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      

ADD/ADHD

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®)       

Allergy

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®)      

Alzheimer's

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®)    

Antipsychotic Agents

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®)      

Asthma/COPD

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®)    

Depression

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®)      

Dermatology

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®)     

Diabetes

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     

Digestive Disorders

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         

Growth Deficiency

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®)      

Heart Disease

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®)      

Hematologic Agents

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      

Hemodialysis

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®)       

Hormone Therapy

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

Infectious Disorders

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®)    

Multiple Sclerosis

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®)      

Ophthalmic Disorders

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    

Otic Agents

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®)    

Osteoporosis

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®)    

Pain Management

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