Preferred Drug List/Prior Authorization List

Updated 04/10 - The updated list is from the February 10, 2010 P&T Committee Meeting.
The effective date is April 1, 2010.

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

ADD/ADHD

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
Stimulants and Related Agents	Amphetamine Mixed Salt	Amphetamine Mixed Salt ER (generic only)
	Amphetamine Mixed Salt ER (Adderall XR® - Brand only)	Armodafinil (Nuvigil®)
	Dexmethylphenidate	Atomoxetine (Strattera®)
	Dexmethylphenidate (Focalin ®)	Dextroamphetamine (Procentra®)
	Dexmethylphenidate ER (Focalin XR®)	Modafinil (Provigil®)
	Dextroamphetamine	Methamphetamine (Desoxyn®)
	Guanfacine ER (Intuniv®)	Methylphenidate LA (Ritalin LA®)
	Lisdexamfetamine (Vyvanse®)
	Methylphenidate
	Methylphenidate ER
	Methylphenidate ER (Concerta®, Metadate CD®)
	Methylphenidate Transdermal (Daytrana Transdermal®)

Allergy

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
Antihistamines - Minimally Sedating	Cetirizine (Generic)	Acrivastin/Pseudoephedrine (Semprex-D®)
	Cetirizine Chewable (Generic)	Desloratadine (Clarinex®)
	Cetirizine - D (Generic)	Desloratadine Syrup (Clarinex®)
	Cetirizine Syrup OTC	Desloratadine/Pseudoephedrine (Clarinex-D®)
	Cetirizine Syrup Rx	Fexofenadine
	Loratadine (Generic)	Fexofenadine-D 12-hour (Generic)
	Loratadine - D (Generic)	Fexofenadine ODT (Allegra ODT®)
	Loratadine Syrup (Generic)	Fexofenadine/Pseudoephedrine (Allegra-D 12-hour®)
		Fexofenadine/Pseudoephedrine (Allegra-D 24-hour®)
		Fexofenadine Syrup (Allegra Syrup®)
		Levocetirizine (Xyzal®)
		Levocetirizine Syrup (Xyzal®)
		Loratadine Chewable OTC - (Claritin®)
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®)

Alzheimer's

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
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®)

Antipsychotic Agents

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
	ORAL
Antipsychotic Agents	Amitriptyline/Perphenazine	Aripiprazole (Abilify®)
	Chlorpromazine	Asenapine sublingual (Saphris)
	Clozapine (Fazaclo®)	Clozapine
	Fluphenazine	Olanzapine/Fluoxetine (Symbyax®)
	Haloperidol	Olanzapine (Zyprexa®)
	Molindone (Moban®)	Paliperidone ER (Invega®)
	Perphenazine
	Quetiapine (Seroquel®)
	Quetiapine ER (Seroquel XR®)
	Risperidone
	Thioridazine
	Thiothixene
	Trifluoperazine
	Ziprasidone (Geodon®)
	INJECTIONS
	Fluphenazine Decanoate	Olanzapine (Zyprexa®)
	Haloperidol Decanoate	Paliperidone Palmitate (Invega Sustenna®)
	Ziprasidone (Geodon®)	Risperidone (Risperdal Consta®)

Asthma/COPD

Descriptive Therapeutic Class	Drugs on PDL		Drugs Which Require PA	Effective Date April 1, 2010
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®)

Depression

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
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

Dermatology

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
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	Benzyl Alcohol (Ulesfia®)	Lindane
	Crotamiton (Eurax®)	Malathion (generic only)
	Malathion (Ovide® - Brand 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	Mupirocin Cream (Bactroban®)
		Retapamulin (Altabax®)
STEROIDS, TOPICAL
Low Potency	Alclometasone Dipropionate	Desonide (Verdeso®)
	Desonide	Desonide (Desonate®)
	Fluocinolone Acetonide (Derma-Smoothe-FS)	Hydrocortisone 2% Lotion (Pediaderm HC®)
	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®)	Mometasone Furoate 0.1% Cream (Momexin®)
	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®)

Diabetes

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
Hypoglycemics, Meglitinides	Repaglinide (Prandin®)	Nateglinide
		Nateglinide (Starlix®)
		Repaglinide/Metformin (Prandimet®)
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®)
	Saxagliptin (Onglyza®)
	Sitagliptin (Januvia®)
	Sitagliptin/Metformin (Janumet®)

Digestive Disorders

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
Antiemetic Agents
	Dronabinol (Marinol® - Brand only)	Aprepitant (Emend®)
	Ondansetron / Ondansetron ODT	Dolasetron (Anzemet®)
		Dronabinol (generic only)
		Granisetron
		Granisetron Transdermal (Sancuso®)
		Nabilone (Cesamet®)
GERD AND RELATED DISORDERS
Proton Pump Inhibitors	Esomeprazole (Nexium®)	Dexlansoprazole (Dexilant®)
	Omeprazole (Legend only)	Esomeprazole Suspension (Nexium®)
		Lansoprazole - Generic
		Lansoprazole Capsule (Prevacid®)
		Lansoprazole Solutabs (Prevacid®)
		Omeprazole Suspension (Prilosec®)
		Pantoprazole
		Pantoprazole Suspension (Protonix®)
		Rabeprazole (Aciphex®)
Pancreatic Enzymes	Dygase	Pancrecarb MS
	Lapase	Ultrase
	Pancrelipase
	Viokase
	Pancrease MT
	Creon
	Pancrelipase (Zenpep®)
ULCERATIVE COLITIS
Ulcerative Colitis Agents	Balsalazide	Mesalamine ER Oral (Apriso®)
	Mesalamine Enemas	Sulfite-free Mesalamine Suspension Enema (SF Rowasa®)
	Mesalamine (Asacol®)	Mesalamine MMX (Lialda®)
	Mesalamine Suppositories (Canasa®)	Mesalamine Oral (Pentasa®)
	Sulfasalazine	Olsalazine Oral (Dipentum®)

Growth Deficiency

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
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	Colchicine (Colcrys®)
	Probenecid
	Probenecid/Colchicine

Heart Disease

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
HYPERLIPIDEMIA
Lipotropics, Other	Cholestyramine	Colesevelam (Welchol®)
	Colestipol	Ezetimibe (Zetia®)
	Fenofibrate (Antara®)	Fenofibrate (Fenoglide®)
	Fenofibrate (Tricor®)	Fenofibrate (Generics)
	Fenofibric Acid (Trilipix®)	Fenofibrate (Lipofen®)
	Gemfibrozil	Fenofibrate (Triglide®)
	Niacin ER (Niaspan®)	Fenofibric Acid (Generic)
	Niacin IR (Niacor®)	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®)
	Pravastatin
	Rosuvastatin (Crestor®)
	Simvastatin
HYPERTENSION
ACE Inhibitors & Direct Renin Inhibitors	Benazepril	Aliskiren (Tekturna®)
	Benazepril/HCTZ	Aliskiren/HCTZ (Tekturna HCT®)
	Captopril	Candesartan (Atacand®)
	Captopril/HCTZ	Candesartan/HCTZ (Atacand HCT®)
	Enalapril	Eprosartan (Teveten®)
	Enalapril/HCTZ	Eprosartan/HCTZ (Teveten HCT®)
	Fosinopril	Irbesartan (Avapro®)
	Fosinopril/HCTZ	Irbesartan/HCTZ (Avalide®)
	Lisinopril	Moexipril
	Lisinopril/HCTZ	Moexipril/HCTZ
	Losartan (Cozaar®)	Olmesartan (Benicar®)
	Losartan/HCTZ (Hyzaar®)	Olmesartan/HCTZ (Benicar HCT®)
	Quinapril	Perindopril (Aceon®)
	Quinapril/HCTZ	Perindopril (Generic)
	Ramipril (Altace®)
	Telmisartan (Micardis®)
	Telmisartan/HCTZ (Micardis HCT®)
	Trandolapril
	Valsartan (Diovan®)
	Valsartan/HCTZ (Diovan HCT®)
Angiotensin Modulators/Calcium Channel Blockers Combination Products	Amlodipine/Benazepril - Generic only	Amlodipine/Telmisartan (Twnysta®)
	Amlodipine/Benazepril (Lotrel®)
	Amlodipine/Olmesartan (Azor®)
	Amlodipine/Valsartan (Exforge®)
	Amlodipine/Valsartan/HCTZ (Exforge HCT®)
	Valsartan/Aliskiren (Valturna®)
	Verapamil SR/Trandolapril (Tarka®)
Beta Adrenergic Receptor	Acebutolol	Betaxolol
Blocking Agents	Atenolol	Carvedilol CR (Coreg CR®)
	Atenolol/Chlorthalidone
	Bisoprolol
	Bisoprolol/HCTZ
	Carvedilol
	Labetalol
	Metoprolol
	Metoprolol /HCTZ
	Metoprolol Succinate ER
	Metoprolol Succinate ER (Toprol XL®)
	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 ER (Cardizem LA®)
	Diltiazem IR	Isradipine SR (Dynacirc CR®)
	Diltiazem ER (Generics)	Nicardipine SR (Cardene SR®)
	Diltiazem SR	Nisoldipine (Sular®)
	Felodipine ER	Nisoldipine - Generics only
	Isradipine IR	Verapamil ER (Covera HS®)
	Nicardipine	Verapamil  ER PM
	Nifedipine ER
	Nifedipine IR
	Nimodipine
	Verapamil
	Verapamil ER (Generics)
	Verapamil IR
	Verapamil SR
PLATELET AGGREGATION INHIBITORS
Platelet Aggregation Inhibitors	Aspirin/Dipyridamole ER (Aggrenox®)	Prasugrel (Effient®)
	Clopidogrel (Plavix®)	Ticlopidine
	Dipyridamole
ANTICOAGULANTS, INJECTABLES
Anticoagulants, Injectable	Dalteparin (Fragmin®)	NONE
	Enoxaparin (Lovenox®)
	Fondaparinux (Arixtra®)
Pulmonary Arterial Hypertension (PAH)	Ambrisentan (Letaris®)	Tadalafil (Adcirca®)
	Bosentan (Tracleer®)	Treprostinil (Tyvaso®)
	Iloprost (Ventavis®)
	Sildenafil (Revatio®)

Hematologic Agents

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
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 April 1, 2010
Phosphate Binders	Calcium Acetate (PhosLo® - Brand only)	Calcium Acetate (Generics)
	Lanthanum (Fosrenol®)	Calcium Acetate (Eliphos®)
	Sevelamer HCL (RenaGel®)	Sevelamer Carbonate (Renvela®)

Hormone Therapy

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
Androgenic Agents	Testosterone Transdermal Patch (Androderm®)	Testosterone Gel 1% (Testim®)
	Testosterone Gel 1% (Androgel®)

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 April 1, 2010
ANTIBIOTICS
Cephalosporin and Related Antibiotics	Amoxicillin/Clavulanate Tablets	Cefdinir
	Amoxicillin/Clavulanate Suspension	Cefpodoxime
	Amoxicillin/Clavulanate Susp (Augmentin®)
	Amoxicillin/Clavulanate ER (Augmentin XR®)
	Cefaclor
	Cefaclor ER
	Cefadroxil
	Cefditoren Pivoxil (Spectracef®)
	Cefixime (Suprax®)
	Cefprozil
	Ceftibuten (Cedax®)
	Cefuroxime Axetil
	Cephalexin
Fluoroquinolones	Oral
	Ciprofloxacin Tablets	Ciprofloxacin Suspension (Cipro Suspension ®)
	Moxifloxacin (Avelox®)	Ciprofloxacin ER
		Ciprofloxacin ER (Proquin XR®)
		Gemifloxacin Mesylate (Factive®)
		Levofloxacin (Levaquin®)
		Norfloxacin (Noroxin®)
		Ofloxacin
Antibiotics, Gastrointestinal	Metronidazole	Metronidazole ER (Flagyl ER®)
	Neomycin	Rifaximin (Xifaxan®)
	Nitazoxanide (Alinia®)
	Tinidazole (Tindamax®)
	Vancomycin (Vancocin®)
Macrolides - Ketolides	Azithromycin	Azithromycin ER (Zmax®)
	Erythromycin Base	Clarithromycin
	Erythromycin Estolate	Clarithromycin ER
	Erythromycin Ethylsuccinate	Telithromycin (Ketek®)
	Erythromycin Stearate
Tetracyclines	Doxycycline	Demeclocycline
	Minocycline	Doxycycline Monohyrate (Nutridox®)
	Tetracycline	Doxycycline DR (Oracea®)
		Minocycline ER (Solodyn®)
Vaginal	Clindamycin Vaginal Cream	None
	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	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®)
		Terbinafine Hydrochloride/Hydroxpyropyl Chitosan (Terbinex Eco-Formula®)
		Voriconazole (VFEND®)
HEPATITIS AGENTS
Hepatitis C Agents	Ribavirin	Consensus Interferon (Infergen®)
	Peginterferon alfa 2A (Pegasys®)	Peginterferon alfa 2B (Peg-Intron®)
		Peginterferon alfa 2B (Peg-Intron Redipen®)

Multiple Sclerosis

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
Multiple Sclerosis Agents (Immunomodulatory Agents)	Glatiramer (Copaxone®)	Interferon beta - 1b (Extavia®)
	Interferon beta - 1a (Avonex®)
	Interferon beta - 1b (Betaseron®)
	Interferon beta - 1a (Rebif®)

Ophthalmic Disorders

Descriptive Therapeutic Class	Drugs on PDL	Drugs Which Require PA	Effective Date April 1, 2010
Allergic Conjunctivitis	Loteprednol (Alrex®)	Azelastine Hydrochloride (Optivar®)
	Olopatadine HCI (Pataday®)	Bepotastine Besilate (Bepreve®)
	Olopatadine HCI (Patanol®)	Cromolyn Sodium
		Emedastine Difumarate (Emadine®)
		Epinastine HCI (Elestat®)
		Ketorolac Tromethamine (Acular®)
		Ketotifen Fumarate
		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®)