Preferred Drug List/Prior Authorization List

Updated January 2012 - The updated list is from the November 2, 2011 P&T Committee Meeting.
The effective date is January 1, 2012.

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Item Number	Disease State/Specialty	Item  Number	Disease State/Specialty
1	ADD/ADHD	15	Hyperlipidemia
2	Allergy	16	Immune Disorders
3	Alzheimer's	17	Infectious Disorders
4	Antipsychotic Agents	18	Multiple Sclerosis
5	Asthma/COPD	19	Ophthalmic Disorders
6	Depression	20	Opiate Dependence Agents
7	Dermatology	21	Otic Agents
8	Diabetes	22	Osteoporosis
9	Digestive Disorders	23	Pain Management
10	Growth Deficiency	24	Parkinson's
11	Heart Disease	25	Sedatives/Hypnotics
12	Hematologic Agents	26	Urology/Incontinence
13	Hemodialysis	27	Smoking Cessation
14	Hormone Therapy	28	Prostate

ADD/ADHD

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Stimulants and Related Agents	Amphetamine Salt Combo (Generic; Adderall®)	Amphetamine Salt Combo ER (Generic Only)
	Amphetamine Salt Combo ER (Adderall XR® - Brand Only)	Armodafinil (Nuvigil®)
	Atomoxetine (Strattera®)	Clonidine Extended-release (Kapvay®)
	Dexmethylphenidate (Focalin® - Brand Only)	Dexmethylphenidate (Generic Only)
	Dexmethylphenidate ER (Focalin XR®)	Dextroamphetamine ER (Generic; Dexadrine®)
	Dextroamphetamine (Generic)	Dextroamphetamine Solution (Procentra®)
	Guanfacine ER (Intuniv®)	Methylphenidate Solution (Generic)
	Lisdexamfetamine (Vyvanse®)	Methamphetamine (Generic; Desoxyn®)
	Methylphenidate (Generic, Metadate CD®)	Methylphenidate ER (Generic Concerta; Ritalin LA®)
	Methylphenidate ER (Generic excluding generic Concerta)(Metadate CD & Concerta Brand only)	Modafinil (Provigil®)
	Methylphenidate IR (Methylin Chewable & Solution®)
	Methylphenidate SR (Ritalin SR®)
	Methylphenidate Transdermal Patches (Daytrana®)

Allergy

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Antihistamines - Minimally Sedating	Cetirizine Syrup OTC	Acrivastin/Pseudoephedrine (Semprex-D®)
	Cetirizine Syrup Rx	Cetirizine Chewable Tablet OTC
	Cetirizine Tablet OTC	Cetirizine Solution 5mg/5cc OTC
	Cetirizine - D OTC	Desloratadine Tablet (Clarinex®)
	Fexofenadine Tablet 30mg, 60mg, 180mg (Generic Only)	Desloratadine ODT (Clarinex ODT®)
	Fexofenadine-D 12-hour (Generic Only)	Desloratadine Syrup (Clarinex®)
	Fexofenadine-D 24-hour (Generic Only)	Desloratadine/Pseudoephedrine (Clarinex-D 12-hour®)
	Loratadine Tab OTC (Generic Only)	Desloratadine/Pseudoephedrine (Clarinex-D 24-hour®)
	Loratadine ODT Tablet OTC (Generic Only)	Fexofenadine Tablet 30mg, 60mg, 180mg (Allegra - Brand Only)
	Loratadine-D Tablet OTC (Generic Only)	Fexofenadine ODT Tablet (Allegra ODT®)
	Loratadine Syrup OTC (Generic Only)	Fexofenadine/Pseudoephedrine (Allegra-D 12-hour® - Brand Only)
		Fexofenadine/Pseudoephedrine (Allegra-D 24-hour® - Brand Only)
		Fexofenadine Syrup (Allegra Syrup®)
		Levocetirizine Tablet (Generic; Xyzal®)
		Levocetirizine Syrup (Generic; Xyzal®)
		Loratadine Capsule OTC - (Claritin® - Brand Only)
		Loratadine Syrup OTC (Claritin® - Brand Only)
		Loratadine Tablet OTC(Claritin®)
		Loratadine OTD (Claritin® - Brand Only)
		Loratadine Chewable OTC - (Claritin®)
		Loratadine-D 12 hours OTC  (Claritin- D®)
		Loratadine-D 24 hours OTC  (Claritin- D®)
Rhinitis Agents, Nasal	Azelastine (Astelin; Astepro®)	Azelastine (Generic)
	Fluticasone Propionate (Flonase® - Brand Only)	Beclomethasone (Beconase AQ®)
	Ipratropium Nasal	Budesonide Aqua (Rhinocort Aqua®)
	Mometasone (Nasonex®)	Ciclesolide (Omnaris®)
	Olopatadine (Patanase®)	Flunisolide
		Fluticasone Furoate (Veramyst®)
		Fluticasone Propionate (Generic Only)
		Triamcinolone (Nasacort AQ®)

Alzheimer's

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Alzheimer's Agents	Donepezil (Aricept® - Brand Only)	Donepezil (Generics Only)
Cholinesterase Inhibitors	Donepezil (Aricept ODT® - Brand Only)	Donepezil ODT (Generics Only)
	Memantine Soluation (Namenda Sol®)	Donepezil 23 mg (Aricept 23mg®)
	Memantine Tablet (Namenda Tab®)	Galantamine Tablet
	Memantine Tablet Dose Pack (Namenda Tab Dose Pack®)	Galantamine ER
	Rivastigmine Capsule (Exelon Capsule® - Brand Only)	Galantamine Oral Solution (Generics; Razadyne®)
	Rivastigmine Transdermal (Exelon Transdermal®)	Rivastigmine Capsule (Generics Only)
		Rivastigmine Oral Solution (Generics; Exelon Solution®)

Antipsychotic Agents

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
	ORAL
Antipsychotic Agents	Amitriptyline/Perphenazine	Aripiprazole Oral Solution (Abilify Oral Solution®)
	Aripiprazole Discmelt (Abilify®)	Clozapine (Clozaril; Fazaclo®)
	Aripiprazole Tablet (Abilify®)	Lurasidone (Latuda®)
	Asenapine (Saphris)	Olanzapine (Zyprexa; Zyprexa Zydis®)
	Chlorpromazine	Olanzapine/Fluoxetine (Symbyax®)
	Clozapine (Generics Only)	Paliperidone ER (Invega®)
	Fluphenazine Elixir	Risperidone ODT (Risperdal® - Brand Only)
	Fluphenazine Tablet	Risperidone Solution (Risperdal® - Brand Only)
	Haloperidol Oral	Risperidone Tablet (Risperdal® - Brand Only)
	Haloperidol Lactate Concentrate
	Iloperidone Dose pack(Fanapt®)
	Iloperidone Tablet (Fanapt®)
	Molindone (Moban®)
	Perphenazine
	Pimozide (Orap®)
	Quetiapine (Seroquel®)
	Quetiapine (Seroquel XR®)
	Risperidone ODT (Generic Only)
	Risperidone Solution (Generic Only)
	Risperidone Tablet (Generic Only)
	Thioridazine
	Thiothixene (Generic; Navane®)
	Trifluoperazine (Generic)
	Ziprasidone (Geodon®)
	INJECTIONS
	Aripiprazole (Abilify®)	Haloperidol Decanoate (Haldol® - Brand Only)
	Fluphenazine Decanoate	Olanzapine (Zyprexa®)
	Haloperidol Decanoate (Generic Only)	Olanzapine (Zyprexa Relprevv®)
	Haloperidol Lactate (Generic Only)	Paliperidone (Invega Sustenna®)
	Risperidone (Risperdal Consta®)
	Ziprasidone (Geodon®)

Asthma/COPD

Descriptive Therapeutic Class	Drugs on PDL		Drugs Which Require PA	Effective Date January 1, 2012
Bronchodilator, Beta-Adrenergic Agents
	INHALATION
	Albuterol Sulfate Nebulizer Solution 100mg/20ml		Albuterol Sulfate HFA MDI (Ventolin HFA®)
	Albuterol Sulfate Nebulizer Solution 2.5mg/3ml		Albuterol Sulfate Nebulizer Low-Dose 0.63mg/3ml, 1.25mg/3ml
	Albuterol Sulfate Nebulizer Solution 2.5mg/0.5ml		Arformoterol Inhalation Solution (Brovana Inhalation Solution®)
	Albuterol Sulfate Nebulizer Low-Dose (Accuneb®)		Formoterol DPI (Foradil®)
	Albuterol Sulfate HFA (ProAir HFA®)		Formoterol Inhalation Solution (Perforomist Inhalation Solution®)
	Albuterol Sulfate HFA MDI (Proventil HFA®)		Indacaterol for Inhalation (Arcapta®)
			Levalbuterol HCL Nebulizer Solution (Generic; Xopenex®)
			Levalbuterol HFA (Xopenex HFA®)
			Pirbuterol (Maxair Autohaler®)
			Salmeterol Xinafoate (Serevent Diskus®)
	ORAL
Bronchodilator, Beta-Adrenergic	Albuterol Sulfate Syrup		Albuterol Sulfate ER (Generic; Vospire ER Tablet®)
Agents cont’	Albuterol Sulfate Tablet		Metaproterenol Sulfate Tablet
	Metaproterenol Sulfate Syrup
	Terbutaline Sulfate
Bronchodilator, Anticholinergics (COPD)	INHALATION
	Albuterol Sulfate/Ipratropium MDI (Combivent®)	Albuterol Sulfate/Ipratropium Nebulizer (Generic Only)
	Albuterol Sulfate/Ipratropium Nebulizer Solution (Duoneb® - Brand Only)
	Ipratropium Nebulizer
	Ipratropium Inhalation Aerosol MDI (Atrovent HFA®)
	Tiotropium Inhalation Powder (Spiriva®)
	ORAL
	NONE	Roflumilast (Daliresp®)
Glucocorticoids, Inhalation	Beclomethasone MDI (QVAR®)	Budesonide DPI (Pulmicort Flexhaler®)
	Budesonide Respules  0.25mg; 0.5mg - 8 years old and under	Budesonide Respules 0.25mg; 0.5mg - 9 years old and over
	Budesonide Respules  0.25mg; 0.5mg (Pulmicort - Respules®) - 8 years old and under	Budesonide Respules 0.25mg; 0.5mg (Pulmicort - Respules®) - 9 years old and over
	Budesonide Respules  1mg (Pulmicort - Respules®) - 8 years old and under	Budesonide Respules 1mg (Pulmicort - Respules®) - 9 years old and over
	Fluticasone MDI (Flovent®)	Budesonide/Formoterol MDI (Symbicort®)
	Fluticasone MDI (Flovent HFA Inhaler®)	Ciclesonide (Alvesco®)
	Fluticasone/Salmeterol DPI (Advair Diskus®)
	Fluticasone/Salmeterol MDI (Advair HFA®)
	Mometasone DPI (Asmanex®)
	Mometasone/Furoate (Dulera®)
Leukotriene Modifiers	Montelukast Chewable Tablet(Singulair®)	Montelukast Gran Pack (Singulair Gran Pack®)
	Montelukast Tablet (Singulair®)	Zafirlukast (Generic Only)
	Zafirlukast (Accolate® - Brand Only)	Zileuton CR (Zyflo CR®)

Depression

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Antidepressants, Other	Bupropion IR	Bupropion HBr ER (Aplenzin®)
	Bupropion SR	Bupropion HCI IR (Wellbutrin®)
	Bupropion XL	Bupropion HCI SR (Wellbutrin SR®)
	Mirtazapine (Generics only)	Bupropion HCI XL (Wellbutrin XL®)
	Mirtazapine ODT (Generics only)	Desvenlafaxine (Pristiq®)
	Trazodone	Duloxetine (Cymbalta®)
	Venlafaxine ER Capsule (Effexor® XR -Brand Only)	Mirtazapine (Remeron®)
	Venlafaxine IR Tablet	Mirtazapine ODT (Remeron ODT®)
		Nefazodone
		Selegiline Patch (Emsam®)
	Venlafaxine	Trazodone Hydrochloride (Oleptro®)
		Venlafaxine ER Capsule (Generic)
		Venlafaxine ER Tablet (Generic; Schwarz; Updstate)
		Vilazodone (Viibryd®)
Selective Serotonin Reuptake Inhibitors (SSRIs)	Citalopram Tablet (Generic)	Citalopram Solution
	Fluoxetine Capsule (Generic)	Citalopram Tablet (Celexa®)
	Fluoxetine Tablet 10mg	Escitalopram Solution (Lexapro®)
	Fluvoxamine Solution	Escitalopram Tablet (Lexapro®)
	Fluvoxamine Oral	Fluoxetine Tablet 20mg
	Paroxetine Suspension (Paxil®)	Fluoxetine Capsule (Prozac; Sarafem®)
	Paroxetine CR Tablet (Paxil CR®)	Fluoxetine DR Capsule (Generic; Prozac Weekly®)
	Paroxetine Tablet (Paxil®)	Fluvoxamine CR (Luvox CR®)
	Paroxetine Tablet (Generic)	Paroxetine Suspension (Generic)
	Sertraline Tablet (Generic)	Paroxetine CR Tablet (Generic)
		Paroxetine Mesylate (Pexeva)
		Sertraline Concentrate (Zoloft; Generic)
		Sertraline Tablet (Zoloft®)

Dermatology

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Antifungals - Topical	Clotrimazole Rx	Butenafine (Mentax®)
	Clotrimazole/Betamethasone	Ciclopirox (CNL8®)
	Econazole	Ciclopirox Cream
	Ketoconazole Cream	Ciclopirox Gel
	Ketoconazole Shampoo (Rx only)	Ciclopirox Shampoo
	Nystatin	Ciclopirox Solution
	Nystatin w/ Triamcinolone	Ciclopirox Suspension
		Ketoconazole (Ketocon Plus®)
		Ketoconazole Foam (Extina®)
		Ketoconazole (Xolegel®)
		Miconazole (Nuzole®)
		Miconazole/zinc oxide/white petrolatum (Vusion®)
		Naftifine (Naftin®)
		Nystatin (Pediaderm AF®)
		Oxiconazole (Oxistat®)
		Sertaconazole Nitrate (Ertaczo®)
		Sulconazole (Exelderm®)
Antiparasitic Agents, Topical	Crotamiton (Eurax®)	Benzyl Alcohol (Ulesfia®)
	Malathion (Ovide® - Brand only)	Lindane
	Permethrin	Malathion (generic only)
		Spinosad (Natroba®)
Antiviral Agents, Topical	Acyclovir Ointment (Zovirax®)	Acyclovir Cream (Zovirax®)
	Penciclovir Cream (Denavir®)	Acyclovir/Hydrocortisone (Xerese®)
Atopic Dermatitis - Immunomodulators	Pimecrolimus (Elidel®)	NONE
	Tacrolimus (Protopic®)
Antibiotics, Topical	Gentamicin Sulfate	Mupirocin Cream (Bactroban®)
	Mupirocin Ointment	Retapamulin (Altabax®)
STEROIDS, TOPICAL
Low Potency	Alclometasone Dipropionate (Aclovate® - Brand Only)	Alclometasone Dipropionate Cream, Ointment (Generic Only)
	Desonide Cream, Ointment (Generic)	Desonate Gel (Generic)
	Hydrocortisone Cream, Lotion, Ointment (Generic)	Desonide/Emollient Combo No. 3 (Desonil Plus®)
		Desonide Lotion (Generic; Desowen; Verdeso®)
		Desonide Cream Kit (Desowen Cream Kit®)
		Desonide Lotion Kit (Desowen Lotion Kit®)
		Desonide Ointment Kit (Desowen Ointment Kit®)
		Fluocinolone Acetonide Shampoo (Capex®)
		Fluocinolone Acetonide (Derma-Smoothe-FS®)
		Hydrocortisone (Texacort®)
		Hydrocortisone Acetate/Urea
		Hydrocortisone/Aloe Gel (Generic; Nuzon®)
		Hydrocortisone/Mineral Oil/Pet Ointment
		Hydrocortisone/Emollient (Pediaderm HC®)
		Triamcinolone (Pediaderm TA®)
Medium Potency	Clocortolone Pivalate (Cloderm®)	Betamethasone Valerate (Luxiq®)
	Fluocinolone Acetonide Cream, Ointment, Solution	Flurandrenolide Tape (Cordran Tape®)
	Fluticasone Propionate Cream, Ointment (Generic)	Fluticasone Propionate Cream, Lotion (Cutivate®)
	Hydrocortisone Butyrate Ointment, Solution	Hydrocortisone Butyrate Cream (Generic; Locoid Lipocream®)
	Hydrocortisone Valerate Cream (Generic)	Hydrocortisone Probutate (Pandel®)
	Prednicarbate Cream (Dermatop®)	Hydrocortisone Valerate Cream (Westcort®)
		Hydrocortisone Valerate Ointment (Generic)
		Mometasone Furoate Cream, Ointment, Solution (Generic; Elocon®)
		Mometasone Furoate (Momexin®)
		Prednicarbate Cream, Ointment (Generic)
		Prednicarbate Ointment (Dermatop®)
High Potency	Amcinonide Lotion (Generic)	Amcinonide Cream, Ointment (Generic)
	Betamethasone Dipropionate Cream, Lotion, Ointment (Generic)	Betamethasone Dipropionate/Prop Glycol Cream, Lotion, Ointment (Generic; Diprolene; Diprolene/AF®)
	Betamethasone Valerate Cream, Lotion, Ointment (Generic)	Betamethasone Dipropionate Gel (Generic; Diprolene®)
	Betamethasone Valerate Cream, Lotion (Beta Val®)	Desoximetasone Cream, Gel, Ointment (Generic; Topicort; Topicort LP®)
	Fluocinonide Cream; Emollient; Gel; Ointment, Solution (Generic)	Diflorasone Diacetate Cream, Ointment (Generic)
	Triamcinolone Acetonide Cream, Ointment (Generic)	Fluocinonide Cream (Vanos®)
		Halcinonide Cream, Ointment (Halog®)
		Triamcinolone Acetonide Aerosol (Kenlag Aerosol®)
		Triamcinolone Acetonide Lotion (Generic)
Very High Potency	Clobetasol Propionate Cream, Gel, Ointment, Solution (Generic)	Clobetasol Propionate Cream (Temovate®)
	Clobetasol Propionate Foam (Olux®)	Clobetasol Propionate Foam (Generic Only)
	Clobetasol Propionate/Emollient (Generic Only)	Clobetasol Propionate (Clobex Lotion, Shampoo, Spray®)
	Halobetasol Propionate Cream, Ointment (Generic)	Clobetasol Propionate - Emollient (Olux-E® - Brand Only)
		Diflorasone Diacetate (Apexicon E®)
		Halobetasol Propionate/Ammonium Lactate (Halac, Halonate, Halonate PAC, Ultravate PAC®)

Diabetes

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Hypoglycemics, Meglitinides	Nateglinide (Starlix®)	Nateglinide (Generic)
	Repaglinide (Prandin®)	Repaglinide/Metformin (Prandimet®)
Hypoglycemics, Thiazolidinediones (TZDs)	Pioglitazone (Actos®)	Pioglitazone/Glimeperide (Duetact®)
		Pioglitazone/Metformin (Actoplus Met®)
		Pioglitazone/Metformin ER (Actoplus Met XR®)
		Rosiglitazone/Glimepiride (Avandaryl®)
		Rosiglitazone (Avandia®)
		Rosiglitazone/Metformin (Avandamet®)
Hypoglycemics	Human Insulin & Pens (Humulin®)	Human Insulin & Pens (Novolin®)
Insulins & Related Agents	Insulin Glargine & Pens (Lantus®)	Insulin Aspart & Pens (Novolog®)
	Insulin Lispro & Pens (Humalog®)	Insulin Aspart/Insulin Aspart Protamine & Pens (Novolog Mix 70/30®)
	Insulin Lispro/Protamine Lispro & Pens (Humalog Mix®)	Insulin Detemir & Pens (Levemir®)
		Insulin Glulisine & Pens (Apidra®)
Hypoglycemics	Exenatide (Byetta, Pens®)	Liraglutide (Victoza®)
Incretin Mimetics/Enhancers	Linagliptin (Tradjenta®)
	Pramlintide (Symlin®)
	Pramlintide Pens (Symlin Pens®)
	Saxagliptin (Onglyza®)
	Saxagliptin /Metformin (Kombiglyze XR)
	Sitagliptin (Januvia®)
	Sitagliptin/Metformin (Janumet®)

Digestive Disorders

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Antiemetic Agents	Aprepitant Oral (Emend®)	Dolasetron IV Inj (Anzemet®)
	Dimenhydrinate Inj	Dolasetron Oral (Anzemet®)
	Dronabinol Oral (Marinol®)	Dronabinol Oral (Generic)
	Meclizine	Fosaprepitant IV Inj (Emend®)
	Metoclopramide Inj	Granisetron IV Inj
	Metoclopramide Oral	Granisetron Oral
	Ondansetron IV Inj	Granisetron Transdermal (Sancuso®)
	Ondansetron Oral ODT	Metoclopramide Oral ODT (Metozolv®)
	Ondansetron Oral Tab	Nabilone (Cesamet®)
	Ondansetron Oral Solution	Ondansetron Oral (Zuplenz®)
	Prochlorperazine Inj	Palonosetron IV Inj (Aloxi®)
	Prochlorperazine Oral
	Prochlorperazine Rectal
	Promethazine Inj
	Promethazine Oral
	Promethazine Rectal
	Scopolamine Oral (Scopace®)
	Scopolamine Transdermal (Transderm-Scop®)
	Trimethobenzamide IM Inj
	Trimethobenzamide Oral
Bile Acid Salt	Ursodiol Capsule (Generic Only)	Chenodiol (Chenodal®)
		Ursodiol Tablet
		Ursodiol USP (Actigall® - Brand Only)
		Ursodiol (URSO 250®)
		Ursodiol (URSO Forte®)
Pancreatic Enzymes	Creon	Pancreaze
	Pancrelipase
	Zenpep
Proton Pump Inhibitors	Esomeprazole (Nexium®)	Dexlansoprazole (Dexilant®)
	Omeprazole (Generic legend only)	Esomeprazole Suspension (Nexium®)
		Lansoprazole Capsule
		Lansoprazole Capsule (Prevacid®)
		Lansoprazole Solutab
		Lansoprazole Solutab (Prevacid®)
		Omeprazole Suspension (Prilosec®)
		Omeprazole/Sodium Bicarbonate (Generic legend only)
		Pantoprazole
		Pantoprazole Suspension (Protonix®)
		Rabeprazole (Aciphex®)
Ulcerative Colitis Agents	Balsalazide	Mesalamine DR (Asacol HD®)
	Mesalamine ER (Apriso®)	Mesalamine Sulfite-free Enema (sfRowasa®)
	Mesalamine Enemas	Mesalamine MMX (Lialda®)
	Mesalamine (Asacol®)	Mesalamine Oral (Pentasa®)
	Mesalamine Suppositories (Canasa®)	Olsalazine Oral (Dipentum®)
	Sulfasalazine

Growth Deficiency

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Growth Deficiency
Growth Hormones	Somatropin (Genotropin®)	Somatropin (Humatrope®)
	Somatropin (Norditropin®)	Somatropin (Omnitrope®)
	Somatropin (Nutropin®)	Somatropin (Saizen®)
	Somatropin (Nutropin AQ®)	Somatropin (Serostim®)
		Somatropin  (Tev-Tropin®)
		Somatropin (Zorbtive®)
GOUT AGENTS
Antihyperuricemics	Allopurinol	Colchicine (Colcrys®)
	Probenecid	Febuxostat (Uloric®)
	Probenecid/Colchicine

Heart Disease

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
HYPERLIPIDEMIA
Lipotropics, Other	Cholestyramine	Colesevelam (Welchol®)
	Colestipol	Ezetimibe (Zetia®)
	Fenofibrate (Tricor®)	Fenofibrate (Antara®)
	Fenofibric Acid (Trilipix®)	Fenofibrate (Fenoglide®)
	Gemfibrozil	Fenofibrate (Generics)
	Niacin ER (Niaspan®)	Fenofibrate (Lipofen®)
	Niacin IR (Niacor®)	Fenofibrate (Triglide®)
		Fenofibric Acid (Generic)
		Fenofibric Acid (Fibricor®)
		Omega-3-acid ethyl esters (Lovaza®)
Statins & Statin Combination Agents	Atorvastatin (Lipitor®)	Amlodipine/Atorvastatin (Caduet®)
	Fluvastatin (Lescol®)	Ezetimibe/Simvastatin (Vytorin®)
	Fluvastatin XL (Lescol XL®)	Lovastatin ER (Altoprev®)
	Lovastatin	Niacin ER/Lovastatin (Advicor®)
	Niacin ER/Simvastatin (Simcor®)	Pitavastatin (Livalo®)
	Pravastatin
	Rosuvastatin (Crestor®)
	Simvastatin
HYPERTENSION
ACE Inhibitors & Direct Renin Inhibitors	Benazepril	Aliskiren (Tekturna®)
	Benazepril/HCTZ	Aliskiren/HCTZ (Tekturna HCT®)
	Captopril	Azilsartan Meoxomil (Edarbi®)
	Captopril/HCTZ	Candesartan (Atacand®)
	Enalapril	Candesartan/HCTZ (Atacand HCT®)
	Enalapril/HCTZ	Eprosartan (Teveten®)
	Fosinopril	Eprosartan/HCTZ (Teveten HCT®)
	Fosinopril/HCTZ	Moexipril
	Irbesartan (Avapro®)	Moexipril/HCTZ
	Irbesartan/HCTZ (Avalide®)	Olmesartan (Benicar®)
	Lisinopril	Olmesartan/HCTZ (Benicar HCT®)
	Lisinopril/HCTZ	Perindopril
	Losartan	Telmisartan (Micardis®)
	Losartan/HCTZ	Telmisartan/HCTZ (Micardis HCT®)
	Quinapril
	Quinapril/HCTZ
	Ramipril
	Trandolapril
	Valsartan (Diovan®)
	Valsartan/HCTZ (Diovan HCT®)
Angiotensin Modulators/Calcium Channel Blockers Combination Products	Amlodipine/Benazepril - Generic only	Amlodipine/Aliskiren (Tekamlo®)
	Amlodipine/Olmesartan (Azor®)	Amlodipine/Aliskiren/HCTZ (Amturnide®)
	Amlodipine/Olmesartan Med/HCTZ (Tribenzor®)	Amlodipine/Benazepril (Lotrel®)
	Amlodipine/Valsartan (Exforge®)	Amlodipine/Telmisartan (Twnysta®)
	Amlodipine/Valsartan/HCTZ (Exforge HCT®)
	Valsartan/Aliskiren (Valturna®)
	Trandolapril/Verapamil
Beta Blockers Agents	Acebutolol	Carvedilol CR (Coreg CR®)
	Atenolol	Metoprolol Succinate ER (Toprol XL)
	Atenolol/Chlorthalidone
	Betaxolol
	Bisoprolol
	Bisoprolol/HCTZ
	Carvedilol
	Labetalol
	Metoprolol
	Metoprolol /HCTZ
	Metoprolol Succinate ER
	Nadolol
	Nadolol/Bendroflumethiazide
	Nebivolol (Bystolic®)
	Penbutolol (Levatol®)
	Pindolol
	Propranolol
	Propranolol ER (Innopran XL®)
	Propranolol LA
	Propranolol/HCTZ
	Sotalol
	Sotalol AF
	Timolol Maleate
Calcium Channel Blockers	Amlodipine
	Diltiazem CD (Cardizem CD 360 mg)	Isradipine SR (Dynacirc CR®)
	Diltiazem IR	Nisoldipine
	Diltiazem ER	Verapamil ER (Covera HS®)
	Diltiazem SR	Verapamil  ER PM
	Felodipine ER
	Isradipine
	Nicardipine
	Nifedipine ER
	Nifedipine IR
	Nimodipine
	Verapamil
	Verapamil ER (Generics)
	Verapamil IR
	Verapamil SR
ANTICOAGULANTS
Platelet Aggregation Inhibitors	Aspirin/Dipyridamole ER (Aggrenox®)	Prasugrel (Effient®)
	Clopidogrel (Plavix®)	Ticlopidine
	Dipyridamole
Anticoagulants	Dabigatran (Pradaxa®)	Enoxaparin (Generic)
	Dalteparin (Fragmin®)	Tinzaparin (Innohep®)
	Enoxaparin (Lovenox®)
	Fondaparinux (Arixtra®)
	Rivaroxaban (Xarelto®)
	Warfarin
Pulmonary Arterial Hypertension (PAH)	Bosentan (Tracleer®)	Ambrisentan (Letaris®)
	Iloprost (Ventavis®)	Treprostinil (Tyvaso®)
	Sildenafil (Revatio®)
	Tadalafil (Adcirca®)

Hematologic Agents

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
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 January 1, 2012
Phosphate Binders	Calcium Acetate (PhosLo®)	Calcium Acetate (Generics)
	Sevelamer HCL (RenaGel®)	Calcium Acetate (Eliphos®)
	Sevelamer Carbonate (Renvela®)	Lanthanum (Fosrenol®)

Hormone Therapy

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Androgenic Agents	Testosterone Transdermal Patch (Androderm®)	Testosterone (Axiron®)
	Testosterone Gel 1% (Androgel®)	Testosterone Gel 1% (Testim®)
		Testosterone Gel (Fortesta®)

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 January 1, 2012
ANTIBIOTICS
Cephalosporin and Related Antibiotics	Amoxicillin/Clavulanate Suspension	Amoxicillin/Clavulanate ER
	Amoxicillin/Clavulanate Tablets	Cefaclor
	Amoxicillin/Clavulanate Susp (Augmentin 125 & 250)	Cefaclor ER 500
	Cefadroxil	Cefdinir
	Cefixime (Suprax®)	Cefditoren Pivoxil
	Cefprozil	Cefpodoxime
	Ceftibuten (Cedax®)	Cefuroxime Axetil Susp (Ceftin®)
	Cefuroxime Tablets
	Cephalexin
Fluoroquinolones	Oral
	Ciprofloxacin Tablets	Ciprofloxacin Suspension (Cipro Suspension ®)
	Levofloxacin (Levaquin®)	Ciprofloxacin ER
		Ciprofloxacin ER (Proquin XR®)
		Gemifloxacin (Factive®)
		Moxifloxacin (Avelox®)
		Norfloxacin (Noroxin®)
		Ofloxacin
Antibiotics, Gastrointestinal	Metronidazole	Fidaxomicin (Dificid®)
	Neomycin	Metronidazole ER (Flagyl ER®)
	Nitazoxanide (Alinia®)	Rifaximin (Xifaxan®)
	Tinidazole (Tindamax®)	Vancomycin (Vancocin®)
Antibiotic, Inhaled	Tombramycin (Tobi®)	Azteonam (Cayston®)
Macrolides - Ketolides	Azithromycin	Azithromycin ER (Zmax®)
	Erythromycin	Clarithromycin
		Clarithromycin ER
		Telithromycin (Ketek®)
Tetracyclines	Doxycycline Hyclate (generic)	Demeclocycline
	Doxycycline Hyclate DR (generic)	Doxycycline Calcium Suspension (Vibramycin®)
	Doxycycline Monohyrate	Doxycycline Hyclate (Doryx®)
	Minocycline Cap	Doxycycline DR (Oracea®)
	Minocycline Tab	Minocycline ER - generic
	Tetracycline
Vaginal	Clindamycin Vaginal Cream	Clindamycin Vaginal Cream (Clindesse®)
	Clindamycin Vaginal Ovules (Cleocin®)
	Metronidazole Vaginal Gel Cream
	Metronidazole Vaginal Gel (Vandazole®)
OPHTHALMIC ANTIBIOTICS - Refer to Opthalmic Disorders
OTIC ANTIBIOTICS -  Refer to Otic Agents
ANTIFUNGALS
Antifungals, Oral	Clotrimazole Troches	Flucytosine (Ancobon®)
	Fluconazole	Griseofulvin Tablets (Grifulvin V®)
	Griseofulvin Suspension	Itraconazole
	Griseofulvin (Gris-Peg®)	Itraconazole Solution (Sporanox®)
	Ketoconazole	Miconazole (Oravig®)
	Nystatin	Posaconazole (Noxafil®)
	Terbinafine (no granules)	Terbinafine (Terbinex®)
		Terbinafine Granules (Lamisil Granules®)
		Voriconazole (generic)
		Voriconazole (VFEND®)
HEPATITIS AGENTS
Hepatitis C Agents	Boceprevir (Victrelis®)	Consensus Interferon (Infergen®)
	Ribavirin	Peginterferon alfa 2B (Peg-Intron®)
	Peginterferon alfa 2A (Pegasys®)	Peginterferon alfa 2B (Peg-Intron Redipen®)
		Telaprevir (Incivek®)

Multiple Sclerosis

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Multiple Sclerosis Agents (Immunomodulatory Agents)	Glatiramer (Copaxone®)	Dalfampridine (Ampyra®)
	Interferon beta - 1a (Avonex®)	Fingolimod (Gilenya®)
	Interferon beta - 1a (Rebif®)	Interferon beta - 1b (Extavia®)
	Interferon beta - 1b (Betaseron®)

Ophthalmic Disorders

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Allergic Conjunctivitis	Cromolyn Sodium	Alcaftadine (Lastacaft®)
	Loteprednol (Alrex®)	Azelastine HC (Generic; Optivar®)
	Olopatadine HCI (Pataday®)	Bepotastine Besilate (Bepreve®)
		Emedastine Difumarate (Emadine®)
		Epinastine HCI (Generic; Elestat®)
		Lodoxamide Tromethamine (Alomide®)
		Nedocromil Sodium (Alocril®)
		Olopatadine HCI (Patanol®)
		Pemirolast Potassium (Alamast®)
Glaucoma Agents
Intraocular Pressure (IOP) Reducers	Betaxolol	Apraclonidine (Generic; Iopidine®)
	Betaxolol (Betoptic S®)	Bimatroprost (Lumigan 2.5ml; 5ml; 7.5ml®)
	Brimonidine 0.15% (Alphagan P 0.15% - Brand Only)	Brimonidine 0.1% (Alphagan P 0.1%®)
	Brimonidine 0.2% (Generic)	Brimonidine 0.15% (Generic only)
	Brimonidine/Timolol (Combigan®)	Dorzolamide (Trusopt® - Brand Only)
	Brinzolamide (Azopt®)	Dorzolamide/Timolol (Cosopt® - Brand Only)
	Carteolol	Latanoprost (Xalatan® - Brand Only)
	Dorzolamide (Generic only)	Levobunolol (Betagan® - Brand Only)
	Dorzolamide/Timolol (Generic only)	Timolol (Timoptic®)
	Latanoprost (Generic only)
	Levobunolol (Generic only)
	Metipranolol (Generic; Optipranolol®)
	Pilocarpine
	Timolol (Generic; Betimol®)
	Timolol LA (Istalol®)
	Travoprost (Travantan Z®)
Ophthalmics, Antibiotic	Besifloxacin (Besivance®)	Azithromycin (AzaSite®)
	Ciprofloxacin Ointment (Ciloxan®)	Bacitracin
	Ciprofloxacin Solution (Generic)	Bacitracin/Polmyxin B Ointment
	Erythromycin	Gatifloxacin 0.5% (Zymaxid®)
	Garamycin Drops	Levofloxacin (Generic; Iquix; Quixin®)
	Garamycin Ointment	Natamycin (Natacyn®)
	Gatifloxacin 0.3% (Zymar®)	Neomycin-Polmyxin-Gramicidin
	Gentamicin Drops	Ofloxacin Solution (Ocuflox® - Brand Only)
	Gentamicin Ointment
	Moxifloxacin (Moxeza; Vigamox®)
	Neomycin-Polymyxin-Bacitracin Ointment
	Ofloxacin Solution (Generic Only)
	Polymyxin B/Trimethoprim (Generic; Polytrim®)
	Sulfacetamide (Generic; Bleph-10®)
	Tobramycin (Generic; Tobrex®)
Ophthalmics, Antibiotic- Steroid Combos	Gentamicin/Prednisolone (Pred-G;Pred-G S.O.P. ®)	Neomycin/Polymyxin B/Hydrocortisone
	Neomycin/Polymyxin B/Dexamethasone	Neomycin/Bacitracin/Polymyxin B/Hydrocortisone
	Sulfacetamide/Prednisolone Ointment (Blephamide S.O.P. ®)	Tobramycin/Dexamethasone Suspension (Generic)
	Sulfacetamide/Prednisolone Solution (Generic; Blephamide®)	Tobramycin/Dexamethasone ST (Tobradex ST®)
	Tobramycin/Dexamethasone Ointment (Tobradex®)
	Tobramycin/Dexamethasone Suspension (Tobradex®)
	Tobramycin/Loteprednol (Zylet®)
Ophthalmics, Anti-Inflammatories	Dexamethasone (Generic; Maxidex®)	Bromfenac (Generic; Bromday; Xibrom®)
	Diclofenac	Difluprednate (Durezol®)
	Fluorometholone 0.1% Ointment (FML S.O.P. ®)	Fluorometholone 0.1% Suspension (FML® - Brand Only)
	Fluorometholone 0.1% Suspension (Generic)	Fluorometholone Acetate 0.1% Solution (Flarex®)
	Fluorometholone 0.25% Suspension (FML Forte®)	Ketorolac (Generic; Acular®)
	Flurbiprofen	Ketorolac LS (Generic; Acular LS®)
	Loteprednol Drops (Lotemax®)	Ketorolac (Acuvail®)
	Loteprednol Ointment (Lotemax®)	Nepafenac (Nevanac®)
	Prednisolone Acetate 0.12% Solution (Generic; Pred Mild®)	Prednisolone Acetate 1% (Pred Forte®)
	Prednisolone Acetate 1% (Generic)	Prednisolone Sodium Phosphate
		Rimexolone (Vexol®)

Opiate Dependence Agents

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
	Buprenorphine/Naloxone Filmtab (Suboxone®)	Buprenorphine Subling Tab (Generic)
	Buprenorphine/Naloxone Subling Tab (Suboxone®)	Buprenorphine Subling Tab (Subutex®)

Otic Agents

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Otic Antibiotics	Ciprofloxacin/Dexamethasone (Ciprodex®)	Ciprofloxacin (Cetraxal OTIC®)
	Neomycin/Polymyxin/HC (Generic; Cortisporin®)	Ciprofloxacin/Hydrocortisone (Cipro HC OTIC®)
	Ofloxacin (Generic; Floxin®)	Neomycin/Colistin/Thonzonium/HC (Coly-Mycin S®)
		Neomycin/Colistin/Thonzonium/HC (Cortisporin TC®)
Otic Anti-Infectives and Anesthetics	Acetic Acid	Acetic Acid/HC
	Acetic Acid/Aluminum	Antipyrine/Benzocaine/Policosanol (Otic Care®)
	Antipyrine/Benzocaine	Antipyrine/Benzocaine/Zinc (Neotic; Otozin®)
	Benzocaine (Pinnacaine®)	Chloroxylenol/Benzocaine/Hydrocortisone (Myoxin; Trioxin®)
	Chloroxylenol/Pramoxine	Chloroxylenol/Pramoxine/Zinc/Glycerine (Zinotic; Zinotic ES®)
	Chloroxylenol/Pramoxine (Pramotic®)
	Pramoxine HC

Osteoporosis

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Bone Resorption Suppression Agents	Alendronate	Alendronate Solution (Fosamax Solution®)
	Calcitonin-Salmon Nasal (Miacalcin®)	Alendronate/Vit D (Fosamax Plus D®)
		Calcitonin-Salmon Nasal (Fortical®)
		Calcitonin - Salmon Nasal (Generics)
		Etidronate Disodium (Generics)
		Etidronate (Didronel®)
		Ibandronate Sodium (Boniva®)
		Raloxifene (Evista®)
		Risedronate (Actonel®)
		Risendronate DR (Atelvia®)
		Teriparatide Subcutaneous (Forteo®)

Pain Management

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Analgesics/Anesthetic, Topical	Diclofenac Sodium Gel (Voltaren®)	Diclofenac Epolamine Patch (Flector®)
	Lidocaine Patch (Lidoderm®)	Diclofenac Sodium (Pennsaid®)
Analgesics, Narcotics Short Acting	Acetaminophen w/Codeine	Fentanyl Buccal (Generics)
	Butalbital Compound with Codeine	Fentanyl Buccal (Fentora®)
	Codeine	Fentanyl Buccal (Onsolis®)
	Dihydrocodeine Bitartrate/Acetaminophen/Caffeine (Generics)	Fentanyl Sublingual (Abstral®)
	Dihydrocodeine Bitartrate/Acetaminophen/Caffeine (Trezix®)	Hydrocodone/Acetaminophen (Hycet®)
	Hydrocodone/Acetaminophen	Hydrocodone/Acetaminophen (Zamicet®)
	Hydrocodone/Ibuprofen	Hydrocodone/Acetaminophen (Zolvit®)
	Hydromorphone	Hydrocodone/Ibuprofen (Ibudone®)
	Meperidine	Hydrocodone/Ibuprofen (Reprexain®)
	Morphine IR	Hydromorphone Liquid (Dilaudid®)
	Oxycodone	Opium Tincture
	Oxycodone/Acetaminophen	Oxymorphone
	Oxycodone w/Aspirin	Oxymorphone IR (Opana®)
	Oxycodone/Ibuprofen	Tapentadol (Nucynta®)
	Pentazocine/Acetaminophen	Tramadol ODT (Rybix ODT®)
	Pentazocine/Naloxone
	Tramadol
	Tramadol/Acetaminophen
Analgesics, Narcotics Long Acting	Fentanyl Transdermal	Buprenorphine Transdermal (Butrans®)
	Fentanyl Transdermal (Duragesic Matrix)	Hydromorphone ER (Exalgo®)
	Methadone HCL	Morphine Sulfate ER (Avinza®)
	Morphine Sulfate ER (Kadian®)	Morphine Sulfate ER/Naltrexone (Embeda®)
	Morphine Sulfate ER (Generic)	Oxycodone ER
		Oxycodone ER (Oxycontin®)
		Oxycodone Reformulated (OxyContin Reformulated®)
		Oxymorphone ER (Opana ER®)
		Tramadol ER
		Tramadol ER (Ryzolt®)
		Tramadol ER (Ultram ER®)
Nonsteroidal Anti - Inflammatories (NSAIDs)	Diclofenac Potassium Oral (Generic)	Celecoxib (Celebrex®)
	Diclofenac Sodium Oral (Generic)	Diclofenac/Misoprostol (Arthrotec®)
	Esomeprazole/Naproxen (Vimovo®)	Diclofenac Potassium (Zipsor®)
	Etodolac	Diclofenac SR
	Flurbiprofen	Diflunisal (Generic; Dolobid®)
	Ibuprofen Rx Suspension (Generic)	Etodolac SR
	Ibuprofen Rx Tablet (Generic)	Fenoprofen (Generic; Nalfon®)
	Indomethacin Capsule	Indomethacin Rectal (Indocin®)
	Indomethacin Suspension (Indocin®)	Indomethacin ER Capsule (Generic)
	Ketoprofen	Ketoprofen ER
	Ketorolac	Ketorolac Nasal Spray (Sprix®)
	Meloxicam Suspension (Mobic® Brand Only)	Meclofenamate
	Meloxicam Tablet (Generic only)	Mefenamic Acid (Generic; Ponstel®)
	Naproxen EC (Generic only)	Meloxicam Suspension (Generic only)
	Naproxen Sodium	Meloxicam Tablet (Mobic® Brand Only)
	Naproxen Suspension (Generic only)	Nabumetone
	Naproxen Tablet (Generic only)	Naproxen EC (Naprosyn® - Brand Only)
	Oxaprozin	Naproxen Suspension (Naprosyn® - Brand Only)
	Piroxicam (Generic; Feldene®)	Naproxen Tablet (Naprosyn® - Brand Only)
	Sulindac	Naproxen 500mg (Naprelan®)
		Tolmetin Capsule
		Tolmetin Tablet
Antimigraine Agents,Triptans	Eletriptan (Relpax®)	Almotriptan (Axert®)
	Sumatriptan (Imitrex® Injection - Brand only)	Diclofenac (Cambia®)
	Sumatriptan (Imitrex® Nasal - Brand only)	Frovatriptan (Frova®)
	Sumatriptan (Oral – Generic only)	Naratriptan
		Rizatriptan (Maxalt®)
		Rizatriptan (Maxalt MLT®)
		Sumatriptan Injection – Generic only
		Sumatriptan Nasal – Generic only
		Sumatriptan (Imitrex Oral) – Brand only
		Sumatriptan/Naproxen (Treximet®)
		Zolmitriptan (Zomig)
		Zolmitriptan (Zomig ZMT®)
		Zolmitriptan (Zomig® Nasal)
Skeletal Muscle Relaxants	Baclofen	Carisoprodol
	Chlorzoxazone	Carisoprodol Compound
	Cyclobenzaprine	Carisoprodol (Soma 250 mg®)
	Methocarbamol	Cyclobenzaprine (Fexmid®)
	Tizanidine (Generics)	Cyclobenzaprine ER (Amrix®)
		Dantrolene Sodium
		Metaxalone
		Orphenadrine
		Orphenadrine Compound
		Tizanidine (Zanaflex®)
Cytokine and CAM Antagonists	Adalimumab Injection (Humira IJ Kit; Humira Kit®)	Abatacept (Orencia Injection; Orencia Sub-Q®)
	Certolizumab Pegol (Cimzia Kit; Syringe Kit®)	Alefacept Injection (Amevive®)
	Etanercept Injection (Enbrel Kit; Pen; Disp Syringe®)	Anakinra Injection (Kineret®)
		Golimumab (Simponi Pen; Disp Syringe®)
		Infliximab Injection (Remicade®)
		Tocilizumab (Actemra®)

Parkinson's

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Antiparkinson Agents - Anticholinergic and Other	Benztropine	Bromocriptine
	Carbidopa/ Levodopa	Carbidopa/ Levodopa ER (Sinemet CR® - Brand Only)
	Carbidopa/ Levodopa ER (Generic Only)	Carbidopa/ Levodopa ODT
	Levodopa/Carbidopa/Entacapone (Stalevo®)	Entacapone (Comtan®)
	Pramipexole (Generic)	Pramipexole (Mirapex®)
	Ropinirole (Generic Only)	Pramipexole ER (Mirapex ER®)
	Selegiline Tablet (Generic)	Rasagiline (Azilect®)
	Trihexyphenidyl Elixir	Ropinirole (Requip® - Brand Only)
	Trihexyphenidyl Tablet	Ropinirole ER (Requip XL®)
		Selegiline Capsule
		Selegiline (Zelapar®)
		Tolcapone (Tasmar®)

Sedatives/Hypnotics

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
Sedative/Hypnotics	Chloral Hydrate Syrup	Chloral Hydrate (Somnote®)
	Temazepam (Generic)	Doxepin (Silenor®)
	Triazolam (Generic Only)	Estazolam
	Zaleplon (Generic Only)	Eszopiclone (Lunesta®)
	Zolpidem (Generic Only)	Flurazepam
		Quazepam (Doral®)
		Ramelteon (Rozerem®)
		Temazepam (Restoril®)
		Temazepam 7.5mg (Generic; Restoril®)
		Temazepam 22.5mg (Generic; Restoril®)
		Triazolam (Halcion® - Brand Only)
		Zalepon (Sonata – Brand Only)
		Zolpidem (Ambien® - Brand Only)
		Zolpidem Sublingual (Edluar; Zolpimist®)
		Zolpidem ER (Generic; Ambien CR®)

Urology/Incontinence

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date January 1, 2012
INCONTINENCE
Bladder Relaxant Preparations	Fesoterodine Fumarate (Toviaz®)	Darifenacin (Enablex®)
	Oxybutynin	Oxybutynin ER
	Solifenacin (VESIcare®)	Oxybutynin Gel (Gelnique Transdermal®)
		Oxybutynin Transdermal (Oxytrol®)
		Tolterodine (Detrol®)
		Tolterodine ER (Detrol LA®)
		Trospium
		Trospium (Sanctura XR®)

Smoking Cessation

SMOKING CESSATION PRODUCTS
Smoking Cessation	Bupropion SR	Nicotine Inhaler (Nicotrol Inhaler®)
	Nicotine Gum Buccal (Generic; Nicorette®)	Nicotine Lozenges OTC Buccal
	Nicotine Lozenges (Nicorette Lozenges®)	Nicotine Lozenges OTC Mucous Membrane
	Nicotine Transdermal (Generic Only)	Nicotine Nasal Spray (Nicotrol Nasal Spray®)
		Nicotine Transdermal (Nicoderm CQ® - Brand Only)
		Varenicline Dose Pack (Chantix Dose Pack®)
		Varenicline Tablet (Chantix Tablet-®)

Prostate

PROSTATE
Benign Prostatic Hyperplasia Treatment (BPH)	Alfuzosin (Uroxatral®)	Doxazosin XL (Cardura XL®)
	Doxazosin	Dutasteride (Avodart®)
	Finasteride	Dutasteride/Tamsulosin (Jalyn®)
	Tamsulosin	Silodosin (Rapaflo®)
	Terazosin

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