Preferred Drug List/Prior Authorization List
Updated 09/09 - The updated list is from the August 12, 2009 P&T Committee
Meeting.
The effective date is October 1, 2009.
|
Item Number |
Disease State/Specialty |
Item |
Disease State/Specialty |
|
1 |
14 |
||
|
2 |
15 |
||
|
3 |
16 |
||
|
4 |
17 |
||
|
5 |
18 |
||
|
6 |
19 |
||
|
7 |
20 |
||
|
8 |
21 |
||
|
9 |
22 |
||
|
10 |
23 |
||
|
11 |
24 |
||
|
12 |
25 |
||
|
13 |
|
|
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
Stimulants
and Related Agents |
Amphetamine
Mixed Salt |
Amphetamine
Mixed Salt ER (generic only) |
|
|
|
Amphetamine
Mixed Salt ER (Adderall XR® - Brand only) |
Atomoxetine
(Strattera®) |
|
|
|
Dexmethylphenidate |
Dextroamphetamine
(Procentra®) |
|
|
|
Dexmethylphenidate
(Focalin ®) |
Modafinil
(Provigil®) |
|
|
|
Dexmethylphenidate
ER (Focalin XR®) |
Methamphetamine
(Desoxyn®) |
|
|
|
Dextroamphetamine |
Methylphenidate
LA (Ritalin LA®) |
|
|
|
Lisdexamfetamine
(Vyvanse®) |
|
|
|
|
Methylphenidate |
|
|
|
|
Methylphenidate
ER |
|
|
|
|
Methylphenidate
ER (Concerta®, Metadate CD®) |
|
|
|
|
Methylphenidate
Transdermal (Daytrana Transdermal®) |
|
|
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
Antihistamines - Minimally Sedating |
Cetirizine OTC -Generic only |
Acrivastin/Pseudoephedrine (Semprex-D®) |
|
|
|
Cetirizine Chewable OTC- Generic only |
Cetirizine OTC (Zyrtec®) |
|
|
|
Cetirizine Syrup OTC - Generic only |
Cetirizine Syrup OTC (Zyrtec®) |
|
|
|
Cetirizine - D OTC - Generic only |
Cetirizine D OTC (Zyrtec-D®) |
|
|
|
Loratadine OTC - Generic only |
Cetirizine RX |
|
|
|
Loratadine Syrup OTC - Generic only |
Cetirizine RX Syrup |
|
|
|
Loratadine - D OTC Generic only |
Desloratadine (Clarinex®) |
|
|
|
|
Desloratadine Syrup (Clarinex®) |
|
|
|
|
Desloratadine/Pseudoephedrine (Clarinex-D®) |
|
|
|
|
Fexofenadine |
|
|
|
|
Fexofenadine ODT (Allegra ODT®) |
|
|
|
|
Fexofenadine/Pseudoephedrine (Allegra-D®) |
|
|
|
|
Fexofenadine Syrup (Allegra Syrup®) |
|
|
|
|
Levocetirizine (Xyzal®) |
|
|
|
|
Levocetirizine Syrup (Xyzal®) |
|
|
|
|
Loratadine Chewable (Children's Claritin Chewable OTC®) |
|
|
|
|
|
|
|
|
|
|
|
|
Rhinitis
Agents, Nasal |
Azelastine
(Astelin®) |
Beclomethasone
AQ (Beconase AQ®) |
|
|
|
Azelastine
(Astepro®) |
Budesonide
Aqua (Rhinocort Aqua®) |
|
|
|
Mometasone
(Nasonex®) |
Ciclesolide
(Omnaris®) |
|
|
|
|
Flunisolide
(Nasarel®) |
|
|
|
|
Flunisolide |
|
|
|
|
Fluticasone
|
|
|
|
|
Fluticasone
Furoate (Veramyst®) |
|
|
|
|
Ipratropium
Nasal |
|
|
|
|
Olopatadine
HCL (Patanase®) |
|
|
|
|
Triamcinolone
(Nasacort AQ®) |
|
|
|
|
|
|
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
Alzheimer's Agents |
Donepezil
(Aricept®) |
Galantamine
|
|
|
Cholinesterase Inhibitors |
Donepezil
(Aricept ODT®) |
Galantamine
ER |
|
|
|
Memantine
HCI (Namenda®) |
Rivastigmine
Oral Solution (Exelon Solution®) |
|
|
|
Rivastigmine
Oral (Exelon®) |
Tacrine
(Cognex®) |
|
|
|
Rivastigmine
Transdermal Patch (Exelon Transdermal®) |
|
|
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
|
ORAL |
|
|
|
Antipsychotic Agents |
Amitriptyline/Perphenazine |
Aripiprazole
(Abilify®) |
|
|
|
Chlorpromazine |
Clozapine
|
|
|
|
Clozapine
(Fazaclo®) |
Olanzapine/Fluoxetine
(Symbyax®) |
|
|
|
Fluphenazine |
Olanzapine
(Zyprexa®) |
|
|
|
Haloperidol |
Paliperidone
ER (Invega®) |
|
|
|
Molindone
(Moban®) |
|
|
|
|
Perphenazine |
|
|
|
|
Quetiapine
(Seroquel®) |
|
|
|
|
Quetiapine
ER (Seroquel XR®) |
|
|
|
|
Risperidone
|
|
|
|
|
Thioridazine |
|
|
|
|
Thiothixene |
|
|
|
|
Trifluoperazine |
|
|
|
|
Ziprasidone
(Geodon®) |
|
|
|
|
|
|
|
|
|
INJECTIONS |
|
|
|
|
Fluphenazine
Decanoate |
Olanzapine
(Zyprexa®) |
|
|
|
Haloperidol
Decanoate |
Risperidone
(Risperdal Consta®) |
|
|
|
Ziprasidone
(Geodon®) |
|
|
|
|
|
|
|
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
|
Bronchodilator, Beta-Adrenergic Agents |
|
|
|
|
|
|
INHALATION |
|
||
|
|
Albuterol
Sulfate Nebulizer |
Albuterol
Sulfate HFA MDI (Proventil HFA®) |
|
|
|
|
Albuterol
Sulfate HFA (ProAir HFA®) |
Albuterol
Sulfate Nebulizer Low-Dose |
|
|
|
|
Albuterol
Sulfate HFA MDI (Ventolin HFA®) |
Arformoterol
Inhalation Solution (Brovana Inhalation Solution®) |
|
|
|
|
Formoterol
DPI (Foradil®) |
Formoterol
Inhalation Solution (Perforomist Inhalation Solution®) |
|
|
|
|
Levalbuterol
Nebulizer HCL (Xopenex ®) |
Levalbuterol
HFA (Xopenex HFA®) |
|
|
|
|
Salmeterol
Xinafoate (Serevent Diskus®) |
Pirbuterol
(Maxair Autohaler®) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
ORAL |
|
||
|
Bronchodilator, Beta-Adrenergic |
Albuterol Sulfate |
Metaproterenol Sulfate |
|
|
|
Agents cont’ |
Albuterol Sulfate ER |
|
|
|
|
|
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/Formoterol
MDI (Symbicort®) |
Budesonide
Respules - 9 years old and over |
|
|
|
|
Budesonide
Respules - 8 years old and under |
Budesonide
Respules (Pulmicort - Respules®) - 9
years old and over |
|
|
|
|
Budesonide
Respules (Pulmicort - Respules®) - 8 years old and under |
Ciclesonide
(Alvesco®) |
|
|
|
|
Flunisolide
MDI (Aerobid®) |
Mometasone
DPI (Asmanex®) |
|
|
|
|
Flunisolide
MDI (Aerobid M®) |
|
|
|
|
|
Fluticasone
MDI (Flovent®) |
|
|
|
|
|
Fluticasone
MDI (Flovent HFA Inhaler) |
|
|
|
|
|
Triamcinolone
MDI (Azmacort®) |
|
|
|
|
|
Fluticasone/Salmeterol
DPI (Advair Diskus®) |
|
|
|
|
|
Fluticasone/Salmeterol
MDI (Advair HFA®) |
|
|
|
|
|
|
|
|
|
|
Leukotriene Modifiers |
Montelukast (Singulair®) |
Zileuton CR (Zyflo CR®) |
|
|
|
|
Zafirlukast (Accolate®) |
|
|
|
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
Antidepressants, Other |
Bupropion
HCI IR |
Bupropion
HBr ER (Aplenzin®) |
|
|
|
Bupropion
HCI SR |
Bupropion
HCI XL |
|
|
|
Mirtazapine |
Bupropion
HCI XL (Wellbutrin XL®) |
|
|
|
Trazodone |
Desvenlafaxine
(Pristiq®) |
|
|
|
Venlafaxine
ER |
Duloxetine
(Cymbalta®) |
|
|
|
|
Nefazodone |
|
|
|
|
Selegiline
Patch (Emsam®) |
|
|
|
|
Venlafaxine |
|
|
|
|
Venlafaxine
ER (Effexor XR brand only) |
|
|
|
|
|
|
|
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 |
|
Antifungals - Topical |
Ciclopirox
Shampoo (Loprox®) |
Butenafine
(Mentax®) |
|
|
|
Clotrimazole
Rx |
Ciclopirox
(CNL8®) |
|
|
|
Clotrimazole/Betamethasone |
Ciclopirox
Cream |
|
|
|
Ketoconazole
Cream |
Ciclopirox
Gel |
|
|
|
Ketoconazole
Shampoo (Rx only) |
Ciclopirox
Solution |
|
|
|
Naftifine
(Naftin®) |
Ciclopirox
Suspension |
|
|
|
Nystatin |
Econazole
|
|
|
|
Nystatin
w/ Triamcinolone |
Ketoconazole
Foam (Extina Foam®) |
|
|
|
Oxiconazole
(Oxistat®) |
Ketoconazole
(Xolegel®) |
|
|
|
|
Miconazole/zinc
oxide/white petrolatum (Vusion®) |
|
|
|
|
Sertaconazole
Nitrate (Ertaczo®) |
|
|
|
|
|
|
|
|
|
|
|
|
Antiparasitic Agents, Topical |
Crotamiton
(Eurax®) |
Lindane |
|
|
|
Malathion
(Ovide® - Brand only) |
Malathion
(generic only) |
|
|
|
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 |
NONE |
|
|
|
Mupirocin Cream Topical (Bactroban®) |
|
|
|
|
Retapamulin (Altabax®) |
|
|
|
STEROIDS, TOPICAL |
|
|
|
|
Low Potency |
Alclometasone
Dipropionate |
Desonide
(Verdeso®) |
|
|
|
Desonide |
Desonide
(Desonate®) |
|
|
|
Fluocinolone
Acetonide (Derma-Smoothe-FS) |
|
|
|
|
Fluocinolone
Acetonide Shampoo (Capex®) |
|
|
|
|
Hydrocortisone |
|
|
|
|
|
|
|
|
Medium Potency |
Fluocinolone
Acetonide |
Clocortolone
Pivalate (Cloderm®) |
|
|
|
Fluticasone
Propionate |
Flurandrenolide
Tape (Cordran Tape®) |
|
|
|
Fluticasone
Propionate Lotion (Cutivate Lotion) |
Hydrocortisone
Butyrate (Locoid Lipocream®) |
|
|
|
Betamethasone
Valerate (Luxiq®) |
|
|
|
|
Hydrocortisone
Butyrate |
|
|
|
|
Hydrocortisone
Valerate |
|
|
|
|
Mometasone
Furoate |
|
|
|
|
Prednicarbate |
|
|
|
|
|
|
|
|
High Potency |
Amcinonide |
Desoximetasone |
|
|
|
Betamethasone
Dipropionate |
Diflorasone
Diacetate |
|
|
|
Betamethasone
Valerate |
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 |
|
Hypoglycemics, Meglitinides |
Nateglinide
(Starlix®) |
Repaglinide/Metformin
(Prandimet®) |
|
|
|
|
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®) |
Human
Insulin & Pens (Novolin®) |
|
|
Insulins & Related Agents |
Insulin
Detemir & Pens (Levemir®) |
Insulin
Aspart & Pens (Novolog®) |
|
|
|
Insulin
Glargine & Pens (Lantus®) |
Insulin
Aspart/Insulin Aspart Protamine & Pens (Novolog Mix 70/30®) |
|
|
|
Insulin
Lispro & Pens (Humalog®) |
Insulin
Glulisine & Pens (Apidra®) |
|
|
|
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 |
|
Antiemetic Agents |
|
|
|
|
|
Dronabinol
(Marinol® - Brand only) |
Aprepitant
(Emend®) |
|
|
|
Ondansetron
/ Ondansetron ODT |
Dolasetron
(Anzemet®) |
|
|
|
|
Dronabinol
(generic only) |
|
|
|
|
Granisetron
|
|
|
|
|
Granisetron
Transdermal (Sancuso®) |
|
|
|
|
Nabilone
(Cesamet®) |
|
|
|
|
|
|
|
|
|
|
|
|
H. Pylori Agents |
Metronidazole+Tetracycline+Bismuth subsalicylate (Helidac®) |
Bismuth Subcitrate Potassium+Metronidazole+Tetracycline (Pylera®) |
|
|
|
|
Lansoprazole+Amoxillin+Clarithromycin (Prevpac®) |
|
|
|
|
|
|
|
GERD AND RELATED DISORDERS |
|
|
|
|
Proton Pump Inhibitors |
Esomeprazole
(Nexium®) |
Dexlansoprazole
(Kapidex®) |
|
|
|
Esomeprazole
Suspension (Nexium®) |
Omeprazole
|
|
|
|
Lansoprazole
Capsule (Prevacid®) |
Omeprazole
Magnesium Suspension (Prilosec Suspension®) |
|
|
|
Lansoprazole
Solutabs (Prevacid®) |
Pantoprazole
|
|
|
|
|
Rabeprazole
(Aciphex®) |
|
|
|
|
|
|
|
|
|
|
|
|
Pancreatic Enzymes |
Dygase |
Pancrecarb MS |
|
|
|
Lapase |
Ultrase |
|
|
|
Pancrelipase |
|
|
|
|
Viokase |
|
|
|
|
|
|
|
|
|
Creon |
|
|
|
|
|
|
|
|
|
|
|
|
|
ULCERATIVE COLITIS |
|
|
|
|
Ulcerative Colitis Agents |
Balsalazide
|
Mesalamine
ER Oral (Pentasa, Apriso®) |
|
|
|
Mesalamine
Enemas |
Mesalamine
MMX (Lialda®) |
|
|
|
Mesalamine
(Asacol®) |
Olsalazine
Oral (Dipentum®) |
|
|
|
Mesalamine
Suppositories (Canasa®) |
|
|
|
|
Sulfasalazine |
|
|
|
|
Sulfite-free
Mesalamine Suspension Enema (SF Rowasa®) |
|
|
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
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 |
Febuxostat
(Uloric®) |
|
|
|
Colchicine |
|
|
|
|
Probenecid |
|
|
|
|
Probenecid/Colchicine |
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|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
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HYPERLIPIDEMIA |
|
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|
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Antihyperlipidemic Agents - Non Statins |
Cholestyramine |
Colesevelam (Welchol®) |
|
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Colestipol |
Ezetimibe (Zetia®) |
|
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Fenofibrate (Tricor®) |
Fenofibrate (Antara®) |
|
|
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Fenofibric Acid (Trilipix®) |
Fenofibrate (Fenoglide®) |
|
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Gemfibrozil |
Fenofibrate (Generics) |
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Niacin ER (Niaspan®) |
Fenofibrate (Lipofen®) |
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Niacin IR (Niacor®) |
Fenofibrate (Triglide®) |
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Omega-3-acid ethyl esters (Lovaza®) |
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Statins & Statin Combination Agents |
Amlodipine/Atorvastatin (Caduet®) |
Ezetimibe/Simvastatin (Vytorin®) |
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Atorvastatin (Lipitor®) |
Niacin ER/Lovastatin (Advicor®) |
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Fluvastatin (Lescol®) |
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Fluvastatin XL (Lescol XL®) |
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Lovastatin |
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Lovastatin ER (Altoprev®) |
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Niacin ER/Simvastatin (Simcor®) |
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Pravastatin |
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Rosuvastatin (Crestor®) |
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Simvastatin |
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HYPERTENSION |
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|
ACE Inhibitors & Related Agents |
Benazepril |
Aliskiren (Tekturna®) |
|
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Benazepril/HCTZ |
Aliskiren/HCTZ (Tekturna HCT®) |
|
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Captopril |
Moexipril |
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Captopril/HCTZ |
Moexipril/HCTZ |
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Enalapril |
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Enalapril/HCTZ |
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Fosinopril |
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Fosinopril/HCTZ |
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Lisinopril |
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Lisinopril/HCTZ |
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Perindopril (Aceon®) |
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Quinapril |
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Quinapril/HCTZ |
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Ramipril (Altace®) |
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Trandolapril |
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Angiotensin Modulators/Calcium Channel Blockers Combination Products |
Amlodipine/Benazepril - Generic only |
Amlodipine/Benazepril (Lotrel®) |
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Amlodipine/Olmesartan (Azor®) |
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Amlodipine/Valsartan (Exforge®) |
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Verapamil SR/Trandolapril (Tarka®) |
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Angiotensin II Receptor Blockers (ARBS) |
Losartan (Cozaar®) |
Candesartan (Atacand®) |
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Losartan/HCTZ (Hyzaar®) |
Candesartan/HCTZ (Atacand HCT®) |
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Irbesartan (Avapro®) |
Eprosartan (Teveten®) |
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Irbesartan/HCTZ (Avalide®) |
Eprosartan/HCTZ (Teveten HCT®) |
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Olmesartan (Benicar®) |
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Olmesartan/HCTZ (Benicar HCT®) |
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Telmisartan (Micardis®) |
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Telmisartan/HCTZ (Micardis HCT®) |
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Valsartan (Diovan®) |
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Valsartan/HCTZ (Diovan HCT®) |
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HYPERTENSION |
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|
Beta Adrenergic Receptor Blocking Agents |
Acebutolol |
Betaxolol |
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Atenolol |
Carvedilol CR (Coreg CR®) |
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Bisoprolol Fumarate |
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Carvedilol |
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Labetalol |
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Metoprolol Succinate ER |
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Metoprolol Tartrate |
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Nadolol |
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Nebivolol (Bystolic®) |
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Penbutolol (Levatol®) |
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Pindolol |
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Propranolol |
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Propranolol ER (Innopran XL®) |
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Propranolol LA |
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Sotalol |
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Sotalol AF |
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Timolol Maleate |
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Calcium Channel Blockers |
Amlodipine |
Diltiazem ER (Cardizem LA®) |
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Diltiazem IR |
Nicardipine SR (Cardene SR®) |
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Diltiazem ER (Generics) |
Nisoldipine - Generics only |
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Diltiazem SR |
Verapamil ER (Covera HS®) |
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Felodipine ER |
Verapamil ER PM |
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Isradipine IR |
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Isradipine SR (Dynacirc CR®) |
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Nicardipine |
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Nifedipine ER |
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Nifedipine IR |
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Nimodipine |
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Nisoldipine (Sular®) |
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Verapamil |
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Verapamil ER (Generics) |
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Verapamil IR |
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Verapamil SR |
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PLATELET AGGREGATION INHIBITORS |
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Platelet Aggregation Inhibitors |
Aspirin/Dipyridamole ER (Aggrenox®) |
Ticlopidine |
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Clopidogrel (Plavix®) |
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Dipyridamole |
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ANTICOAGULANTS, INJECTABLES |
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Anticoagulants, Injectable |
Dalteparin (Fragmin®) |
Tinzaparin (Innohep®) |
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Enoxaparin (Lovenox®) |
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Fondaparinux (Arixtra®) |
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Pulmonary Arterial Hypertension (PAH) |
Ambrisentan (Letaris®) |
Bosentan (Tracleer®) |
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Sildenafil (Revatio®) |
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Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
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HEMATOPOIETIC AGENTS |
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Erythropoietins |
Darbepoetin alfa (Aranesp®) |
Epoetin alfa (Epogen®) |
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Epoetin alfa (Procrit®) |
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Anticoagulants - refer to HEART DISEASE |
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Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
Phosphate Binders |
Calcium
Acetate (PhosLo® - Brand only) |
Calcium
Acetate (Generics) |
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Lanthanum
(Fosrenol®) |
Calcium
Acetate (Eliphos®) |
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Sevelamer
HCL (RenaGel®) |
Sevelamer
Carbonate (Renvela®) |
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Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
|
Androgenic Agents |
Testosterone
Transdermal Patch (Androderm®) |
Testosterone
Gel 1% (Testim®) |
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Testosterone
Gel 1% (Androgel®) |
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Hyperlipidemia - Refer to Heart Disease
Immune Disorders - Refer to Multiple Sclerosis
|
Descriptive Therapeutic Class |
Drugs on PDL |
Drugs Which Require PA |
Effective Date |
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ANTIBIOTICS |
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Cephalosporin and Related Antibiotics |
Amoxicillin/Clavulanate
Tablets |
Cefdinir
|
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Amoxicillin/Clavulanate
Suspension |
Cefpodoxime
|
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Amoxicillin/Clavulanate
Susp (Augmentin®) |
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Amoxicillin/Clavulanate
ER (Augmentin XR®) |
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Cefaclor |
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Cefaclor
ER |
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Cefadroxil
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Cefditoren
Pivoxil (Spectracef®) |
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Cefixime
(Suprax®) |
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Cefprozil |
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Ceftibuten
(Cedax®) |
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Cefuroxime
Axetil |
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Cephalexin |
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Fluoroquinolones |
Oral |
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Ciprofloxacin Tablets |
Ciprofloxacin Suspension (Cipro Suspension ®) |
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Moxifloxacin (Avelox®) |
Ciprofloxacin ER |
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Ciprofloxacin ER (Proquin XR®) |
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Gemifloxacin Mesylate (Factive®) |
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Levofloxacin (Levaquin®) |
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Norfloxacin (Noroxin®) |
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Ofloxacin |
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Antibiotics, Gastrointestinal |
Metronidazole |
Metronidazole ER (Flagyl ER®) |
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|
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Neomycin |
Rifaximin (Xifaxan®) |
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Nitazoxanide (Alinia®) |
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Tinidazole (Tindamax®) |
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Vancomycin (Vancocin®) |
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Macrolides - Ketolides |
Azithromycin |
Azithromycin ER (Zmax®) |
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Erythromycin Base |
Clarithromycin |
|
|
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Erythromycin Estolate |
Clarithromycin ER |
|
|
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Erythromycin Ethylsuccinate |
Telithromycin (Ketek®) |
|
|
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Erythromycin Stearate |
|
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Tetracyclines |
Doxycycline |
Demeclocycline |
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|
|
Minocycline |
Doxycycline
DR (Oracea®) |
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|
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Tetracycline |
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Vaginal |
Clindamycin Vaginal Cream |
None |
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Clindamycin Vaginal Cream (Clindesse®) |
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Clindamycin Vaginal Ovules (Cleocin®) |
|
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Metronidazole Vaginal Gel |
|
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Metronidazole Vaginal
Gel (Vandazole®) |
|
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|
ANTIFUNGALS |
|
|
|
|
Antifungals, Oral |
Fluconazole |
Clotrimazole
Troches |
|
|
|
Griseofulvin
(Gris-Peg®) |
Flucytosine
(Ancobon®) |
|
|
|
Griseofulvin
Suspension |
Griseofulvin
Tablets (Grifulvin V®) |
|
|
|
Ketoconazole |
Itraconazole |
|
|
|
Nystatin |
Posaconazole
(Noxafil®) |
|
|
|
Terbinafine
(no granules) |
Terbinafine
Granules (Lamisil Granules®) |
|
|
|
|
Voriconazole
(VFEND®) |
|
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|
HEPATITIS AGENTS |
|
|
|
|
Hepatitis C Agents |
Ribavirin |
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 |
|
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 |
|
Allergic Conjunctivitis |
Loteprednol
(Alrex®) |
Azelastine
Hydrochloride (Optivar®) |
|
|
|
Olopatadine
HCI (Pataday®) |
Cromolyn
Sodium |
|
|
|
Olopatadine
HCI (Patanol®) |
Emedastine
Difumarate (Emadine®) |
|
|
|
|
Epinastine
HCI (Elestat®) |
|
|
|
|
Ketorolac
Tromethamine (Acular®) |
|
|
|
|
Ketotifen
Fumarate (RX only) |
|
|
|
|
Lodoxamide
Tromethamine (Alomide®) |
|
|
|
|
Nedocromil
Sodium (Alocril®) |
|
|
|
|
Pemirolast
Potassium (Alamast®) |
|
|
|
|
|
|
|
Glaucoma Agents |
|
|
|
|
Intraocular Pressure (IOP) Reducers |
Betaxolol |
Bimatoprost
(Lumigan®) |
|
|
|
Betaxolol
(Betoptic S®) |
Dorzolamide
(generic only) |
|
|
|
Brimonidine
Tartrate (Alphagan P®) |
Dorzolamide/Timolol
(generic only) |
|
|
|
Brimonidine
Tartrate |
|
|
|
|
Brimonidine/Timolol
(Combigan®) |
|
|
|
|
Brinzolamide
(Azopt®) |
|
|
|
|
Carteolol |
|
|
|
|
Dipivefrin
(Propine®) |
|
|
|
|
Dorzolamide
(Trusopt® - Brand only) |
|
|
|
|
Dorzolamide/Timolol
(Cosopt® - Brand only) |
|
|
|
|
Latanoprost
(Xalatan®) |
|
|
|
|
Levobunolol |
|
|
|
|
Metipranolol |
|
|
|
|
Pilocarpine |
|
|
|
|
Timolol
(Betimol®) |
|
|
|
|
Timolol
Maleate |
|
|
|
|
Timolol
LA (Istalol®) |
|
|
|
|
Travoprost
(Travatan, Travantan Z®) |
|
|
|
|
|
|
|
|
|
|
|
|
|
Ophthalmics, Antibiotic |
Bacitracin/Polmyxin |
Azithromycin
1% (AzaSite®) |
|
|
|
Erythromycin |
Ciprofloxacin
Ointment (Ciloxan®) |
|
|
|
Gentamicin |
Ciprofloxacin
Solution |
|
|
|
Moxifloxacin
(Vigamox®) |
Gatifloxacin
(Zymar®) |
|
|
|
Neomycin-Polmyxin-Gramicidin |
Levofloxacin
(Iquix®) |
|
|
|
Tobramycin
(Tobrex®) |
Levofloxacin
(Quixin®) |
|
|
|
Triple
Antibiotic |
Natamycin
(Natacyn®) |
|
|
|
|
Ofloxacin Solution |
|
|
|
|
|
|
|
Ophthalmics, Anti-Inflammatories |
Dexamethasone
(Maxidex®) |
Bromfenac
(Xibrom®) |
|
|
|
Dexamethasone
Sodium Phosphate |
Diflurprednate
(Durezol®) |
|
|
|
Diclofenac |
Fluocinolone
(Retisert®) |
|
|
|
Fluorometholone |
Ketorolac
(Acular LS®) |
|
|
|
Fluorometholone
(Flarex®) |
Ketorolac
PF (Acular PF®) |
|
|
|
Fluorometholone
(FML Forte®) |
Nepafenac
(Nevanac®) |
|
|
|
Fluorometholone
(FML S.O.P.®) |
Rimexolone
(Vexol®) |
|
|
|
Flurbiprofen |
Triamcinolone
Acetonide (Triesence®) |
|
|
|