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.


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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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 Molina Medicaid Solutions Provider Relations Unit at 225-924-5040 or 800-473-2783.