|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Stimulants and Related Agents
|
Amphetamine Salt Combo (Generic;
Adderall�)
|
Amphetamine Salt Combo ER (Generic Only)
|
|
|
|
Amphetamine
Salt Combo ER (Adderall XR�
- Brand Only)
|
Armodafinil
(Nuvigil�)
|
|
|
|
Atomoxetine (Strattera�)
|
Clonidine Extended-release (Kapvay�)
|
|
|
|
Dexmethylphenidate
(Focalin� - Brand Only)
|
Dexmethylphenidate
(Generic Only)
|
|
|
|
Dexmethylphenidate ER (Focalin XR�)
|
Dextroamphetamine ER (Generic;
Dexadrine�)
|
|
|
|
Dextroamphetamine (Generic)
|
Dextroamphetamine Solution (Procentra�)
|
|
|
|
Guanfacine ER
(Intuniv�)
|
Methylphenidate
Solution (Generic)
|
|
|
|
Lisdexamfetamine (Vyvanse�)
|
Methamphetamine (Generic; Desoxyn�)
|
|
|
|
Methylphenidate (Generic, Metadate CD�)
|
Methylphenidate ER (Generic Concerta; Ritalin
LA�)
|
|
|
|
Methylphenidate ER (Generic excluding generic
Concerta)(Metadate CD & Concerta Brand only)
|
Modafinil (Provigil�)
|
|
|
|
Methylphenidate IR
(Methylin Chewable & Solution�)
|
|
|
|
|
Methylphenidate SR
(Ritalin SR�)
|
�
|
|
|
|
Methylphenidate
Transdermal Patches (Daytrana�)
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Antihistamines - Minimally
Sedating
|
Cetirizine Syrup
OTC
|
Acrivastin/Pseudoephedrine
(Semprex-D�)
|
|
|
|
Cetirizine
Syrup Rx
|
Cetirizine
Chewable Tablet OTC
|
|
|
|
Cetirizine
Tablet OTC
|
Cetirizine
Solution 5mg/5cc OTC
|
|
|
|
Cetirizine - D
OTC
|
Desloratadine
Tablet (Clarinex�)
|
|
|
|
Fexofenadine
Tablet 30mg, 60mg, 180mg (Generic Only)
|
Desloratadine
ODT (Clarinex ODT�)
|
|
|
|
Fexofenadine-D
12-hour (Generic Only)
|
Desloratadine
Syrup (Clarinex�)
|
|
|
|
Fexofenadine-D
24-hour (Generic Only)
|
Desloratadine/Pseudoephedrine (Clarinex-D
12-hour�)
|
|
|
|
Loratadine Tab
OTC (Generic Only)
|
Desloratadine/Pseudoephedrine (Clarinex-D
24-hour�)
|
|
|
|
Loratadine ODT
Tablet OTC (Generic Only)
|
Fexofenadine
Tablet 30mg, 60mg, 180mg (Allegra - Brand Only)
|
|
|
|
Loratadine-D
Tablet OTC (Generic Only)
|
Fexofenadine ODT
Tablet (Allegra ODT�)
|
|
|
|
Loratadine Syrup
OTC (Generic Only)
|
Fexofenadine/Pseudoephedrine (Allegra-D
12-hour� - Brand Only)
|
|
|
|
|
Fexofenadine/Pseudoephedrine (Allegra-D
24-hour� - Brand Only)
|
|
|
|
|
Fexofenadine
Syrup (Allegra Syrup�)
|
|
|
|
|
Levocetirizine
Tablet (Generic; Xyzal�)
|
|
|
|
|
LevocetirizineSyrup (Generic; Xyzal�)
|
|
|
|
|
Loratadine Capsule
OTC - (Claritin� - Brand Only)
|
|
|
|
|
Loratadine Syrup
OTC (Claritin� - Brand Only)
|
|
|
|
|
Loratadine Tablet
OTC(Claritin�)
|
|
|
|
|
Loratadine OTD
(Claritin� - Brand Only)
|
|
|
|
|
Loratadine
Chewable OTC - (Claritin�)
|
|
|
|
|
Loratadine-D 12
hours OTC (Claritin- D�)
|
|
|
|
|
Loratadine-D 24
hours OTC (Claritin- D�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Rhinitis Agents, Nasal
|
Azelastine (Astelin; Astepro�)
|
Azelastine (Generic)
|
|
|
|
Fluticasone Propionate
(Flonase� -
Brand Only)
|
Beclomethasone
(Beconase AQ�)
|
|
|
|
Ipratropium Nasal
|
Budesonide Aqua (Rhinocort Aqua�)
|
|
|
|
Mometasone
(Nasonex�)
|
Ciclesolide (Omnaris�)
|
|
|
|
Olopatadine (Patanase�)
|
Flunisolide
|
|
|
|
|
Fluticasone
Furoate (Veramyst�)
|
|
|
|
|
Fluticasone Propionate (Generic Only)
|
|
|
|
|
Triamcinolone (Nasacort AQ�)
|
|
|
|
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
|
ORAL
|
|
|
Antipsychotic Agents
|
Amitriptyline/Perphenazine
|
Aripiprazole Oral Solution (Abilify Oral
Solution�)
|
|
|
|
Aripiprazole
Discmelt (Abilify�)
|
Clozapine
(Clozaril; Fazaclo�)
|
|
|
|
Aripiprazole
Tablet (Abilify�)
|
Lurasidone
(Latuda�)
|
|
|
|
Asenapine
(Saphris)
|
Olanzapine
(Zyprexa; Zyprexa Zydis�)
|
|
|
|
Chlorpromazine
|
Olanzapine/Fluoxetine (Symbyax�)
|
|
|
|
Clozapine (Generics Only)
|
Paliperidone ER (Invega�)
|
|
|
|
Fluphenazine Elixir
|
Risperidone ODT
(Risperdal� - Brand Only)
|
|
|
|
Fluphenazine
Tablet
|
Risperidone Solution
(Risperdal� - Brand Only)
|
|
|
|
Haloperidol
Oral
|
Risperidone Tablet
(Risperdal� - Brand Only)
|
|
|
|
Haloperidol
Lactate Concentrate
|
|
|
|
|
Iloperidone
Dose pack(Fanapt�)
|
|
|
|
|
Iloperidone
Tablet (Fanapt�)
|
|
|
|
|
Molindone (Moban�)
|
|
|
|
|
Perphenazine
|
|
|
|
|
Pimozide
(Orap�)
|
|
|
|
|
Quetiapine (Seroquel�)
|
|
|
|
|
Quetiapine (Seroquel XR�)
|
|
|
|
|
Risperidone ODT (Generic Only)
|
|
|
|
|
Risperidone
Solution (Generic Only)
|
|
|
|
|
Risperidone
Tablet (Generic Only)
|
|
|
|
|
Thioridazine
|
|
|
|
|
Thiothixene (Generic; Navane�)
|
|
|
|
|
Trifluoperazine (Generic)
|
|
|
|
|
Ziprasidone
(Geodon�)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
INJECTIONS
|
|
|
|
Aripiprazole (Abilify�)
|
Haloperidol Decanoate (Haldol�
-
Brand Only)
|
|
|
|
Fluphenazine
Decanoate
|
Olanzapine
(Zyprexa�)
|
|
|
|
Haloperidol Decanoate (Generic Only)
|
Olanzapine
(Zyprexa Relprevv�)
|
|
|
|
Haloperidol
Lactate (Generic Only)
|
Paliperidone
(Invega Sustenna�)
|
|
|
|
Risperidone (Risperdal
Consta�)
|
|
|
|
|
Ziprasidone (Geodon�)
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Bronchodilator, Beta-Adrenergic
Agents
|
|
|
|
|
|
INHALATION
|
|
|
|
Albuterol Sulfate Nebulizer Solution
100mg/20ml
|
Albuterol Sulfate HFA MDI (Ventolin
HFA�)
|
|
|
|
Albuterol
Sulfate Nebulizer Solution 2.5mg/3ml
|
Albuterol
Sulfate Nebulizer Low-Dose 0.63mg/3ml, 1.25mg/3ml
|
|
|
|
Albuterol
Sulfate Nebulizer Solution 2.5mg/0.5ml
|
Arformoterol
Inhalation Solution (Brovana Inhalation Solution�)
|
|
|
|
Albuterol
Sulfate Nebulizer Low-Dose (Accuneb�)
|
Formoterol
DPI (Foradil�)
|
|
|
|
Albuterol Sulfate HFA (ProAir HFA�)
|
Formoterol Inhalation Solution (Perforomist Inhalation
Solution�)
|
|
|
|
Albuterol Sulfate
HFA MDI (Proventil HFA�)
|
Indacaterol for Inhalation
(Arcapta�)
|
|
|
|
|
Levalbuterol HCL
Nebulizer Solution (Generic; Xopenex�)
|
|
|
|
|
Levalbuterol HFA (Xopenex HFA�)
|
|
|
|
|
Pirbuterol (Maxair Autohaler�)
|
|
|
|
|
Salmeterol Xinafoate (Serevent Diskus�)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
ORAL
|
|
|
Bronchodilator,
Beta-Adrenergic
|
Albuterol
Sulfate Syrup
|
Albuterol
Sulfate ER (Generic; Vospire ER
Tablet�)
|
|
|
Agents
cont�
|
Albuterol
Sulfate Tablet
|
Metaproterenol
Sulfate Tablet
|
|
|
|
Metaproterenol
Sulfate Syrup
|
|
|
|
|
Terbutaline
Sulfate
|
|
|
|
|
|
|
|
|
Bronchodilator, Anticholinergics
(COPD)
|
INHALATION
|
|
|
|
Albuterol
Sulfate/Ipratropium MDI (Combivent�)
|
Albuterol
Sulfate/Ipratropium Nebulizer (Generic Only)
|
|
|
|
Albuterol
Sulfate/Ipratropium Nebulizer Solution (Duoneb� - Brand Only)
|
|
|
|
|
Ipratropium
Nebulizer
|
|
|
|
|
Ipratropium
Inhalation Aerosol MDI (Atrovent HFA�)
|
|
|
|
|
Tiotropium
Inhalation Powder (Spiriva�)
|
|
|
|
|
|
|
|
|
|
ORAL
|
|
|
|
NONE
|
Roflumilast
(Daliresp�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Glucocorticoids, Inhalation
|
Beclomethasone MDI (QVAR�)
|
Budesonide DPI (Pulmicort Flexhaler�)
|
|
|
|
Budesonide Respules�
0.25mg; 0.5mg - 8 years old and under
|
Budesonide Respules�0.25mg; 0.5mg - 9 years old and
over
|
|
|
|
Budesonide Respules�
0.25mg; 0.5mg (Pulmicort - Respules�) - 8 years old and under
|
Budesonide Respules 0.25mg; 0.5mg (Pulmicort -
Respules�)� - 9 years
old and over
|
|
|
|
Budesonide Respules 1mg (Pulmicort - Respules�) - 8
years old and under
|
Budesonide Respules 1mg (Pulmicort - Respules�) - 9
years old and over
|
|
|
|
Fluticasone MDI (Flovent�)
|
Budesonide/Formoterol MDI (Symbicort�)
|
|
|
|
Fluticasone MDI (Flovent HFA Inhaler�)
|
Ciclesonide (Alvesco�)
|
|
|
|
Fluticasone/Salmeterol DPI (Advair
Diskus�)
|
|
|
|
|
Fluticasone/Salmeterol MDI (Advair HFA�)
|
|
|
|
|
Mometasone
DPI (Asmanex�)
|
|
|
|
|
Mometasone/Furoate
(Dulera�)
|
�
|
|
|
|
|
|
|
|
|
|
|
|
|
Leukotriene
Modifiers
|
Montelukast
Chewable Tablet(Singulair�)
|
Montelukast Gran
Pack (Singulair Gran Pack�)
|
|
|
|
Montelukast
Tablet (Singulair�)
|
Zafirlukast
(Generic Only)
|
|
|
|
Zafirlukast
(Accolate� - Brand Only)
|
Zileuton CR (Zyflo
CR�)
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Antidepressants, Other
|
Bupropion IR
|
Bupropion HBr ER (Aplenzin�)
|
|
|
|
Bupropion SR
|
Bupropion HCI IR (Wellbutrin�)
|
|
|
|
Bupropion
XL
|
Bupropion
HCI SR (Wellbutrin SR�)
|
|
|
|
Mirtazapine (Generics only)
|
Bupropion HCI XL (Wellbutrin XL�)
|
|
|
|
Mirtazapine ODT (Generics only)
|
Desvenlafaxine (Pristiq�)
|
|
|
|
Trazodone
|
Duloxetine (Cymbalta�)
|
|
|
|
Venlafaxine ER Capsule
(Effexor�
XR -Brand Only)
|
Mirtazapine (Remeron�)
|
|
|
|
Venlafaxine IR Tablet
|
Mirtazapine ODT (Remeron ODT�)
|
|
|
|
|
Nefazodone
|
|
|
|
|
Selegiline Patch (Emsam�)
|
|
|
|
Venlafaxine
|
Trazodone
Hydrochloride (Oleptro�)
|
|
|
|
|
Venlafaxine
ER Capsule (Generic)
|
|
|
|
|
Venlafaxine
ER Tablet (Generic; Schwarz; Updstate)
|
|
|
|
|
Vilazodone
(Viibryd�)
|
|
|
|
|
|
|
|
Selective
Serotonin Reuptake Inhibitors (SSRIs)
|
Citalopram Tablet (Generic)
|
Citalopram Solution
|
|
|
|
Fluoxetine Capsule (Generic)
|
Citalopram Tablet (Celexa�)
|
|
|
|
Fluoxetine Tablet 10mg
|
Escitalopram Solution (Lexapro�)
|
|
|
|
Fluvoxamine Solution
|
Escitalopram Tablet (Lexapro�)
|
|
|
|
Fluvoxamine Oral
|
Fluoxetine Tablet 20mg
|
|
|
|
Paroxetine Suspension (Paxil�)
|
Fluoxetine Capsule (Prozac; Sarafem�)
|
|
|
|
Paroxetine
CR Tablet (Paxil CR�)
|
Fluoxetine
DR Capsule (Generic; Prozac Weekly�)
|
|
|
|
Paroxetine
Tablet (Paxil�)
|
Fluvoxamine
CR (Luvox CR�)
|
|
|
|
Paroxetine
Tablet (Generic)
|
Paroxetine
Suspension (Generic)
|
|
|
|
Sertraline
Tablet (Generic)
|
Paroxetine
CR Tablet (Generic)
|
|
|
|
|
Paroxetine
Mesylate (Pexeva)
|
|
|
|
|
Sertraline
Concentrate (Zoloft; Generic)
|
|
|
|
|
Sertraline
Tablet (Zoloft�)
|
|
|
|
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Antifungals -
Topical
|
Clotrimazole Rx
|
Butenafine (Mentax�)
|
|
|
|
Clotrimazole/Betamethasone
|
Ciclopirox (CNL8�)
|
|
|
|
Econazole
|
Ciclopirox Cream
|
|
|
|
Ketoconazole Cream
|
Ciclopirox Gel
|
|
|
|
Ketoconazole Shampoo (Rx only)
|
Ciclopirox Shampoo
|
|
|
|
Nystatin
|
Ciclopirox Solution
|
|
|
|
Nystatin w/ Triamcinolone
|
Ciclopirox Suspension
|
|
|
|
|
Ketoconazole
(Ketocon Plus�)
|
|
|
|
|
Ketoconazole Foam (Extina�)
|
|
|
|
|
Ketoconazole
(Xolegel�)
|
|
|
|
|
Miconazole
(Nuzole�)
|
|
|
|
|
Miconazole/zinc oxide/white petrolatum
(Vusion�)
|
|
|
|
|
Naftifine
(Naftin�)
|
|
|
|
|
Nystatin
(Pediaderm AF�)
|
|
|
|
|
Oxiconazole (Oxistat�)
|
|
|
|
|
Sertaconazole Nitrate
(Ertaczo�)
|
|
|
|
|
Sulconazole
(Exelderm�)
|
|
|
|
|
|
|
|
Antiparasitic
Agents, Topical
|
Crotamiton (Eurax�)
|
Benzyl Alcohol
(Ulesfia�)
|
|
|
|
Malathion
(Ovide� - Brand only)
|
Lindane
|
|
|
|
Permethrin
|
Malathion
(generic only)
|
|
|
|
|
Spinosad (Natroba�)
|
|
|
|
|
|
|
|
Antiviral
Agents, Topical
|
Acyclovir
Ointment (Zovirax�)
|
Acyclovir Cream
(Zovirax�)
|
|
|
|
Penciclovir Cream
(Denavir�)
|
Acyclovir/Hydrocortisone
(Xerese�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Atopic
Dermatitis - Immunomodulators
|
Pimecrolimus
(Elidel�)
|
NONE
|
|
|
|
Tacrolimus
(Protopic�)
|
|
|
|
|
|
|
|
|
Antibiotics,
Topical
|
Gentamicin
Sulfate
|
Mupirocin Cream
(Bactroban�)
|
|
|
|
Mupirocin
Ointment
|
Retapamulin
(Altabax�)
|
|
|
|
|
|
|
|
STEROIDS,
TOPICAL
|
|
|
|
|
Low
Potency
|
Alclometasone Dipropionate (Aclovate� - Brand
Only)
|
Alclometasone Dipropionate Cream, Ointment (Generic
Only)
|
|
|
|
Desonide Cream, Ointment (Generic)
|
Desonate Gel (Generic)
|
|
|
|
Hydrocortisone Cream, Lotion, Ointment
(Generic)
|
Desonide/Emollient Combo No. 3 (Desonil
Plus�)
|
|
|
|
|
Desonide Lotion
(Generic; Desowen; Verdeso�)
|
|
|
|
|
Desonide Cream Kit
(Desowen Cream Kit�)
|
|
|
|
|
Desonide Lotion Kit
(Desowen Lotion Kit�)
|
|
|
|
|
Desonide Ointment Kit
(Desowen Ointment Kit�)
|
|
|
|
|
Fluocinolone Acetonide
Shampoo (Capex�)
|
|
|
|
|
Fluocinolone Acetonide
(Derma-Smoothe-FS�)
|
|
|
|
|
Hydrocortisone
(Texacort�)
|
|
|
|
|
Hydrocortisone
Acetate/Urea
|
|
|
|
|
Hydrocortisone/Aloe
Gel (Generic; Nuzon�)
|
|
|
|
|
Hydrocortisone/Mineral
Oil/Pet Ointment
|
|
|
|
|
Hydrocortisone/Emollient
(Pediaderm HC�)
|
|
|
|
|
Triamcinolone
(Pediaderm TA�)
|
|
|
|
|
|
|
|
Medium
Potency
|
Clocortolone Pivalate (Cloderm�)
|
Betamethasone Valerate
(Luxiq�)
|
|
|
|
Fluocinolone
Acetonide Cream, Ointment, Solution
|
Flurandrenolide
Tape (Cordran Tape�)
|
|
|
|
Fluticasone Propionate Cream, Ointment
(Generic)
|
Fluticasone Propionate Cream, Lotion
(Cutivate�)
|
|
|
|
Hydrocortisone Butyrate Ointment,
Solution
|
Hydrocortisone Butyrate Cream (Generic; Locoid
Lipocream�)
|
|
|
|
Hydrocortisone Valerate Cream (Generic)
|
Hydrocortisone
Probutate (Pandel�)
|
|
|
|
Prednicarbate Cream (Dermatop�)
|
Hydrocortisone
Valerate Cream (Westcort�)
|
|
|
|
|
Hydrocortisone
Valerate Ointment (Generic)
|
|
|
|
|
Mometasone Furoate
Cream, Ointment, Solution (Generic; Elocon�)
|
|
|
|
|
Mometasone Furoate
(Momexin�)
|
|
|
|
|
Prednicarbate Cream,
Ointment (Generic)
|
|
|
|
|
Prednicarbate
Ointment (Dermatop�)
|
|
|
|
|
|
|
|
|
|
|
|
|
High
Potency
|
Amcinonide Lotion (Generic)
|
Amcinonide Cream, Ointment (Generic)
|
|
|
|
Betamethasone Dipropionate Cream, Lotion, Ointment
(Generic)
|
Betamethasone Dipropionate/Prop Glycol Cream, Lotion,
Ointment (Generic; Diprolene;
Diprolene/AF�)
|
|
|
|
Betamethasone Valerate Cream, Lotion, Ointment
(Generic)
|
Betamethasone Dipropionate Gel (Generic;
Diprolene�)
|
|
|
|
Betamethasone Valerate Cream, Lotion (Beta
Val�)
|
Desoximetasone Cream, Gel, Ointment (Generic; Topicort;
Topicort LP�)
|
|
|
|
Fluocinonide Cream; Emollient; Gel; Ointment, Solution
(Generic)
|
Diflorasone Diacetate Cream, Ointment
(Generic)
|
|
|
|
Triamcinolone Acetonide Cream, Ointment
(Generic)
|
Fluocinonide Cream (Vanos�)
|
|
|
|
|
Halcinonide Cream,
Ointment (Halog�)
|
|
|
|
|
Triamcinolone
Acetonide Aerosol (Kenlag Aerosol�)
|
|
|
|
|
Triamcinolone Acetonide
Lotion (Generic)
|
|
|
|
|
|
|
|
|
|
|
|
|
Very High
Potency
|
Clobetasol
Propionate Cream, Gel, Ointment, Solution
(Generic)
|
Clobetasol
Propionate Cream (Temovate�)
|
|
|
|
Clobetasol
Propionate Foam (Olux�)
|
Clobetasol
Propionate Foam (Generic Only)
|
|
|
|
Clobetasol
Propionate/Emollient (Generic Only)
|
Clobetasol
Propionate (Clobex Lotion, Shampoo, Spray�)
|
|
|
|
Halobetasol
Propionate Cream, Ointment (Generic)
|
Clobetasol
Propionate - Emollient (Olux-E� - Brand Only)
|
|
|
|
|
Diflorasone
Diacetate (Apexicon E�)
|
|
|
|
|
Halobetasol
Propionate/Ammonium Lactate (Halac, Halonate, Halonate PAC,
Ultravate PAC�)
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Hypoglycemics, Meglitinides
|
Nateglinide (Starlix�)
|
Nateglinide
(Generic)
|
|
|
|
Repaglinide (Prandin�)
|
Repaglinide/Metformin
(Prandimet�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Hypoglycemics, Thiazolidinediones
(TZDs)
|
Pioglitazone
(Actos�)
|
Pioglitazone/Glimeperide
(Duetact�)
|
|
|
|
|
Pioglitazone/Metformin (Actoplus
Met�)
|
|
|
|
|
Pioglitazone/Metformin ER (Actoplus Met
XR�)
|
|
|
|
|
Rosiglitazone/Glimepiride
(Avandaryl�)
|
|
|
|
|
Rosiglitazone
(Avandia�)
|
|
|
|
|
Rosiglitazone/Metformin
(Avandamet�)
|
|
|
|
|
|
|
|
Hypoglycemics
|
Human Insulin & Pens (Humulin�)
|
Human Insulin & Pens (Novolin�)
|
|
|
Insulins
& Related Agents
|
Insulin Glargine & Pens (Lantus�)
|
Insulin Aspart & Pens (Novolog�)
|
|
|
|
Insulin Lispro & Pens (Humalog�)
|
Insulin Aspart/Insulin Aspart Protamine & Pens
(Novolog Mix 70/30�)
|
|
|
|
Insulin Lispro/Protamine Lispro & Pens (Humalog
Mix�)
|
Insulin Detemir & Pens
(Levemir�)
|
|
|
|
|
Insulin Glulisine & Pens
(Apidra�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Hypoglycemics
|
Exenatide
(Byetta, Pens�)
|
Liraglutide
(Victoza�)
|
|
|
Incretin
Mimetics/Enhancers
|
Linagliptin
(Tradjenta�)
|
|
|
|
|
Pramlintide
(Symlin�)
|
|
|
|
|
Pramlintide Pens
(Symlin Pens�)
|
|
|
|
|
Saxagliptin
(Onglyza�)
|
|
|
|
|
Saxagliptin
/Metformin (Kombiglyze XR)
|
|
|
|
|
Sitagliptin
(Januvia�)
|
|
|
|
|
Sitagliptin/Metformin (Janumet�)
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
|
|
|
|
Antiemetic
Agents
|
Aprepitant Oral
(Emend�)
|
Dolasetron IV Inj
(Anzemet�)
|
|
|
|
Dimenhydrinate
Inj
|
Dolasetron Oral (Anzemet�)
|
|
|
|
Dronabinol
Oral (Marinol�)
|
Dronabinol Oral (Generic)
|
|
|
|
Meclizine
|
Fosaprepitant IV Inj
(Emend�)
|
|
|
|
Metoclopramide
Inj
|
Granisetron IV
Inj
|
|
|
|
Metoclopramide
Oral
|
Granisetron Oral
|
|
|
|
Ondansetron IV Inj
|
Granisetron
Transdermal (Sancuso�)
|
|
|
|
Ondansetron Oral
ODT
|
Metoclopramide Oral
ODT (Metozolv�)
|
|
|
|
Ondansetron Oral Tab
|
Nabilone
(Cesamet�)
|
|
|
|
Ondansetron Oral
Solution
|
Ondansetron Oral
(Zuplenz�)
|
|
|
|
Prochlorperazine Inj
|
Palonosetron IV Inj
(Aloxi�)
|
|
|
|
Prochlorperazine Oral
|
|
|
|
|
Prochlorperazine
Rectal
|
|
|
|
|
Promethazine Inj
|
|
|
|
|
Promethazine Oral
|
|
|
|
|
Promethazine Rectal
|
|
|
|
|
Scopolamine Oral
(Scopace�)
|
|
|
|
|
Scopolamine
Transdermal (Transderm-Scop�)
|
|
|
|
|
Trimethobenzamide IM
Inj
|
|
|
|
|
Trimethobenzamide Oral
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Bile Acid
Salt
|
Ursodiol Capsule
(Generic Only)
|
Chenodiol
(Chenodal�)
|
|
|
|
|
Ursodiol Tablet
|
|
|
|
|
Ursodiol USP
(Actigall� - Brand Only)
|
|
|
|
|
Ursodiol (URSO
250�)
|
|
|
|
|
Ursodiol (URSO
Forte�)
|
|
|
|
|
|
|
|
Pancreatic
Enzymes
|
Creon
|
Pancreaze
|
|
|
|
Pancrelipase
|
|
|
|
|
Zenpep
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Proton Pump
Inhibitors
|
Esomeprazole (Nexium�)
|
Dexlansoprazole
(Dexilant�)
|
|
|
|
Omeprazole (Generic
legend only)
|
Esomeprazole Suspension (Nexium�)
|
|
|
|
|
Lansoprazole
Capsule
|
|
|
|
|
Lansoprazole Capsule (Prevacid�)
|
|
|
|
|
Lansoprazole
Solutab
|
|
|
|
|
Lansoprazole Solutab (Prevacid�)
|
|
|
|
|
Omeprazole
Suspension (Prilosec�)
|
|
|
|
|
Omeprazole/Sodium
Bicarbonate (Generic legend only)
|
|
|
|
|
Pantoprazole
|
|
|
|
|
Pantoprazole
Suspension (Protonix�)
|
|
|
|
|
Rabeprazole (Aciphex�)
|
|
|
|
|
|
|
|
Ulcerative
Colitis Agents
|
Balsalazide
|
Mesalamine DR (Asacol HD�)
|
|
|
|
Mesalamine ER (Apriso�)
|
Mesalamine
Sulfite-free Enema (sfRowasa�)
|
|
|
|
Mesalamine Enemas
|
Mesalamine MMX (Lialda�)
|
|
|
|
Mesalamine
(Asacol�)
|
Mesalamine
Oral (Pentasa�)
|
|
|
|
Mesalamine Suppositories (Canasa�)
|
Olsalazine Oral (Dipentum�)
|
|
|
|
Sulfasalazine
|
|
|
|
|
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
HYPERLIPIDEMIA
|
|
|
|
|
Lipotropics,
Other
|
Cholestyramine
|
Colesevelam (Welchol�)
|
|
|
|
Colestipol
|
Ezetimibe (Zetia�)
|
|
|
|
Fenofibrate (Tricor�)
|
Fenofibrate (Antara�)
|
|
|
|
Fenofibric Acid (Trilipix�)
|
Fenofibrate (Fenoglide�)
|
|
|
|
Gemfibrozil
|
Fenofibrate (Generics)
|
|
|
|
Niacin ER (Niaspan�)
|
Fenofibrate (Lipofen�)
|
|
|
|
Niacin IR (Niacor�)
|
Fenofibrate (Triglide�)
|
|
|
|
|
Fenofibric Acid
(Generic)
|
|
|
|
|
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�)
|
Pitavastatin
(Livalo�)
|
|
|
|
Pravastatin
|
|
|
|
|
Rosuvastatin
(Crestor�)
|
|
|
|
|
Simvastatin
|
|
|
|
|
|
|
|
|
HYPERTENSION
|
|
|
|
|
ACE
Inhibitors & Direct Renin
Inhibitors
|
Benazepril
|
Aliskiren
(Tekturna�)
|
|
|
|
Benazepril/HCTZ
|
Aliskiren/HCTZ (Tekturna
HCT�)
|
|
|
|
Captopril
|
Azilsartan Meoxomil
(Edarbi�)
|
|
|
|
Captopril/HCTZ
|
Candesartan
(Atacand�)
|
|
|
|
Enalapril
|
Candesartan/HCTZ (Atacand HCT�)
|
|
|
|
Enalapril/HCTZ
|
Eprosartan
(Teveten�)
|
|
|
|
Fosinopril
|
Eprosartan/HCTZ (Teveten
HCT�)
|
|
|
|
Fosinopril/HCTZ
|
Moexipril
|
|
|
|
Irbesartan
(Avapro�)
|
Moexipril/HCTZ
|
|
|
|
Irbesartan/HCTZ
(Avalide�)
|
Olmesartan
(Benicar�)
|
|
|
|
Lisinopril
|
Olmesartan/HCTZ (Benicar
HCT�)
|
|
|
|
Lisinopril/HCTZ
|
Perindopril
|
|
|
|
Losartan
|
Telmisartan
(Micardis�)
|
|
|
|
Losartan/HCTZ
|
Telmisartan/HCTZ (Micardis
HCT�)
|
|
|
|
Quinapril
|
|
|
|
|
Quinapril/HCTZ
|
|
|
|
|
Ramipril
|
|
|
|
|
Trandolapril
|
|
|
|
|
Valsartan
(Diovan�)
|
|
|
|
|
Valsartan/HCTZ (Diovan
HCT�)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Angiotensin
Modulators/Calcium Channel Blockers Combination
Products
|
Amlodipine/Benazepril -
Generic only
|
Amlodipine/Aliskiren
(Tekamlo�)
|
|
|
|
Amlodipine/Olmesartan
(Azor�)
|
Amlodipine/Aliskiren/HCTZ
(Amturnide�)
|
|
|
|
Amlodipine/Olmesartan Med/HCTZ (Tribenzor�)
|
Amlodipine/Benazepril
(Lotrel�)
|
|
|
|
Amlodipine/Valsartan
(Exforge�)
|
Amlodipine/Telmisartan
(Twnysta�)
|
|
|
|
Amlodipine/Valsartan/HCTZ (Exforge
HCT�)
|
|
|
|
|
Valsartan/Aliskiren (Valturna�)
|
|
|
|
|
Trandolapril/Verapamil
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Beta
Blockers Agents
|
Acebutolol
|
Carvedilol CR (Coreg
CR�)
|
|
|
|
Atenolol
|
Metoprolol
Succinate ER (Toprol XL)
|
|
|
|
Atenolol/Chlorthalidone
|
|
|
|
|
Betaxolol
|
|
|
|
|
Bisoprolol
|
|
|
|
|
Bisoprolol/HCTZ
|
|
|
|
|
Carvedilol
|
|
|
|
|
Labetalol
|
|
|
|
|
Metoprolol
|
|
|
|
|
Metoprolol
/HCTZ
|
|
|
|
|
Metoprolol Succinate
ER
|
|
|
|
|
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 CD (Cardizem CD
360 mg)
|
Isradipine SR (Dynacirc
CR�)
|
|
|
|
Diltiazem IR
|
Nisoldipine
|
|
|
|
Diltiazem ER
|
Verapamil ER (Covera
HS�)
|
|
|
|
DiltiazemSR
|
Verapamil ER
PM
|
|
|
|
Felodipine
ER
|
|
|
|
|
Isradipine
|
|
|
|
|
Nicardipine
|
|
|
|
|
Nifedipine
ER
|
|
|
|
|
Nifedipine IR
|
|
|
|
|
Nimodipine
|
|
|
|
|
Verapamil
|
|
|
|
|
Verapamil ER
(Generics)
|
|
|
|
|
VerapamilIR
|
|
|
|
|
Verapamil SR
|
|
|
|
|
|
|
|
|
ANTICOAGULANTS
|
|
|
|
|
Platelet
Aggregation Inhibitors
|
Aspirin/Dipyridamole ER
(Aggrenox�)
|
Prasugrel
(Effient�)
|
|
|
|
Clopidogrel
(Plavix�)
|
Ticlopidine
|
|
|
|
Dipyridamole
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Anticoagulants
|
Dabigatran
(Pradaxa�)
|
Enoxaparin
(Generic)
|
|
|
|
Dalteparin
(Fragmin�)
|
Tinzaparin (Innohep�)
|
|
|
|
Enoxaparin
(Lovenox�)
|
|
|
|
|
Fondaparinux
(Arixtra�)
|
|
|
|
|
Rivaroxaban
(Xarelto�)
|
|
|
|
|
Warfarin
|
|
|
|
|
|
|
|
|
Pulmonary
Arterial Hypertension (PAH)
|
Bosentan
(Tracleer�)
|
Ambrisentan
(Letaris�)
|
|
|
|
Iloprost
(Ventavis�)
|
Treprostinil
(Tyvaso�)
|
|
|
|
Sildenafil
(Revatio�)
|
|
|
|
|
Tadalafil
(Adcirca�)
|
|
|
|
|
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
ANTIBIOTICS
|
|
|
|
|
Cephalosporin
and Related Antibiotics
|
Amoxicillin/Clavulanate Suspension
|
Amoxicillin/Clavulanate ER
|
|
|
|
Amoxicillin/Clavulanate Tablets
|
Cefaclor
|
|
|
|
Amoxicillin/Clavulanate Susp (Augmentin 125 &
250)
|
Cefaclor ER500
|
|
|
|
Cefadroxil
|
Cefdinir
|
|
|
|
Cefixime (Suprax�)
|
Cefditoren Pivoxil
|
|
|
|
Cefprozil
|
Cefpodoxime
|
|
|
|
Ceftibuten (Cedax�)
|
Cefuroxime AxetilSusp
(Ceftin�)
|
|
|
|
Cefuroxime Tablets
|
|
|
|
|
Cephalexin
|
|
|
|
|
|
|
|
|
Fluoroquinolones
|
Oral
|
|
|
|
CiprofloxacinTablets
|
Ciprofloxacin
Suspension(Cipro Suspension �)
|
|
|
|
Levofloxacin
(Levaquin�)
|
Ciprofloxacin
ER
|
|
|
|
|
Ciprofloxacin ER
(Proquin XR�)
|
|
|
|
|
Gemifloxacin
(Factive�)
|
|
|
|
|
Moxifloxacin
(Avelox�)
|
|
|
|
|
Norfloxacin
(Noroxin�)
|
|
|
|
|
Ofloxacin
|
|
|
|
|
|
|
|
Antibiotics,
Gastrointestinal
|
Metronidazole
|
Fidaxomicin
(Dificid�)
|
|
|
|
Neomycin
|
Metronidazole ER
(Flagyl ER�)
|
|
|
|
Nitazoxanide
(Alinia�)
|
Rifaximin
(Xifaxan�)
|
|
|
|
Tinidazole
(Tindamax�)
|
Vancomycin
(Vancocin�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Antibiotic, Inhaled
|
Tombramycin
(Tobi�)
|
Azteonam
(Cayston�)
|
|
|
|
|
|
|
|
Macrolides -
Ketolides
|
Azithromycin
|
Azithromycin ER
(Zmax�)
|
|
|
|
Erythromycin
|
Clarithromycin
|
|
|
|
|
Clarithromycin
ER
|
|
|
|
|
Telithromycin
(Ketek�)
|
|
|
|
|
|
|
|
Tetracyclines
|
Doxycycline Hyclate (generic)
|
Demeclocycline
|
|
|
|
Doxycycline Hyclate DR (generic)
|
Doxycycline
Calcium Suspension (Vibramycin�)
|
|
|
|
Doxycycline
Monohyrate
|
Doxycycline
Hyclate (Doryx�)
|
|
|
|
Minocycline
Cap
|
Doxycycline
DR (Oracea�)
|
|
|
|
Minocycline
Tab
|
Minocycline ER -
generic
|
|
|
|
Tetracycline
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Vaginal
|
Clindamycin
Vaginal Cream
|
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
|
Clotrimazole Troches
|
Flucytosine
(Ancobon�)
|
|
|
|
Fluconazole
|
Griseofulvin Tablets (Grifulvin V�)
|
|
|
|
Griseofulvin Suspension
|
Itraconazole
|
|
|
|
Griseofulvin (Gris-Peg�)
|
Itraconazole
Solution (Sporanox�)
|
|
|
|
Ketoconazole
|
Miconazole
(Oravig�)
|
|
|
|
Nystatin
|
Posaconazole (Noxafil�)
|
|
|
|
Terbinafine (no granules)
|
Terbinafine
(Terbinex�)
|
|
|
|
|
Terbinafine Granules (Lamisil Granules�)
|
|
|
|
|
Voriconazole (generic)
|
|
|
|
|
Voriconazole (VFEND�)
|
|
|
HEPATITIS
AGENTS
|
|
|
|
|
Hepatitis C
Agents
|
Boceprevir
(Victrelis�)
|
Consensus
Interferon (Infergen�)
|
|
|
|
Ribavirin
|
Peginterferon
alfa 2B (Peg-Intron�)
|
|
|
|
Peginterferon
alfa 2A (Pegasys�)
|
Peginterferon
alfa 2B (Peg-Intron Redipen�)
|
|
|
|
|
Telaprevir
(Incivek�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Allergic
Conjunctivitis
|
Cromolyn Sodium
|
Alcaftadine
(Lastacaft�)
|
|
|
|
Loteprednol
(Alrex�)
|
Azelastine HC
(Generic; Optivar�)
|
|
|
|
Olopatadine
HCI (Pataday�)
|
Bepotastine
Besilate (Bepreve�)
|
|
|
|
|
Emedastine Difumarate (Emadine�)
|
|
|
|
|
Epinastine
HCI (Generic; Elestat�)
|
|
|
|
|
Lodoxamide Tromethamine (Alomide�)
|
|
|
|
|
Nedocromil
Sodium (Alocril�)
|
|
|
|
|
Olopatadine HCI (Patanol�)
|
|
|
|
�
|
Pemirolast Potassium (Alamast�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Glaucoma
Agents
|
|
|
|
|
Intraocular
Pressure (IOP) Reducers
|
Betaxolol
|
Apraclonidine (Generic; Iopidine�)
|
|
|
|
Betaxolol
(Betoptic S�)
|
Bimatroprost
(Lumigan 2.5ml; 5ml; 7.5ml�)
|
|
|
|
Brimonidine 0.15% (Alphagan P 0.15% - Brand
Only)
|
Brimonidine 0.1%
(Alphagan P 0.1%�)
|
|
|
|
Brimonidine 0.2% (Generic)
|
Brimonidine 0.15%
(Generic only)
|
|
|
|
Brimonidine/Timolol (Combigan�)
|
Dorzolamide
(Trusopt� - Brand Only)
|
|
|
|
Brinzolamide (Azopt�)
|
Dorzolamide/Timolol
(Cosopt� - Brand Only)
|
|
|
|
Carteolol
|
Latanoprost (Xalatan� - Brand Only)
|
|
|
|
Dorzolamide (Generic
only)
|
Levobunolol
(Betagan� - Brand Only)
|
|
|
|
Dorzolamide/Timolol
(Generic only)
|
Timolol
(Timoptic�)
|
|
|
|
Latanoprost
(Generic only)
|
|
|
|
|
Levobunolol (Generic only)
|
|
|
|
|
Metipranolol (Generic; Optipranolol�)
|
|
|
|
|
Pilocarpine
|
|
|
|
|
Timolol
(Generic; Betimol�)
|
|
|
|
|
Timolol LA (Istalol�)
|
|
|
|
|
Travoprost (Travantan Z�)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ophthalmics,
Antibiotic
|
Besifloxacin
(Besivance�)
|
Azithromycin (AzaSite�)
|
|
|
|
Ciprofloxacin Ointment (Ciloxan�)
|
Bacitracin
|
|
|
|
Ciprofloxacin Solution (Generic)
|
Bacitracin/Polmyxin B Ointment
|
|
|
|
Erythromycin
|
Gatifloxacin
0.5% (Zymaxid�)
|
|
|
|
Garamycin Drops
|
Levofloxacin (Generic; Iquix; Quixin�)
|
|
|
|
Garamycin Ointment
|
Natamycin (Natacyn�)
|
|
|
|
Gatifloxacin
0.3% (Zymar�)
|
Neomycin-Polmyxin-Gramicidin
|
|
|
|
Gentamicin Drops
|
Ofloxacin Solution (Ocuflox� - Brand Only)�
|
|
|
|
Gentamicin Ointment
|
|
|
|
|
Moxifloxacin
(Moxeza; Vigamox�)
|
|
|
|
|
Neomycin-Polymyxin-Bacitracin
Ointment
|
|
|
|
|
Ofloxacin Solution
(Generic Only)
|
|
|
|
|
Polymyxin
B/Trimethoprim (Generic; Polytrim�)
|
|
|
|
|
Sulfacetamide
(Generic; Bleph-10�)
|
|
|
|
|
Tobramycin (Generic;
Tobrex�)
|
|
|
|
|
|
|
|
|
Ophthalmics,
Antibiotic- Steroid Combos
|
Gentamicin/Prednisolone
(Pred-G;Pred-G S.O.P. �)
|
Neomycin/Polymyxin
B/Hydrocortisone
|
|
|
|
Neomycin/Polymyxin
B/Dexamethasone
|
Neomycin/Bacitracin/Polymyxin
B/Hydrocortisone
|
|
|
|
Sulfacetamide/Prednisolone
Ointment (Blephamide S.O.P. �)
|
Tobramycin/Dexamethasone
Suspension (Generic)
|
|
|
|
Sulfacetamide/Prednisolone
Solution (Generic; Blephamide�)
|
Tobramycin/Dexamethasone
ST (Tobradex ST�)
|
|
|
|
Tobramycin/Dexamethasone
Ointment (Tobradex�)
|
|
|
|
|
Tobramycin/Dexamethasone
Suspension (Tobradex�)
|
|
|
|
|
Tobramycin/Loteprednol
(Zylet�)
|
|
|
|
|
|
|
|
|
Ophthalmics,
Anti-Inflammatories
|
Dexamethasone (Generic; Maxidex�)
|
Bromfenac (Generic;
Bromday; Xibrom�)
|
|
|
|
Diclofenac
|
Difluprednate (Durezol�)
|
|
|
|
Fluorometholone 0.1% Ointment (FML S.O.P.
�)
|
Fluorometholone 0.1% Suspension (FML� - Brand
Only)
|
|
|
|
Fluorometholone 0.1% Suspension (Generic)
|
Fluorometholone Acetate 0.1% Solution
(Flarex�)
|
|
|
|
Fluorometholone 0.25% Suspension (FML
Forte�)
|
Ketorolac
(Generic; Acular�)
|
|
|
|
Flurbiprofen
|
Ketorolac LS (Generic; Acular LS�)
|
|
|
|
Loteprednol Drops (Lotemax�)
|
Ketorolac (Acuvail�)
|
|
|
|
Loteprednol Ointment (Lotemax�)
|
Nepafenac (Nevanac�)
|
|
|
|
Prednisolone Acetate 0.12% Solution (Generic; Pred
Mild�)
|
Prednisolone Acetate 1% (Pred Forte�)
|
|
|
|
Prednisolone Acetate 1% (Generic)
|
Prednisolone Sodium Phosphate
|
|
|
|
|
Rimexolone
(Vexol�)
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Analgesics/Anesthetic,
Topical
|
Diclofenac
Sodium Gel (Voltaren�)
|
Diclofenac
Epolamine Patch (Flector�)
|
|
|
|
Lidocaine Patch
(Lidoderm�)
|
Diclofenac
Sodium (Pennsaid�)
|
|
|
|
|
|
|
|
Analgesics,
Narcotics Short Acting
|
Acetaminophen
w/Codeine
|
Fentanyl Buccal
(Generics)
|
|
|
|
Butalbital
Compound with Codeine
|
Fentanyl Buccal
(Fentora�)
|
|
|
|
Codeine
|
Fentanyl Buccal
(Onsolis�)
|
|
|
|
Dihydrocodeine
Bitartrate/Acetaminophen/Caffeine (Generics)
|
Fentanyl Sublingual
(Abstral�)
|
|
|
|
Dihydrocodeine
Bitartrate/Acetaminophen/Caffeine (Trezix�)
|
Hydrocodone/Acetaminophen
(Hycet�)
|
|
|
|
Hydrocodone/Acetaminophen
|
Hydrocodone/Acetaminophen
(Zamicet�)
|
|
|
|
Hydrocodone/Ibuprofen
|
Hydrocodone/Acetaminophen
(Zolvit�)
|
|
|
|
Hydromorphone
|
Hydrocodone/Ibuprofen (Ibudone�)
|
|
|
|
Meperidine
|
Hydrocodone/Ibuprofen
(Reprexain�)
|
|
|
|
Morphine
IR
|
Hydromorphone Liquid
(Dilaudid�)
|
|
|
|
Oxycodone
|
Opium
Tincture
|
|
|
|
Oxycodone/Acetaminophen
|
Oxymorphone
|
|
|
|
Oxycodone
w/Aspirin
|
Oxymorphone IR
(Opana�)
|
|
|
|
Oxycodone/Ibuprofen
|
Tapentadol
(Nucynta�)
|
|
|
|
Pentazocine/Acetaminophen
|
Tramadol ODT (Rybix
ODT�)
|
|
|
|
Pentazocine/Naloxone
|
|
|
|
|
Tramadol
|
|
|
|
|
Tramadol/Acetaminophen�
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Analgesics,
Narcotics Long Acting
|
Fentanyl
Transdermal
|
Buprenorphine
Transdermal (Butrans�)
|
|
|
|
Fentanyl Transdermal
(Duragesic Matrix)
|
Hydromorphone ER
(Exalgo�)
|
|
|
|
Methadone
HCL
|
Morphine Sulfate
ER (Avinza�)
|
|
|
|
Morphine Sulfate
ER (Kadian�)
|
Morphine
Sulfate ER/Naltrexone (Embeda�)
|
|
|
|
Morphine Sulfate ER
(Generic)
|
Oxycodone
ER
|
|
|
|
|
Oxycodone ER
(Oxycontin�)
|
|
|
|
|
Oxycodone
Reformulated (OxyContin Reformulated�)
|
|
|
|
|
Oxymorphone ER
(Opana ER�)
|
|
|
|
|
Tramadol
ER
|
|
|
|
|
Tramadol ER
(Ryzolt�)
|
|
|
|
|
Tramadol ER
(Ultram ER�)
|
|
|
|
|
|
|
|
Nonsteroidal
Anti - Inflammatories (NSAIDs)
|
Diclofenac Potassium Oral (Generic)
|
Celecoxib (Celebrex�)
|
|
|
|
Diclofenac Sodium Oral
(Generic)
|
Diclofenac/Misoprostol
(Arthrotec�)
|
|
|
|
Esomeprazole/Naproxen (Vimovo�)
|
Diclofenac
Potassium (Zipsor�)
|
|
|
|
Etodolac
|
Diclofenac SR
|
|
|
|
Flurbiprofen
|
Diflunisal (Generic;
Dolobid�)
|
|
|
|
Ibuprofen Rx Suspension (Generic)
|
Etodolac SR
|
|
|
|
Ibuprofen Rx Tablet (Generic)
|
Fenoprofen (Generic;
Nalfon�)
|
|
|
|
Indomethacin Capsule
|
Indomethacin Rectal
(Indocin�)
|
|
|
|
Indomethacin Suspension (Indocin�)
|
Indomethacin ER Capsule
(Generic)
|
|
|
|
Ketoprofen
|
Ketoprofen
ER
|
|
|
|
Ketorolac
|
Ketorolac Nasal Spray
(Sprix�)
|
|
|
|
Meloxicam Suspension (Mobic� Brand Only)
|
Meclofenamate
|
|
|
|
Meloxicam Tablet (Generic only)
|
Mefenamic Acid (Generic;
Ponstel�)
|
|
|
|
Naproxen
EC (Generic only)
|
Meloxicam Suspension
(Generic only)
|
|
|
|
Naproxen
Sodium
|
Meloxicam Tablet (Mobic�
Brand Only)
|
|
|
|
Naproxen
Suspension (Generic only)
|
Nabumetone
|
|
|
|
Naproxen
Tablet (Generic only)
|
Naproxen EC (Naprosyn� -
Brand Only)
|
|
|
|
Oxaprozin
|
Naproxen
Suspension (Naprosyn� - Brand Only)
|
|
|
|
Piroxicam
(Generic; Feldene�)
|
Naproxen
Tablet (Naprosyn� - Brand Only)
|
|
|
|
Sulindac
|
Naproxen
500mg (Naprelan�)
|
|
|
|
|
Tolmetin
Capsule
|
|
|
|
|
Tolmetin
Tablet
|
|
|
|
|
|
|
|
|
|
|
|
|
Antimigraine
Agents,Triptans
|
Eletriptan
(Relpax�)
|
Almotriptan
(Axert�)
|
|
|
|
Sumatriptan
(Imitrex� Injection - Brand only)
|
Diclofenac
(Cambia�)
|
|
|
|
Sumatriptan
(Imitrex� Nasal - Brand only)
|
Frovatriptan
(Frova�)
|
|
|
|
Sumatriptan
(Oral � Generic only)
|
Naratriptan
|
|
|
|
|
Rizatriptan
(Maxalt�)
|
|
|
|
|
Rizatriptan
(Maxalt MLT�)
|
|
|
|
|
Sumatriptan
Injection � Generic only
|
|
|
|
|
Sumatriptan
Nasal � Generic only
|
|
|
|
|
Sumatriptan (Imitrex
Oral) � Brand only
|
|
|
|
|
Sumatriptan/Naproxen (Treximet�)
|
|
|
|
|
Zolmitriptan
(Zomig)
|
|
|
|
|
Zolmitriptan
(Zomig ZMT�)
|
|
|
|
|
Zolmitriptan
(Zomig� Nasal)
|
|
|
|
|
|
|
|
Skeletal
Muscle Relaxants
|
Baclofen
|
Carisoprodol
|
|
|
|
Chlorzoxazone
|
Carisoprodol
Compound
|
|
|
|
Cyclobenzaprine
|
Carisoprodol (Soma
250 mg�)
|
|
|
|
Methocarbamol
|
Cyclobenzaprine
(Fexmid�)
|
|
|
|
Tizanidine
(Generics)
|
Cyclobenzaprine ER
(Amrix�)
|
|
|
|
|
Dantrolene
Sodium
|
|
|
|
|
Metaxalone
|
|
|
|
|
Orphenadrine
|
|
|
|
|
Orphenadrine
Compound
|
|
|
|
|
Tizanidine
(Zanaflex�)
|
|
|
|
|
|
|
|
Cytokine and
CAM Antagonists
|
Adalimumab
Injection (Humira IJ Kit; Humira Kit�)
|
Abatacept (Orencia
Injection; Orencia Sub-Q�)
|
|
|
|
Certolizumab Pegol
(Cimzia Kit; Syringe Kit�)
|
Alefacept
Injection (Amevive�)
|
|
|
|
Etanercept
Injection (Enbrel Kit; Pen; Disp Syringe�)
|
Anakinra Injection
(Kineret�)
|
|
|
|
|
Golimumab (Simponi
Pen; Disp Syringe�)
|
|
|
|
|
Infliximab
Injection (Remicade�)
|
|
|
|
|
Tocilizumab
(Actemra�)
|
|
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
Gainwell Technologies Provider Relations Unit at 225-924-5040 or
800-473-2783.� ��
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Stimulants and Related Agents
|
Amphetamine Salt Combo (Generic;
Adderall�)
|
Amphetamine Salt Combo ER (Generic Only)
|
|
|
|
Amphetamine
Salt Combo ER (Adderall XR�
- Brand Only)
|
Armodafinil
(Nuvigil�)
|
|
|
|
Atomoxetine (Strattera�)
|
Clonidine Extended-release (Kapvay�)
|
|
|
|
Dexmethylphenidate
(Focalin� - Brand Only)
|
Dexmethylphenidate
(Generic Only)
|
|
|
|
Dexmethylphenidate ER (Focalin XR�)
|
Dextroamphetamine ER (Generic;
Dexadrine�)
|
|
|
|
Dextroamphetamine (Generic)
|
Dextroamphetamine Solution (Procentra�)
|
|
|
|
Guanfacine ER
(Intuniv�)
|
Methylphenidate
Solution (Generic)
|
|
|
|
Lisdexamfetamine (Vyvanse�)
|
Methamphetamine (Generic; Desoxyn�)
|
|
|
|
Methylphenidate (Generic, Metadate CD�)
|
Methylphenidate ER (Generic Concerta; Ritalin
LA�)
|
|
|
|
Methylphenidate ER (Generic excluding generic
Concerta)(Metadate CD & Concerta Brand only)
|
Modafinil (Provigil�)
|
|
|
|
Methylphenidate IR
(Methylin Chewable & Solution�)
|
|
|
|
|
Methylphenidate SR
(Ritalin SR�)
|
�
|
|
|
|
Methylphenidate
Transdermal Patches (Daytrana�)
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Antihistamines - Minimally
Sedating
|
Cetirizine Syrup
OTC
|
Acrivastin/Pseudoephedrine
(Semprex-D�)
|
|
|
|
Cetirizine
Syrup Rx
|
Cetirizine
Chewable Tablet OTC
|
|
|
|
Cetirizine
Tablet OTC
|
Cetirizine
Solution 5mg/5cc OTC
|
|
|
|
Cetirizine - D
OTC
|
Desloratadine
Tablet (Clarinex�)
|
|
|
|
Fexofenadine
Tablet 30mg, 60mg, 180mg (Generic Only)
|
Desloratadine
ODT (Clarinex ODT�)
|
|
|
|
Fexofenadine-D
12-hour (Generic Only)
|
Desloratadine
Syrup (Clarinex�)
|
|
|
|
Fexofenadine-D
24-hour (Generic Only)
|
Desloratadine/Pseudoephedrine (Clarinex-D
12-hour�)
|
|
|
|
Loratadine Tab
OTC (Generic Only)
|
Desloratadine/Pseudoephedrine (Clarinex-D
24-hour�)
|
|
|
|
Loratadine ODT
Tablet OTC (Generic Only)
|
Fexofenadine
Tablet 30mg, 60mg, 180mg (Allegra - Brand Only)
|
|
|
|
Loratadine-D
Tablet OTC (Generic Only)
|
Fexofenadine ODT
Tablet (Allegra ODT�)
|
|
|
|
Loratadine Syrup
OTC (Generic Only)
|
Fexofenadine/Pseudoephedrine (Allegra-D
12-hour� - Brand Only)
|
|
|
|
|
Fexofenadine/Pseudoephedrine (Allegra-D
24-hour� - Brand Only)
|
|
|
|
|
Fexofenadine
Syrup (Allegra Syrup�)
|
|
|
|
|
Levocetirizine
Tablet (Generic; Xyzal�)
|
|
|
|
|
LevocetirizineSyrup (Generic; Xyzal�)
|
|
|
|
|
Loratadine Capsule
OTC - (Claritin� - Brand Only)
|
|
|
|
|
Loratadine Syrup
OTC (Claritin� - Brand Only)
|
|
|
|
|
Loratadine Tablet
OTC(Claritin�)
|
|
|
|
|
Loratadine OTD
(Claritin� - Brand Only)
|
|
|
|
|
Loratadine
Chewable OTC - (Claritin�)
|
|
|
|
|
Loratadine-D 12
hours OTC (Claritin- D�)
|
|
|
|
|
Loratadine-D 24
hours OTC (Claritin- D�)
|
|
|
|
|
|
|
|
|
|
|
|
|
Rhinitis Agents, Nasal
|
Azelastine (Astelin; Astepro�)
|
Azelastine (Generic)
|
|
|
|
Fluticasone Propionate
(Flonase� -
Brand Only)
|
Beclomethasone
(Beconase AQ�)
|
|
|
|
Ipratropium Nasal
|
Budesonide Aqua (Rhinocort Aqua�)
|
|
|
|
Mometasone
(Nasonex�)
|
Ciclesolide (Omnaris�)
|
|
|
|
Olopatadine (Patanase�)
|
Flunisolide
|
|
|
|
|
Fluticasone
Furoate (Veramyst�)
|
|
|
|
|
Fluticasone Propionate (Generic Only)
|
|
|
|
|
Triamcinolone (Nasacort AQ�)
|
|
|
|
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
|
ORAL
|
|
|
Antipsychotic Agents
|
Amitriptyline/Perphenazine
|
Aripiprazole Oral Solution (Abilify Oral
Solution�)
|
|
|
|
Aripiprazole
Discmelt (Abilify�)
|
Clozapine
(Clozaril; Fazaclo�)
|
|
|
|
Aripiprazole
Tablet (Abilify�)
|
Lurasidone
(Latuda�)
|
|
|
|
Asenapine
(Saphris)
|
Olanzapine
(Zyprexa; Zyprexa Zydis�)
|
|
|
|
Chlorpromazine
|
Olanzapine/Fluoxetine (Symbyax�)
|
|
|
|
Clozapine (Generics Only)
|
Paliperidone ER (Invega�)
|
|
|
|
Fluphenazine Elixir
|
Risperidone ODT
(Risperdal� - Brand Only)
|
|
|
|
Fluphenazine
Tablet
|
Risperidone Solution
(Risperdal� - Brand Only)
|
|
|
|
Haloperidol
Oral
|
Risperidone Tablet
(Risperdal� - Brand Only)
|
|
|
|
Haloperidol
Lactate Concentrate
|
|
|
|
|
Iloperidone
Dose pack(Fanapt�)
|
|
|
|
|
Iloperidone
Tablet (Fanapt�)
|
|
|
|
|
Molindone (Moban�)
|
|
|
|
|
Perphenazine
|
|
|
|
|
Pimozide
(Orap�)
|
|
|
|
|
Quetiapine (Seroquel�)
|
|
|
|
|
Quetiapine (Seroquel XR�)
|
|
|
|
|
Risperidone ODT (Generic Only)
|
|
|
|
|
Risperidone
Solution (Generic Only)
|
|
|
|
|
Risperidone
Tablet (Generic Only)
|
|
|
|
|
Thioridazine
|
|
|
|
|
Thiothixene (Generic; Navane�)
|
|
|
|
|
Trifluoperazine (Generic)
|
|
|
|
|
Ziprasidone
(Geodon�)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
INJECTIONS
|
|
|
|
Aripiprazole (Abilify�)
|
Haloperidol Decanoate (Haldol�
-
Brand Only)
|
|
|
|
Fluphenazine
Decanoate
|
Olanzapine
(Zyprexa�)
|
|
|
|
Haloperidol Decanoate (Generic Only)
|
Olanzapine
(Zyprexa Relprevv�)
|
|
|
|
Haloperidol
Lactate (Generic Only)
|
Paliperidone
(Invega Sustenna�)
|
|
|
|
Risperidone (Risperdal
Consta�)
|
|
|
|
|
Ziprasidone (Geodon�)
|
|
|
|
Descriptive
Therapeutic Class
|
Drugs on
PDL
|
Drugs Which
Require PA
|
Effective
Date
January 1, 2012
|
|
Bronchodilator, Beta-Adrenergic
Agents
|
|
|
|
|
|
INHALATION
|
|
|
|
Albuterol Sulfate Nebulizer Solution
100mg/20ml
|
Albuterol Sulfate HFA MDI (Ventolin
HFA�)
|
|
|
|
Albuterol
Sulfate Nebulizer Solution 2.5mg/3ml
|
Albuterol
Sulfate Nebulizer Low-Dose 0.63mg/3ml, 1.25mg/3ml
|
|
|
|
Albuterol
Sulfate Nebulizer Solution 2.5mg/0.5ml
|
Arformoterol
Inhalation Solution (Brovana Inhalation Solution�)
|
|
|
|
Albuterol
Sulfate Nebulizer Low-Dose (Accuneb�)
|
Formoterol
DPI (Foradil�)
|
|
|
|
Albuterol Sulfate HFA (ProAir HFA�)
|
Formoterol Inhalation Solution (Perforomist Inhalation
Solution�)
|
|
|
|
Albuterol Sulfate
HFA MDI (Proventil HFA�)
|
Indacaterol for Inhalation
(Arcapta�)
|
|
|
|
|
Levalbuterol HCL
Nebulizer Solution (Generic; Xopenex�)
|
|
|
|
|
Levalbuterol HFA (Xopenex HFA�)
|
|
|
|
|
Pirbuterol (Maxair Autohaler�)
|
|
|
|
|
Salmeterol Xinafoate (Serevent Diskus�)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
ORAL
|
|
|
Bronchodilator,
Beta-Adrenergic
|
Albuterol
Sulfate Syrup
|
Albuterol
Sulfate ER (Generic; Vospire ER
Tablet�)
|
|
|
Agents
cont�
|
Albuterol
Sulfate Tablet
|
Metaproterenol
Sulfate Tablet
|
|
|
|
Metaproterenol
Sulfate Syrup
|
|
|
|
|
Terbutaline
Sulfate
|
|
|
|
|