Preferred Drug List/Prior Authorization List

Updated 11/08 - The updated list is from the August 13, 2008 P&T Committee Meeting.  
The effective date is November 1, 2008.


Item Number Disease State/Specialty Item 
Number
Disease State/Specialty
1 ADD/ADHD 14 Hormone Therapy
2 Allergy 15 Hyperlipidemia
3 Alzheimer's 16 Immune Disorders
4 Antipsychotic Agents 17 Infectious Disorders
5 Asthma/COPD 18 Multiple Sclerosis
6 Depression 19 Ophthalmic Disorders
7 Dermatology 20 Otic Agents
8 Diabetes 21 Osteoporosis
9 Digestive Disorders 22 Pain Management
10 Growth Deficiency 23 Parkinson's
11 Heart Disease 24 Sedatives/Hypnotics
12 Hematologic Agents 25 Urology/Incontinence
13 Hemodialysis      

ADD/ADHD

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Stimulants and Related Agents Amphetamine Mixed Salt  Atomoxetine (Strattera®)   
   Amphetamine Mixed Salt ER (Adderall XR®) Modafinil (Provigil®)   
   Dexmethylphenidate Methamphetamine (Desoxyn®)   
   Dexmethylphenidate (Focalin XR®) Methylphenidate LA (Ritalin LA®)   
   Dextroamphetamine     
   Lisdexamfetamine (Vyvanase®)      
   Methylphenidate      
   Methylphenidate ER       
   Methylphenidate ER ( Concerta®; Metadate CD®)      
    Methylphenidate Transdermal (Daytrana Transdermal®)       

Allergy

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Antihistamines - Minimally Sedating Fexofenadine Acrivastin/Pseudoephedrine (Semprex-D®)   
   Fexofenadine Syrup (Allegra Syrup®) Cetirizine (Zyrtec®)   
   Cetirizine OTC Cetirizine Chewable (Zyrtec Chewable®)   
   Cetirizine-D OTC Cetirizine Syrup (Zyrtec Syrup®)   
  Loratadine OTC Cetirizine/Pseudoephedrine (Zyrtec-D®)    
   Loratadine-D OTC Desloratadine (Clarinex®)   
    Desloratadine Syrup (Clarinex®)  
    Desloratadine/Pseudoephedrine (Clarinex-D®)  
        Fexofenadine ODT (Allegra ODT®)   
        Fexofenadine/Pseudoephedrine (Allegra-D®)     
        Levocetirizine (Xyzal®)    
        Loratadine Chewable (Children's Claritin Chewable OTC®)   
            
Rhinitis Agents, Nasal Azelastine (Astelin®) Beclomethasone AQ (Beconase AQ®)    
   Fluticasone (generic only) Budesonide Aqua (Rhinocort Aqua®)   
   Fluticasone Furoate (Veramyst®) Ciclesolide (Omnaris®)   
   Ipratropium Nasal Flunisolide (Nasarel®)   
     Mometasone (Nasonex®) Flunisolide      
   Triamcinolone AQ (Nasacort AQ®) Fluticasone (Flonase Brand only®)   

Alzheimer's

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Alzheimer's Agents  Donepezil (Aricept®) Galantamine (Razadyne®)    
Cholinesterase Inhibitors Donepezil (Aricept ODT®) Galantamine (Razadyne ER®)   
    Memantine HCI (Namenda®) Rivastigmine Oral (Exelon ®)    
    Rivastigmine Transdermal Patch (Exelon Transdermal®)  
    Tacrine (Cognex®)  

Antipsychotic Agents

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Antipsychotic, Atypical Clozapine Aripiprazole (Abilify®)  
  Quetiapine Fumarate (Seroquel®)   Clozapine (Fazaclo®)  
  Risperidone (Risperdal®) Olanzapine/Fluoxetine (Symbyax®)  
  Ziprasidone (Geodon®)   Olanzapine (Zyprexa®)   
     Paliperidone ER (Invega®)     
     Quetiapine XR (Seroquel XR®)     

Asthma/COPD

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Bronchodilator, Beta-Adrenergic Agents        
 

INHALATION      

   
  Albuterol Sulfate Inhaler Albuterol Sulfate Nebulizer Low-Dose   
  Albuterol Sulfate Nebulizer Arformoterol Inhalation Solution (Brovana Inhalation Solution®)  
   Albuterol Sulfate HFA (ProAir HFA®) Formoterol Inhalation Solution (Perforomist Inhalation Solution®)   
  Albuterol Sulfate HFA MDI (Proventil HFA®) Metaproterenol Inhalation   
  Albuterol Sulfate HFA MDI (Ventolin HFA®) Metaproterenol Sulfate MDI (Alupent Inhaler®)  
  Formoterol DPI (Foradil®)    
  Levalbuterol HFA (Xopenex HFA®)     
  Levalbuterol Nebulizer HCL (Xopenex®)     
  Pirbuterol (Maxair Autohaler®)     
   Salmeterol Xinafoate (Serevent Diskus®)      
       
  

ORAL         

  
Bronchodilator, Beta-Adrenergic  Albuterol Sulfate NONE   
Agents cont’  Albuterol Sulfate ER     
  Metaproterenol Sulfate     
  Terbutaline Sulfate      
       
Bronchodilator, Anticholinergics

INHALATION      

  
   Albuterol Sulfate/Ipratropium MDI (Combivent®) Albuterol Sulfate/Ipratropium Nebulizer   
   Ipratropium Nebulizer      
   Ipratropium Inhalation Aerosol MDI (Atrovent HFA®)      
   Tiotropium Inhalation Powder (Spiriva®)      
           
Corticosteroids, Inhalation Beclomethasone MDI (QVAR®)      
  Budesonide DPI (Pulmicort Flexhaler®) Budesonide Respules (Pulmicort - Respules®) - 9 years old and over    
  Budesonide/Formoterol MDI Inhalation (Symbicort Inhalation®) Mometasone DPI (Asmanex®)     
   Budesonide Respules (Pulmicort - Respules®) - 8 years old and under      
  Flunisolide MDI (Aerobid®)      
   Flunisolide MDI (Aerobid M®)     
    Fluticasone MDI (Flovent®)      
  Fluticasone MDI (Flovent HFA Inhalers®)    
  Fluticasone/Salmeterol DPI (Advair Diskus®)       
  Fluticasone/Salmeterol MDI (Advair HFA®)    
  Triamcinolone MDI (Azmacort®)    
           
Leukotriene Modifiers Montelukast (Singulair®) Zileuton CR (Zyflo CR®)  
  Zafirlukast (Accolate®)    

Depression

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Antidepressants, Other Bupropion IR Bupropion XL   
    Bupropion SR Desvenlafaxine (Pristiq®)   
    Mirtazapine Duloxetine (Cymbalta®)      
   Trazodone  Nefazodone   
  Venlafaxine ER (Effexor XR®) Selegiline Patch (Emsam®)    
    Venlafaxine      
          
         
Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram Fluvoxamine CR (Luvox CR®)     
    Escitalopram (Lexapro®) Fluoxetine ER (Prozac Weekly®)   
   Fluoxetine Paroxetine CR   
    Fluvoxamine        
    Paroxetine Mesylate (Pexeva®)        
   Paroxetine      
   Sertraline      

Dermatology

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Antifungals - Topical Ciclopirox Cream Butenafine (Mentax®)   
  Ciclopirox Gel Ciclopirox (CNL8®)  
    Ciclopirox Suspension Ciclopirox Shampoo (Loprox®)    
  Clotrimazole Ciclopirox Solution     
  Clotrimazole/Betamethasone Econazole   
   Ketoconazole (Xolagel®) Ketoconazole Foam (Extina Foam®)       
    Ketoconazole Cream Miconazole/zinc oxide/white petrolatum (Vusion®)       
   Ketoconazole Shampoo (Rx Only) Oxiconazole (Oxistat®)    
   Naftifine (Naftin®) Sertaconazole Nitrate (Ertaczo®)   
   Nystatin      
   Nystatin w/ Triamcinolone       
            
            
Antiparasitic Agents, Topical Crotamiton (Eurax®)   Lindane      
   Malathion (Ovide®)         
   Permethrin         
            
Antiviral Agents, Topical   Penciclovir Cream (Denavir®)   Acyclovir Cream (Zovirax®)      
      Acyclovir Ointment (Zovirax®)      
            
            
            
Atopic Dermatitis - Immunomodulators Pimecrolimus (Elidel®) NONE   
   Tacrolimus (Protopic®)     
        
Impetigo Agents, Topical  Mupirocin Ointment Topical Mupirocin Cream Topical (Bactroban®)   
   Retapamulin (Altabax®)     
         
STERIODS, TOPICAL        
Low Potency  Desonide  Alclometasone Dipropionate    
  Fluocinolone Acetonide (Derma-Smoothe-FS)  Desonide (Verdeso®)    
  Hydrocortisone Desonide (Desonate®)    
        
Medium Potency  Hydrocortisone Butyrate (Lucoid Lipocream®)  Flurandrenolide (Cordran®)    
  Betamethasone Valerate (Luxiq®)  Flurandrenolide Tape (Cordran Tape®)    
  Hydrocortisone Valerate  Prednicarbate    
  Hydrocortisone Butyrate  Mometasone Furoate    
    Clocortolone Pivalate (Cloderm®)    
    Fluticasone Propionate    
        
High Potency  Betamethasone Dipropionate  Amcinonide    
  Betamethasone Valerate  Desoximetasone    
  Fluocinolone Acetonide  Diflorasone Diacetate    
  Fluocinolone Acetonide Shampoo (Capex®)  Fluocinonide (Vanos®)    
  Fluocinonide  Halcinonide (Halog®)   
  Fluocinonide-E      
  Fluocinonide Emollient      
  Triamcinolone Acetonide      
        
Very High Potency  Clobetasol Propionate  Clobetasol Propionate (Clobex®)    
  Clobetasol Emollient  Clobetasol Propionate (Olux-Olux-E Pack®)    
  Halobetasol Propionate  Clobetasol Propionate (Olux-E®)    
        
        
        

Diabetes

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Hypoglycemics, Meglitinides Nateglinide (Starlix®) Repaglinide (Prandin®)   
         
Hypoglycemics, Thiazolidinediones (TZDs) Pioglitazone (Actos®) NONE   
  Pioglitazone/Glimeperide (Duetact®)    
   Pioglitazone/Metformin (Actoplus Met®)      
   Rosiglitazone (Avandia®)      
   Rosiglitazone/Glimepiride (Avandaryl®)      
   Rosiglitazone/Metformin (Avandamet®)      
           
Hypoglycemics Human Insulin & Pens (Humulin®) Insulin Glulisine & Pens (Apidra®)   
Insulins & Related Agents  Human Insulin & Pens (Novolin®)    
   Insulin Aspart & Pens (Novolog®)     
  Insulin Aspart/Insulin Aspart Protamine & Pens (Novolog Mix 70/30®)     
  Insulin Detemir & Pens (Levemir®)    
  Insulin Glargine & Pens (Lantus®)    
  Insulin Lispro & Pens (Humalog®)    
  Insulin Lispro/Protamine Lispro & Pens (Humalog Mix®)    
       
Hypoglycemics Exenatide (Byetta, Pens®) None  
Incretin Mimetics/Enhancers Pramlintide (Symlin®)    
  Pramlintide Pens (Symlin Pens®)    
  Sitagliptin (Januvia®)       
  Sitagliptin/Metformin (Janumet®)    

Digestive Disorders

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Antiemetic Agents

Oral            

  

   Aprepitant (Emend®) Dolasetron (Anzemet®)  
   Dronabinol (Marinol®) Granisetron  
  Ondansetron / Ondansetron ODT Nabilone (Cesamet®)  
       
       
GERD AND RELATED DISORDERS         
Proton Pump Inhibitors Esomeprazole (Nexium capsule®) Omeprazole (generic legend only)  
  Esomeprazole (Nexium Suspension®) Omeprazole (Zegerid ®)  
  Lansoprazole (Prevacid Capsule®) Pantoprazole (Protonix®)  
        Lansoprazole (Prevacid Solutab®) Rabeprazole (Aciphex®)    
   Lansoprazole (Prevacid Suspension®)    
            
Pancreatic Enzymes   Dygase   Pancrecarb MS      
   Lapase         
   Pancrelipase         
   Viokase         
   Lipram         
   Pancrease MT         
   Ultrase         
   Creon         
            
ULCERATIVE COLITIS       
Ulcerative Colitis Agents Balsalazide (Colazal®) Mesalamine Oral (Pentasa®)   
     Mesalamine Enemas Mesalamine MMX (Lialda®)      
   Mesalamine (Asacol®) Olsalazine Oral (Dipentum®)   
    Mesalamine Suppositories (Canasa®)       
    Sulfasalazine         

Growth Deficiency

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Growth Deficiency           
Growth Hormones Somatropin (Norditropin®) Somatropin (Genotropin®)   
    Somatropin (Nutropin®) Somatropin (Humatrope®)    
     Somatropin (Nutropin AQ®) Somatropin (Omnitrope®)    
        Somatropin  (Tev-Tropin®) Somatropin (Serostim®)      
     Somatropin (Saizen®) Somatropin (Zorbtive®)   

Heart Disease

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
HYPERLIPIDEMIA          
Antihyperlipidemic Agents - Non Statins Cholestyramine Colesevelam (Welchol®)   
    Colestipol Ezetimibe (Zetia®)    
  Fenofibrate (Tricor®) Fenofibrate generic  
   Gemfibrozil Fenofibrate (Antara®)   
   Niacin ER (Niaspan®) Fenofibrate (Fenoglide®)   
    Fenofibrate (Lipofen®)   
      Fenofibrate (Triglide®)     
       Omega-3-acid ethyl esters (Lovaza®)   
           
Statins & Statin Combination Agents Atorvastatin (Lipitor®) Amlodipine/Atorvastatin (Caduet®)  
  Ezetimibe/Simvastatin (Vytorin®) Lovastatin ER (Altoprev®)  
    Fluvastatin (Lescol®) Niacin ER/Lovastatin (Advicor®)  
   Fluvastatin XL (Lescol XL®) Rosuvastatin (Crestor®)   
   Lovastatin     
    Pravastatin       
   Simvastatin      
   Niacin ER/Simvastatin (Simcor®)     
       
           
HYPERTENSION       
ACE Inhibitors & Related Agents Benazepril Aliskiren (Tekturna®)  
     Benazepril/HCTZ  Moexipril    
  Captopril Moexipril/HCTZ   
  Captopril/HCTZ    
  Enalapril    
  Enalapril/HCTZ    
  Fosinopril    
  Fosinopril/HCTZ    
  Lisinopril    
  Lisinopril/HCTZ    
    Perindopril (Aceon®)     
    Quinapril     
    Quinapril/HCTZ     
  Ramipril (Altace®)    
   Trandolapril      
          
          
       
       
          
Angiotensin Modulators/Calcium Channel Blockers Combination Products Amlodipine/Benazepril Felodipine/Enalapril (Lexxel®)  
   Amlodipine/Olmesartan (Azor®) Verapamil SR/Trandolapril (Tarka®)  
     Amlodipine/Valsartan (Exforge®)      
             
Angiotensin II Receptor Blockers (ARBS) Losartan (Cozaar®) Candesartan (Atacand®)  
   Losartan/HCTZ (Hyzaar®) Candesartan/HCTZ (Atacand HCT®)   
   Irbesartan (Avapro®) Eprosartan (Teveten®)   
   Irbesartan/HCTZ (Avalide®) Eprosartan/HCTZ (Teveten HCT®)   
   Olmesartan (Benicar®)      
   Olmesartan/HCTZ (Benicar HCT®)      
    Telmisartan (Micardis®)        
   Telmisartan/HCTZ (Micardis HCT®)        
     Valsartan (Diovan®)       
    Valsartan/HCTZ (Diovan HCT®)       
          
HYPERTENSION         
Beta Adrenergic Receptor Blocking Agents Acebutolol Carvedilol CR (Coreg CR®)   
    Atenolol Nebivolol (Bystolic®)   
    Betaxolol Penbutolol (Levatol®)    
     Bisoprolol Fumarate Propranolol ER (Innopran XL®)  
    Carvedilol      
  Labetalol    
  Metoprolol Tartrate    
  Metoprolol ER     
  Nadolol     
   Pindolol    
   Propranolol    
   Propranolol LA       
  Sotalol    
  Sotalol AF    
  Timolol Maleate    
       
Calcium Channel Blockers Amlodipine Nicardipine SR (Cardene SR®)    
  Diltiazem IR Verapamil ER (Covera HS®)  
  Diltiazem ER (Generics)    
  Diltiazem ER (Cardizem LA®)    
  Diltiazem SR    
    Felodipine ER     
   Isradipine IR     
  Isradipine SR (Dynacirc CR®)    
  Nicardipine       
  Nifedipine ER       
  Nifedipine IR      
  Nimodipine    
  Nisoldipine (Sular®)     
  Verapamil IR    
   Verapamil ER (Generics)     
  Verapamil ER PM     
  Verapamil SR     
       
PLATELET AGGREGATION INHIBITORS        
Platelet Aggregation Inhibitors Aspirin/Dipyridamole ER (Aggrenox®) Ticlopidine  
  Clopidogrel (Plavix®)    
  Dipyridamole    
        
ANTICOAGULANTS, INJECTABLES       
Anticoagulants, Injectable Dalteparin (Fragmin®) Fondaparinux (Arixtra®)     
    Enoxaparin (Lovenox®) Tinzaparin (Innohep®)   
          

Hematologic Agents

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
HEMATOPOIETIC AGENTS       
Erythropoietins Darbepoetin alfa (Aranesp®) Epoetin alfa (Epogen®)   
  Epoetin alfa (Procrit®)    
       
Anticoagulants - refer to HEART DISEASE      

Hemodialysis

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Phosphate Binders Calcium Acetate (PhosLo®) Lanthanum (Fosrenol®)   
  Sevelamer (RenaGel®) Sevelamer Carbonate (Renvela®)      
           

Hormone Therapy

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Androgenic Agents Testosterone Gel 1% (Testim®) Testosterone Gel 1% (Androgel®)   
   Testosterone Transdermal Patch (Androderm®)      
          

Hyperlipidemia - Refer to Heart Disease

Immune Disorders - Refer to Multiple Sclerosis

Infectious Disorders

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
ANTIBIOTICS        
Cephalosporin and Related Antibiotics Amoxicillin/Clavulanate (Tablets & Suspension) Cefaclor (Raniclor®)  
  Amoxicillin/Clavulanate XR (Augmentin XR®) Cefditoren Pivoxil (Spectracef®)  
    Cefaclor Cefpodoxime  
    Cefaclor ER  
   Cefadroxil   
   Cefdinir   
  Cefixime (Suprax®)    
   Ceftibuten (Cedax®)       
   Cefuroxime Axetil       
  Cefprozil    
  Cephalexin     
        
        
       
Fluoroquinolones 

 Oral

  
   Ciprofloxacin  Ciprofloxacin Suspension 
(Cipro Suspension ®)
 
    Moxifloxacin (Avelox®) Ciprofloxacin ER   
    Ciprofloxacin ER (Proquin XR®)   
     Gemifloxacin Mesylate (Factive®)   
      Levofloxacin (Levaquin®)    
    Norfloxacin (Noroxin®)  
    Ofloxacin  
       
       
       
Antibiotics, Gastrointestinal Metronidazole Metronidazole ER (Flagyl ER®)  
  Nitazoxanide (Alinia®) Neomycin  
  Tinidazole (Tindamax®) Rifaximin (Xifaxan®)  
  Vancomycin (Vancocin®)    
       
Macrolides Azithromycin  Clarithromycin  
   Azithromycin ER (Zmax®) Clarithromycin ER  
   Erythromycin Base Telithromycin (Ketek®)  
  Erythromycin Estolate    
   Erythromycin Ethylsuccinate     
  Erythromycin Stearate    
        
 Vaginal Clindamycin Vaginal Cream   None  
  Clindamycin Vaginal Cream (Clindesse®)     
  Clindamycin Vaginal Ovules (Cleocin®)     
  Metronidazole Vaginal Gel     
        
OPHTHALMIC ANTIBIOTICS -
Refer to Opthalmic Disorders
        
OTIC ANTIBIOTICS - 
Refer to Otic Agents
       
ANTIFUNGALS        
Antifungals, Oral Clotrimazole  Flucytosine (Ancobon®)  
    Fluconazole Griseofulvin (Grifulvin V®) (Tablets)   
  Griseofulvin Suspension Itraconazole  
     Griseofulvin (Gris-Peg®) Posaconazole (Noxafil®)   
    Ketoconazole Terbinafine Granules (Lamisil Granules®)  
    Nystatin Voriconazole (VFEND®)  
  Terbinafine (no granules)    
       
HEPATITIS AGENTS      
Hepatitis B Agents Adefovir Dipivoxil (Hepsera®) NONE  
  Entecavir (Baraclude®)    
  Lamivudine (Epivir HBV®)    
  Telbivudine (Tyzeka®)    
       
Hepatitis C Agents Ribavirin (Generics only) Consensus Interferon (Infergen®)  
  Peginterferon alfa 2A (Pegasys®)    
  Peginterferon alfa 2B (Peg-Intron®)    
  Peginterferon alfa 2B (Peg-Intron Redipen®)    

Multiple Sclerosis

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Multiple Sclerosis Agents (Immunomodulatory Agents) Glatiramer (Copaxone®) None     
  Interferon beta - 1a (Avonex®)    
    Interferon beta - 1b (Betaseron®)        
   Interferon beta - 1a (Rebif®)      

Ophthalmic Disorders

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Allergic Conjunctivitis Azelastine Hydrochloride (Optivar®) Cromolyn Sodium  
   Epinastine HCI (Elestat®) Emedastine Difumarate (Emadine®)  
   Ketorolac Tromethamine (Acular®) Ketotifen Fumarate  
   Loteprednol (Alrex®) Lodoxamine Tromethamine (Alomide®)  
   Olopatadine HCI (Pataday®) Nedocromil Sodium (Alocril®)  
    Olopatadine Hydrochloride (Patanol®) Pemirolast Potassium (Alamast®)  
          
Glaucoma Agents      
Intraocular Pressure (IOP) Reducers Betaxolol Bimatroprost (Lumigan®)  
   Betaxolol (Betoptic S®)    
   Brimonidine Tartrate (Alphagan P®)     
   Brimonidine Tartrate      
   Brimonidine/Timolol (Combigan®)      
   Brinzolamide (Azopt®)        
   Carteolol    
    Dipivefrin      
  Dorzolamide (Trusopt®)    
  Dorzolamide/Timolol (Cosopt®)    
  Latanoprost (Xalatan®)    
  Levobunolol    
  Metipranolol    
  Pilocarpine    
  Timolol (Betimol®)    
  Timolol Maleate    
  Timolol LA (Istalol®)    
  Travoprost (Travatan, Travantan Z®)    
       
       
Ophthalmics, Antibiotic Erythromycin Azithromycin 1% (AzaSite®)  
  Gatifloxacin (Zymar®) Ciprofloxacin Ointment (Ciloxan®)  
  Levofloxacin (Iquix®) Ciprofloxacin Solution  
  Maxifloxacin (Vigamox®) Levofloxacin (Quixin®)    
    Ofloxacin Solution  
       
Ophthalmics, NSAIDS Bromfenac (Xibrom®) NONE  
  Diclofenac    
  Flurbiprofen    
  Ketorlac (Acular LS®)    
  Ketorlac PF (Acular PF®)    
    Nepafenac (Nevanac®)        

Otic Agents

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Fluoroquinolones Ciprofloxacin/Dexamethasone (Ciprodex OTIC®) Ciprofloxacin/Hydrocortisone (Cipro HC OTIC®)  
  Ofloxacin    

Osteoporosis

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Bone Resorption Suppression Agents Alendronate Sodium (generics only) Alendronate Sodium (Fosamax Brand only®)  
   Calcitonin - Salmon (Fortical®) Alendronate Solution (Fosamax®)   
   Calcitonin-Salmon Nasal (Miacalcin®) Alendronate/Vit D (Fosamax Plus D®)    
   Ibandronate Sodium (Boniva®) Etidronate (Didronel®)   
   Risedronate (Actonel®) Raloxifene (Evista®)    
      Risedronate/Calcium (Actonel with Calcium®)    
      Teriparatide Subcutaneous (Forteo®)    

Pain Management

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Analgesics/Anesthetic, Topical Diclofenac Sodium Gel (Voltaren®) Diclofenac Epolamine Patch (Flector®)   
Lidocaine Patch (Lidoderm®)     
    
Analgesics, Narcotics Short Acting Acetaminophen w/Codeine Acetaminophen/ Caffeine/ Dihydrocodeine Bitartrate (Panlor DC®)   
   Aspirin w/Codeine Fentanyl Citrate Buccal (Generics & Actiq, Fentora®)    
  Codeine Phosphate Opium Tincture   
  Codeine Sulfate Oxymorphone (Numorphan®)    
      Dihydrocodeine Bitartrate/Acetaminophen/Caffeine (Generics) Oxymorphone IR (Opana®)  
   Hydrocodone/Acetaminophen Propoxyphene Napsylate (Darvon-N®)   
   Hydrocodone Bitartrate/Ibuprofen     
   Hydromorphone     
   Meperidine HCL     
  Morphine Sulfate IR    
  Oxycodone IR    
   Oxycodone/Acetaminophen     
   Oxycodone w/Aspirin      
   Oxycodone/Ibuprofen     
   Pentazocine/Naloxone HCL     
    Pentazocine/Acetaminophen       
    Propoxyphene HCL     
   Propoxyphene HCL w/APAP     
   Propoxyphene Napsylate w/APAP      
   Tramadol      
    Tramadol/Acetaminophen        
          
Analgesics, Narcotics Long Acting Fentanyl Transdermal (Generic)  Fentanyl Transdermal (Duragesic®) - Brand Only       
   Methadone HCL  Morphine Sulfate ER (Avinza®)       
   Morphine Sulfate ER (Kadian®)  Oxycodone ER       
   Morphine Sulfate ER (Generic)  Oxycodone (Oxycontin®)       
     Oxymorphone ER (Opana ER®)       
      Tramadol ER (Ultram ER®)     
           
Nonsteroidal Anti - Inflammatories (NSAIDs) Celecoxib (Celebrex®) Diclofenac/Misoprostol (Arthrotec®)  
   Diclofenac Lansoprazole/Naproxen (Prevacid NapraPAC)  
   Etodolac Meclofenamate Sodium  
   Fenoprofen Mefenamic Acid  
    Flurbiprofen Nabumetone  
   Ibuprofen (Rx Only) Tolmetin Sodium  
   Indomethacin     
   Ketoprofen     
   Ketorolac      
  Meloxicam    
   Naproxen (Rx Only)     
   Oxaprozin     
   Piroxicam     
   Sulindac     
         
           
Immunomodulators and Related Agents Adalimumab (Humira®) Abatacept (Orencia®)   
for Arthritis  Anakinra (Kineret®) Alefacept (Amevive®)   
   Efalizumab (Raptiva®) Infliximab (Remicade®)   
   Etanercept (Enbrel®)      
           
Antimigraine Agents,Triptans Eletriptan (Relpax®) Almotriptan (Axert®)    
  Sumatriptan (Imitrex® Nasal) Frovatriptan (Frova®)   
    Sumatriptan (Imitrex® Oral) Naratriptan (Amerge®)    
    Sumatriptan (Imitrex® Subcutaneous) Rizatriptan (Maxalt®, Maxalt MLT®)     
       Zolmitriptan (Zomig, Zomig ZMT®)     
       Zolmitriptan (Zomig® nasal)     
             
Skeletal Muscle Relaxants     Baclofen  Carisoprodol (Soma 250 mg®)      
     Chlorzoxazone  Cyclobenzaprine (Fexmid®)     
     Cyclobenzaprine - Generics  Cyclobenzaprine ER (Amrix®)      
     Methocarbamol  Dantrolene Sodium      
     Carisoprodol - Generics  Metaxalone (Skelaxin®)      
     Carisoprodol Compound  Orphenadrine      
     Orphenadrine Compound  Tizanidine (Zanaflex®)      
     Tizanidine - Generics        
             

Parkinson's

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Antiparkinson Agents - Anticholinergic and Other Benztropine Bromocriptine   
   Levodopa/Carbidopa (Generics Only) Entacapone (Comtan®)  
    Levodopa/Carbidopa/Entacapone (Stalevo®) Levodopa/Carbidopa (Parcopa®)    
  Pramipexole (Mirapex®) Rasagiline (Azilect®)  
   Ropinirole (Requip®) Rotigotine Transdermal (Neupro®)  
   Selegiline Selegiline (Zelapar®)  
   Trihexyphenidyl Tolcapone (Tasmar®)  
         

Sedatives/Hypnotics

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
Sedative/Hypnotics Chloral Hydrate  Estazolam  
  Eszopiclone (Lunesta®) Flurazepam  
   Ramelteon (Rozerem®) Quazepam (Doral®)   
    Temazepam Zaleplon (Sonata®)   
   Temazepam (Restoril 7.5mg ®) Zolpidem CR (Ambien CR®)   
    Triazolam       
   Zolpidem      

Urology/Incontinence

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
November 1, 2008
INCONTINENCE        
Bladder Relaxant Preparations Darifenacin (Enablex®) Oxybutynin ER   
      Oxybutynin Tolterodine (Detrol®)   
    Oxybutynin transdermal (Oxytrol®)     
      Solifenacin (VESIcare®)       
   Tolterodine ER (Detrol LA®)      
   Trospium (Sanctura®)      
    Trospium (Sanctura XR®)           
PROSTATE        
Benign Prostatic Hyperplasia Treatment (BPH) Alfuzosin (Uroxatral®) Doxazosin XL (Cardura XL)   
    Doxazosin      
   Dutasteride (Avodart®)     
  Finasteride    
     Tamsulosin (Flomax®)     
   Terazosin       

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The PDL list is also available in PDF (Adobe Acrobat) format for download. Click here for instructions.

 This website will be updated when changes (additions or deletions) are made to the PDL. These PDL changes will also be in a message in the provider’s remittance advice.

A complete provider training packet is available by contacting the Provider Relations Unit at Unisys at 225-924-5040 or 800-473-2783.