATE SOD CAP 100MG Generic Preferred 00615058501

4

OTC -


4

OTC -

DOCUSATE SOD CAP 50MG Brand Preferred 51079052140

4

OTC -


4

OTC -

DOCUSATE SOD LIQ 150/15ML Generic Preferred 47679041211

4

OTC -

DOCUSATE SOD LIQ 50MG/5ML Generic Preferred 10135011708

4

OTC -

DOCUSATE SOD SYP 20MG/5ML Generic Preferred 10135012108

4

OTC -

DOCUSATE SOD SYP 50/15ML Brand Preferred 00054818704

4

OTC -

DOCUSATE SOD SYP 50/15ML Generic Preferred 51079039738

4

OTC -

DOCUSATE SOD SYP 60/15ML Generic Preferred 00223634001

4

OTC -

DOCUSATE SODIUM/CASANTHRA

DOC SOD/CAS CAP 100-30 Generic Preferred 00005324834

4

OTC -

DOCUSIL PreferredGeneric 4OTC

DOK PreferredGeneric 4OTC

DOK PLUS


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISCELLANEOUS GI

DOK PLUS CAP 100-30 Generic Preferred 52246042410

4

OTC -

DOK PLUS TAB NEW FORM Generic Preferred 00904564360

4

OTC -

ENEMA DISPOSABLE PreferredGeneric 4OTC

EQUATE STOOL SOFTENER PreferredGeneric 4OTC

FIBER LAXATIVE PreferredGeneric 4OTC

FLEET ENEMA PreferredBrand 4OTC

FLEET PHOSPHO SODA PreferredBrand 4OTC

GENFIBER PreferredGeneric 4OTC

K-PEK

K-PEK SUS Generic Preferred 00536121083

4

OTC -

MAGIC BULLETS PreferredGeneric 4OTC

METAFIBER PreferredGeneric 4OTC

METAMUCIL

METAMUCIL CAP 0.52GM Brand Preferred 37000040511

4

OTC -

METAMUCIL POW 28.3%CIT Generic Preferred 37000074135

4

OTC -

METAMUCIL POW 28.3%ORG Generic Preferred 37000074078

4

OTC -

METAMUCIL POW 30.9% OR Generic Preferred 37000001307

4

OTC -

METAMUCIL POW 48.57% Generic Preferred 37000001008

4

OTC -

METAMUCIL POW 50% Generic Preferred 37000074022

4

OTC -

METAMUCIL POW 58.6 ORG Brand Preferred 37000074108

4

OTC -

METAMUCIL POW 58.6% OR Generic Preferred 37000002405

4

OTC -

METAMUCIL POW 58.6%CIT Generic Preferred 37000002201

4

OTC -

METAMUCIL POW 58.6% Generic Preferred 37000004801

4

OTC -

METAMUCIL POW 92% RGSF Brand Preferred 37000074021

4

OTC -

METAMUCIL POW 92% Brand Preferred 37000074020

4

OTC -

METAMUCIL POW ORANGE Brand Preferred 37000074010

4

OTC -

METAMUCIL POW ORANGE Generic Preferred 37000074018

4

OTC -

METAMUCIL POW REGULAR Brand Preferred 37000074038

4

OTC -

METAMUCIL POW REGULAR Generic Preferred 54569330600

4

OTC -

METAMUCIL POW SF ORAN Brand Preferred 37000074004

4

OTC -

METAMUCIL POW SF REG Brand Preferred 37000074001

4

OTC -

METAMUCIL POW SINGLE Generic Preferred 37000074016

4

OTC -

METAMUCIL POW STRAW Brand Preferred 37000074013

4

OTC -

METAMUCIL POW Brand Preferred 37000074044

4

OTC -

METAMUCIL POW Generic Preferred 37000074009

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISCELLANEOUS GI

METAMUCIL ORIGINAL TEXTUR PreferredGeneric 4OTC

METAMUCIL SUNRISE PreferredGeneric 4OTC

MILK OF MAGNESIA

MILK OF MAG SUS 400MG/5M Generic Preferred 11917004048

4

OTC -

MILK OF MAGN SUS 400/5ML Generic Preferred 54274092116

4

OTC -

MILK OF MAGN SUS 405/5ML Generic Preferred 25077005652

4

OTC -

MILK OF MAGN SUS MINT Generic Preferred 51017010912

4

OTC -

MILK OF MAGN SUS REGULAR Generic Preferred 58948039640

4

OTC -

MILK OF MAGN SUS Generic Preferred 00054856704

4

OTC -

MLK MAGNESIA SUS MINT Generic Preferred 36800020660

4

OTC -

NATURAL VEGETABLE LAXATIV PreferredGeneric 4OTC

NATURAL VEGETABLE ORANGE PreferredGeneric 4OTC

NATURAL VEGETABLE REGULAR PreferredGeneric 4OTC

PHILLIPS MILK OF MAGNESIA PreferredGeneric 4OTC

RA BISACODYL PreferredGeneric 4OTC

RA COL-RITE PreferredGeneric 4OTC

RA SENNA-LAX PreferredBrand 4OTC

SENEXON

SENEXON TAB 187MG Generic Preferred 00536452801

4

OTC -

SENNA PreferredBrand/Generic 4OTC

SENNA TAB 217MG Brand Preferred 24208017510

4

OTC -

SENNA TAB 8.6MG Brand Preferred 00904516580

4

OTC -

SENNA CONCENTRATE LAXATIV PreferredGeneric 4OTC

SENNA LAX PreferredGeneric 4OTC

SENNA S PreferredGeneric 4OTC

SENNA-GEN PreferredGeneric 4OTC

SENNA-PLUS PreferredGeneric 4OTC

SENOKOT

SENOKOT GRA 326/TSP Brand Preferred 00034110020

4

OTC -

SENOKOT SYP 8.8MG/5M Brand Preferred 00034180020

4

OTC -

SENOKOT TAB 187MG Brand Preferred 54569208400

4

OTC -

SENOKOT CHILDRENS PreferredBrand 4OTC

SENOKOT XTRA PreferredBrand 4OTC

SORBITOL PreferredBrand/Generic 4OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISCELLANEOUS GI

STOOL SOFTENER PreferredGeneric 4OTC

STOOL SOFTENER PLUS STIMU PreferredGeneric 4OTC

SUCRALFATE PreferredGeneric 4

UNI-CENNA

UNI-CENNA SYP Generic Preferred 00677188142

4

OTC -

UNI-CENNA TAB 187MG Generic Preferred 00677085901

4

OTC -

UNI-EASE PLUS PreferredGeneric 4OTC

UNIFIBER PreferredBrand 4OTC

URSO PreferredBrand 4

URSODIOL PreferredGeneric 4

V-R GENTLE LAXATIVE PreferredGeneric 4OTC

ACTIGALL Non-PreferredBrand 8

BENEFIBER Non-PreferredBrand 8OTC

BISACODYL

BISACODYL KIT Generic Non-Preferred 00054809719

8

OTC -

CARAFATE Non-PreferredBrand 8

COLACE

COLACE CAP 100MG Brand Non-Preferred 00087071401

8

OTC -

COLACE CAP 50MG Brand Non-Preferred 00087071301

8

OTC -

COLACE LIQ 150/15ML Brand Non-Preferred 00087071702

8

OTC -

COLACE SYP 60/15ML Brand Non-Preferred 00087072001

8

OTC -

DIOCTO-C

DIOCTO-C CAP 100-30 Generic Non-Preferred 00304011000

8

OTC -

DIOCTO-C SYP 60-30/15 Generic Non-Preferred 00472093016

8

OTC -

DOCUSATE SODIUM

DOCUSATE SOD POW USP NF Brand Non-Preferred 49452265001

8

DOCUSATE SOD POW USP Brand Non-Preferred 38779125404

8

DOCUSATE SOD POW Brand Non-Preferred 49452266501

8

DOCUSATE SOD TAB 100MG Generic Non-Preferred 00223085201

8

OTC -

DOCUSATE SODIUM/CASANTHRA

DOC SOD/CAS CAP 100-30 Generic Non-Preferred 00005324860

8

OTC -

DOC SOD/CAS SYP 100-30 Generic Non-Preferred 00781681416

8

OTC -

DOC SOD/CAS SYP 60-30/15 Generic Non-Preferred 00364716816

8

OTC -

DOC SOD/CAS TAB 100/30 Generic Non-Preferred 00839126206

8

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


MISCELLANEOUS GI

DOK PLUS

DOK PLUS SYP 60-30/15 Generic Non-Preferred 00904091916

8

OTC -

DULCOLAX Non-PreferredBrand/Generic 8OTC

FIBERCON Non-PreferredBrand 8OTC

K-PEK

K-PEK SUS 750/15ML Generic Non-Preferred 00536297059

8

OTC -

MALTSUPEX Non-PreferredBrand 8OTC

METAMUCIL

METAMUCIL POW 28% ORNG Generic Non-Preferred 37000074087

8

OTC -

METAMUCIL POW 63% EF Brand Non-Preferred 37000001203

8

OTC -

METAMUCIL POW EFF ORNG Brand Non-Preferred 37000001503

8

OTC -

METAMUCIL WAF 1.7GM Brand Non-Preferred 37000002901

8

OTC -

MILK OF MAGNESIA

MILK OF MAGN CHW 325MG Generic Non-Preferred 00003053640

8

OTC -

MILK OF MAGN CON Generic Non-Preferred 00054856504

8

OTC -

PHILLIPS MILK OF MAGNESIA Non-PreferredBrand 8OTC

SENEXON

SENEXON TAB 8.6MG Generic Non-Preferred 00536590401

8

OTC -

SENNA

SENNA POW USP Brand Non-Preferred 38779158607

8

OTC -

SENNA POW Brand Non-Preferred 00923322903

8

OTC -

SENNA TAB 8.6MG Brand Non-Preferred 54868492900

8

OTC -

SENOKOT

SENOKOT SUP 652MG Brand Non-Preferred 00034170006

8

OTC -

SENOKOT TAB 8.6MG Brand Non-Preferred 00034120010

8

OTC -

SENOKOT S Non-PreferredBrand 8OTC

SUCRALFATE Non-PreferredBrand 8

UNI-CENNA

UNI-CENNA TAB 8.6MG Generic Non-Preferred 00677171901

8

OTC -

V-R NATURAL SENNA LAXATIV Non-PreferredGeneric 8OTC

MISCELLANEOUS MINERALS

CALCARB 600 PreferredGeneric 4OTC

CALCARB/D 600 PreferredGeneric 4OTC

CALCIUM

CALCIUM TAB 500MG Generic Preferred 00274196760

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



CALCIUM TAB 600MG Generic Preferred 48107005122

4

OTC -

CALCIUM TAB Generic Preferred 48107004923

4

OTC -

CALCIUM + D

CALCIUM + D TAB 600MG Generic Preferred 66375010501

4

OTC -

CALCIUM + D TAB Generic Preferred 49348042610

4

OTC -

CALCIUM 600 PreferredGeneric 4OTC

CALCIUM 600 + D PreferredGeneric 4OTC

CALCIUM 600/VITAMIN D PreferredGeneric 4OTC

CALCIUM 600-D PreferredGeneric 4OTC

CALCIUM CARBONATE PreferredGeneric 4OTC

CALCIUM CITRATE PreferredBrand/Generic 4OTC

CALCIUM GLUCONATE

CALCIUM GLUC CHW 1000MG Brand Preferred 00143117001

4

OTC -

CALCIUM GLUC CHW 650MG Brand Preferred 00143116501

4

OTC -

CALCIUM GLUC TAB 10GR Generic Preferred 00677003210

4

OTC -

CALCIUM GLUC TAB 1GM Brand Preferred 00223059301

4

OTC -

CALCIUM GLUC TAB 1GM Generic Preferred 00002203602

4

OTC -

CALCIUM GLUC TAB 500MG Generic Preferred 00002203902

4

OTC -


4

OTC -

CALCIUM GLUC TAB 975MG Brand Preferred 00536341710

4

OTC -


4

OTC -

CALCIUM LACTATE PreferredBrand/Generic 4OTC

CALCIUM/VITAMIN D

CALCIUM 600 TAB 600MG Generic Preferred 24385087972

4

OTC -

CALCIUM/D TAB 250MG Generic Preferred 00349853801

4

OTC -

CALCIUM/D TAB 500/200 Generic Preferred 63739029101

4

OTC -


4

OTC -

CALCIUM/D TAB 600-200 Generic Preferred 63739031201

4

OTC -

CALCIUM/D TAB 600MG Brand Preferred 48107004925

4

OTC -


4

OTC -

CALTRATE 600 PreferredGeneric 4OTC

CALTRATE 600 PLUS/VIT D PreferredGeneric 4OTC

CITRACAL

CITRACAL TAB 200 MG Brand Preferred 00178080001

4

OTC -

CITRACAL + D PreferredBrand 4OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



CITRUS CALCIUM 1500 + D PreferredGeneric 4OTC

CVS CALCIUM-600/VIT D PreferredGeneric 4OTC

CVS OYSTER SHELL CALCIUM PreferredGeneric 4OTC

DEXFERRUM PreferredGeneric 4

ETHEDENT PreferredGeneric 4

FEOSTAT

FEOSTAT CHW 100MG Brand Preferred 00456037200

4

OTC -

FEOSTAT SUS 100/5ML Brand Preferred 00456037308

4

OTC -

FER-GEN-SOL PreferredGeneric 4OTC

FERGON

FERGON ELX 300/5ML Brand Preferred 00024101916

4

OTC -

FERGON TAB 240MG Brand Preferred 00024101500

4

OTC -

FER-IN-SOL PreferredGeneric 4OTC

FER-IRON PreferredGeneric 4OTC

FERRONATE PreferredGeneric 4OTC

FERROUS GLUCONATE PreferredBrand/Generic 4OTC

FERROUS SULFATE

FE SULFATE TAB 83MG Brand Preferred 43292055647

4

OTC -

FE SULFATE TAB Generic Preferred 37205041478

4

OTC -

FERR SULFATE TAB 325MG FC Generic Preferred 00603017929

4

OTC -

FERROUS SUL TAB 325MG Generic Preferred 49999019700

4

OTC -

FERROUS SULF CAP 167MG Brand Preferred 00719246610

4

OTC -

FERROUS SULF CAP 167MG Generic Preferred 00580015201

4

OTC -


4

OTC -

FERROUS SULF CAP 325MG Brand Preferred 00904216460

4

OTC -


4

OTC -

FERROUS SULF DRO 125MG/ML Generic Preferred 00832805750

4

OTC -

FERROUS SULF DRO 75/0.6ML Generic Preferred 00603076247

4

OTC -

FERROUS SULF ELX 220/5ML Generic Preferred 00005327837

4

OTC -

FERROUS SULF SYP 300/5ML Brand Preferred 00121053005

4

OTC -

FERROUS SULF SYP 300/5ML Generic Preferred 51079023810

4

OTC -

FERROUS SULF TAB 200MG Generic Preferred 00677125101

4

OTC -


4

OTC -

FERROUS SULF TAB 324MG EC Generic Preferred 00574060801

4

OTC -

FERROUS SULF TAB 325MG EC Generic Preferred 00136217210

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status




4

OTC -

FERROUS SULF TAB 5GR Generic Preferred 00781116101

4

OTC -

FERROUS SULF TAB Generic Preferred 49614056178

4

OTC -

FLUOR-A-DAY

FLUOR-A-DAY CHW 0.25MG Generic Preferred 66116016430

4

FLUOR-A-DAY CHW 0.5MG Generic Preferred 51817061116

4

FLUOR-A-DAY CHW 1MG Generic Preferred 51817062216

4

FLUOR-A-DAY DRO 0.125MG Generic Preferred 51817065661

4

FLUORIDE PreferredGeneric 4

HM CALCIUM PreferredGeneric 4OTC

INFED

INFED INJ 50MG/ML Generic Preferred 00364301247

4

KLOR-CON PreferredGeneric 4

KLOR-CON 10 PreferredGeneric 4

KLOR-CON 8 PreferredGeneric 4

KLOR-CON M10 PreferredGeneric 4

KLOR-CON M20 PreferredGeneric 4

KLOR-CON/EF PreferredGeneric 4

K-PHOS PreferredBrand 4

K-VESCENT PreferredGeneric 4

LURIDE

LURIDE CHW 0.25MG Brand Preferred 00126018621

4


4


4

LURIDE CHW 1MG Brand Preferred 00126000610

4

LURIDE DRO 0.125MG Brand Preferred 00126000331

4

LURIDE DRO 0.5MG/ML Brand Preferred 00126000262

4

LURIDE SF CHW 0.25MG Brand Preferred 00126000921

4

MAGNESIUM GLUCONATE PreferredBrand/Generic 4OTC

MAGNESIUM SULFATE PreferredBrand/Generic 4

MAGNESIUM SU INJ 12.5% Brand Preferred 00074494301

4

MAGNESIUM SU INJ 40MG/ML Brand Preferred 00074376003

4

MAGNESIUM SU INJ 50% Brand Preferred 00469852510

4

MAGNESIUM SU INJ 80MG/ML Brand Preferred 00074376101

4

MICRO-K PreferredBrand/Generic 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



NEUTRA-PHOS

NEUTRA-PHOS CAP Brand Preferred 11414020205

4

OTC -

NEUTRA-PHOS POW CAP 1.25 Brand Preferred 00575022905

4

NEUTRA-PHOS POW -K Brand Preferred 11414020301

4

OTC -

NEUTRA-PHOS POW Brand Preferred 00575023015

4

OTC -

NORMAL SALINE FLUSH PreferredGeneric 4

NORMAL SALINE I.V. FLUSH PreferredGeneric 4

OS-CAL PreferredBrand/Generic 4OTC

OS-CAL 500 + D PreferredBrand/Generic 4OTC

OYSCO 500/D PreferredGeneric 4OTC

OYST-CAL PreferredGeneric 4OTC

OYST-CAL D PreferredGeneric 4OTC

OYST-CAL/VITAMIN D PreferredGeneric 4OTC

OYSTER CALCIUM PreferredBrand/Generic 4OTC

OYSTER SHELL CALCIUM/D PreferredGeneric 4OTC

OYSTER SHELL CALCIUM/VITA PreferredGeneric 4OTC

OYSTER SHELL/VITAMIN D

OYSTER SHELL TAB /D 250MG Generic Preferred 00349602601

4

OTC -

OYSTER SHELL TAB /D 500MG Generic Preferred 12333997001

4

OTC -

OYSTER SHELL TAB /VIT D Generic Preferred 10956068209

4

OTC -

OYSTERCAL 500 + D PreferredGeneric 4OTC

OYSTERCAL-D PreferredGeneric 4OTC

P.T.E. -5 PreferredBrand 4

POTASSIUM BICARBONATE PreferredGeneric 4

POTASSIUM CHLORIDE PreferredBrand/Generic 4

POT CHLORIDE INJ 1.5MEQ Brand Preferred 00074499301

4

POT CHLORIDE INJ 10MEQ Brand Preferred 00338070948

4

POT CHLORIDE INJ 2.4MEQ Brand Preferred 00074493801

4


4


4

POT CHLORIDE INJ 3MEQ/ML Brand Preferred 00469683025

4


4

POT CHLORIDE POW 100MEQ Brand Preferred 00436070217

4


4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status




4


4


4


4

POT CHLORIDE SOL 5% Brand Preferred 00054871504

4

POTASSIUM CHLORIDE CR PreferredGeneric 4

POTASSIUM CHLORIDE ER PreferredBrand/Generic 4

POTASSIUM CHLORIDE SA PreferredGeneric 4

POTASSIUM CHLORIDE SR PreferredGeneric 4

RA CALCIUM PLUS VITAMIN D PreferredGeneric 4OTC

SELENIUM

SELENIUM TAB 100MCG Generic Preferred 10135020101

4

OTC -

SELENIUM TAB 50MCG Generic Preferred 00084102301

4

OTC -

SLOW-MAG PreferredBrand 4OTC

SODIUM BICARBONATE PreferredGeneric 4

SODIUM CHLORIDE

SOD CHLORIDE INJ 0.2% Brand Preferred 39769003105

4

SOD CHLORIDE INJ 0.9% Generic Preferred 17474300201

4

SOD CHLORIDE INJ 2.5/ML Generic Preferred 00074489301

4

SOD CHLORIDE INJ 23.4% Brand Preferred 00074113002

4

SOD CHLORIDE INJ 23.4% Generic Preferred 54569390800

4

SOD CHLORIDE INJ 3% Generic Preferred 00264780510

4

SOD CHLORIDE INJ 4MEQ/ML Generic Preferred 54569222600

4

SOD CHLORIDE INJ 5% Generic Preferred 00264780610

4

SOD CHLORIDE TAB 1GM Brand Preferred 00002010902

4

OTC -

SOD CHLORIDE TAB 1GM Generic Preferred 00223176001

4

OTC -

SOD CHLORIDE TAB 2.25GM Brand Preferred 00002202302

4

OTC -

SOD CHLORIDE TAB 650MG Generic Preferred 00527111610

4

OTC -

SODIUM CHLOR INJ 0.9% Generic Preferred 00338004511

4

SODIUM CHLORIDE 0.45% PreferredBrand/Generic 4

SODIUM FLUORIDE PreferredBrand/Generic 4

SSKI PreferredBrand 4

TUMS 500 PreferredGeneric 4OTC

V-R CALCIUM 600 +D PreferredGeneric 4OTC

V-R OYSTER SHELL CALCIUM/ PreferredGeneric 4OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



ZINC SULFATE

ZINC SULFATE CAP 137MG Brand Preferred 00615164201

4

OTC -

ZINC SULFATE CAP 200MG Brand Preferred 00615163513

4

ZINC SULFATE CAP 220MG Generic Preferred 00157035201

4

ZINC SULFATE INJ 1MG/ML Brand Preferred 00517611001

4

ZINC SULFATE INJ 1MG/ML Generic Preferred 00338036161

4


4


4

ZINC SULFATE INJ 5MG/ML Generic Preferred 00469632030

4

ZINC SULFATE TAB 200MG Generic Preferred 00536490510

4

OTC -

ZINC SULFATE TAB 220MG Generic Preferred 00093011401

4

OTC -

CALCIUM

CALCIUM CHW 250MG Generic Non-Preferred 31604002460

8

OTC -

CALCIUM CHW CHOC Generic Non-Preferred 49614070572

8

OTC -

CALCIUM INJ Generic Non-Preferred 00402022070

8

CALCIUM TAB 150MG Generic Non-Preferred 00418305121

8

OTC -

CALCIUM + D

CALCIUM + D TAB 600MG Generic Non-Preferred 66375010502

8

OTC -

CALCIUM CARBONATE Non-PreferredBrand 8OTC

CALCIUM GLUCONATE

CALCIUM GLUC CHW 1000MG Brand Non-Preferred 00143117025

8

OTC -

CALCIUM GLUC CHW 650MG Brand Non-Preferred 00143116525

8

OTC -

CALCIUM GLUC INJ 10% Generic Non-Preferred 00009026202

8

CALCIUM GLUC POW Brand Non-Preferred 00406692403

8

CALCIUM GLUC POW Generic Non-Preferred 00395043401

8

OTC -

CALCIUM/VITAMIN D

CALCIUM/D CAP Brand Non-Preferred 54629016501

8

OTC -

CALCIUM/D TAB 600MG Generic Non-Preferred 10135025757

8

OTC -

CALCIUM/D TAB 90MG Generic Non-Preferred 00002204402

8

OTC -

CALTRATE PLUS Non-PreferredBrand 8OTC

CITRACAL

CITRACAL TAB EFFER Brand Non-Preferred 00178081130

8

OTC -

FEOSTAT

FEOSTAT DRO 45/0.6ML Brand Non-Preferred 00456037421

8

OTC -

FERGON


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



FERGON CAP Brand Non-Preferred 00024101603

8

OTC -

FER-IN-SOL Non-PreferredBrand 8OTC

FERREX 150 Non-PreferredGeneric 8OTC

FERROUS SULFATE

FE SULFATE POW USP/NF Brand Non-Preferred 49452315001

8

OTC -

FE SULFATE POW USP Brand Non-Preferred 62991166601

8

OTC -

FERROUS SULF GRA USP NF Brand Non-Preferred 49452314001

8

OTC -

FERROUS SULF GRA USP Brand Non-Preferred 38779128805

8

OTC -

FERROUS SULF GRA Brand Non-Preferred 00406557203

8

OTC -

FERROUS SULF LIQ 300/5ML Brand Non-Preferred 00054828104

8

OTC -

FERROUS SULF LIQ 300/5ML Generic Non-Preferred 10350008316

8

OTC -

FE-TINIC Non-PreferredGeneric 8OTC

FLUOR-A-DAY

FLUOR-A-DAY LOZ 2.2MG Generic Non-Preferred 51817067216

8

INFED

INFED INJ 50MG/ML Generic Non-Preferred 00364301228

8

K-DUR Non-PreferredBrand 8

KLOR-CON Non-PreferredBrand 8

K-LYTE Non-PreferredBrand 8

K-LYTE DS Non-PreferredBrand 8

K-PHOS NEUTRAL Non-PreferredBrand 8

K-TABS Non-PreferredBrand 8

LURIDE

LURIDE DRO 0.125MG Brand Non-Preferred 00126012550

8

MAGNESIUM SULFATE

MAGN SULFATE CAP 70MG Brand Non-Preferred 53191031101

8

OTC -

MG SO4/D5W INJ 10MG/ML Brand Non-Preferred 00074672709

8

MG SO4/D5W INJ 20MG/ML Brand Non-Preferred 00074672803

8

NEUTRA-PHOS

NEUTRA-PHOS POW K CAPS Brand Non-Preferred 00575022601

8

OTC -

NEUTRA-PHOS SOL Brand Non-Preferred 00575023101

8

OTC -

NIFEREX Non-PreferredBrand/Generic 8OTC

NIFEREX-150 Non-PreferredGeneric 8OTC

NU-IRON 150 Non-PreferredGeneric 8OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



OYSTER SHELL/VITAMIN D

OYSTER SHELL TAB /D 150MG Generic Non-Preferred 47679052601

8

OTC -

OYSTER SHELL TAB /D 500MG Generic Non-Preferred 47679070935

8

OTC -

POLYSACCHARIDE IRON COMPL Non-PreferredBrand/Generic 8OTC

POTASSIUM BICARBONATE Non-PreferredBrand 8

POTASSIUM CHLORIDE

POT CHLORIDE CRY USP NF Brand Non-Preferred 49452577001

8

OTC -

POT CHLORIDE CRY Brand Non-Preferred 00406684503

8

OTC -

POT CHLORIDE GRA USP NF Brand Non-Preferred 49452578001

8

POT CHLORIDE GRA USP Brand Non-Preferred 62991154901

8

POT CHLORIDE GRA Brand Non-Preferred 51552032405

8

POT CHLORIDE POW USP FCC Brand Non-Preferred 10106305201

8

POT CHLORIDE POW Brand Non-Preferred 00406683803

8

POT CHLORIDE TAB 13.4MEQ Brand Non-Preferred 00002013102

8

POT CHLORIDE TAB 4MEQ EC Brand Non-Preferred 00002010502

8

SELENIUM

SELENIUM TAB 200MCG Generic Non-Preferred 00904420352

8

OTC -

SLOW FE Non-PreferredBrand 8OTC

SODIUM CHLORIDE

SOD CHLORIDE CRY REAGENT Brand Non-Preferred 49452668501

8

SOD CHLORIDE CRY Brand Non-Preferred 00406758103

8

SOD CHLORIDE GRA USP NF Brand Non-Preferred 49452669001

8

OTC -

SOD CHLORIDE GRA USP/NF Brand Non-Preferred 62991137201

8

OTC -

SOD CHLORIDE GRA Brand Non-Preferred 00406753203

8

OTC -

SOD CHLORIDE INJ 0.9% Generic Non-Preferred 63807010011

8

SOD CHLORIDE KIT 0.9% Brand Non-Preferred 00024181520

8

SOD CHLORIDE POW USP NF Brand Non-Preferred 49452670001

8

SOD CHLORIDE POW Brand Non-Preferred 38779062908

8

VIACTIV Non-PreferredBrand 8OTC

ZINC SULFATE

ZINC SULFATE GRA USP/NF Brand Non-Preferred 62991116801

8

ZINC SULFATE POW FCC Brand Non-Preferred 49452836001

8

OTC -

ZINC SULFATE POW Brand Non-Preferred 00406887203

8

OTC -

ZINC SULFATE TAB 25MG Generic Non-Preferred 00394012502

8

OTC -

MISCELLANEOUS NARCOTICS


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



ACETAMINOPHEN/CODEINE

APAP/CODEINE ELX 120-12/5 Generic Preferred 00054300550

4

APAP/CODEINE TAB 300-15MG Generic Preferred 00047063424

4


4


4

ACETAMINOPHEN/CODEINE #2 PreferredGeneric 4



ASPIRIN/CODEINE PreferredGeneric 4

BUTAL/ASA/CAFF/COD PreferredGeneric 4

BUTALBITAL/ASPIRIN/CAFFEI PreferredGeneric 4

CODEINE PHOSPHATE

CODEINE PHOS INJ 30MG/2ML Brand Preferred 00074109702

4

CODEINE PHOS INJ 60MG/2ML Brand Preferred 00074110202

4

CODEINE PHOS SOL 15MG/5ML Brand Preferred 00054316163

4

CODEINE SULFATE PreferredBrand/Generic 4

ENDOCET

ENDOCET TAB 5-325MG Generic Preferred 60951060275

4

ENDOCET TAB 7.5-325M Generic Preferred 60951070070

4

ENDODAN PreferredGeneric 4

HYDROCODONE BITARTRATE/AP PreferredGeneric 4

HYDROCODONE/ACETAMINOPHE

N

PreferredGeneric 4

HYDROCODONE/APAP PreferredGeneric 4

HYDROCODONE-APAP PreferredGeneric 4

HYDROMORPHONE HCL PreferredBrand/Generic 4

HYDROMORPHON INJ 10MG/ML Generic Preferred 00074217201

4


4


4


4

HYDROMORPHON POW Generic Preferred 63275200101

4

HYDROMORPHON SUP 3MG Generic Preferred 00574722406

4

HYDROMORPHON TAB 1MG Generic Preferred 00879071401

4


4


4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status




4


4

MEPERIDINE HCL

MEPERIDINE INJ 100MG/ML Generic Preferred 00641115035

4


4


4

MEPERIDINE INJ 300MG Generic Preferred 00074603001

4


4


4

MEPERIDINE SYP 50MG/5ML Generic Preferred 00054354563

4

MEPERIDINE TAB 100MG Generic Preferred 00054459625

4

MEPERIDINE TAB 50MG Generic Preferred 00054459525

4

MORPHINE SULFATE

MORPHINE SUL SOL 20MG/ML Generic Preferred 00186112385

4

MORPHINE SUL TAB 10MG Brand Preferred 00002254902

4

MORPHINE SUL TAB 15MG Generic Preferred 00054458225

4

MORPHINE SUL TAB 30MG Generic Preferred 00054458325

4

MSIR

MSIR SOL 20MG/ML Generic Preferred 00034052301

4

MSIR TAB 15MG Generic Preferred 00034051810

4

MSIR TAB 30MG Generic Preferred 00034051910

4

OXYCODONE HCL PreferredBrand/Generic 4

OXYCODONE/ACETAMINOPHEN PreferredGeneric 4

OXYCODONE/ASPIRIN

OXYCOD/ASA TAB Generic Preferred 00102315501

4

OXYDOSE PreferredGeneric 4

OXYFAST PreferredGeneric 4

PENTAZOCINE/NALOXONE HCL PreferredGeneric 4

PROPOXYPHENE COMPOUND-65 PreferredBrand/Generic 4

PROPOXYPHENE HCL PreferredGeneric 4

PROPOXYPHENE/ACETAMINOPHE

PROPOXY/APAP TAB 65/650MG Generic Preferred 00182080001

4

PROPOXY/APAP TAB 65-650MG Generic Preferred 00047097924

4

PROPOXYPHENE-N/ACETAMINOP PreferredGeneric 4

ROXANOL


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



ROXANOL SOL 20MG/ML Brand Preferred 00054375144

4

ROXICET

ROXICET SOL 5-325/5 Brand Preferred 00054368663

4

ROXICODONE PreferredBrand 4

ROXICODONE INTENSOL PreferredBrand 4

SUBOXONE PreferredBrand 4

MORPHINE SULFATE ER Non-PreferredGeneric 7

ACETAMINOPHEN/CODEINE

APAP/CODEINE CAP 300-30MG Generic Non-Preferred 00182172601

8

APAP/CODEINE CAP 300-60MG Generic Non-Preferred 00182172701

8

APAP/CODEINE SUS 120-12/5 Generic Non-Preferred 00580002716

8

ACTIQ Non-PreferredBrand 8

ANEXSIA Non-PreferredBrand/Generic 8

ASCOMP/CODEINE Non-PreferredGeneric 8

BUTALBITAL/APAP/CAFFEINE/ Non-PreferredGeneric 8

CAPITAL/CODEINE Non-PreferredBrand 8

CODEINE PHOSPHATE

CODEINE PHOS POW USP Brand Non-Preferred 62991140401

8

CODEINE PHOS POW Brand Non-Preferred 00406154832

8

CODEINE PHOS TAB SOL 15MG Brand Non-Preferred 00002255602

8


8


8

DARVOCET-N 100 Non-PreferredBrand 8

DARVOCET-N 50 Non-PreferredBrand 8

DARVON Non-PreferredBrand 8

DARVON COMPOUND-65 Non-PreferredBrand 8

DARVON-N Non-PreferredBrand 8

DEMEROL Non-PreferredBrand 8

DILAUDID Non-PreferredBrand 8

DILAUDID-5 Non-PreferredBrand 8

DILAUDID-HP Non-PreferredBrand 8

ENDOCET

ENDOCET TAB 10-650MG Generic Non-Preferred 60951079770

8

ENDOCET TAB 7.5-500M Generic Non-Preferred 60951079670

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



FIORICET/CODEINE Non-PreferredBrand 8

HYDROCODONE/IBUPROFEN Non-PreferredGeneric 8

HYDROMORPHONE HCL

HYDROMORPHON LIQ 1MG/ML Generic Non-Preferred 00054338750

8

LORCET 10/650 Non-PreferredBrand 8

LORCET PLUS Non-PreferredBrand 8

LORTAB 5 Non-PreferredBrand/Generic 8

MAXIDONE Non-PreferredBrand 8

MEPERIDINE HCL Non-PreferredBrand/Generic 8

MEPERIDINE POW Generic Non-Preferred 58298054301

8

MORPHINE SULFATE

MORP SULFATE POW USP Brand Non-Preferred 49452002801

8

MORPHINE SUL POW USP Brand Non-Preferred 62991140301

8

MORPHINE SUL POW Brand Non-Preferred 00406152153

8

MORPHINE SUL SOL 10MG/5ML Generic Non-Preferred 00186112495

8

MORPHINE SUL SOL 20MG/5ML Generic Non-Preferred 60432012300

8


8


8

MORPHINE SUL TAB 10MG Brand Non-Preferred 63304070601

8


8

MORPHINE SUL TAB 15MG Generic Non-Preferred 00002255002

8


8

MORPHINE SUL TAB 30MG Generic Non-Preferred 00002255102

8

MORPHINE/D5W INJ 0.2MG/ML Brand Non-Preferred 00074606302

8

MORPHINE/D5W INJ 1MG/ML Brand Non-Preferred 00074606202

8

MORPHINE SULFATE ER Non-PreferredGeneric 8

MSIR Non-PreferredBrand/Generic 8

MSIR SOL 10MG/5ML Generic Non-Preferred 00034052101

8

MSIR SOL 20MG/5ML Generic Non-Preferred 00034052202

8

NORCO Non-PreferredBrand 8

OXYCODONE/APAP Non-PreferredGeneric 8

OXYCODONE/ASPIRIN

OXYCOD/ASA TAB Generic Non-Preferred 00879046452

8

OXYIR Non-PreferredBrand 8

PENTAZOCINE/ACETAMINOPHEN Non-PreferredGeneric 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



PERCOCET Non-PreferredBrand 8

PERCODAN Non-PreferredBrand 8

PHRENILIN W/CAFFEINE/CODE Non-PreferredGeneric 8

PROPOXYPHENE/ACETAMINOPHE Non-PreferredBrand/Generic 8

PROPOXY/APAP CAP 65-650 Generic Non-Preferred 00115431201

8

ROXANOL

ROXANOL SOL 10/2.5ML Brand Non-Preferred 00054878111

8

ROXANOL SOL 20MG/5ML Brand Non-Preferred 00054878511

8

ROXANOL TAB 30MG SR Brand Non-Preferred 00054878024

8

ROXICET

ROXICET TAB 5-500MG Brand Non-Preferred 00054478425

8

SUBUTEX Non-PreferredBrand 8

SYNALGOS-DC Non-PreferredBrand 8

TALACEN Non-PreferredBrand 8

TALWIN NX Non-PreferredBrand 8

TYLENOL/CODEINE #3 Non-PreferredBrand 8

TYLENOL/CODEINE #4 Non-PreferredBrand 8

TYLOX Non-PreferredBrand 8

VICOPROFEN Non-PreferredBrand 8

ZYDONE Non-PreferredBrand/Generic 8

MONOPHASIC COMBINATION O/CS

ALESSE-21 PreferredBrand 4

ALESSE-28 PreferredBrand 4

DEMULEN 1/35-28 PreferredBrand 4

DEMULEN 1/50-28 PreferredBrand 4

DESOGEN PreferredBrand 4

LEVLEN-28 PreferredBrand 4

LO/OVRAL 21 PreferredBrand 4

LO/OVRAL 28 PreferredBrand 4

LOESTRIN FE PreferredBrand 4

LOESTRIN FE 1/20 PreferredBrand 4

MODICON PreferredBrand 4

NORINYL 1+35

NORINYL TAB 1+35-28 Brand Preferred 54868044200

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



ORTHO-CEPT-28 PreferredBrand 4

ORTHO-CYCLEN-28 PreferredBrand 4



OVCON-35/28 PreferredBrand 4

OVCON-50 28 PreferredBrand 4

YASMIN 28 PreferredBrand 4

APRI Non-PreferredGeneric 8

AVIANE Non-PreferredGeneric 8

BREVICON-28 Non-PreferredBrand 8

CRYSELLE-28 Non-PreferredGeneric 8

KARIVA Non-PreferredGeneric 8

LESSINA-28 Non-PreferredGeneric 8

LEVLITE-28 Non-PreferredBrand 8

LEVORA 0.15/30-28 Non-PreferredGeneric 8

LOESTRIN 1.5/30-21 Non-PreferredBrand 8

LOESTRIN 1/20-21 Non-PreferredBrand 8

LOW-OGESTREL Non-PreferredGeneric 8

MICROGESTIN Non-PreferredGeneric 8

MICROGESTIN FE Non-PreferredGeneric 8

MIRCETTE Non-PreferredBrand 8

MONONESSA Non-PreferredGeneric 8

NECON .5/35-28 Non-PreferredGeneric 8




NORDETTE-28 Non-PreferredBrand 8

NORINYL 1+35

NORINYL TAB 1+35-21 Brand Non-Preferred 00025025706

8

NORINYL TAB 1+35-28 Brand Non-Preferred 00025025906

8

NORINYL TAB 1+35-28R Brand Non-Preferred 00025025912

8

NORTREL 0.5/35 (28) Non-PreferredGeneric 8

NORTREL 1/35 (28) Non-PreferredGeneric 8

OGESTREL Non-PreferredGeneric 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



OVRAL 21 Non-PreferredBrand 8

OVRAL 28 Non-PreferredBrand 8

PORTIA-28 Non-PreferredGeneric 8

SPRINTEC 28 Non-PreferredGeneric 8

ZOVIA 1/35E Non-PreferredGeneric 8

ZOVIA 1/50E Non-PreferredGeneric 8

MOUTH ANTI-FECTIVES

LIDOCAINE VISCOUS PreferredGeneric 4

MYCOSTATIN

MYCOSTATIN SUS 100000U Brand Preferred 00003058810

4

NYSTATIN PreferredGeneric 4

MYCELEX Non-PreferredBrand 8

MYCOSTATIN

MYCOSTATIN LOZ 200000U Brand Non-Preferred 00003054320

8

MYCOSTATIN SUS 100000U Brand Non-Preferred 00003058850

8

MOUTH ANTISEPTICS

CHLORHEXIDINE GLUCONATE PreferredGeneric 4

TRIAMCINOLONE IN ORABASE PreferredGeneric 4

APHTHASOL Non-PreferredBrand 8

PERIDEX Non-PreferredBrand 8

XYLOCAINE Non-PreferredBrand 8

MULTIPLE SCLEROSIS AGENTS

AVONEX Non-PreferredBrand 5

BETASERON W/DILUENT Non-PreferredBrand 5

COPAXONE Non-PreferredBrand 6

AVONEX Non-PreferredBrand 8

REBIF Non-PreferredBrand 8

MUSCLE RELAXANT COMBINATIONS

CARISOPRODOL/ASPIRIN Non-PreferredGeneric 8

CARISOPRODOL/ASPIRIN/CODE Non-PreferredGeneric 8

ORPHENADRINE COMPOUND DS Non-PreferredGeneric 8

ORPHENADRINE/ASA/CAFF Non-PreferredGeneric 8

ORPHENGESIC FORTE Non-PreferredGeneric 8

NARCOTIC ANTAGONISTS

NALTREXONE HCL PreferredGeneric 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NARCOTIC ANTAGONISTS

REVIA Non-PreferredBrand 8

NASAL MISC.

AYR PreferredGeneric 4OTC

BACTROBAN NASAL PreferredBrand 4

DEEP SEA NASAL SPRAY PreferredGeneric 4OTC

NASAL MOISTURIZER PreferredGeneric 4OTC

NASAL SPRAY PreferredGeneric 4OTC

NASALCROM PreferredBrand 4OTC

SALINE MIST PreferredGeneric 4OTC

SALINE NASAL SPRAY PreferredGeneric 4OTC

SEA MIST SPRAY PreferredGeneric 4OTC

ASTELIN Non-PreferredBrand 8

ATROVENT Non-PreferredBrand 8

IPRATROPIUM BROMIDE Non-PreferredGeneric 8

NASAL STEROIDS

NASONEX PreferredBrand 1

FLONASE PreferredBrand

00173045301

1M

BECONASE PreferredBrand 4

BECONASE AQ PreferredBrand 4

FLUNISOLIDE PreferredBrand 4

NASALIDE PreferredBrand 4

NASACORT Non-PreferredBrand 8

NASACORT AQ Non-PreferredBrand 8

NASAREL Non-PreferredBrand 8

RHINOCORT Non-PreferredBrand 8

RHINOCORT AQUA Non-PreferredBrand 8

NICARDIPINES

CARDENE Non-PreferredBrand 8

CARDENE SR Non-PreferredBrand 8

NICARDIPINE HCL Non-PreferredGeneric 8

NICOTINE PATCHES / TABLETS

NICODERM CQ PreferredBrand 4OTC

FP NICOTINE Non-PreferredGeneric 8OTC

NICOTINE Non-PreferredGeneric 8OTC

NICOTINE TRANSDERMAL SYST Non-PreferredBrand/Generic 8OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NICOTINE PATCHES / TABLETS

NICOTROL Non-PreferredBrand 8

ZYBAN Non-PreferredBrand 8

NICOTINE REPLACEMENT - OTHER

NICOTINE PreferredGeneric 4OTC

NICOTINE POLACRILEX PreferredGeneric 4OTC

COMMIT Non-PreferredBrand 8OTC

NICORETTE Non-PreferredBrand 8OTC

NICORETTE REFILL Non-PreferredBrand 8OTC

NICORETTE STARTER KIT Non-PreferredBrand 8OTC

NICOTROL INHALER Non-PreferredBrand 8

NICOTROL NS Non-PreferredBrand 8

NIFEDIPINES

ADALAT CC PreferredBrand 4

NIFEDIPINE Non-PreferredBrand/Generic 5

NIFEDIPINE ER Non-PreferredGeneric 5

AFEDITAB CR Non-PreferredGeneric 8

NIFEDICAL XL Non-PreferredGeneric 8

NIFEDIPINE Non-PreferredBrand/Generic 8

PROCARDIA XL Non-PreferredBrand 8

NISOLDIPINE

SULAR PreferredBrand 4

NITRO - OINTMENT/CAP/CR

NITROBID

NITROBID OIN 2% Brand Preferred 00088155249

4

NITROGLYCERIN CR PreferredGeneric 4

NITROGLYCERIN ER PreferredGeneric 4

NITROGLYCERIN SR PreferredGeneric 4

NITROGLYCERIN TD PreferredGeneric 4

NITRO-TIME PreferredGeneric 4

NITROBID

NITROBID PL CAP 2.5MG CR Brand Non-Preferred 00088155041

8

NITROBID PL CAP 6.5MG CR Brand Non-Preferred 00088155141

8

NITROBID PL CAP 9MG CR Brand Non-Preferred 00088155341

8

NITRO - PATCHES

NITREK PreferredGeneric 1


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NITRO - PATCHES

NITRO-DUR

NITRO-DUR DIS 0.8MG/HR Brand Preferred 00085081901

1

NITROGLYCERIN

NITROGLYCERI DIS 0.1MG/HR Generic Preferred 62451330535

1


1


1


1

NITROGLYCERN DIS 0.4MG/HR Generic Preferred 49730011230

1

NITROGLYCERIN TRANSDERMAL PreferredGeneric 1

MINITRAN PreferredGeneric 3

NITRO-DUR

NITRO-DUR DIS 0.1MG/HR Brand Non-Preferred 00085330501

8


8


8


8


8

NITROGLYCERIN

NITRO-TRANSD DIS 0.2MG/HR Generic Non-Preferred 49730011130

8

NITRO - SUBLINGUAL / SPRAY

NITROGLYCERIN PreferredBrand/Generic 4

NITROGLYCER INJ 5MG/ML Generic Preferred 00074410401

4

NITROGLYCER SUB 0.15MG Generic Preferred 00615258901

4


4


4


4

NITROLINGUAL

NITROLINGUAL AER 0.4/DOSE Brand Preferred 58016645501

4

NITROQUICK


4

NITROSTAT

NITROSTAT SUB 0.3MG Brand Preferred 00071041724

4


4


4

NITROTAB PreferredGeneric 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NITRO - SUBLINGUAL / SPRAY

NITROGLYCERIN

NITROGLYCER INJ 10MG/ML Generic Non-Preferred 51309060905

8

NITROGLYCER INJ 5MG/ML Generic Non-Preferred 00548611900

8

NITROLINGUAL

NITROLINGUAL SPR PUMPSPRA Brand Non-Preferred 54569497400

8

NITROQUICK

NITROQUICK SUB 0.3MG Generic Non-Preferred 54868475600

8


8


8

NITROSTAT

NITROSTAT INJ 50/10ML Brand Non-Preferred 00071457510

8

NITROSTAT INJ 8MG/10ML Brand Non-Preferred 00071457210

8

Non-Benzodiazepine - GABA-Receptor Modulators

AMBIEN Non-PreferredBrand 7

SONATA Non-PreferredBrand 8

NON-SEDATING ANTIHISTIMINES

ALAVERT

ALAVERT TAB NON-DROW Generic Preferred 00573262048

4

OTC -

CLARITIN

CLARITIN SYP 5MG/5ML Brand Preferred 11523716301

4

OTC -

LORATADINE

LORATADINE TAB 10MG Generic Preferred 37205034665

4

OTC -

TAVIST ND PreferredGeneric 4OTC

CLARINEX Non-PreferredBrand 5

ALAVERT

ALAVERT TAB 10MG Generic Non-Preferred 00573264515

8

OTC -

ALAVERT TAB NON-DROW Generic Non-Preferred 00573262006

8

OTC -

ALLEGRA Non-PreferredBrand 8

CLARITIN

CLARITIN SYP 10/10ML Brand Non-Preferred 00085061202

8

CLARITIN TAB 10MG Brand Non-Preferred 00085045803

8

CLARITIN TAB REDITAB Brand Non-Preferred 00085112802

8

LORATADINE

LORATADINE TAB 10MG Generic Non-Preferred 11822319680

8

OTC -

ZYRTEC Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NON-SEDATING ANTIHISTIMINES / DECONGESTANTS

ALLEGRA-D Non-PreferredBrand 8

CLARITIN-D 12 HOUR Non-PreferredBrand 8

CLARITIN-D 24 HOUR Non-PreferredBrand 8

ZYRTEC-D Non-PreferredBrand 8

NSAIDS

ALL DAY RELIEF PreferredGeneric 4OTC

CHILDRENS IBUPROFEN PreferredGeneric 4OTC

CHILDREN'S IBUPROFEN PreferredGeneric 4OTC

CHILD'S IBUPROFEN PreferredGeneric 4OTC

DICLOFENAC POTASSIUM PreferredGeneric 4

DICLOFENAC SODIUM DR PreferredGeneric 4

DICLOFENAC SODIUM EC PreferredGeneric 4

DICLOFENAC SODIUM ER PreferredGeneric 4

DICLOFENAC SODIUM XR PreferredGeneric 4

ETODOLAC PreferredGeneric 4

ETODOLAC CR

ETODOLAC CR TAB 400MG Generic Preferred 00228267111

4

ETODOLAC CR TAB 500MG Generic Preferred 59911362101

4

ETODOLAC ER

ETODOLAC ER TAB 400 Generic Preferred 00093112201

4

ETODOLAC ER TAB 400MG Generic Preferred 51672405101

4


4

ETODOLAC EXTENDED-RELEASE


4

FENOPROFEN CALCIUM

FENOPROFEN TAB 600MG Generic Preferred 52959006730

4

FLURBIPROFEN PreferredGeneric 4

IBU PreferredGeneric 4

IBUPROFEN PreferredBrand/Generic 4OTC

IBUPROFEN SUS 100/5ML Brand Preferred 50962047603

4

IBUPROFEN TAB 300MG Brand Preferred 00247142320

4

INDOMETHACIN

INDOMETHACIN CAP 25MG Generic Preferred 51309072214

4

INDOMETHACIN CAP 50MG Generic Preferred 00003029550

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NSAIDS

INDOMETHACIN CR PreferredGeneric 4

INDOMETHACIN ER PreferredGeneric 4

KETOPROFEN

KETOPROFEN CAP 25MG Brand Preferred 00005328443

4

KETOPROFEN ER PreferredGeneric 4

KETOROLAC TROMETHAMINE PreferredGeneric 4

MECLOFENAMATE SODIUM

MECLOFEN SOD CAP 100MG Brand Preferred 00378300001

4

MECLOFEN SOD CAP 50MG Brand Preferred 00378215001

4

NABUMETONE PreferredGeneric 4

NAPROSYN

NAPROSYN SUS 125/5ML Brand Preferred 00004002828

4

NAPROXEN PreferredGeneric 4

NAPROXEN DR

NAPROXEN DR TAB 500MG Generic Preferred 55175283002

4

NAPROXEN SODIUM

NAPROXEN TAB 220MG Generic Preferred 55045273702

4

OTC -

NAPROXEN SOD TAB 220MG Generic Preferred 00113036862

4

OTC -


4


4

NAPROXEN SOD TAB Generic Preferred 65504001492

4

OTC -

OXAPROZIN PreferredGeneric 4

PIROXICAM PreferredGeneric 4

SULINDAC PreferredGeneric 4

TOLMETIN SODIUM PreferredGeneric 4

ANAPROX DS Non-PreferredBrand 8

ANSAID Non-PreferredBrand 8

CATAFLAM Non-PreferredBrand 8

CHILDRENS MOTRIN Non-PreferredBrand 8OTC

CLINORIL Non-PreferredBrand 8

DAYPRO Non-PreferredBrand 8

EC-NAPROSYN Non-PreferredBrand 8

ETODOLAC CR

ETODOLAC CR TAB 600MG Generic Non-Preferred 59911362201

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NSAIDS

ETODOLAC ER

ETODOLAC ER TAB 600MG Generic Non-Preferred 51672405301

8

ETODOLAC EXTENDED-RELEASE

ETODOLAC ER TAB 600MG Generic Non-Preferred 00093111801

8

FELDENE Non-PreferredBrand 8

FENOPROFEN CALCIUM

FENOPROFEN CAP 200MG Generic Non-Preferred 00093060201

8

FENOPROFEN CAP 300MG Generic Non-Preferred 00047008124

8

FLURBIPROFEN Non-PreferredBrand 8

IBU-200 Non-PreferredGeneric 8OTC

IBUPROFEN

IBUPROFEN POW USP NF Brand Non-Preferred 49452365701

8

IBUPROFEN POW USP Brand Non-Preferred 62991108101

8

IBUPROFEN POW Brand Non-Preferred 38779029900

8

INDOMETHACIN Non-PreferredBrand/Generic 8

INDOMETHACIN POW Generic Non-Preferred 00574059001

8

INDOMETHACIN SUP 50MG Generic Non-Preferred 00182703117

8

INDOMETHACIN SUS 25MG/5ML Generic Non-Preferred 00054342363

8

KETOPROFEN

KETOPROFEN POW BP Brand Non-Preferred 49452391601

8

KETOPROFEN POW USP Brand Non-Preferred 49452496201

8

KETOPROFEN POW Brand Non-Preferred 38779007800

8

LODINE Non-PreferredBrand 8

LODINE XL Non-PreferredBrand 8

MECLOFENAMATE SODIUM

MECLOFEN SOD POW USP/NF Brand Non-Preferred 49452439701

8

MECLOFEN SOD POW Brand Non-Preferred 38779023704

8

MOBIC Non-PreferredBrand 8

MOTRIN Non-PreferredBrand 8OTC

NALFON Non-PreferredBrand 8

NAPRELAN Non-PreferredBrand 8

NAPROSYN

NAPROSYN TAB 250MG Brand Non-Preferred 00004631201

8


8


8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


NSAIDS

NAPROXEN Non-PreferredBrand 8

NAPROXEN DR

NAPROXEN DR TAB 375MG Generic Non-Preferred 00093100501

8

NAPROXEN DR TAB Generic Non-Preferred 52959019430

8

NAPROXEN SODIUM Non-PreferredBrand/Generic 8

NAPROXEN SOD TAB 500MG CR Generic Non-Preferred 62037082675

8

ORUVAIL Non-PreferredBrand 8

PIROXICAM Non-PreferredBrand 8

PONSTEL Non-PreferredBrand 8

RELAFEN Non-PreferredBrand 8

SULINDAC Non-PreferredBrand 8

TOLMETIN SODIUM Non-PreferredBrand 8

VOLTAREN Non-PreferredBrand 8

VOLTAREN-XR Non-PreferredBrand 8

OPHTHALMIC ANTIBIOTICS

AK-POLY-BAC PreferredGeneric 4

AK-SULF PreferredGeneric 4

BACITRACIN PreferredGeneric 4

BACITRACIN/NEOMYCIN/POLYM PreferredGeneric 4

BACITRACIN/POLYMYXIN B PreferredGeneric 4

ERYTHROMYCIN PreferredGeneric 4

GENTAK PreferredBrand/Generic 4

GENTAMICIN SULFATE PreferredBrand/Generic 4

NEOMYCIN/BACITRACIN/POLYM

NEO/BAC/POLY OIN OP Generic Preferred 52959023903

4

NEOMYCIN/POLYMYXIN/GRAMIC PreferredGeneric 4

OCUSULF-10 PreferredGeneric 4

OCUTRICIN

OCUTRICIN OIN OP Generic Preferred 55175442401

4

POLYMYXIN B SULFATE/TRIME PreferredGeneric 4

POLYTRIM PreferredBrand/Generic 4

SODIUM SULFACETAMIDE PreferredBrand/Generic 4

SULFACETAMIDE SODIUM PreferredBrand/Generic 4

TOBRAMYCIN SULFATE PreferredGeneric 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


OPHTHALMIC ANTIBIOTICS

TOBREX PreferredGeneric 4

TRIMETHOPRIM SULFATE/POLY PreferredGeneric 4

VIROPTIC PreferredBrand 4

NEOMYCIN/BACITRACIN/POLYM

NEO/BAC/POLY OIN OP Generic Non-Preferred 52959023900

8

OCUTRICIN

OCUTRICIN SOL OP Generic Non-Preferred 47202363901

8

TOBREX Non-PreferredBrand 8

TRIFLURIDINE Non-PreferredGeneric 8

ZYMAR Non-PreferredBrand 8

OPHTHALMIC NSAIAS

VOLTAREN PreferredBrand 4

ACULAR Non-PreferredBrand 8

OPHTHALMIC QUINOLONES

CILOXAN PreferredBrand 1

OCUFLOX PreferredBrand

11980077905

1M

VIGAMOX PreferredBrand

00065401303

1M

QUIXIN PreferredBrand 2

OSTEOPOROSIS

ACTONEL PreferredBrand 4

FOSAMAX PreferredBrand 4

DIDRONEL Non-PreferredBrand 8

EVISTA Non-PreferredBrand 8

FORTEO Non-PreferredBrand 8

MIACALCIN Non-PreferredBrand 8

Other Antihistamines

ALLER-CHLOR PreferredGeneric 4OTC

ALLERGY PreferredGeneric 4OTC

ALTARYL

ALTARYL ELX 12.5/5ML Generic Preferred 59390000335

4

OTC -

BANOPHEN

BANOPHEN CAP 25MG Generic Preferred 00904514724

4

OTC -

BANOPHEN ELX 12.5/5ML Generic Preferred 66116063212

4

OTC -

BANOPHEN LIQ 12.5/5 Generic Preferred 00904517416

4

OTC -

BANOPHEN TAB 25MG Generic Preferred 00904203059

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



CHLORPHENIRAMINE MALEATE

CHLORPHENIR CAP 12MG CR Generic Preferred 00185551201

4

CHLORPHENIR CAP 12MG ER Generic Preferred 10135022101

4

CHLORPHENIR CAP 12MG SA Generic Preferred 00157030401

4

CHLORPHENIR CAP 12MG SR Generic Preferred 51432008103

4

OTC -

CHLORPHENIR CAP 12MG TD Generic Preferred 00005322734

4

CHLORPHENIR CAP 12MG TR Generic Preferred 00603278521

4

CHLORPHENIR CAP 8MG CR Generic Preferred 00440728030

4

CHLORPHENIR CAP 8MG ER Generic Preferred 10135021201

4

CHLORPHENIR CAP 8MG SA Generic Preferred 00157030301

4

CHLORPHENIR CAP 8MG SR Generic Preferred 51432007903

4

OTC -

CHLORPHENIR CAP 8MG TD Generic Preferred 00781260201

4

CHLORPHENIR CAP 8MG TR Generic Preferred 00603278421

4

CHLORPHENIR SYP 2MG/5ML Generic Preferred 00223624401

4

OTC -

CHLORPHENIR TAB 12MG CR Brand Preferred 00440727730

4

CHLORPHENIR TAB 12MG CR Generic Preferred 00615161810

4

CHLORPHENIR TAB 12MG TD Generic Preferred 00783011509

4

CHLORPHENIR TAB 4MG Generic Preferred 53258010713

4

OTC -

CHLORPHENIR TAB 8MG CR Generic Preferred 00615161710

4

CHLORPHENIR TAB 8MG SR Generic Preferred 51432008003

4

CHLORPHENIR TAB 8MG TD Generic Preferred 00783011409

4

CHLOR-TRIMETON REPETABS

CHLOR-TRIMET TAB 12MG CR Brand Preferred 00085000902

4

OTC -

CHLOR-TRIMET TAB 8MG CR Brand Preferred 00085037409

4

OTC -

CLEMASTINE FUMARATE

CLEMASTINE SYP 0.67/5ML Generic Preferred 00093030912

4

CLEMASTINE TAB 1.34MG Generic Preferred 00093030701

4

CLEMASTINE TAB 2.68MG Generic Preferred 00093030801

4

COMPLETE ALLERGY

COMPLETE ALG ELX 12.5/5ML Generic Preferred 37205056526

4

OTC -

COMPLETE ALL CAP 25MG Generic Preferred 10916008724

4

OTC -

CYPROHEPTADINE HCL

CYPROHEPTAD SYP 2MG/5ML Generic Preferred 00182135540

4

CYPROHEPTAD TAB 4MG Generic Preferred 00102247001

4

DIPHENHIST


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



DIPHENHIST CAP 25MG Generic Preferred 00536359435

4

OTC -

DIPHENHIST ELX 12.5/5ML Generic Preferred 00536047047

4

OTC -

DIPHENHIST TAB 25MG Generic Preferred 00536359701

4

OTC -

DIPHENHYDRAMINE HCL

DIPHENHYDRAM CAP 25MG Generic Preferred 00536375801

4

OTC -

DIPHENHYDRAM CAP 50MG Generic Preferred 00093013901

4

DIPHENHYDRAM ELX 12.5/5ML Generic Preferred 00537253016

4

DIPHENHYDRAM INJ 50MG/ML Generic Preferred 00402082710

4

DIPHENHYDRAM LIQ 12.5/5ML Generic Preferred 00677160333

4

DIPHENHYDRAM LIQ 12.5MG/5 Generic Preferred 61073002604

4

OTC -

DIPHENHYDRAM TAB 25MG Generic Preferred 00615350229

4

OTC -

HYDRAMINE

HYDRAMINE ELX 12.5/5ML Generic Preferred 49999024704

4

OTC -

Q-DRYL

Q-DRYL CAP 25MG Generic Preferred 00603024018

4

OTC -

Q-DRYL ELX 12.5/5ML Generic Preferred 00603082254

4

OTC -

ALTARYL

ALTARYL SYP 12.5/5ML Generic Non-Preferred 59390006535

8

OTC -

BANOPHEN

BANOPHEN TAB 25MG Generic Non-Preferred 00904555124

8

OTC -

CHLORPHENIRAMINE MALEATE

CHLORPHENIR INJ 100MG/ML Brand Non-Preferred 00402000610

8

CHLORPHENIR INJ 100MG/ML Generic Non-Preferred 00314061670

8

CHLORPHENIR INJ 10MG/ML Generic Non-Preferred 00223731010

8

CHLORPHENIR POW MALEATE Brand Non-Preferred 38779028301

8

CHLORPHENIR TAB 8MG CR Brand Non-Preferred 51655000724

8

OTC -

CHLOR-TRIMETON REPETABS

CHLOR-TRIMET TAB 8MG CR Brand Non-Preferred 00085037402

8

OTC -

CLEMASTINE FUMARATE Non-PreferredBrand/Generic 8

CLEMASTINE TAB 2.68MG Generic Non-Preferred 00615450213

8

COMPLETE ALLERGY

COMPLETE ALL TAB 25MG Generic Non-Preferred 37205027062

8

OTC -

CYPROHEPTADINE HCL

CYPROHEPTAD SYP 2MG/5ML Generic Non-Preferred 51079031610

8

CYPROHEPTAD TAB 4MG Generic Non-Preferred 00615153613

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



DIPHEN AF Non-PreferredGeneric 8OTC

DIPHENHIST

DIPHENHIST TAB 25MG Generic Non-Preferred 00536359735

8

OTC -

DIPHENHYDRAMINE HCL

DIPHENHYDRAM CAP 25MG Generic Non-Preferred 47682018247

8

OTC -

DIPHENHYDRAM CAP 50MG Generic Non-Preferred 61392022351

8

OTC -

DIPHENHYDRAM INJ 10MG/ML Generic Non-Preferred 00469908587

8

DIPHENHYDRAM SYP 12.5/5ML Generic Non-Preferred 00223613501

8

DIPHENHYDRAM TAB 25MG Generic Non-Preferred 00615350243

8

OTC -

DIPHENHYDRAM TAB 50MG Generic Non-Preferred 00536377206

8

OTC -

HYDRAMINE

HYDRAMINE SYP 12.5/5ML Generic Non-Preferred 11845043013

8

OTC -

Q-DRYL

Q-DRYL TAB 25MG Generic Non-Preferred 00603023918

8

OTC -

OTHER ANTI-HYPERTENSIVES - CENTRAL

CATAPRES-TTS-1 PreferredBrand 4



CLONIDINE HCL PreferredGeneric 4

GUANFACINE HCL PreferredGeneric 4

HYDRALAZINE HCL

HYDRALAZINE TAB 100MG Generic Preferred 00147025810

4


4


4


4

METHYLDOPA PreferredBrand/Generic 4

METHYLDOPA TAB 125MG Generic Preferred 00005384923

4


4


4

MINOXIDIL PreferredGeneric 4

PRAZOSIN HCL PreferredGeneric 4

RESERPINE

RESERPINE TAB 0.1MG Brand Preferred 00185003201

4

RESERPINE TAB 0.1MG Generic Preferred 00093082710

4

RESERPINE TAB 0.25MG Brand Preferred 00185013401

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


OTHER ANTI-HYPERTENSIVES - CENTRAL

RESERPINE TAB 0.25MG Generic Preferred 00143153525

4

CATAPRES Non-PreferredBrand 8

CLONIDINE HCL Non-PreferredBrand 8

GUANABENZ ACETATE Non-PreferredBrand/Generic 8

HYDRALAZINE HCL

HYDRALAZINE INJ 20MG/ML Generic Non-Preferred 39769002102

8

METHYLDOPA

METHYLDOPA SUS 250/5ML Generic Non-Preferred 50962035005

8

RESERPINE

RESERPINE CRY USP Brand Non-Preferred 17317046201

8

RESERPINE POW USP Brand Non-Preferred 62991147501

8

RESERPINE POW Brand Non-Preferred 38779015901

8

RESERPINE TAB 0.25MG Generic Non-Preferred 00093082110

8

TENEX Non-PreferredBrand 8

OTHER DOPAMINERGICS/CARBII/LEVO

AMANTADINE HCL

AMANTADINE CAP 100MG Generic Preferred 00047085324

4

AMANTADINE SYP 50MG/5ML Generic Preferred 00121064616

4

BROMOCRIPTINE MESYLATE PreferredGeneric 4

CARBIDOPA/LEVODOPA PreferredGeneric 4

CARBIDOPA/LEVODOPA ER PreferredGeneric 4

LODOSYN PreferredBrand 4

PARLODEL

PARLODEL CAP 5MG Brand Preferred 00078010205

4

SELEGILINE HCL PreferredGeneric 4

AMANTADINE HCL

AMANTADINE TAB 100MG Generic Non-Preferred 00832011100

8

BROMOCRIPTINE MESYLATE Non-PreferredBrand 8

ELDEPRYL Non-PreferredBrand 8

PARLODEL

PARLODEL TAB 2.5MG Brand Non-Preferred 00078001705

8

SELEGILINE HCL Non-PreferredBrand 8

SINEMET Non-PreferredBrand 8

PATCHES/ VAGINAL PRODUCTS

NUVARING Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


PATCHES/ VAGINAL PRODUCTS

ORTHO EVRA Non-PreferredBrand 8

PLATELET AGGREGATION INHIBITORS

DIPYRIDAMOLE PreferredGeneric 4

PLAVIX PreferredBrand 4

TICLOPIDINE HCL PreferredGeneric 4

PROGESTIN ONLY CONTRACEPTIVES

ORTHO MICRONOR PreferredBrand 4

CAMILA Non-PreferredGeneric 8

ERRIN Non-PreferredGeneric 8

JOLIVETTE Non-PreferredGeneric 8

NORA-BE Non-PreferredGeneric 8

NOR-QD Non-PreferredBrand 8

OVRETTE 28 Non-PreferredBrand 8

PROGESTINS

MEDROXYPROGESTERONE

ACETA

PreferredGeneric 4

NORETHINDRONE ACETATE PreferredGeneric 4

PROGESTERONE MICRONIZED PreferredBrand/Generic 4

AYGESTIN Non-PreferredBrand 8

NORETHINDRONE ACETATE Non-PreferredBrand 8

PROMETRIUM Non-PreferredBrand 8

PROVERA Non-PreferredBrand 8

PROSTAGLANDINS - GI

MISOPROSTOL PreferredGeneric 4

CYTOTEC Non-PreferredBrand 8

PROSTAGLANDINS - OPHTHALMIC

XALATAN PreferredBrand 1

TRAVATAN PreferredBrand 2

LUMIGAN PreferredBrand 3

RESCULA Non-PreferredBrand 8

PROTON PUMP INHIBITOR

PREVACID

PREVACID CAP 15MG DR Brand Preferred 00300154119

1

PREVACID CAP 30MG DR Brand Preferred 00300304613

1

PRILOSEC OTC

PRILOSEC OTC TAB 20MG Brand Preferred 37000045504

1

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


PROTON PUMP INHIBITOR

PROTONIX PreferredBrand 1

PROTONIX PreferredBrand 4

ACIPHEX Non-PreferredBrand 5

OMEPRAZOLE Non-PreferredGeneric 6

NEXIUM Non-PreferredBrand 7

OMEPRAZOLE Non-PreferredGeneric 8

PREVACID

PREVACID GRA 15MG Brand Non-Preferred 00300730930

8

PREVACID GRA 30MG Brand Non-Preferred 00300731130

8

PRILOSEC Non-PreferredBrand 8

PRILOSEC OTC

PRILOSEC OTC TAB 20MG Brand Non-Preferred 37000045502

8

OTC -

PULMONARY ANTI-HYPERTENSIVES

FLOLAN Non-PreferredBrand 8

TRACLEER Non-PreferredBrand 8

PURINE ANALOG

AZASAN PreferredBrand/Generic 4

AZASAN TAB 75 MG Brand Preferred 66591023141

4

AZATHIOPRINE PreferredGeneric 4

AZASAN

AZASAN TAB 100MG Brand Non-Preferred 66591024141

8

AZATHIOPRINE Non-PreferredBrand 8

IMURAN Non-PreferredBrand 8

RHEUMATOID ARTHRITIS

ARAVA Non-PreferredBrand 7

ENBREL Non-PreferredBrand 8

HUMIRA Non-PreferredBrand 8

KINERET Non-PreferredBrand 8

RSV PROPHYLAXIS

SYNAGIS Non-PreferredBrand 8

SCABICIDES AND PEDICULICIDES

ACTICIN PreferredGeneric 4

ELIMITE PreferredBrand/Generic 4

EURAX PreferredBrand 4

LICE TREATMENT CREME RINS PreferredGeneric 4OTC


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


SCABICIDES AND PEDICULICIDES

LINDANE PreferredBrand/Generic 4

NIX CREME RINSE PreferredBrand 4

OVIDE PreferredBrand 4

PERMETHRIN PreferredGeneric 4

RID PreferredBrand 4OTC

SEDATIVE HYPNOTICS - BENZODIAZEPINES

DORAL PreferredBrand 4

ESTAZOLAM PreferredGeneric 4

FLURAZEPAM HCL PreferredGeneric 4

TEMAZEPAM PreferredBrand/Generic 4

TRIAZOLAM PreferredGeneric 4

PROSOM Non-PreferredBrand 8

RESTORIL Non-PreferredBrand 8

SELECTED DOPAMIN AGONISTS

MIRAPEX PreferredBrand 1

REQUIP PreferredBrand 2

PERMAX PreferredBrand 3

PERGOLIDE MESYLATE Non-PreferredGeneric 8

SELECTED NARCOTICS

TRAMADOL HCL PreferredGeneric 4

BUTORPHANOL TARTRATE Non-PreferredGeneric 8

NALBUPHINE HCL Non-PreferredBrand/Generic 8

NUBAIN Non-PreferredBrand/Generic 8

STADOL NS Non-PreferredBrand 8

ULTRACET Non-PreferredBrand 8

ULTRAM Non-PreferredBrand 8

SELECTIVE ALPHA ADRENERGIC AGONISTS

ALPHAGAN PreferredBrand 4

ALPHAGAN P PreferredBrand 4

IOPIDINE Non-PreferredBrand 8

SELECTIVE SEROTONIN AGONISTS (5HT)--Injectables

IMITREX

IMITREX KIT 6MG/.5ML Brand Preferred 00173044901

4

IMITREX STATDOSE PEN PreferredBrand 4

IMITREX STATDOSE REFILL PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


SELECTIVE SEROTONIN AGONISTS (5HT)--Injectables

IMITREX

IMITREX INJ 6MG/.5ML Brand Non-Preferred 54569370600

8

IMITREX SPR 20MG/ACT Brand Non-Preferred 00173052300

8

IMITREX SPR 5MG/ACT Brand Non-Preferred 00173052400

8

SELECTIVE SEROTONIN AGONISTS (5HT)--Tabs

MAXALT PreferredBrand 1

MAXALT-MLT PreferredBrand 1

IMITREX PreferredBrand

54569542600

1M

AXERT PreferredBrand 2

RELPAX PreferredBrand 2

AMERGE PreferredBrand 4

ZOMIG PreferredBrand 4

ZOMIG ZMT PreferredBrand 4

FROVA Non-PreferredBrand 8

SOMATOSTATIC AGENTS

SANDOSTATIN PreferredBrand 4

SANDOSTATIN LAR DEPOT PreferredBrand 4

SPECIAL ATYPICALS

CLOZAPINE PreferredGeneric 4

CLOZAPINE Non-PreferredBrand 8

CLOZARIL Non-PreferredBrand 8

STEROID INHALANTS

AEROBID PreferredBrand 4

AZMACORT PreferredBrand 4

FLOVENT PreferredBrand 4

FLOVENT ROTADISK PreferredBrand 4

QVAR PreferredBrand 4

VANCERIL

VANCERIL AER 42MCG Brand Preferred 40893088817

4

AEROBID-M Non-PreferredBrand 8

PULMICORT Non-PreferredBrand 8

PULMICORT TURBUHALER Non-PreferredBrand 8

VANCERIL

VANCERIL DS AER 84MCG Brand Non-Preferred 52959059801

8

STEROID LOCAL ANESTHETICS


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


STEROID LOCAL ANESTHETICS

PRAMOSONE PreferredBrand 4

LIDA MANTLE HC Non-PreferredBrand 8

TETRACYCLINES

DOXYCYCLINE HYCLATE

DOXYCYCL HYC CAP 100MG Generic Preferred 58864019020

4

DOXYCYCL HYC CAP 50MG Generic Preferred 00003067440

4

DOXYCYCL HYC TAB 100MG Generic Preferred 00003081240

4

DOXYCYCL HYC TAB 50MG Generic Preferred 00586054002

4

DYNACIN PreferredBrand/Generic 4

DYNACIN TAB 50MG Brand Preferred 99207049010

4

MINOCYCLINE HCL PreferredBrand/Generic 4

MINOCYCLINE TAB 100MG Brand Preferred 00005937618

4

MINOCYCLINE TAB 50MG Brand Preferred 00005937523

4

SUMYCIN PreferredBrand/Generic 4

TETRACYCLINE HCL PreferredBrand/Generic 4

VIBRAMYCIN

VIBRAMYCIN SYP 50MG/5ML Brand Preferred 00069097151

4

DECLOMYCIN Non-PreferredBrand 8

DORYX Non-PreferredBrand 8

DOXYCYCLINE HYCLATE Non-PreferredBrand/Generic 8

DOXYCYCL HYC INJ 100MG Generic Non-Preferred 00056510169

8

DOXYCYCL HYC INJ 200MG Generic Non-Preferred 00056510201

8

DOXYCYCLINE MONOHYDRATE Non-PreferredGeneric 8

DYNACIN

DYNACIN CAP 75MG Brand Non-Preferred 99207049905

8

DYNACIN TAB 100MG Brand Non-Preferred 99207049211

8

DYNACIN TAB 75MG Brand Non-Preferred 99207049110

8

MINOCYCLINE HCL

MINOCYCLINE POW Brand Non-Preferred 38779024003

8

MONODOX Non-PreferredBrand 8

PERIOSTAT Non-PreferredBrand 8

VIBRAMYCIN

VIBRAMYCIN CAP 100MG Brand Non-Preferred 00069095050

8

VIBRAMYCIN CAP 50MG Brand Non-Preferred 00069094050

8

VIBRAMYCIN INJ 100MG Brand Non-Preferred 00049096077

8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


TETRACYCLINES

VIBRAMYCIN INJ 200MG Brand Non-Preferred 00049098081

8

VIBRAMYCIN SUS 25MG/5ML Brand Non-Preferred 00069097065

8

THYROID HORMONES

ARMOUR THYROID PreferredBrand 4

CYTOMEL PreferredBrand 4

LEVOTHROID

LEVOTHROID TAB 100MCG Generic Preferred 00075254206

4


4


4


4


4


4


4


4


4


4


4


4

LEVOTHYROXINE SODIUM

LEVOTHYROXIN TAB 100MCG Generic Preferred 00615252213

4


4


4


4


4


4


4


4


4


4


4


4

LEVOXYL PreferredGeneric 4

THYROID PreferredBrand/Generic 4

THYROID TAB 3 GR Brand Preferred 54569861300

4

THYROLAR-1 PreferredBrand 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


THYROID HORMONES

THYROLAR-1/2 PreferredBrand 4

THYROLAR-1/4 PreferredBrand 4

UNITHROID PreferredGeneric 4

LEVOTHROID

LEVOTHROID INJ 200MCG Generic Non-Preferred 00456014088

8

LEVOTHROID INJ 500MCG Generic Non-Preferred 00456014188

8

LEVOTHYROXINE SODIUM

LEVOTHYROXIN INJ 200MCG Generic Non-Preferred 00186185501

8

LEVOTHYROXIN INJ 500MCG Generic Non-Preferred 00186185601

8

SYNTHROID Non-PreferredBrand 8

THYROID

THYROID POW 0.23% Brand Non-Preferred 49452781101

8

THYROID POW USP Brand Non-Preferred 17317057901

8

THYROID POW Brand Non-Preferred 00527061204

8

TOPICAL ANTI-FUNGALS

CLOTRIMAZOLE PreferredGeneric 4

CLOTRIMAZOLE/BETAMETHASON PreferredGeneric 4

KETOCONAZOLE PreferredGeneric 4

LOPROX

LOPROX CRE 0.77% Brand Preferred 00039019015

4

LOPROX CRE 1% Brand Preferred 00039000915

4

LOPROX LOT 1% Brand Preferred 00039000806

4

MICONAZOLE NITRATE

MICONAZOLE CRE 2% Generic Preferred 00168014231

4

OTC -

NIZORAL

NIZORAL SHA 2% Brand Preferred 50458022304

4

NYSTATIN PreferredGeneric 4

NYSTATIN/TRIAMCINOLONE PreferredGeneric 4

NYSTOP PreferredGeneric 4

PEDI-DRI PreferredGeneric 4

SPECTAZOLE PreferredBrand 4

TINACTIN

TINACTIN AER 1% Brand Preferred 00085016502

4

OTC -

TINACTIN AER POWD 1% Brand Preferred 00085007204

4

OTC -

TINACTIN CRE 1% Brand Preferred 00085071506

4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


TOPICAL ANTI-FUNGALS

CLOTRIMAZOLE Non-PreferredBrand 8

ECONAZOLE NITRATE Non-PreferredBrand/Generic 8

EXELDERM Non-PreferredBrand 8

HYDROCORTISONE IODOQUINOL Non-PreferredGeneric 8

HYDROCORTISONE/IODOQUINOL Non-PreferredGeneric 8

LAMISIL Non-PreferredBrand 8

LAMISIL AT Non-PreferredBrand 8OTC

LOPROX

LOPROX GEL TOPICAL Brand Non-Preferred 99207001301

8

LOPROX LOT 0.77% Brand Non-Preferred 00039019106

8

LOPROX TS Non-PreferredBrand 8

LOTRIMIN Non-PreferredBrand 8

LOTRISONE Non-PreferredBrand 8

MENTAX Non-PreferredBrand 8

MICONAZOLE NITRATE

MICONAZOLE AER 2% Generic Non-Preferred 52735083255

8

OTC -

MICONAZOLE AER POWD 2% Generic Non-Preferred 00839771654

8

OTC -

MONISTAT-DERM Non-PreferredBrand 8

MYCOLOG-II Non-PreferredBrand 8

MYCOSTATIN Non-PreferredBrand 8

NAFTIN Non-PreferredBrand 8

NIZORAL

NIZORAL CRE 2% Brand Non-Preferred 00247024615

8

NYSTATIN Non-PreferredBrand 8

OXISTAT Non-PreferredBrand 8

PEDI-DRI Non-PreferredBrand 8

PENLAC NAIL LACQUER Non-PreferredBrand 8

TINACTIN

TINACTIN POW 1% Brand Non-Preferred 00085044405

8

OTC -

TINACTIN SOL 1% Brand Non-Preferred 00085033305

8

OTC -

TOPICAL CORTICOSTEROIDS

BETAMETHASONE DIPROPIONAT

BETAMETH DIP CRE 0.05% Generic Preferred 00182501051

4

BETAMETH DIP LOT 0.05% Generic Preferred 00093030239

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



BETAMETH DIP OIN 0.05% Generic Preferred 00093030315

4

BETAMETHASONE VALERATE PreferredGeneric 4

BETA-VAL PreferredGeneric 4

CAPEX PreferredBrand 4

CLOBETASOL PROPIONATE PreferredGeneric 4

CLOBETASOL PROPIONATE E PreferredGeneric 4

CORMAX

CORMAX CRE 0.05% Generic Preferred 55515042015

4

CUTIVATE PreferredBrand 4

CYCLOCORT PreferredBrand 4

DERMA-SMOOTHE/FS PreferredBrand 4

DESONIDE PreferredGeneric 4

DESOWEN

DESOWEN CRE 0.05% Brand Preferred 00299577015

4

DESOWEN LOT 0.05% Brand Preferred 00299576502

4

DESOXIMETASONE PreferredBrand/Generic 4

DIPROLENE PreferredBrand 4

DIPROLENE AF PreferredBrand 4

ELOCON

ELOCON CRE 0.1% Brand Preferred 00085056701

4

ELOCON LOT 0.1% Brand Preferred 00085085401

4

FLUOCINOLONE ACETONIDE

FLUOCIN ACET CRE 0.01% Generic Preferred 00168005815

4

FLUOCIN ACET CRE 0.025% Generic Preferred 00182115059

4

FLUOCIN ACET OIN 0.025% Generic Preferred 00832856916

4

FLUOCIN ACET SOL 0.01% Generic Preferred 00168005960

4

FLUOCINONIDE PreferredGeneric 4

FLUOCINONIDE-E PreferredGeneric 4

HALOG PreferredBrand 4

HYDROCORTISONE

HYDROCORT CRE 0.5% Generic Preferred 00182095145

4

OTC -

HYDROCORT CRE 1% Generic Preferred 55045111608

4

OTC -

HYDROCORT CRE 2.5% Generic Preferred 00168008016

4

HYDROCORT LOT 0.5% Generic Preferred 00144522508

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



HYDROCORT LOT 1% MAX Generic Preferred 00182501437

4

OTC -

HYDROCORT LOT 1% Generic Preferred 00168028704

4

OTC -

HYDROCORT LOT 2.5% Generic Preferred 00603778552

4

HYDROCORT OIN 0.5% Generic Preferred 00719520557

4

OTC -

HYDROCORT OIN 1% Generic Preferred 00223416101

4

HYDROCORT OIN 2.5% Generic Preferred 00168014616

4

HYDROCRTSONE LOT 2.5% Generic Preferred 00904545403

4

HYDROCORTISONE VALERATE PreferredGeneric 4

KENALOG

KENALOG OIN 0.1% Brand Preferred 00003050860

4

LOCOID PreferredBrand 4

MOMETASONE FUROATE PreferredGeneric 4

NUTRACORT PreferredGeneric 4

PSORCON PreferredBrand 4

TRIAMCINOLONE ACETONIDE

TRIAMCINOLON CRE 0.025% Generic Preferred 00182121645

4


4

TRIAMCINOLON CRE 0.5% HP Generic Preferred 00537618315

4


4

TRIAMCINOLON CRE LP .025% Generic Preferred 40893038115

4

TRIAMCINOLON LOT 0.025% Generic Preferred 00168033660

4

TRIAMCINOLON LOT 0.1% Generic Preferred 00168033760

4

TRIAMCINOLON OIN 0.025% Generic Preferred 10350009901

4

TRIAMCINOLON OIN 0.05% Brand Preferred 46287001016

4


4


4

ULTRAVATE PreferredBrand 4

ACLOVATE Non-PreferredBrand 8

ANUSOL HC-1 Non-PreferredBrand 8OTC

ARISTOCORT A Non-PreferredBrand 8

AUGMENTED BETAMETHASONE D Non-PreferredGeneric 8

BETAMETHASONE DIPROPIONAT

BETA DIPROP GEL 0.05% Generic Non-Preferred 00168026615

8

BETAMETHASONE VALERATE Non-PreferredBrand 8

CLOBETASOL PROPIONATE Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



CLODERM Non-PreferredBrand 8

CORDRAN Non-PreferredBrand 8

CORDRAN SP Non-PreferredBrand 8

CORDRAN TAPE Non-PreferredBrand 8

CORMAX

CORMAX OIN 0.05% Generic Non-Preferred 55515041015

8

CORMAX SOL 0.05% Generic Non-Preferred 54569465600

8

DERMATOP Non-PreferredBrand 8

DESONIDE Non-PreferredBrand 8

DESOWEN

DESOWEN OIN 0.05% Brand Non-Preferred 00299577515

8

DIFLORASONE DIACETATE Non-PreferredGeneric 8

ELOCON

ELOCON OIN 0.1% Brand Non-Preferred 00085037001

8

FLUOCINOLONE ACETONIDE

FLUOCIN ACET CRE 0.01% Generic Non-Preferred 00182114959

8

FLUOCINONIDE Non-PreferredBrand 8

HYDROCORTISONE

HYDROCORT AER 0.5% Generic Non-Preferred 11383002033

8

OTC -

HYDROCORT CRE 0.5% Generic Non-Preferred 00168001408

8

OTC -

HYDROCORT GEL 1% Generic Non-Preferred 00223431320

8

HYDROCORT POW Generic Non-Preferred 00374200005

8

KENALOG

KENALOG AER SPRAY Brand Non-Preferred 54569215300

8

KENALOG CRE 0.025% Brand Non-Preferred 00003017270

8


8


8

KENALOG LOT 0.025% Brand Non-Preferred 00003017360

8

KENALOG LOT 0.1% Brand Non-Preferred 00003050220

8

KENALOG OIN 0.025% Brand Non-Preferred 00003049570

8


8


8

KENALOG-H CRE 0.1% Brand Non-Preferred 00003171115

8

LIDEX Non-PreferredBrand 8

LUXIQ Non-PreferredBrand 8


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status



NUTRACORT Non-PreferredBrand 8

OLUX Non-PreferredBrand 8

PSORCON E Non-PreferredBrand 8

SYNALAR Non-PreferredBrand 8

TEMOVATE Non-PreferredBrand 8

TRIAMCINOLONE ACETONIDE

TRIAMCINOLON CRE 0.5% Generic Non-Preferred 00223444324

8

TRIAMCINOLON POW MICRONIZ Brand Non-Preferred 38779001101

8

TRIAMCINOLON POW USP Brand Non-Preferred 17317071901

8

TRIAMCINOLON POW Brand Non-Preferred 00574045005

8

TRIAMCINOLON POW Generic Non-Preferred 00802395817

8

WESTCORT Non-PreferredBrand 8

TOPICAL STEROID COMBINATIONS

CARMOL-HC Non-PreferredBrand 8

TRI-CYCLICS

AMITRIPTYLINE HCL

AMITRIPTYLIN TAB 100MG Generic Preferred 00005358023

4


4


4


4


4


4

IMIPRAMINE HCL

IMIPRAM HCL TAB 10MG Generic Preferred 00005321534

4


4


4

CLOMIPRAMINE HCL Non-PreferredGeneric 7

DESIPRAMINE HCL Non-PreferredBrand/Generic 7

DOXEPIN HCL Non-PreferredBrand/Generic 7

IMIPRAMINE HCL

IMIPRAM HCL TAB 10MG Generic Non-Preferred 00054841825

7


7


7

NORTRIPTYLINE HCL Non-PreferredBrand/Generic 7

SURMONTIL Non-PreferredBrand 7


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


TRI-CYCLICS

AMITRIPTYLINE HCL

AMITRIPTYLIN INJ 10MG/ML Generic Non-Preferred 00223716210

8

AMOXAPINE Non-PreferredBrand/Generic 8

ANAFRANIL Non-PreferredBrand 8

DESIPRAMINE HCL Non-PreferredBrand/Generic 8

DOXEPIN HCL Non-PreferredBrand/Generic 8

ELAVIL Non-PreferredBrand 8

IMIPRAMINE HCL Non-PreferredBrand/Generic 8

NORPRAMIN Non-PreferredBrand 8

NORTRIPTYLINE HCL Non-PreferredBrand/Generic 8

PAMELOR Non-PreferredBrand 8

SINEQUAN Non-PreferredBrand 8

TOFRANIL Non-PreferredBrand 8

TOFRANIL-PM Non-PreferredBrand 8

VIVACTIL Non-PreferredBrand 8

TRI-PHASIC COMBINATIONS

ORTHO TRI-CYCLEN PreferredBrand 4

ORTHO-NOVUM 7/7/7-28 PreferredBrand 4

TRI-LEVLEN PreferredBrand 4

TRIPHASIL 28 PreferredBrand 4

CYCLESSA Non-PreferredBrand 8

ENPRESSE-28 Non-PreferredGeneric 8

ESTROSTEP FE Non-PreferredBrand 8

NECON 7/7/7 Non-PreferredGeneric 8

NORTREL 7/7/7 Non-PreferredGeneric 8

ORTHO TRI-CYCLEN LO Non-PreferredBrand 8

TRI-NORINYL 28 Non-PreferredBrand 8

TRIVORA-28 Non-PreferredGeneric 8

ULCER ANTI-INFECTIVE

HELIDAC PreferredBrand 4

PREVPAC PreferredBrand 4

URINARY CHOLINERGICS

URECHOLINE

URECHOLINE TAB 10MG Brand Preferred 00006041268

4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


URINARY CHOLINERGICS


4


4


4

URECHOLINE

URECHOLINE INJ 5MG/ML Brand Non-Preferred 00006778629

8

VAGINAL ANTI- FUNGALS

CLOTRIMAZOLE PreferredGeneric 4OTC

GYNE-LOTRIMIN

GYNE-LOTRIM CRE 1% VAG Brand Preferred 54569313200

4

OTC -

MICONAZOLE PreferredGeneric 4OTC

MICONAZOLE 3

MICONAZOLE 3 KIT COMBO PA Generic Preferred 24385060502

4

OTC -

MICONAZOLE 3 KIT COMBO PK Generic Preferred 24385060602

4

OTC -

MICONAZOLE 3 KIT COMBO Generic Preferred 36800003436

4

MICONAZOLE 7

MICONAZOLE CRE TUBE/KIT Generic Preferred 00113021429

4

OTC -

MICONAZOLE 7 CRE 2% VAGIN Generic Preferred 55045272605

4

OTC -

MICONAZOLE 7 CRE 2% W/APP Generic Preferred 70030059029

4

OTC -

MICONAZOLE 7 CRE 2% Generic Preferred 52735024980

4

OTC -

MICONAZOLE 7 SUP 100MG Generic Preferred 00182700521

4

OTC -

MICONAZOLE NITRATE PreferredGeneric 4OTC

MONISTAT 1 PreferredBrand 4OTC

MONISTAT 3

MONISTAT 3 CRE 4% Brand Preferred 00062540101

4

OTC -

MONISTAT 3 CRE Brand Preferred 00062540201

4

OTC -

MONISTAT 7 PreferredBrand 4OTC

NYSTATIN

NYSTATIN TAB 100000U Brand Preferred 65473070509

4

GYNAZOLE-1 Non-PreferredBrand 8

GYNE-LOTRIMIN

GYNE-LOTRIM TAB 100MG VA Brand Non-Preferred 00085067004

8

OTC -

GYNE-LOTRIM TAB 500MG VA Brand Non-Preferred 00085039601

8

MICONAZOLE 3

MICONAZOLE 3 SUP 200MG Generic Non-Preferred 00472173803

8

MICONAZOLE 7


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


VAGINAL ANTI- FUNGALS

MICONAZOLE 7 SUP 100MG Generic Non-Preferred 54868362100

8

OTC -

MONISTAT 3

MONISTAT 3 KIT COMBIN Brand Non-Preferred 00062543001

8

OTC -

MONISTAT 3 SUP 200MG Brand Non-Preferred 00062543701

8

MYCELEX-3 Non-PreferredBrand 8OTC

NYSTATIN

NYSTATIN TAB 100000U Brand Non-Preferred 54569124700

8

TERAZOL 3 Non-PreferredBrand 8

TERAZOL 7 Non-PreferredBrand 8

VAGINAL ANTI-BACTERIALS

METROGEL VAGINAL PreferredBrand 1

CLEOCIN PreferredBrand

00009344801

1M

CLEOCIN PreferredBrand 3

VAGINAL ESTROGENS

PREMARIN PreferredBrand 4

ESTRACE Non-PreferredBrand 8

ESTRING Non-PreferredBrand 8

VAGIFEM Non-PreferredBrand 8

VAGINAL-OTHER

ACID JELLY PreferredGeneric 4

AMINO ACID CERVICAL Non-PreferredGeneric 8

VASOPRESSINS

DDAVP Non-PreferredBrand 5



DESMOPRESSIN ACETATE Non-PreferredGeneric 8

STIMATE Non-PreferredBrand 8

VERAPAMILS

VERAPAMIL HCL CR PreferredGeneric 1

VERAPAMIL HCL ER

VERAPAMIL TAB 120MG ER Generic Preferred 51079089401

1

VERAPAMIL TAB 180MG CR Generic Preferred 17236009401

1


1


1

VERAPAMIL TAB CR 120MG Generic Preferred 54868443200

1


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


VERAPAMILS

VERAPAMIL HCL SR

VERAPAMIL TAB 120MG SR Generic Preferred 51285048002

1


1


1


1


1

CALAN

CALAN TAB 120MG Brand Preferred 00014186131

4


4


4

VERAPAMIL HCL

VERAPAMIL TAB 120MG Generic Preferred 00003361001

4


4


4

CALAN

CALAN SR TAB 240MG Brand Non-Preferred 00403051730

8

CALAN SR Non-PreferredBrand 8

COVERA-HS Non-PreferredBrand 8

VERAPAMIL HCL

VERAPAMIL INJ 2.5MG/ML Generic Non-Preferred 00074401101

8

VERAPAMIL HCL ER

VERAPAMIL CAP 120MG ER Generic Non-Preferred 00093515101

8


8


8

VERAPAMIL HCL SR

VERAPAMIL CAP 120MG SR Generic Non-Preferred 00591288001

8


8


8


8

VERELAN Non-PreferredBrand 8

VERELAN PM Non-PreferredBrand 8

VITAMINS

AQUASOL E PreferredGeneric 4OTC

ASCORBIC ACID


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


VITAMINS

ASCORBIC ACD CHW 100MG Generic Preferred 74312001720

4

OTC -


4

OTC -


4

OTC -

ASCORBIC ACD INJ 500MG/ML Generic Preferred 00223718450

4

ASCORBIC ACD SYP 20MG/ML Generic Preferred 00472090704

4

OTC -

ASCORBIC ACD SYP 500/5ML Generic Preferred 00223633101

4

OTC -

ASCORBIC ACD TAB 1000MG Generic Preferred 00084017801

4

OTC -


4

OTC -


4

OTC -


4

OTC -

ASCORBIC ACI TAB 50MG Generic Preferred 00223233101

4

OTC -

ASCORBOC ACD TAB 250MG Generic Preferred 54807093101

4

OTC -

BIOTIN FORTE PreferredBrand 4OTC

CALCITRIOL PreferredGeneric 4

CYANOCOBALAMIN PreferredGeneric 4

DRISDOL

DRISDOL DRO 8000U/ML Brand Preferred 00024039102

4

OTC -

FOLIC ACID

FOLIC ACID CAP 20MG Brand Preferred 53191034401

4

OTC -

FOLIC ACID CAP 5MG Brand Preferred 53191034301

4

OTC -

MEPHYTON PreferredBrand 4

NIACIN

NIACIN TAB 1000MG Brand Preferred 00098197408

4

OTC -

NIACIN TAB 125MG CR Brand Preferred 00580172101

4

OTC -

NIACIN TAB 25MG Brand Preferred 00003061050

4

OTC -

NIACIN CR PreferredGeneric 4OTC

NIACIN SR PreferredGeneric 4OTC

NIACIN TD PreferredGeneric 4OTC

NIACIN TR PreferredBrand/Generic 4OTC

NIACOR PreferredGeneric 4OTC

SLO-NIACIN PreferredBrand/Generic 4OTC

THIAMINE HCL PreferredBrand/Generic 4OTC

THIAMINE HCL TAB 10MG Brand Preferred 00527108010

4

OTC -

THIAMINE HCL TAB 5MG Brand Preferred 00527107910

4

OTC -

VITAMIN B-1 PreferredBrand/Generic 4


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


VITAMINS

VITAMIN B-12

VITAMIN B-12 INJ 1000MCG Generic Preferred 00102183003

4

VITAMIN B-12 INJ 100MCG Generic Preferred 00677032223

4

VITAMIN B-12 INJ 30MCG/ML Brand Preferred 00527015558

4

VITAMIN B-12 TAB 1000MCG Generic Preferred 11845069301

4

OTC -


4

OTC -


4

OTC -


4

OTC -

VITAMIN B-12 TAB 25MCG Brand Preferred 74312001680

4

OTC -


4

OTC -


4

OTC -


4

OTC -

VITAMIN B-2 PreferredBrand/Generic 4OTC

VITAMIN C

VITAMIN C CAP 500MG Generic Preferred 00349853701

4

OTC -

VITAMIN C CHW 1000MG Brand Preferred 31604002466

4

OTC -

VITAMIN C CHW 1000MG Generic Preferred 24385075078

4

OTC -


4

OTC -


4

OTC -


4

OTC -


4

OTC -

VITAMIN C LIQ 500/5ML Generic Preferred 24385056726

4

OTC -

VITAMIN C SYP 250/5ML Generic Preferred 51079022931

4

OTC -

VITAMIN C SYP 500/5ML Generic Preferred 00536016085

4

OTC -

VITAMIN C TAB 1000MG Generic Preferred 58940729300

4

OTC -


4

OTC -

VITAMIN C TAB 2000MG Brand Preferred 00904418652

4

OTC -


4

OTC -


4

OTC -

VITAMIN D PreferredBrand/Generic 4

VITAMIN E

VIT E MTC CAP 200IU Generic Preferred 54629020101

4

OTC -

VIT E SOLUBL CAP 400IU Generic Preferred 54629040501

4

OTC -

VITAMIN E CAP 1000IU Generic Preferred 00005331719

4

OTC -


4

OTC -


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


VITAMINS


4

OTC -


4

OTC -

VITAMIN E CAP 500IU Brand Preferred 00143333301

4

OTC -


4

OTC -


4

OTC -

VITAMIN E CHW 100IU Brand Preferred 00098194308

4

OTC -


4

OTC -

VITAMIN E CHW 200IU Generic Preferred 24385026881

4

OTC -


4

OTC -

VITAMIN E INJ 200MG/ML Generic Preferred 00314079330

4

VITAMIN E TAB 100MG Generic Preferred 49260012083

4

OTC -

VITAMIN E TAB 400IU Generic Preferred 00003093225

4

OTC -

VITAMIN E/D-ALPHA PreferredGeneric 4OTC

VITAMIN K1 PreferredGeneric 4

AQUASOL E Non-PreferredBrand 8OTC

ASCORBIC ACID Non-PreferredBrand/Generic 8OTC

ASCORBIC ACD CRY Generic Non-Preferred 49260012154

8

OTC -

ASCORBIC ACD INJ 100MG/ML Generic Non-Preferred 00223887710

8


8


8

ASCORBIC ACD INJ 500/2ML Generic Non-Preferred 00223887502

8


8

ASCORBIC ACD POW 100% Generic Non-Preferred 00157079716

8

OTC -

ASCORBIC ACD POW Generic Non-Preferred 00098700099

8

OTC -

CALCITRIOL Non-PreferredBrand 8

CYANOCOBALAMIN Non-PreferredBrand 8

DRISDOL

DRISDOL CAP 50000IU Brand Non-Preferred 00024039202

8

FOLIC ACID

FOLIC ACID INJ 5MG/ML Brand Non-Preferred 63323018410

8

FOLIC ACID POW USP NF Brand Non-Preferred 49452318001

8

OTC -

FOLIC ACID POW USP Brand Non-Preferred 17317017501

8

OTC -

FOLIC ACID POW Brand Non-Preferred 38779022401

8

OTC -

NASCOBAL Non-PreferredBrand 8

NIACIN


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


VITAMINS

NIACIN POW FCC Brand Non-Preferred 49452484501

8

OTC -

NIACIN POW USP/NF Brand Non-Preferred 51552053450

8

OTC -

NIACIN POW USP Brand Non-Preferred 51552055901

8

OTC -

NIACIN POW Brand Non-Preferred 00098000297

8

OTC -

ROCALTROL Non-PreferredBrand 8

THIAMINE HCL

THIAMINE HCL POW USP NF Brand Non-Preferred 49452773001

8

THIAMINE HCL POW USP Brand Non-Preferred 62991206801

8

THIAMINE HCL POW Brand Non-Preferred 51552014325

8

VITAMIN B-12

VITAMIN B-12 CHW 1000MCG Brand Non-Preferred 31604002464

8

OTC -

VITAMIN B-12 SUB 1000MCG Brand Non-Preferred 11845096601

8

OTC -


8

OTC -


8

OTC -

VITAMIN B-12 SUB 2500MCG Generic Non-Preferred 74312003860

8

OTC -

VITAMIN C

VITAMIN C CRY Generic Non-Preferred 00537409904

8

OTC -

VITAMIN C LIQ 500/5ML Brand Non-Preferred 60258014016

8

OTC -

VITAMIN C POW Brand Non-Preferred 54629092602

8

OTC -

VITAMIN C POW Generic Non-Preferred 00536510497

8

OTC -

VITAMIN C SOL 300MG/ML Generic Non-Preferred 00580039231

8

VITAMIN E

VITAMIN E DRO 15IU/0.3 Generic Non-Preferred 64376040430

8

OTC -

VITAMIN E POW USP/NF Brand Non-Preferred 49452812001

8

WEIGHT LOSS

DIDREX Non-PreferredBrand 8

MERIDIA Non-PreferredBrand 8

PHENTERMINE HCL Non-PreferredBrand/Generic 8

XENICAL Non-PreferredBrand 8

WOUND / DECUBITUS CARE

ACCUZYME PreferredBrand 4

ETHEZYME PreferredBrand 4

ETHEZYME 830 PreferredGeneric 4

REGRANEX Non-PreferredBrand 8

XANTHINES


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


XANTHINES

AMINOPHYLLINE PreferredBrand/Generic 4

AMINOPHYLLIN INJ 25MG/ML Generic Preferred 00074738501

4

AMINOPHYLLIN SOL 105/5ML Generic Preferred 00054304563

4

AMINOPHYLLIN TAB 100MG EC Generic Preferred 00115215101

4

AMINOPHYLLIN TAB 100MG Generic Preferred 00054402525

4

AMINOPHYLLIN TAB 200MG EC Generic Preferred 00115216201

4

AMINOPHYLLIN TAB 200MG Generic Preferred 00054402625

4

THEOLAIR PreferredBrand/Generic 4

THEOLAIR-SR TAB 250MG Brand Preferred 00089034510

4

THEOLAIR-SR TAB 500MG Brand Preferred 00089034725

4

THEOPHYLLINE CR

THEOPHYLLINE CAP 300MG CR Generic Preferred 00536465701

4

THEOPHYLLINE TAB 100MG CR Generic Preferred 60346071330

4


4


4


4

THEOPHYLLINE ER

THEOPHYLLINE CAP 100MG ER Generic Preferred 00047019624

4


4


4


4

THEOPHYLLINE TAB 100MG ER Generic Preferred 00258358401

4


4


4


4


4

UNIPHYL PreferredBrand 4

AMINOPHYLLINE

AMINOPHYLLIN POW Generic Non-Preferred 00527061104

8

AMINOPHYLLIN SUP 250MG Generic Non-Preferred 00223501000

8

AMINOPHYLLIN SUP 500MG Generic Non-Preferred 00223501250

8

QUIBRON-T Non-PreferredBrand 8

QUIBRON-T/SR Non-PreferredBrand 8

THEO-24 Non-PreferredBrand 8

THEOLAIR


MaineCare PDL



Drug Name

Brand

Indicator

Pref /

Non-Pref Status


XANTHINES

THEOLAIR TAB 125MG Brand Non-Preferred 00089034210

8

THEOLAIR TAB 250MG Brand Non-Preferred 00089034410

8

THEOPHYLLINE CR

THEOPHYLLINE TAB 100MG CR Generic Non-Preferred 00904161061

8

THEOPHYLLINE TAB 300MG CR Generic Non-Preferred 61392001751

8

THEOPHYLLINE ER

THEOPHYLLINE TAB 100MG ER Generic Non-Preferred 57480036501

8


drug list reflects utilization items only mainecare pdl ......retin-a cre 0.1% brand preferred 4...

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