Preferred Drug List/Prior Authorization List
Updated 03/07 - The updated list is from the February 7, 2007 P&T Committee Meeting.
The effective date is April 1, 2007.
| 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 |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Stimulants and Related Agents | Amphetamine Mixed Salt | Atomoxetine (Strattera®) | |
| Amphetamine Mixed Salt ER (Adderall XR) | Modafinil (Provigil®) | ||
| Dexmethylphenidate (Focalin®) | Pemoline | ||
| Dexmethylphenidate (Focalin XR®) | Methamphetamine (Desoxyn®) | ||
| Dextroamphetamine | Methylphenidate LA (Ritalin LA®) | ||
| Methylphenidate | |||
| Methylphenidate ER | |||
| Methylphenidate ER ( Concerta®; Metadate CD®) | |||
| Methylphenidate Transdermal (Daytrana Transdermal®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Antihistamines - Minimally Sedating | Acrivastin/Pseudoephedrine (Semprex-D®) | Cetirizine (Zyrtec®) | |
| Desloratadine Syrup (Clarinex Syrup®) | Cetirizine/Pseudoephedrine (Zyrtec-D®) | ||
| Loratadine OTC | Desloratadine (Clarinex®) | ||
| Loratadine-D OTC | Desloratadine/Pseudoephedrine (Clarinex-D®) | ||
| Fexofenadine | |||
| Fexofenadine/Pseudoephedrine (Allegra-D®) | |||
| Rhinitis Agents, Nasal | Azelastine (Astelin®) | Beclomethasone AQ (Beconase AQ®) | |
| Flunisolide Spray | Budesonide Aqua (Rhinocort Aqua®) | ||
| Fluticasone (Flonase®) Brand Only | Flunisolide Aqueous (Nasarel®) | ||
| Ipratropium (Atrovent®) | Fluticasone (generic) | ||
| Mometasone (Nasonex®) | |||
| Triamcinolone AQ (Nasacort AQ®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Alzheimer's Agents | Donepezil (Aricept, Aricept ODT®) | Galantamine (Razadyne®) | |
| Cholinesterase Inhibitors | Memantine HCI (Namenda®) | Galantamine (Razadyne ER®) | |
| Rivastigmine (Exelon®) | Tacrine (Cognex®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Antipsychotic, Atypical | Clozapine | Aripiprazole (Abilify®) | |
| Clozapine (Fazaclo®) | Olanzapine/Fluoxetine (Symbyax®) | ||
| Risperidone (Risperdal®) | Olanzapine (Zyprexa®) | ||
| Quetiapine Fumarate (Seroquel®) | |||
| Ziprasidone (Geodon®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Bronchodilator, Beta-Adrenergic Agents | |||
|
INHALATION |
|||
| Albuterol Sulfate (Nebulizer and Inhaler) | Albuterol Sulfate Nebulizer Solution (Accuneb®) | ||
| Albuterol Sulfate HFA | Albuterol Sulfate HFA MDI (Ventolin HFA®) | ||
| Albuterol Sulfate HFA MDI(Proventil HFA®) | Formoterol DPI (Foradil®) | ||
| Levalbuterol HCL (Xopenex HFA®) | Metaproterenol Inhalation | ||
| Levalbuterol HCL (Xopenex Nebulizer) | |||
| Pirbuterol (Maxair Autohaler®) | Metaproterenol Sulfate (Alupent Inhalant®) | ||
| Salmeterol Xinafoate (Serevent Diskus®) | |||
|
ORAL |
|||
| Albuterol Sulfate | Albuterol Sulfate ER (Vospire ER®) | ||
| Metaproterenol Sulfate | |||
| Terbutaline Sulfate | |||
| Bronchodilator, Anticholinergics |
INHALATION |
||
| Albuterol Sulfate/Ipratropium MDI (Combivent®) | Albuterol Sulfate/Ipratropium (DuoNeb®) | ||
| Ipratropium Nebulizer | |||
| Ipratropium MDI (Atrovent HFA®) | |||
| Tiotropium (Spiriva®) | |||
| Corticosteroids, Inhalation | Beclomethasone MDI (QVAR®) | ||
| Budesonide Respules (Pulmicort - Respules®) - 8 years old and under | Budesonide Respules (Pulmicort - Respules®) - 9 years old and over | ||
| Flunisolide MDI (Aerobid®) | Budesonide DPI (Pulmicort Turbuhaler®) | ||
| Flunisolide MDI (Aerobid M®) | |||
| Fluticasone MDI (Flovent HFA®) | |||
| Fluticasone/Salmeterol DPI (Advair Diskus®) | |||
| Mometasone DPI (Asmanex®) | |||
| Triamcinolone MDI (Azmacort®) | |||
| Leukotriene Modifiers | Montelukast (Singulair®) | Zileuton (Zyflo®) | |
| Zafirlukast (Accolate®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Antidepressants, Other | Bupropion IR | Bupropion ER (Wellbutrin XL®) | |
| Bupropion SR | Duloxetine (Cymbalta®) | ||
| Mirtazapine | Nefazodone | ||
| Mirtazepine Soltab | Selegiline Transdermal (Emsam®) | ||
| Trazodone | |||
| Venlafaxine | |||
| Venlafaxine ER (Effexor XR®) | |||
| Selective Serotonin Reuptake Inhibitors (SSRIs) | Citalopram | Fluoxetine ER (Prozac Weekly®) | |
| Escitalopram (Lexapro®) | Sertraline (generic) | ||
| Fluoxetine | |||
| Fluoxetine (Sarafem®) | |||
| Fluvoxamine | |||
| Paroxetine HCl | |||
| Paroxetine HCl CR (Paxil CR®) | |||
| Paroxetine Mesylate (Pexeva®) | |||
| Sertraline (Zoloft - brand only®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Antifungals - Topical | Butenafine (Mentax®) | Ciclopirox (Penlac®) | |
| Ciclopirox gel (Loprox®) | Ciclopirox shampoo (Loprox®) | ||
| Ciclopirox cream/lotion | Ketoconazole gel (Xolagel®) | ||
| Clotrimazole | Miconazole/zinc oxide/white petrolatum (Vusion®) | ||
| Clotrimazole/Betamethasone | Oxiconazole (Oxistat®) | ||
| Econazole | Sertaconazole Nitrate (Ertaczo®) | ||
| Ketoconazole (Cream) | |||
| Ketoconazole (Shampoo) (Rx Only) | |||
| Naftifine (Naftin®) | |||
| Nystatin | |||
| Nystatin w/ Triamcinolone | |||
| Sulconazole (Exelderm®) | |||
| Atopic Dermatitis - Immunomodulators | Pimecrolimus (Elidel®) | NONE | |
| Tacrolimus (Protopic®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Hypoglycemics, Meglitinides | Nateglinide (Starlix®) | Repaglinide (Prandin®) | |
| Hypoglycemics, Thiazolidinediones (TZDs) & TZD Combination Agents | Pioglitazone (Actos®) | NONE | |
| Pioglitazone/Glimeperide (Duetact®) | |||
| Pioglitazone/Metformin (Actoplus Met®) | |||
| Rosiglitazone (Avandia®) | |||
| Rosiglitazone/Glimepiride (Avandaryl®) | |||
| Rosiglitazone/Metformin (Avandamet®) | |||
| Insulins & Related Agents | Humalog | Insulin Glulisine (Apidra®) | |
| Humalog Mix | Insulin Inhalation Powder (Exubera Inhalation®) | ||
| Humulin | Novolin | ||
| Insulin Detemir (Levemir®) | Novolog | ||
| Insulin Glargine (Lantus®) | Novolog Mix 70/30 | ||
| Incretin Mimetics | Exenatide (Byetta®) | NONE | |
| Amylin Analogs | Pramlintide (Symlin®) | NONE |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Antiemetic Agents |
Oral |
|
|
| Aprepitant (Emend®) | Dolasetron (Anzemet®) | ||
| Ondansetron (Zofran®, Zofran ODT®) | Granisetron (Kytril®) | ||
| GERD AND RELATED DISORDERS | |||
| Proton Pump Inhibitors | Esomeprazole (Nexium®) | Omeprazole (generic legend only) | |
| Lansoprazole Capsule (Prevacid®) | Omeprazole (Zegerid ®) | ||
| Lansoprazole Suspension (Prevacid®) | Pantoprazole (Protonix®) | ||
| Lansoprazole Solutab (Prevacid®) | Rabeprazole (Aciphex®) | ||
| ULCERATIVE COLITIS | |||
| Ulcerative Colitis Agents | Balsalazide (Colazal®) | Mesalamine (Pentasa®) | |
| Mesalamine Enemas | Olsalazine (Dipentum®) | ||
| Mesalamine (Asacol®) | |||
| Mesalamine Suppositories (Canasa®) | |||
| Sulfasalazine |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Growth Deficiency | |||
| Growth Hormones | Somatropin (Genotropin®) | Somatropin (Humatrope®) | |
| Somatropin (Nutropin AQ®) | Somatropin (Norditropin®) | ||
| Somatropin (Tev-Tropin®) | Somatropin (Nutropin®) | ||
| Somatropin (Saizen®) | Somatropin (Zorbtive®) | ||
| Somatropin (Serostim®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| HYPERLIPIDEMIA | |||
| Antihyperlipidemic Agents - Non Statins | Cholestyramine | Colesevelam (Welchol®) | |
| Colestipol (Colestid®) | Ezetimibe (Zetia®) | ||
| Fenofibrate (Tricor®) | Fenofibrate generic | ||
| Gemfibrozil | Fenofibrate (Antara®) | ||
| Niacin ER (Niaspan®) | Fenofibrate (Triglide®) | ||
| Omega-3-acid ethyl esters (Omacor®) | |||
| Statins & Statin Combination Agents | Atorvastatin (Lipitor®) | Atorvastatin (Caduet®) | |
| Ezetimibe/Simvastatin (Vytorin®) | Pravastatin | ||
| Fluvastatin (Lescol®) | |||
| Fluvastatin XL (Lescol XL®) | |||
| Lovastatin | |||
| Lovastatin ER (Altoprev®) | |||
| Niacin ER/Lovastatin (Advicor®) | |||
| Rosuvastatin (Crestor®) | |||
| Simvastatin | |||
| HYPERTENSION | |||
| ACE Inhibitors | Benazepril | Moexipril (Univasc®) | |
| Benazepril/HCTZ | Moexipril/HCTZ (Uniretic®) | ||
| Captopril | |||
| Captopril/HCTZ | |||
| Enalapril | |||
| Enalapril/HCTZ | |||
| Fosinopril | |||
| Fosinopril/HCTZ | |||
| Lisinopril | |||
| Lisinopril/HCTZ | |||
| Perindopril (Aceon®) | |||
| Quinapril | |||
| Quinapril/HCTZ | |||
| Ramipril (Altace®) | |||
| Trandolapril (Mavik®) | |||
| HYPERTENSION | |||
| ACE Inhibitors/Calcium Channel Blockers Combination Products | Amlodipine/Benazepril (Lotrel®) | Felodipine/Enalapril (Lexxel®) | |
| Verapamil SR/Trandolapril (Tarka®) | |||
| Angiotensin II Receptor Blockers (ARBS) | Iosartan (Cozaar®) | Candesartan (Atacand®) | |
| Iosartan/HCTZ (Hyzaar®) | Candesartan/HCTZ (Atacand HCT®) | ||
| Irbesartan (Avapro®) | Eprosartan (Teveten®) | ||
| Irbesartan/HCTZ (Avalide®) | Eprosartan/HCTZ (Teveten HCT®) | ||
| Olmesartan (Benicar®) | |||
| Olmesartan/HCTZ (Benicar HCT®) | |||
| Telmisartan (Micardis®) | |||
| Telmisartan/HCTZ (Micardis HCT®) | |||
| Valsartan (Diovan®) | |||
| Valsartan/HCTZ (Diovan HCT®) | |||
| HYPERTENSION | |||
| Beta Adrenergic Receptor Blocking Agents | Acebutolol | Penbutolol (Levatol®) | |
| Atenolol | Propranolol XL (Innopran XL®) | ||
| Betaxolol | |||
| Bisoprolol Fumarate | |||
| Carvedilol (Coreg®) | |||
| Labetalol | |||
| Metoprolol Tartrate | |||
| Metoprolol XL (Toprol XL®) | |||
| Nadolol | |||
| Pindolol | |||
| Propranolol | |||
| Propranolol LA (Inderal LA®) | |||
| Sotalol | |||
| Sotalol AF | |||
| Timolol Maleate | |||
| Calcium Channel Blockers | Amlodipine (Norvasc®) | Nicardipine SR (Cardene SR®) | |
| Diltiazem IR | Nimodipine (Nimotop®) | ||
| Diltiazem ER (Generics) | Verapamil ER (Covera HS®) | ||
| Diltiazem ER (Cardizem LA®) | |||
| Diltiazem SR | |||
| Felodipine ER | |||
| Isradipine IR | |||
| Isradipine SR (Dynacirc CR®) | |||
| Nicardipine | |||
| Nifedipine ER | |||
| Nifedipine IR | |||
| Nisoldipine (Sular®) | |||
| Verapamil IR | |||
| Verapamil (Generics) | |||
| Verapamil ER (Verelan PM®) | |||
| Verapamil SR | |||
| PLATELET AGGREGATION INHIBITORS | |||
| Platelet Aggregation Inhibitors | Aspirin/Dipyridamole ER (Aggrenox®) | Ticlopidine | |
| Clopidogrel (Plavix®) | |||
| Dipyridamole | |||
| ANTICOAGULANTS, INJECTABLES | |||
| Anticoagulants, Injectable | Dalteparin (Fragmin®) | Tinzaparin (Innohep®) | |
| Enoxaparin (Lovenox®) | |||
| Fondaparinux (Arixtra®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| HEMATOPOIETIC AGENTS | |||
| Erythropoietins | Darbepoetin alfa (Aranesp®) | Epoetin alfa (Epogen®) | |
| Epoetin alfa (Procrit®) | |||
| Anticoaqulants - refer to HEART DISEASE |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Phosphate Binders | Calcium Acetate (PhosLo®) | NONE | |
| Lanthanum (Fosrenol®) | |||
| Sevelamer (RenaGel®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Androgenic Agents | Testosterone Gel 1% (Androgel®) | None | |
| Testosterone Gel 1% (Testim®) | |||
| Testosterone Transdermal Patch (Androderm®) |
Hyperlipidemia - Refer to Heart Disease
Immune Disorders - Refer to Multiple Sclerosis
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| ANTIBIOTICS | |||
| Cephalosporin and Related Antibiotics | Amoxicillin/Clavulanate | Cefaclor (Raniclor®) | |
| Amoxicillin/Clavulanate XR (Augmentin XR®) | Cefdinir (Omnicef®) | ||
| Cefaclor | Cefditoren Pivoxil (Spectracef®) | ||
| Cefaclor ER | Cephalexin (Panixine®) | ||
| Cefadroxil | Loracarbef (Lorabid®) | ||
| Cefixime (Suprax®) | |||
| Cefpodoxime Proxetil | |||
| Cefprozil | |||
| Ceftibuten (Cedax®) | |||
| Cefuroxime axetil | |||
| Cephalexin | |||
| Fluoroquinolones, |
Oral |
Oral |
|
| Ciprofloxacin | Ciprofloxacin Suspension (Cipro Suspension ®) |
||
| Moxifloxacin (Avelox®) | Ciprofloxacin ER (Cipro XR®) | ||
| Ofloxacin | Ciprofloxacin ER (Proquin XR®) | ||
| Gemifloxacin Mesylate (Factive®) | |||
| Levofloxacin (Levaquin®) | |||
| Hepatitis C Agents | Ribavirin (Generics only) | Consensus Interferon alfacon-1 (Infergen®) | |
| Peginterferon alfa 2A (Pegasys®) | Ribavirin (Copegus®) | ||
| Peginterferon alfa 2B (Peg-intron®) | Ribavirin (Rebetol®) | ||
| Peginterferon alfa 2B (Peg-intron Redipen®) | |||
| Macrolides | Azithromycin | Telithromycin (Ketek®) | |
| Azithromycin (Zithromax®) | |||
| Azithromycin ER (Zmax®) | |||
| Clarithromycin | |||
| Clarithromycin ER (Biaxin XL®) | |||
| Erythromycin Stearate | |||
| Erythromycin Base | |||
| Erythromycin Estolate | |||
| Erythromycin Ethylsuccinate | |||
| OPHTHALMIC ANTIBIOTICS - Refer to Opthalmic Disorders |
|||
| OTIC ANTIBIOTICS - Refer to Otic Agents |
|||
| ANTIFUNGALS | |||
| Antifungals, Oral | Clotrimazole | Flucytosine (Ancobon®) | |
| Fluconazole | Griseofulvin (Grifulvin V®) (Tablets) | ||
| Griseofulvin Suspension | Itraconazole | ||
| Griseofulvin (Gris-Peg®) | Posaconazole (Noxafil®) | ||
| Ketoconazole | Voriconazole (VFEND) | ||
| Nystatin | |||
| Terbinafine (Lamisil®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Multiple Sclerosis Agents (Immunomodulatory Agents) | Glatiramer (Copaxone®) | None | |
| Interferon beta - 1a (Avonex®) | |||
| Interferon beta - 1a (Betaseron®) | |||
| Interferon beta - 1a (Rebif®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Allergic Conjunctivitis | Cromolyn Sodium | Azelastine Hydrochloride (Optivar®) | |
| Epinastine HCI (Elestat®) | Emedastine Difumarate (Emadine®) | ||
| Ketorolac Tromethamine (Acular®) | Ketotifen Fumarate (Zaditor®) | ||
| Loteprednol (Alrex®) | Lodoxamine Tromethamine (Alomide®) | ||
| Olopatadine Hydrochloride (Patanol®) | Nedocromil Sodium (Alocril®) | ||
| Pemirolast Potassium (Alamast®) | |||
| Glaucoma Agents | |||
| Intraocular Pressure (IOP) Reducers | Betaxolol | Timolol Maleate (Istalol®) | |
| Betaxolol (Betoptic S®) | |||
| Brimonidine Tartrate (Alphagan P®) | |||
| Brimonidine Tartrate | |||
| Brinzolamide (Azopt®) | |||
| Carteolol | |||
| Dipivefrin | |||
| Dorzolamide (Trusopt®) | |||
| Dorzolamide/Timolol (Cosopt®) | |||
| Levobunolol | |||
| Metipranolol | |||
| Pilocarpine | |||
| Timolol (Betimol®) | |||
| Timolol Maleate | |||
| Prostaglandin Inhibitors | Bimatoprost (Lumigan®) | Latanoprost (Xalatan®) | |
| Travoprost (Travatan®) | |||
| Antibiotics, Ophthalmic | Bacitracin | Ciprofloxacin Ointment (Ciloxan®) | |
| Bacitracin/Polymyxin | Levofloxacin (Quixin®) | ||
| Ciprofloxacin Solution | Moxifloxacin (Vigamox®) | ||
| Erythromycin | |||
| Gatifloxacin (Zymar®) | |||
| Gentamicin Sulfate | |||
| Ofloxacin | |||
| Polymyxin/Trimethoprim | |||
| Sulfacetamide | |||
| Triple Antibiotic | |||
| Tobramycin Sulfate |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Fluoroquinolones | Ciprofloxacin/Dexamethasone (Ciprodex OTIC®) | Ciprofloxacin/Hydrocortisone (Cipro HC OTIC®) | |
| Ofloxacin (Floxin OTIC®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Bone Resorption Suppression Agents | Alendronate (Fosamax®) | Calcitonin - Salmon nasal spray (Fortical®) | |
| Aldendronate/Vitamin D3 (Fosamax Plus D®) | Etidronate (Didronel®) | ||
| Calcitonin-salmon (Miacalcin®) | Raloxifene (Evista®) | ||
| Ibandronate Sodium (Boniva®) | Risedronate (Actonel®) | ||
| Riserdronate w/ Calcium (Actonel w/ Calcium®) | |||
| Teriparatide (Forteo®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Narcotics | Acetaminophen w/Codeine | Acetaminophen/Caffeine/ Dihydrocodeine Bitartrate (Panlor DC®) |
|
| Aspirin w/Codeine | Fentanyl Citrate Buccal (Generics & Actiq®) | ||
| Belladonna & Opium | Fentanyl Transdermal (Generic) | ||
| Butalbital Compound w/Codeine | Morphine Sulfate ER (Avinza ®) | ||
| Butalbital/Caff/APAP/Codeine | Opium Tincture | ||
| Butalbital/Caff/ASA/Codeine | Oxycodone ER | ||
| Butorphanol Tartrate | Oxycodone (Oxycontin ®) | ||
| Carisoprodol Compound/Codeine | Oxycodone/Ibuprofen (Combunox®) | ||
| Codeine Phosphate | Oxymorphone (Numorphan®) | ||
| Oxymorphone IR (Opana®) | |||
| Oxymorphone ER (Opana ER®) | |||
| Codeine Sulfate | Propoxyphene Napsylate (Darvon-N®) | ||
| Dihydrocodeine Bitartrate/Acetaminophen/Caffeine (Generics) | Tramadol ER (Ultram ER®) | ||
| Fentanyl Transdermal (Duragesic®) - Brand Only | |||
| Hydrocodone/Acetaminophen | |||
| Hydrocodone Bitartrate/ibuprofen | |||
| Hydromorphone HCL | |||
| Meperidine HCL | |||
| Methadone HCL | |||
| Methadose | |||
| Morphine Sulfate (Rectal) | |||
| Morphine Sulfate ER (Kadian®) | |||
| Morphine Sulfate ER | |||
| Morphine Sulfate IR | |||
| Oxycodone HCL IR | |||
| Oxycodone/Acetaminophen | |||
| Oxycodone w/Aspirin | |||
| Pentazocine/Naloxone HCL | |||
| Pentazocine/Acetaminophen | |||
| Propoxyphene HCL | |||
| Propoxyphene HCL Compound | |||
| Propoxyphene HCL w/APAP | |||
| Propoxyphene Napsylate w/APAP | |||
| Tramadol | |||
| Tramadol/Acetaminophen | |||
| Nonsteroidal Anti - Inflammatories (NSAIDs) | Diclofenac | Celecoxib (Celebrex®) | |
| Etodolac | Diclofenac/Misoprostol (Arthrotec®) | ||
| Fenoprofen | Lansoprazole/Naproxen (Prevacid NapraPAC) | ||
| Flurbiprofen | Meclofenamate Sodium | ||
| Ibuprofen (Rx Only) | Mefenamic Acid (Ponstel®) | ||
| Indomethacin | Meloxicam (Mobic®) | ||
| Ketoprofen | |||
| Ketorolac | |||
| Nabumetone | |||
| Naproxen (Rx Only) | |||
| Naproxen Sodium | |||
| Oxaprozin | |||
| Piroxicam | |||
| Sulindac | |||
| Tolmetin Sodium | |||
| Immunomodulators and Related Agents | Adalimumab (Humira®) | Abatacept (Orencia®) | |
| Anakinra (Kineret®) | Alefacept (Amevive®) | ||
| Efalizumab (Raptiva®) | Infliximab (Remicade®) | ||
| Etanercept (Enbrel®) | |||
| Triptans | Naratriptan (Amerge®) | Almotriptan (Axert®) | |
| Rizatriptan (Maxalt®, Maxalt MLT®) | Eletriptan (Relpax®) | ||
| Sumatriptan (Imitrex® Nasal) | Frovatriptan (Frova®) | ||
| Sumatriptan (Imitrex® Oral) | Zolmitriptan (Zomig, Zomig ZMT®) | ||
| Sumatriptan (Imitrex® Subcutaneous) | Zolmitriptan (Zomig® nasal) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Antiparkinson Agents - Anticholinergic and Other | Benztropine Mesylate | Levodopa/Carbidopa (Parcopa®) | |
| Entacapone (Comtan®) | Rasagiline (Azilect®) | ||
| Levodopa/Carbidopa | Selegine (Zelapar®) | ||
| Levodopa/Carbidopa/Entacapone (Stalevo®) | Tolcapone (Tasmar®) | ||
| Pergolide | |||
| Pramipexole (Mirapex®) | |||
| Procyclidine (Kemadrin®) | |||
| Ropinirole (Requip®) | |||
| Selegiline | |||
| Trihexyphenidyl |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| Sedative/Hypnotics | Chloral Hydrate | Estrazolam | |
| Eszopiclone (Lunesta®) | Flurazepam | ||
| Ramelteon (Rozerem®) | Quazepam (Doral®) | ||
| Temazepam | Zaleplon (Sonata®) | ||
| Temazepam (Restoril 7.5mg ®) | Zolpidem (Ambien®) | ||
| Triazolam | |||
| Zolpidem CR (Ambien CR®) |
| Descriptive Therapeutic Class | Drugs on PDL | Drugs Which Require PA | Effective Date April 1, 2007 |
| INCONTINENCE | |||
| Antiincontinence Agents | Darifenacin (Enablex®) | Oxybutynin ER (Ditropan XL®) | |
| Oxybutynin | Tolterodine (Detrol®) | ||
| Oxybutynin ER - (Generics only) | Tolterodine extended release - (Detrol LA®) | ||
| Oxybutynin transdermal (Oxytrol®) | |||
| Solifenacin (VESIcare®) | |||
| Trospium (Sanctura®) | |||
| PROSTATE | |||
| Drugs for Treatment of Benign Prostatic Hyperplasia (BPH) | Alfuzosin (Uroxatral®) | Doxazosin XL (Cardura XL) | |
| Doxazosin | |||
| Dutasteride (Avodart®) | |||
| Finasteride | |||
| Tamsulosin (Flomax®) | |||
| Terazosin |
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 Provider
Relations Unit at Unisys at 225-924-5040 or 800-473-2783.