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.


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®)