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 |
| 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®) |
| 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®) |
| 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®) |
| 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®) |
| 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®) | |||
| 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 |
| 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®) | ||
| 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®) |
| 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 | |||
| 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®) |
| 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®) | ||
| 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 |
| 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®) | ||
| 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
| 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®) | |||
| 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®) |
| 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®) |
| 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 |
| 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®) |
| 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 | |||
| 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®) | ||
| 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 |
| 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 |
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.