Preferred Drug List/Prior Authorization List
(Updated 6/2/05)


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

ADD/ADHD

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Stimulants and Related Agents Amphetamine Mixed Salt  Atomoxetine (Strattera�)   
   Amphetamine Mixed Salt ER (Adderall XR�) Modafinil (Provigil�)   
   Dexmethylphenidate (Focalin�)      
   Dextroamphetamine      
  Methamphetamine HCL    
   Methylphenidate      
   Methylphenidate ER       
   Methylphenidate ER ( Concerta�; Metadate CD�)      
    Methylphenidate LA (Ritalin LA�)       
   Pemoline      

Allergy

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Anticholinergic Agents - Nasal Ipratropium (Atrovent�) NONE   
         
Antihistamines - Minimally Sedating Desloratadine Syrup (Clarinex Syrup�) Cetirizine (Zyrtec�)    
   Loratadine Syrup OTC Cetirizine Chewable (Zyrtec� Chewable)   
   Loratadine OTC Cetirizine Syrup (Zyrtec Syrup�)    
   Loratadine-D OTC Cetirizine/Pseudoephedrine (Zyrtec-D�)   
     Desloratadine (Clarinex�)   
     Fexofenadine (Allegra�)   
      Fexofenadine/Pseudoephedrine (Allegra-D�)   
             
Antihistamines - Nasal Azelastine (Astelin�) NONE  
           
Corticosteroids, Nasal Flunisolide Spray Beclomethasone AQ (Beconase AQ�)  
   Fluticasone (Flonase�) Budesonide Aqua (Rhinocort Aqua�)   
      Flunisolide Aqueous (Nasarel�)   
      Mometasone (Nasonex�)   
      Triamcinolone AQ (Nasacort AQ�)   

Alzheimer's

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Alzheimer's Agents - Donepezil (Aricept�) Tacrine (Cognex�)    
Cholinesterase Inhibitors Galantamine (Reminyl�)      
   Rivastigmine (Exelon�)      

Asthma/COPD

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Beta-Adrenergic Agents        
 

INHALATION

      
  Albuterol Sulfate (Nebulizer and Inhaler) Albuterol Sulfate/Ipratropium (DuoNeb�)   
   Albuterol Sulfate HFA MDI(Proventil HFA�) Albuterol Sulfate HFA MDI(Ventolin HFA�)   
  Albuterol Sulfate Nebulizer Solution (Accuneb�) Formoterol DPI (Foradil�)   
  Albuterol Sulfate/Ipratropium MDI (Combivent�) Metaproterenol Sulfate (Alupent Inhalant�)   
  Levalbuterol HCL (Xopenex�) Pirbuterol (Maxair�, Maxair Autohaler�)   
  Metaproterenol Sulfate (Nebulizer Only)      
   Salmeterol Xinafoate (Serevent Diskus�)      
         
  

ORAL

      
  Albuterol Sulfate Albuterol Sulfate ER (Volmax�; Vospire ER�)   
  Metaproterenol Sulfate     
  Terbutaline Sulfate     
         
Corticosteroids, Inhalation Beclomethasone MDI (QVAR�)      
  Budesonide Respules (Pulmicort - Respules�) - 21 years old and under Budesonide Respules (Pulmicort - Respules�)    
  Flunisolide MDI (Aerobid�) Budesonide DPI (Pulmicort Turbuhaler�)   
   Flunisolide MDI (Aerobid M�)      
  Fluticasone MDI (Flovent� Inhaler)      
  Fluticasone DPI (Flovent Rotadisc�)       
  Triamcinolone MDI (Azmacort�)    
    Fluticasone/Salmeterol DPI (Advair Diskus�)      
          
Leukotriene Modifiers Montelukast (Singulair�) None  
  Zafirlukast (Accolate�)    

Depression

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Antidepressants, Other Bupropion IR Bupropion ER (Wellbutrin XL�)   
    Bupropion SR  Duloxetine (Cymbalta�)   
    Mirtazapine        
   Mirtazepine Soltab      
  Nefazodone      
  Trazodone     
  Venlafaxine (Effexor�)       
   Venlafaxine ER (Effexor XR�)      
         
Selective Serotonin Reuptake Inhibitors (SSRIs) Escitalopram (Lexapro�) Citalopram (Celexa�)     
    Fluoxetine (except Sarafem�) Fluoxetine ER (Prozac Weekly�)   
   Fluvoxamine Fluoxetine (Sarafem�)   
   Paroxetine HCL      
   Paroxetine HCL  CR (Paxil CR�)      
   Paroxetine Mesylate (Pexeva�)     
   Sertraline (Zoloft�)      

Dermatology

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Antifungals - Topical Butenafine (Mentax�) Ciclopirox (Loprox�)  
  Clotrimazole Ciclopirox (Penlac�)    
  Clotrimazole/Betamethasone Terbinafine (Lamisil�)   
   Econazole        
   Ketoconazole       
   Ketoconazole (Nizoral Shampoo - Rx ONLY)       
   Naftifine (Naftin�)       
   Nystatin        
   Nystatin w/ Triamcinolone       
   Oxiconazole (Oxistat�)         
    Sulconazole (Exelderm�)        
            
Atopic Dermatitis - Immunomodulators Pimecrolimus (Elidel�) NONE   
   Tacrolimus (Protopic�)     

 Diabetes

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Hypoglycemics, Alpha - Glucosidase Inhibitors Miglitol (Glyset�) Acarbose (Precose�)   
        
Hypoglycemics, Meglitinides Nateglinide (Starlix�) Repaglinide (Prandin�)   
        
Hypoglycemics, Metformin Containing Metformin None     
    Metformin ER (Fortamet�)      
    Metformin XR      
   Metformin Oral Solution (Riomet�)      
   Metformin/Glipizide (Metaglip�)      
   Metformin/Glyburide      
   Metformin/Rosiglitazone (Avandamet�)      
         
Hypoglycemics, Sulfonylureas Acetohexamide NONE   
  Chlorpropamide    
  Glimepiride (Amaryl�)    
  Glipizide    
  Glipizide XL (Glucotrol XL�)    
  Glyburide    
  Glyburide Extended Release    
  Tolazamide    
  Tolbutamide    
       
Hypoglycemics, Thiazolidinediones (TZDs) Pioglitazone (Actos�) Rosiglitazone (Avandia�)   
       
Insulins Humalog (Children 18 years and under) Humalog (Over 18 years)  
   Insulin Glargine (Lantus�) Humalog Mix 75/25   
  Novolin N Humulin L   
  Novolin R Humulin N  
  Novolin 70/30 Humulin R  
  Novolog Humulin U  
  Novolog Mix Humulin 50/50  
  Relion R Humulin 70/30  
  Relion N      
  Relion 70/30     

Digestive Disorders

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Antiemetic Agents

Oral

  

  
   Aprepitant (Emend�) Dolasetron (Anzemet�)  
   Dronabinol (Marinol�) Granisetron (Kytril�)  
   Metoclopramide    
   Ondansetron (Zofran�, Zofran ODT�)    
         
   

Injectable

  

  
   Metoclopramide Injection Dolasetron Injection (Anzemet�)   
   Ondansetron Injection (Zofran�) Granisetron Injection (Kytril�)     
        
Antivertigo Agents Scopolamine, Transdermal 
(Transderm Scop�)		 Scopolamine, Oral (Scopace�)  
       
GERD AND RELATED DISORDERS         
H2 Antagonists Cimetidine Nizatidine (Axid�)  
   Famotidine Famotidine RPD (Pepcid RPD�)  
   Ranitidine Ranitidine Efferdose 
(Zantac Efferdose�)		  
       Ranitidine Granules (Zantac Granules�)  
       
H. Pylori Agents Amoxicillin Bismuth Subsalicylate/Metronidazole/
Tetracycline (Helidac�)		  
  Clarithromycin (Biaxin�) Lansoprazole/Amoxicillin/
Clarithromycin (Prevpac�)		  
  Lansoprazole (Prevacid �)    
       
Proton Pump Inhibitors Lansoprazole Capsule  (Prevacid�) Esomeprazole (Nexium�)  
  Lansoprazole Solutab  (Prevacid�) Omeprazole (legend products only)  
      Lansoprazole Suspension  (Prevacid�) Omeprazole (Zegerid �)    
      Pantoprazole (Protonix�)  
      Rabeprazole (Aciphex�)   
            
ULCERATIVE COLITIS       
Ulcerative Colitis Agents Balsalazide (Colazal�) Mesalamine (Asacol�)  
    Mesalamine Enemas Mesalamine Suppositories (Canasa�)    
   Mesalamine (Pentasa�)  Olsalazine (Dipentum�)    
    Sulfasalazine        

Growth Deficiency

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Growth Deficiency           
Growth Hormones Somatropin (Norditropin�) Somatropin (Genotropin�)   
    Somatropin (Nutropin AQ�) Somatropin (Humatrope�)    
     Somatropin  (Tev-Tropin�) Somatropin (Nutropin�)    
           Somatropin (Saizen�)      
        Somatropin (Serostim�)   

Heart Disease

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
HYPERLIPIDEMIA          
Antihyperlipidemic Agents - Non Statins Cholestyramine Colesevelam (Welchol�)   
    Colestipol (Colestid�) Ezetimibe (Zetia�)   
   Fenofibrate (Tricor�) Fenofibrate (Antara�)   
   Gemfibrozil Fenofibrate (Lofibra�)   
   Niacin ER (Niaspan�)      
   Niacin Rx      
             
Statins Ezetimibe/Simvastatin (Vytorin�) Atorvastatin (Caduet�)  
    Fluvastatin (Lescol�) Atorvastatin (Lipitor�)  
   Fluvastatin XL (Lescol XL�) Pravastatin (Pravachol�)   
   Lovastatin Pravastatin/Buffered Aspirin (Pravigard PAC)   
    Lovastatin ER (Altoprev�)       
   Niacin ER/Lovastatin (Advicor�)      
   Rosuvastatin (Crestor�)     
  Simvastatin (Zocor�)    
           
HYPERTENSION       
ACE Inhibitors Benazepril Quinapril (Accupril�)  
     Benazepril/HCTZ        
  Captopril      
  Captopril/HCTZ       
  Enalapril    
  Enalapril/HCTZ    
  Fosinopril    
  Fosinopril/HCTZ (Monopril-HCT�)    
    Lisinopril     
  Lisinopril/HCTZ    
  Moexipril    
  Moexipril/HCTZ (Uniretic�)    
   Perindopril (Aceon�)      
   Quinapril/HCTZ (Accuretic�)      
   Ramipril (Altace�)      
  Trandolapril (Mavik�)    
       
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�)   
    Telmisartan (Micardis�) Eprosartan (Teveten�)   
   Telmisartan/HCTZ (Micardis HCT�) Eprosartan/HCTZ (Teveten HCT�)   
   Valsartan (Diovan�) Irbesartan (Avapro�)  
   Valsartan/HCTZ (Diovan HCT�) Irbesartan/HCTZ (Avalide�)   
       Olmesartan (Benicar�)     
        Olmesartan/HCTZ (Benicar HCT�)     
          
Beta Adrenergic Receptor Blocking Agents Acebutolol Carteolol (Cartrol�)  
   Atenolol Carvedilol (Coreg�)  
   Betaxolol Penbutolol (Levatol�)   
    Bisoprolol Fumarate     
  Labetalol    
  Metoprolol Tartrate    
  Metoprolol XL (Toprol XL�)     
  Nadolol     
   Pindolol    
   Propranolol    
   Propranolol LA (Inderal LA�)       
  Propranolol XL (Innopran XL�)      
  Sotalol    
  Sotalol AF    
  Timolol Maleate    
       
Calcium Channel Blockers Diltiazem ER Amlodipine (Norvasc�)    
  Diltiazem IR Isradipine (Dynacirc�)  
   Diltiazem LA (Cardizem LA�) Nicardipine SR (Cardene SR�)   
  Diltiazem SA  Nimodipine (Nimotop�)  
    Felodipine ER Verapamil ER (Covera HS�)   
   Isradipine SR (Dynacirc CR�)      
  Nicardipine       
  Nifedipine IR       
  Nifedipine ER      
  Nisoldipine (Sular�)     
   Verapamil ER (Verelan PM�)      
  Verapamil IR    
  Verapamil SA     
       
INTERMITTENT CLAUDICATION AGENTS        
Intermittent Claudication Agents Cilostazol (Pletal�) NONE  
  Pentoxifylline    
         
PLATELET AGGREGATION INHIBITORS        
Platelet Aggregation Inhibitors Aspirin/Dipyridamole ER (Aggrenox�) Ticlopidine  
  Clopidogrel (Plavix�)    
  Dipyridamole    
        
ANTICOAGULANTS, INJECTABLES       
Anticoagulants, Injectable Dalteparin (Fragmin�) Fondaparinux (Arixtra�)     
    Enoxaparin (Lovenox�) Tinzaparin (Innohep�)   

Hematologic Agents

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
HEMATOPOIETIC AGENTS       
Erythropoietins Epoetin alfa (Procrit�) Epoetin alfa (Epogen�)   
  Darbepoetin alfa (Aranesp�)    
       
Anticoaqulants - refer to HEART DISEASE      

Hemodialysis

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Phosphate Binders Calcium Acetate (PhosLo�) Sevelamer (RenaGel�)   
  Lanthanum (Fosrenol�)       
   Magnesium Carbonate, Calcium Carbonate, Folic Acid (Magnebind 400 Rx�)       

Hormone Therapy

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Contraceptives MONOPHASIC MONOPHASIC  
All covered contraceptives are on the PDL. Alesse; Apri; Aviane NONE  
   Brevicon      
   Demulen; Desogen    
  Lessina; Levlen; Levlite; Levora    
  Lo/Ovral; Loestrin FE; Low-Ogestrel    
  Microgestin FE; Modicon    
  Necon; Nelova; Nordette; Norinyl; Notrel    
  Ogestrel; Ortho-Cept; Ortho-Cyclen; Ortho-Novum    
  Ovcon; Ovral    
  Portia    
  Yasmin    
  Zovia 1/50    
         
  BIPHASIC BIPHASIC  
  Kariva NONE  
  Mircette    
  Necon    
  Ortho-Novum 10/11    
          
     TRIPHASIC TRIPHASIC  
  Cyclessa NONE   
  Enpresse; Estrostep     
  Ortho TriCyclen; Ortho-Novum 7/7/7     
  Tri-Levlen; Tri-Norinyl; Triphasil; Trivora     
          
   PROGESTIN ONLY PROGESTIN ONLY  
   Nor-Q.D. NONE  
   Ortho Micronor     
   Ovrette     
          
   EMERGENCY CONTRACEPTION EMERGENCY CONTRACEPTION  
    Preven NONE  
          
   TRANSDERMAL & VAGINAL RING TRANSDERMAL & VAGINAL RING  
   NuvaRing NONE  
   Ortho Evra     
         
Estrogen Agents - Oral and Transdermal ORAL ORAL  
   Conjugated Estrogens (Premarin�) Esterified Estrogens (Estratab)  
  Diethylstilbestrol    
  Esterified Estrogens (Menest�)    
  Estradiol     
  Estropipate    
  Synthetic Conjugated Estrogens (Cenestin�)    
       
    TRANSDERMAL PATCH TRANSDERMAL PATCH   
   Estradiol Estradiol (Climara�)  
           
Combination Estrogen Agents 17β-Estradiol/Norethindrone Acetate (Activella�) 17β-Estradiol/Levonorgestrel (Climara Pro�)     
   17β-Estradiol/Norethindrone Acetate (CombiPatch�)          
   17β-Estradiol/Norgestimate (Ortho-Prefest�)       
     Conjugated Estrogens (CE)/Medroxyprogesterone Acetate (MPA) (Premphase�)        
   Conjugated Estrogens /Medroxyprogesterone Acetate (Prempro�)      
     Ethinyl Estradiol/Norethindrone Acetate (Femhrt�)         

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
October 1, 2004
ANTIBIOTICS        
Cephalosporin and Related Antibiotics Amoxicillin/Clavulanate Cefaclor (Raniclor�)  
    Amoxicillin/Clavulanate (Augmentin ES-600�) Ceftibuten (Cedax�)  
    Amoxicillin/Clavulanate XR (Augmentin XR�) Cephalexin (Panixene�)  
  Cefaclor Loracarbef (Lorabid�)  
  Cefaclor ER    
   Cefadroxil Monohydrate    
  Cefdinir (Omnicef�)     
  Cefditoren Pivoxil (Spectracef�)     
  Cefixime (Suprax�)    
  Cefpodoxime Proxetil    
   Cefprozil (Cefzil�)      
  Cefuroxime axetil     
  Cephalexin    
  Cephradine (Velosef�)    
       
Fluoroquinolones, 

Injectable

     
  Ciprofloxacin (Cipro�) None  
  Gatifloxacin (Tequin�)    
  Levofloxacin (Levaquin�)    
  Moxifloxacin (Avelox�)    
   Ofloxacin (Floxin�)      
       
Fluoroquinolones, 

Oral

     
  Ciprofloxacin (Cipro�) Lomefloxacin (Maxaquin�)  
  Ciprofloxacin ER (Cipro XR�) Norfloxacin (Noroxin�)  
    Gatifloxacin (Tequin�)        
  Levofloxacin (Levaquin�)     
  Moxifloxacin (Avelox�)    
   Ofloxacin      
       
Macrolides Azithromycin (Zithromax�) None  
  Clarithromycin (Biaxin�)     
  Clarithromycin ER (Biaxin XL�)     
   Erythromycin Stearate     
   Erythromycin Base     
  Erythromycin Estolate    
  Erythromycin Ethyl succinate     
        
OPHTHALMIC ANTIBIOTICS -
Refer to Opthalmic Disorders		         
OTIC ANTIBIOTICS - 
Refer to Otic Agents		        
ANTIFUNGALS        
Antifungals, Oral Fluconazole (Diflucan�) Clotrimazole (Mycelex Troche�)  
   Griseofulvin Flucytosine (Ancobon�)  
   Ketoconazole Itraconazole (Sporanox�)  
   Nystatin Nystatin (Mycostatin pastiles�)  
   Terbinafine (Lamisil�) Voriconazole (VFEND)   
          

Multiple Sclerosis

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Multiple Sclerosis Agents (Immunomodulatory Agents) Interferon beta - 1a (Avonex�)      
    Interferon beta - 1a (Betaseron�)      
   Glatiramer (Copaxone�)      
   Interferon beta - 1a (Rebif�)      

Ophthalmic Disorders

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Allergic Conjunctivitis Azelastine Hydrochloride (Optivar�) Ketotifen Fumarate (Zaditor�)  
   Cromolyn Sodium Lodoxamine Tromethamine (Alomide�)  
   Emedastine Difumarate (Emadine�) Nedocromil Sodium (Alocril�)  
   Ketorolac Tromethamine (Acular�)      
   Levocabastine (Livostin�)      
   Loteprednol (Alrex�)      
   Olopatadine Hydrochloride (Patanol�)       
   Pemirolast Potassium (Alamast�)      
          
Glaucoma Agents      
Intraocular Pressure (IOP) Reducers Betaxolol NONE  
   Betaxolol (Betoptic S�)     
   Brimonidine (Alphagen P�)     
   Brimonidine Tartrate      
   Brinzolamide (Azopt�)        
   Carteolol    
    Dipivefrin      
  Dorzolamide (Trusopt�)    
  Dorzolamide/Timolol (Cosopt�)    
  Epinephrine    
  Levobunolol    
  Metipranolol    
  Pilocarpine    
  Timolol (Betimol�)    
  Timolol Maleate    
       
Prostaglandin Inhibitors Bimatoprost (Lumigan�) Unoprostone (Rescula�)  
    Latanoprost (Xalatan�)     
  Travoprost (Travatan�)    
       
Antibiotics, Ophthalmic Bacitracin Gatifloxacin (Zymar�)   
  Ciprofloxacin (Ciloxan�)    
   Erythromycin    
  Gentamicin Sulfate    
  Levofloxacin (Quixin�)    
  Moxifloxacin (Vigamox�)    
  Ofloxacin (Ocuflox�)    
  Tobramycin Sulfate    

Otic Agents

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Antibiotics, Others Neomycin/Colistin/
Thonzonium/HC 
(Coly-Mycin S�)		 Neomycin/Colistin/
Thonzonium/HC 
(Cortisporin - TC�)		   
    Neomycin/Polymyxin/HC (Pediotic�)      
   Neomycin/Polymyxin/HC      
               
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
October 1, 2004
Bone Resorption Suppression Agents Alendronate (Fosamax�) Etidronate (Didronel�)  
   Calcitonin-salmon (Miacalcin�) Raloxifene (Evista�)   
   Risedronate (Actonel�) Teriparatide (Forteo�)  

Pain Management

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Narcotics Acetaminophen w/Codeine Acetaminophen/Caffeine/
Dihydrocodeine Bitartrate (Panlor DC, Panlor SS�)  		   
   Acetaminophen w/Codeine (Capital w/Codeine�) Aspirin/Caffeine/Dihydrocodeine Bitartrate (Synalgos-DC�)    
  Aspirin w/Codeine Fentanyl Citrate (Actiq�)   
  Belladonna & Opium Hydromorphone ER (Palladone �)    
      Butalbital Compound w/Codeine Morphine Sulfate ER (Avinza �)  
   Butalbital/Caff/APAP/Codeine Opium Tincture   
   Butorphanol Tartrate Oxycodone ER   
   Carisoprodol Compound/Codeine Oxycodone (Oxycontin �)   
   Codeine Phosphate Oxymorphone (Numorphan�)   
   Codeine Sulfate Propoxyphene Napsylate (Darvon-N�)  
   Fentanyl Transdermal (Duragesic�)     
   Fiortal w/Codeine #3     
   Hydrocodone/Acetaminophen     
   Hydrocodone/Acetaminophen (Maxidone; Zydone�)      
    Hydrocodone Bitartrate/Ibuprofen (Vicoprofen�)         
    Hydromorphone HCL       
     Meperidine HCL       
   Meperidine w/Promethazine     
   Methadone HCL     
   Methadose     
   Morphine Sulfate (Oral)     
   Morphine Sulfate (Rectal)    
    Morphine Sulfate ER (Kadian�)     
   Morphine Sulfate IR      
   Oxycodone HCL      
   Oxycodone/Acetaminophen     
    Oxycodone/Acetaminophen (Percocet 10/325mg;       
   2.5/325mg;7.5/325mg�)      
   Oxycodone w/Acetaminophen (Roxicet�)        
    Oxycodone w/Aspirin       
    Pentazocine/Naloxone HCL     
   Pentazocine/Acetaminophen     
   Propoxyphene HCL      
   Propoxyphene HCL Compound       
   Propoxyphene HCL w/APAP      
    Propoxyphene Napsylate w/APAP       
   Tramadol (Ultram�)      
   Tramadol/
Acetaminophen  (Ultracet�)		        
           
Nonsteroidal Anti - Inflammatories (NSAIDs) Diclofenac Diclofenac/Misoprostol (Arthrotec�)  
   Etodolac       
   Fenoprofen     
   Flurbiprofen     
    Ibuprofen     
   Indomethacin     
   Ketoprofen     
   Ketorolac     
     Lansoprazole/Naproxen (Prevacid NapraPAC)      
   Meclofenamate Sodium      
   Mefenamic Acid (Ponstel�)      
   Meloxicam (Mobic�)     
   Nabumetone      
   Naproxen      
   Naproxen Sodium     
   Oxaprozin     
   Piroxicam     
   Sulindac     
   Tolmetin Sodium     
           
Selective Cyclooxygenase Cox 2 Inhibitors Celecoxib (Celebrex�) None    
   Rofecoxib (Vioxx�)      
   Valdecoxib (Bextra�)     
          
Immunomodulators and Related Agents for Arthritis Adalimumab (Humira�) Anakinra (Kineret�)   
   Etanercept (Enbrel�) Infliximab (Remicade�)   
   Leflunomide (Arava�)      
           
Skeletal Muscle Relaxants Baclofen Dantrolene (Dantrium�)  
     Carisoprodol      
   Chlorzoxazone    
   Cyclobenzaprine     
   Diazepam     
   Metaxalone (Skelaxin�)    
   Methocarbamol     
   Orphenadrine Citrate     
   Tizanidine (Zanaflex�)    
           
Triptans Almotriptan (Axert�) Eletriptan (Relpax�)    
  Rizatriptan (Maxalt�, Maxalt MLT�) Frovatriptan (Frova�)   
    Zolmitriptan (Zomig�, Zomig ZMT�) Naratriptan (Amerge�)    
    Zolmitriptan (Zomig nasal) Sumatriptan (Imitrex� Nasal)     
     Sumatriptan (Imitrex - Subcutaneous) Sumatriptan (Imitrex� - Oral)     

Parkinson's

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Antiparkinson Agents - Anticholinergic and Other Benztropine Mesylate Procyclidine (Kemadrin�)   
   Entacapone (Comtan�) Tolcapone (Tasmar�)  
   Levodopa (Larodopa�)     
   Levodopa/Carbidopa     
  Levodopa/Carbidopa/Entacapone (Stalevo�)    
   Pergolide     
   Pramipexole (Mirapex�)     
    Ropinirole (Requip�)     
   Selegiline     
   Trihexyphenidyl     

Sedatives/Hypnotics

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
Sedative/Hypnotics Chloral Hydrate  Quazepam (Doral�)  
    Estrazolam      
    Flurazepam     
    Temazepam      
   Temazepam 7.5 & 22.5 mg (Restoril 7.5mg & 22.5mg�    
    Triazolam       
   Zaleplon (Sonata�)      
  Zolpidem (Ambien�)    

Urology

Descriptive Therapeutic Class Drugs on PDL Drugs Which Require PA Effective Date
October 1, 2004
INCONTINENCE        
Antiincontinence Agents Darifenacin (Enablex�) Solifenacin (VESIcare�)   
      Oxybutynin Tolterodine (Detrol�)   
    Oxybutynin extended release - (Ditropan XL�) Tolterodine extended release - 
(Detrol LA�)		   
      Oxybutynin transdermal (Oxytrol�) Trospium (Sanctura�)    
               
PROSTATE        
Drugs for Treatment of Benign Prostatic Hyperplasia (BPH)  Alfuzosin (Uroxatral�) Dutasteride (Avodart�)   
    Doxazosin       
   Finasteride (Proscar�)     
     Tamsulosin (Flomax�)     
   Terazosin     

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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.