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 |