Item
Number |
Drug
Name |
Drugs
on PDL |
Drugs
Which
Require PA |
Implementation
Date |
| 1 |
Proton Pump Inhibitors |
Lansoprazole
(Prevacid�) |
Esomeprazole
(Nexium�) |
June
10, 2002 |
| |
|
Pantoprazole (Protonix�) |
Omeprazole
(Prilosec�) |
|
| |
|
|
Rabeprazole
(Aciphex�) |
|
| |
|
|
|
|
| 1 |
Proton Pump Inhibitors |
Lansoprazole (Prevacid�) |
Esomeprazole (Nexium�) |
October
14, 2002 |
| |
UPDATES |
|
Omeprazole
(Prilosec�) |
|
| |
|
|
Pantoprazole
(Protonix�) |
|
| |
|
|
Rabeprazole
(Aciphex�) |
|
| |
|
|
|
|
| 2 |
Selective Cycloxgenase |
|
|
|
| |
Cox 2 Inhibitors |
Valdecoxib
(Betxtra�) |
Rofecoxib
(Vioxx�) |
June
10, 2002 |
| |
|
Celecoxib
(Celebrex�) |
|
|
| |
|
|
|
|
| 3 |
Statins |
Atorvastatin
(Lipitor�) |
Simvastatin
(Zocor�) |
June
24, 2002 |
| |
|
Fluvastatin
(Lescol�) |
|
|
| |
|
Fluvastatin
XL (Lescol XL�) |
|
|
| |
|
Lovastatin
(Mevacor�) |
|
|
| |
|
Pravastatin
(Pravachol�) |
|
|
| |
|
|
|
|
| |
Statins |
Fluvastatin (Lescol) |
Atorvastatin (Lipitor) |
March 26, 2003 |
| |
UPDATES |
Fluvastatin XL (Lescol
XL) |
Pravastatin (Pravachol) |
|
| |
|
Lovastatin |
|
|
| |
|
Lovastatin ER (Altocor) |
|
|
| |
|
Simvastatin (Zocar) |
|
|
| |
|
|
|
|
| 4 |
Leukotriene Modifiers |
Montelukast
(Singulair�) |
Zileuton
(Zyflo�) |
July
1, 2002 |
| |
|
Zafirlukast
(Accolate�) |
|
|
| |
|
|
|
|
| 5 |
Oral Diabetic Medications |
|
|
|
| |
Prandin/Starlix |
Nateglinide
(Starlix�) |
Repaglinide
(Prandin�) |
July
1, 2002 |
| |
Precose/Glyset |
Acarbose
(Precose�) |
Miglitol
(Glyset�) |
|
| |
|
|
|
|
| 6 |
Nasal Steroids |
Beclomethasone
(Beconase AQ�) |
Beclomethasone
(Vancenase�) |
July
15, 2002 |
| |
|
Beclomethasone
(Beconase AQ�) |
Beclomethasone
(Vancenase AQ�) |
|
| |
|
Mometasone
(Nasonex�) |
Budesonide
(Rhinocort�) |
|
| |
|
Triamcinolone
(Tri-Nasal�) |
Budesonide
(Rhinocort Agua�) |
|
| |
|
|
Flunisloide
(Nasarel�) |
|
| |
|
|
Flunisloide
(Nasalide�) |
|
| |
|
|
Fluticasone
(Flonase�) |
|
| |
|
|
Triamcinolone
(Nasacort�) |
|
| |
|
|
Triamcinolone
(Nasacort AQ�) |
|
| |
|
|
|
|
| 7 |
Inhaled Steroids |
Budesonide
(Pulmicort Respules) |
Beclomethasone
Dipropionate (Belcovent�) |
July
15, 2002 |
| |
|
Fluticasone
(Flovent/Flovent Rotadisk�) |
Beclomethasone
Dipropionate (Vanceril�) |
|
| |
|
Triamcinolone
(Azmacort�) |
Beclomethasone
Dipropionate (Vanceril DS�) |
|
| |
|
|
Baclomethasone
Dipropionate HFA (Qvar�) |
|
| |
|
|
Budesonide
(Pulmicort Turbuhaler�) |
|
| |
|
|
Flunisolide
(Aerobid�, Aerobid-M�) |
|
| |
|
|
Fluticasone/Salmeterol
(Advair�) |
|
| |
|
|
|
|
| 7 |
Inhaled Steroids |
Budesonide
(Pulmicort Respules) |
Beclomethasone
Dipropionate (Belcovent�) |
October
14, 2002 |
| |
UPDATES |
Fluticasone
(Flovent/Flovent Rotadisk�) |
Beclomethasone
Dipropionate (Vanceril�) |
|
| |
|
Fluticasone/Salmeterol(Advair�) |
Beclomethasone
Dipropionate (Vanceril DS�) |
|
| |
|
Triamcinolone
(Azmacort�) |
Baclomethasone
Dipropionate HFA (Qvar�) |
|
| |
|
Fluticasone/Salmeterol
(Advair�) |
Budesonide
(Pulmicort Turbuhaler�) |
|
| |
|
|
Flunisolide
(Aerobid�, Aerobid-M�) |
|
| |
|
|
|
|
| |
|
|
|
|
| 8 |
H2 Antagonists |
Cimetidine |
Nizatidine
(Axid�) |
August 5, 2002 |
| |
|
Famotidine |
Famotidine
RPD (Pepcid RPD�) |
|
| |
|
Ranitidine |
Ranitidine
Efferdose (Zantac Efferdose�) |
|
| |
|
|
Ranitidine
Granules (Zantac Granules�) |
|
| |
|
|
|
|
| 9 |
Selective
Serotonin |
|
|
|
| |
Reuptake
Inhibitors |
Citalopram
(Celexa�) |
Fluoxetine
(Sarafem�) |
August 5, 2002 |
| |
|
Paroxetine
(Paxil�) |
Fluoxetine
Weekly (Prozac Weekly�) |
|
| |
|
Fluoxetine |
Sertraline
(Zoloft�) |
|
| |
|
Fluvoxamine |
|
|
| |
|
|
|
|
| 10 |
Minimally Sedating
Antihistamines |
Loratadine
(Claritin�) |
Cetirizine
(Zyrtec�) |
August 5, 2002 |
| |
|
Loratadine/Pseudoephedrine
(Claritin-D 12,24 hour) |
Cetirizine/Pseudoephedrine
(Zyrtec-D�) |
|
| |
|
Desloratadine
(Clarinex�) |
Fexofenadine
(Allegra�) |
|
| |
|
|
Fexofenadine/Pseudoephedrine
(Allegra-D�) |
|
| |
|
|
|
|
| 11 |
ACE Inhibitors |
Benazepril
(Lotensin�) |
Perindopril
(Aceon�) |
August
12, 2002 |
| |
|
Benazepril/HCTZ
(LotensinHCT�) |
Ramipril
(Altace�) |
|
| |
|
Captopril |
|
|
| |
|
Captopril/HCTZ |
|
|
| |
|
Enalapril |
|
|
| |
|
Enalapril/HCTZ |
|
|
| |
|
Fosinopril
(Monopril�) |
|
|
| |
|
Fosinopril/HCTZ
(Monopril-HCT�) |
|
|
| |
|
Lisinopril |
|
|
| |
|
Lisinopril/HCTZ |
|
|
| |
|
Moexipril
(Univasc�) |
|
|
| |
|
Moexipril/HCTZ
(Uniretic�) |
|
|
| |
|
Quinapril
(Accupril�) |
|
|
| |
|
Quinapril/HCTZ
(Accuretic�) |
|
|
| |
|
Trandolapril
(Mavik�) |
|
|
| |
|
|
|
|
| 12 |
Angiotensin II
Receptor |
|
|
|
| |
Blockers (ARBS) |
Telmisartan
(Micardis�) |
Candesartan
(Atacand�) |
August
12, 2002 |
| |
|
Telmisartan/HCTZ
(Micardis HCT�) |
Candesartan/HCTZ
(Atacand HCT�) |
|
| |
|
Valsartan
(Diovan�) |
Eprosartan
(Teveten�) |
|
| |
|
Valsartan/HCTZ
(Diovan HCT�) |
Irbesartan
(Avapro�) |
|
| |
|
|
Irbesartan/HCTZ
(Avalide�) |
|
| |
|
|
Losartan
(Cozaar�) |
|
| |
|
|
Losartan/HCTZ
(Hyzaar�) |
|
| |
|
|
|
|
| 13 |
Calcium Channel
Blockers |
Diltiazem
HCL |
Amlodipine
(Norvasc�) |
August
12, 2002 |
| |
|
Diltiazem
SR |
Bepridil
(Vascor�) |
|
| |
|
Diltiazem
XR |
Diltiazem
ER (Tiazac�) |
|
| |
|
Felodipine
(Plendil�) |
Isradipine
(Dynacirc�) |
|
| |
|
Nicardipine |
Isradipine
SR (Dynacirc CR�) |
|
| |
|
Nifedipine |
Nicardipine
SR (Cardene SR�) |
|
| |
|
Nifedipine
SR |
Nimodipine
(Nimotop�) |
|
| |
|
Nisoldipine
(Sular�) |
Verapamil
ER (Covera HS�) |
|
| |
|
Verapamil |
Verapamil
SR (Verelan PM�) |
|
| |
|
Verapamil
SR |
|
|
| |
|
|
|
|
| 14 |
Triptans |
Almotriptan
(Axert�) |
Naratriptan
(Amerge�) |
August
19, 2002 |
| |
|
Zolmitriptan
(Zomig, Zomig ZMT�) |
Rizatriptan
(Maxalt, Maxalt MLT�) |
|
| |
|
|
Sumatriptan
(Imitrex - tablets, nasal spray and injection) |
|
| |
|
|
|
|
| |
Triptans |
Almotriptan (Axert) |
Frovatriptan (Frova) |
March 26, 2003 |
| |
UPDATES |
Rizatriptan (Maxalt;
Maxalt MLT) |
Naratriptan (Amerge) |
|
| |
|
Sumatriptan (Imitrex) |
Zolmitriptan (Zomig,
Zomig ZMT) |
|
| |
|
|
|
|
| 15 |
Oral Diabetic
Medications |
|
|
|
| |
Sulfonylureas |
Acetohexamide |
NONE |
August 19, 2002 |
| |
|
Chlorpropamide |
|
|
| |
|
Glimepiride
(Amaryl�) |
|
|
| |
|
Glipizide |
|
|
| |
|
Glipizide
XL (Glucotrol XL�) |
|
|
| |
|
Glyburide |
|
|
| |
|
Glyburide
extended release |
|
|
| |
|
Tolazamide |
|
|
| |
|
Tolbutamide |
|
|
| |
|
|
|
|
| |
Biguanides |
Metformin |
Metformin
XR (Glucophage XR�) |
August
19, 2002 |
| |
|
|
Metformin/Glyburide
(Glucovance�) |
|
| |
|
|
|
|
| |
Thiazolidinediones |
Pioglitazone
(Actos�) |
NONE |
August
19, 2002 |
| |
|
Rosiglitazone
(Avandia�) |
|
|
| |
|
|
|
|
| 16 |
Cephalosporin and
Related |
|
|
|
| |
Antibotics |
Amoxicillin/Clavulanate
(Augmentin�) |
|
August
26, 2002 |
| |
|
Amoxicillin/Clavulanate
(Augmentin ES-600�) |
|
|
| |
|
Cefaclor |
Cefpodoxime
Proxetil (Vantin�) |
|
| |
|
Cefaclor
ER |
Ceftibuten
(Cedax�) |
|
| |
|
Cefadroxil
Monohydrate |
Loracarbef
(Lorabid�) |
|
| |
|
Cefdinir
(Omnicef�) |
|
|
| |
|
Cefditoren
Pivoxil (Spectracef�) |
|
|
| |
|
Cefixime
(Suprax�) |
|
|
| |
|
Cefprozil
(Cefzil�) |
|
|
| |
|
Cefuroxime
Axetil |
|
|
| |
|
Cephalexin |
|
|
| |
|
Cephradine |
|
|
| |
|
|
|
|
| 17 |
Fluoroquinolones |
Ciprofloxacin
(Cipro�) |
Levofloxacin
(Levaquin�) |
August
26, 2002 |
| |
|
Gatifloxacin
(Tequin�) |
Lomefloxacin
(Maxaquin�) |
|
| |
|
Moxifloxacin
(Avelox; Avelox ABC Pack�) |
Norfloxacin
(Noroxin�) |
|
| |
|
|
Ofloxacin
(Floxin�) |
|
| |
|
|
Sparfloxacin
(Zagam�) |
|
| |
|
|
|
|
| 18 |
Macrolides |
Azithromycin
(Zithromax�) |
Clarithromycin
(Biaxin�) |
August
26, 2002 |
| |
|
Dirithromycin
(Dynabac�) |
Clarithromycin
SA (Biaxin XL�) |
|
| |
|
Erythromycin
Base |
Erythromycin
Base (PCE 333mg & 500mg) |
|
| |
|
Erythromycin
Estolate |
Troleandomycin
(TAO) |
|
| |
|
Erythromycin
Ethylsuccinate |
|
|
| |
|
Erythromycin
Stearate |
|
|
| |
|
|
|
|
| |
Macrolides |
Azithomycin (Zithromax) |
Erythromycin Base
(PCE 333mg & 500mg) |
March 26, 2003 |
| |
UPATES |
Dirithromycin (Dynabac) |
Troleandomycin
(TAO) |
|
| |
|
Erythromycin Base |
|
|
| |
|
Erythromycin
Estolate |
|
|
| |
|
Erythromycin
Ethylsuccinate |
|
|
| |
|
Erythromycin
Stearate |
|
|
| |
|
Clarithromycin
(Biaxin) |
|
|
| |
|
Clarithromycin
SA (Biaxin XL) |
|
|
| |
|
|
|
|
| 19 |
Antivirals |
Acyclovir |
Famciclovir
(Famvir�) |
September
3, 2002 |
| |
|
Amantadine
HCL |
Valganciclovir
(Valcyte�) |
|
| |
|
Ganciclovir
(Cytovene�) |
Zanamivir
(Relenza�) |
|
| |
|
Oseltamivir
(Tamiflu�) |
|
|
| |
|
Rimantadine
HCL |
|
|
| |
|
Valacyclovir
(Valtrex�) |
|
|
| |
|
|
|
|
| 20 |
Oral Antifungals |
Fluconazole
(Diflucan�) |
Clotrimazole
(Mycelex Troche�) |
September
3, 2002 |
| |
|
Griseofulvin |
Flucytosine
(Ancobon�) |
|
| |
|
Ketoconazole |
Itraconazole
(Sporanox�) |
|
| |
|
Nystatin |
|
|
| |
|
Terbinafine
(Lamisil�) |
|
|
| |
|
|
|
|
| 21 |
ACE
Inhibitors/Calcium Channel Blockers |
|
|
|
| |
Combination
Products |
Amlodipine/Benazepril
(Lotrel�) |
Felodipine/Enalapril
(Lexxel�) |
September
9, 2002 |
| |
|
Verapamil
SR/Trandolapril (Tarka�) |
|
|
| |
|
|
|
|
| 22 |
Intermittent
Claudication |
|
|
|
| |
Medications |
Pentoxifylline |
Cilostazol
(Pletal�) |
September
9, 2002 |
| |
|
|
|
|
| 23 |
Platelet
Aggregation Inhibitors |
Aspirin/Dipyridamole
ER (Aggrenox�) |
NONE |
September
9, 2002 |
| |
|
Clopidogrel
(Plavix�) |
|
|
| |
|
Dipyridamole |
|
|
| |
|
Ticlopidine |
|
|
| |
|
|
|
|
| 24 |
Antiincontinence
Agents |
Flavoxate
(Urispas�) |
Tolterodine
(Detrol�) |
September
16, 2002 |
| |
|
Oxybutynin |
Tolterodine
LA (Detrol LA�) |
|
| |
|
Oxybutynin
XL (Ditropan XL�) |
|
|
| |
|
|
|
|
| 25 |
Beta-Adrenergic
Agents |
|
|
|
| |
|
INHALATION |
|
|
| |
|
Albuterol
Sulfate (Nebulizer and Inhaler) |
Albuterol
Sulfate Nebulizer Solution (Accuneb�) |
September
16, 2002 |
| |
|
Albuterol
Sulfate (Proventil HFA�): Ventolin
HFA�) |
Albuterol
Sulfate/Ipratropium (Duoneb�) |
|
| |
|
Albuterol
Sulfate/Ipratropium (Combivent�) |
Levalbuterol
HCL (Xopenex�) |
|
| |
|
Metaproterenol
Sulfate (Nebulizer Only) |
Metaproterenol
Sulfate (Alupent Inhalant�) |
|
| |
|
|
Pirbuterol
(Maxair, Autohaler) |
|
| |
|
|
Salmeterol
Xinafoate (Serevent; Serevent/Diskus) |
|
| |
|
|
Terbutaline
Sulfate Inhaler |
|
| |
|
|
|
|
| |
|
ORAL |
|
|
| |
|
Albuterol
Sulfate |
Albuterol
Sulfate (Proventil Repetabs�) |
|
| |
|
Metaproterenol
Sulfate |
Albuterol
Sulfate SA (Volmax�) |
|
| |
|
Terbutaline
Sulfate |
|
|
| |
|
Formoterol
(Foradil�) |
|
|
| |
|
|
|
|
| 25 |
Beta-Adrenergic Agents |
|
|
|
| |
UPDATES |
INHALATION
|
|
|
| |
|
Albuterol Sulfate (Nebulizer and
Inhaler) |
Albuterol Sulfate Nebulizer
Solution (Accuneb�) |
October 14, 2002 |
| |
|
Albuterol Sulfate (Proventil HFA:
Ventolin HFA�) |
Albuterol Sulfate/Ipratropium (Duoneb�) |
|
| |
|
Albuterol Sulfate/Ipratropium (Combivent�) |
Bitolterol Mesylate (Tornalate�) |
|
| |
|
Metaproterenol Sulfate (Nebulizer
Only) |
Levalbuterol HCL (Xopenex�) |
|
| |
|
Salmeterol Xinafoate (Serevent;Serevent/Diskus) |
Metaproterenol Sulfate (Alupent
Inhalant�) |
|
| |
|
|
Pirbuterol (Maxair, Autohaler) |
|
| |
|
|
Terbutaline Sulfate Inhaler |
|
| |
|
|
|
|
| 26 |
Bone Resorption
Suppression |
Alendronate
(Fosamax�) |
Etidronate
(Didronel�) |
September
16, 2002 |
| |
Agents |
Calcitonin-salmon
(Miacalcin�) |
Raloxifene
(Evista�) |
|
| |
|
|
Risedronate
(Actonel�) |
|
| |
|
|
Tiludronate
(Skelid�) |
|
| 26 |
Bone Resorption
Suppression |
Alendronate
(Fosamax�) |
Etidronate
(Didronel�) |
February
12, 2003 |
| |
Agents
UPDATES |
Calcitonin-salmon
(Miacalcin�) |
Raloxifene
(Evista�) |
|
| |
|
Risedronate
(Actonel�) |
Tiludronate
(Skelid�) |
|
| |
|
|
|
|
| 27 |
Narcotics |
Acetaminophen
w/Codeiene |
Aspirin/Caffeine/Dihydrocodeine
Bitartrate |
September
23, 2002 |
| |
|
Acetaminophen/Caffeiene/Dihydrocodeine
Bitartrate |
(Synalgos-DC) |
|
| |
|
(Panlor
SS) |
|
|
| |
|
Aspirin
w/Codeine |
Acetaminophen
w/Codeine (Capital w/Codeine) |
|
| |
|
Belladonna
& Opium |
Fentanyl
Citrate (Actiq�) |
|
| |
|
Butalbital
Compound w/Codeine |
Hydrocodone/Acetaminophen
(Maxidone;Zydone) |
|
| |
|
Butalbital/Caff/APAP/Codeine |
Morphine
Sulfate ER (Kadian�) |
|
| |
|
Butorphanol
Tartrate |
Opium
Tincture |
|
| |
|
Carisoprodol
Compound/Codeine |
Oxycodone
(Roxicodone;Roxicodone Intensol�) |
|
| |
|
Codeine
Phosphate |
Oxycodone/Acetaminophen
(Percocet 10/325mg; |
|
| |
|
Codeine
Sulfate |
2.5/325mg;7.5/325mg�) |
|
| |
|
Dihydrocodeine/APAP/Caffeine |
Oxycodone
CR (Oxycontin�) |
|
| |
|
Fentanyl
Transdermal (Duragesic�) |
Oxymorphone
(Numorphan�) |
|
| |
|
Flortal
w/Codeine #3 |
Propoxyphene
Napsylate (Darvon-N�) |
|
| |
|
Hydrocodone/Acetaminophen |
|
|
| |
|
Hydrocodone
Bitartrate/ibuprofen (Vicoprofen�) |
|
|
| |
|
Hydromorphone
HCL |
|
|
| |
|
Meperidine
HCL |
|
|
| |
|
Meperidine
w/Promethazine |
|
|
| |
|
Methadone
HCL |
|
|
| |
|
Methadose |
|
|
| |
|
Morphine
Sulfate (Oral) |
|
|
| |
|
Morphine
Sulfate (Rectal) |
|
|
| |
|
Morphine
Sulfate ER (Avinza�) |
|
|
| |
|
Morphine
Sulfate IR |
|
|
| |
|
Oxycodone
HCL (except Roxicodone, Roxicodone |
|
|
| |
|
Intensol) |
|
|
| |
|
Oxycodone
w/Acetaminophen (Roxicet�) |
|
|
| |
|
Oxycodone/Acetaminophen |
|
|
| |
|
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�) |
|
|
| |
|
|
|
|
| 28 |
Stimulants |
Amphetamine
Salts Combo |
Methamphetamine
(Desoxyn�) |
October
14, 2002 |
| |
|
Amphetamine
Salts Combo/XR (Adderall XR) |
Modafinil
(Provigil�) |
|
| |
|
Dexmethylphenidate
(Focalin�) |
|
|
| |
|
Desmethylphenidate
Sulfate |
|
|
| |
|
Methylphenidate |
|
|
| |
|
Methylphenidate
ER (Metadate CD) |
|
|
| |
|
Methylphenidate
ER (Concerta�) |
|
|
| |
|
Methylphenidate
LA (Ritalin LA) |
|
|
| |
|
Methylphenidate/SR
(Ritalin SR/Generic) |
|
|
| |
|
Pemoline |
|
|
| |
|
|
|
|
| 29 |
Alpha Adrenergic
Blocking |
Doxazosin |
NONE |
October
14, 2002 |
| |
Agents and
Finasteride |
Finasteride
(Proscar�) |
|
|
| |
|
Prazosin |
|
|
| |
|
Tamsulosin
(Flomax�) |
|
|
| |
|
Terazosin |
|
|
| |
|
|
|
|
| 30 |
Beta Adrenergic
Receptor |
Acebutolol |
Carteolol
(Cartrol�) |
October
21, 2002 |
| |
Blocking Agents |
Atenolol |
Carvedilol
(Coreg�) |
|
| |
|
Betaxolol |
Penbutolol
(Levatol�) |
|
| |
|
Bisoprolol |
Propranolol
LA (Inderal LA�) |
|
| |
|
Labetalol |
Sotalol
(Betapace AF�) |
|
| |
|
Metoprolol |
|
|
| |
|
Metoprolol
XL (Toprol XL) |
|
|
| |
|
Nadolol |
|
|
| |
|
Pindolol |
|
|
| |
|
Propanolol |
|
|
| |
|
Sotalol |
|
|
| |
|
Timolol |
|
|
| 30 |
Beta Adrenergic
Receptor |
Acebutolol |
Carteolol
(Cartol�) |
February
12, 2003 |
| |
Blocking Agents
UPDATES |
Atenolol |
Penbutolol
(Levatol�) |
|
| |
|
Betaxolol |
Propranolol
LA (Inderal LA�) |
|
| |
|
Bisoprolol |
Sotalol
(Betapace AF�) |
|
| |
|
Carvedilol
(Coreg�) |
|
|
| |
|
Labetalol |
|
|
| |
|
Metoprolol |
|
|
| |
|
Metoprolol
XL (Toprol XL) |
|
|
| |
|
Nadolol |
|
|
| |
|
Pindolol |
|
|
| |
|
Propanolol |
|
|
| |
|
Solatol |
|
|
| |
|
Timolol |
|
|
| |
|
|
|
|
| 31 |
Estrogen Agents -
Oral and Transdermal |
ORAL |
|
|
| |
|
Conjugated
Estrogens (Premarin�) |
Esterified
Estrogens (Estratab) |
October
21, 2002 |
| |
|
Diethylstilbestrol |
|
|
| |
|
Esterified
Estrogens (Menest�) |
|
|
| |
|
Estradiol |
|
|
| |
|
Estropipate |
|
|
| |
|
Synthetic
Conjugated Estrogens (Cenestin�) |
|
|
| |
|
TRANSDERMAL PATCH |
|
|
| |
|
Estradiol |
Estradiol
(Climara�) |
|
| |
|
|
|
|
| 32 |
Contraceptives |
MONOPHASIC |
MONOPHASIC |
October
21, 2002 |
| |
All covered
contraceptives are |
Alesse;
Apri; Aviane |
NONE |
|
| |
on the PDL. |
Brevicon |
|
|
| |
|
Demulen;
Desogen |
|
|
| |
|
Lessina;
Levien; 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 |
October
21, 2002 |
| |
|
Karvia |
NONE |
|
| |
|
Mircette |
|
|
| |
|
Necon |
|
|
| |
|
Ortho-Novum
10/11 |
|
|
| |
|
TRIPHASIC |
TRIPHASIC |
October
21, 2002 |
| |
|
Cyclessa |
NONE |
|
| |
|
Enpresse;
Estrostep |
|
|
| |
|
Ortho
TriCyclen; Ortho-Novum 7/7/7 |
|
|
| |
|
Tri-Levlen;
Tri-Norinyl; Triphasil; Trivora |
|
|
| |
|
PROGESTIN
ONLY |
PROGESTIN
ONLY |
October
21, 2002 |
| |
|
Nor-Q.D. |
NONE |
|
| |
|
Ortho
Micronor |
|
|
| |
|
Ovrette |
|
|
| |
|
EMERGENCY
CONTRACEPTION |
EMERGENCY
CONTRACEPTION |
October
21, 2002 |
| |
|
Preven |
NONE |
|
| |
|
|
|
|
| |
|
TRANSDERMAL
& VAGINAL RING |
TRANSDERMAL
& VAGINAL RING |
October
21, 2002 |
| |
|
NuvaRing |
NONE |
|
| |
|
Ortho
Evra |
|
|
| |
|
|
|
|
| 33 |
Sedative/Hypnotics |
Estrazolam |
Chloral
Hydrate (Aquachloral Supprettes) |
October
21, 2002 |
| |
|
Flurazepam |
Quazepam
(Doral�) |
|
| |
|
Temazepam
15mg; 30mg |
Temazepam
7.5mg (Restoril�) |
|
| |
|
Triazolam |
Zaleplon
(Sonata�) |
|
| |
|
Zolpidem
(Ambien�) |
|
|
| |
|
|
|
|
| 34 |
Skeletal Muscle
Relaxants |
Baclofen |
Dantrolene
(Dantrium�) |
October
21, 2002 |
| |
|
Carisoprodol |
|
|
| |
|
Chlorzoxazone |
|
|
| |
|
Cyclobenzaprine |
|
|
| |
|
Diazepam |
|
|
| |
|
Metaxalone
(Skelaxin�) |
|
|
| |
|
Methocarbamol |
|
|
| |
|
Orphenadrine
Citrate |
|
|
| |
|
Tizanidine
(Zanaflex�) |
|
|
| |
|
|
|
|
| 35 |
Prostaglandin
Inhibitors |
|
|
|
| |
Opthalmics |
Latanoprost
(Xalatan�) |
Bimatoprost
(Lumigan�) |
October
28, 2002 |
| |
|
Travoprost
(Travatan�) |
Unoprostone
(Rescula�) |
|
| |
|
|
|
|
| 36 |
Antifungals -
Topical |
Clotrimazole |
Butenafine
(Mentax�) |
October
28, 2002 |
| |
|
Clotrimazole/Bethamethasone |
Ciclopirox
(Loprox�) |
|
| |
|
Ketoconazole |
Ciclopirox
(Penlac�) |
|
| |
|
Ketoconazole (Nizoral
Shampoo) |
Econazole
(Spectazole�) |
|
| |
|
Miconazole
Nitrate |
Oxiconazole
(Oxistat�) |
|
| |
|
Miconazole/HC
(Fungoid HC) Discontinued |
Terbinafine
(Lamisil�) |
|
| |
|
Naftifine
(Naftin�) |
|
|
| |
|
Nystatin |
|
|
| |
|
Nystatin
w/ Triamcinolone |
|
|
| |
|
Sodium
Thiosulfate/Salicylate (Versiclear and Generics) |
|
|
| |
|
Sulconazole
(Exelderm) |
|
|
| |
|
|
|
|
| 37 |
Antiemetic/Antivertigo
Agents |
ANTIEMETIC
AGENTS |
ANTIEMETIC
AGENTS |
October
28, 2002 |
| |
|
Metoclopramide |
Dolasetron
(Anzemet�) |
|
| |
|
Dronabinol
(Marinol�) |
Granisetron
(Kytril�) |
|
| |
|
Ondansetron
(Zofran�) |
Thiethylperazine
Maleate (Torecan�) |
|
| |
|
Prochlorperazine |
|
|
| |
|
ANTIVERTIGO
AGENTS |
ANTIVERTIGO
AGENTS |
October
28, 2002 |
| |
|
Scopolamine,
Transdermal (Transderm Scop) |
Scopolamine,
Oral (Scopace) |
|
| |
|
|
|
|
| 38 |
Antihistamines -
Nasal |
NONE |
Azelastine
(Astelin�) |
October
28, 2002 |
| |
|
|
|
|
| 39 |
Anticholinergic
Agents - Nasal |
NONE |
Ipratropium
(Atrovent�) |
October
28, 2002 |
| |
|
|
|
|
| 40 |
Insulins |
Humalog
(Children 18 years and under) |
Humalog
(Over 18 years) |
November
4, 2002 |
| |
|
Novolin
L |
Humalog
Mix 75/25 |
|
| |
|
Novolin
N |
Humulin
L |
|
| |
|
Novolin
R |
Humulin
N |
|
| |
|
Novolin
70/30 |
Humulin
R |
|
| |
|
Novolog |
Humulin
U |
|
| |
|
Relion
R |
Humulin
50/50 |
|
| |
|
Relion
N |
Humulin
70/30 |
|
| |
|
Relion
70/30 |
Lantus |
|
| |
|
Novolog
Mix |
|
|
| |
|
|
|
|
| 41 |
Antihyperlipidemic
Agents - |
Cholestyramine |
Colesevelam
(Welchol�) |
February
12, 2003 |
| |
Non Statins |
Clofibrate |
|
|
| |
|
Colestipol
(Colestid�) |
|
|
| |
|
Fenofibrate
(Tricor�) |
|
|
| |
|
Gemfibrozil |
|
|
| |
|
Niacin
ER (Niaspan�) |
|
|
| |
|
Niacin
ER/Lovastatin (Advicor�) |
|
|
| |
|
Cholestyramine/Aspartane |
|
|
| |
|
|
|
|
| 42 |
Combination
Estrogen Agents |
17β-Estradiol/Norgestimate
(Ortho-Prefast�) |
17β-Estradiol/Norethindrone
Acetate (Activella�) |
February
19, 2003 |
| |
|
Conjugated
Estrogens (CE)/Medroxyprogesterone Acetate (MPA) (Premphase) |
17β-Estradiol/Norethindrone
Acetate (CombiPatch) |
|
| |
|
|
Conjugated
Estrogens CE)/Medroxyprogesterone Acetate (MPA) (Prempro) |
|
| |
|
|
Ethinyl
Estradiol/Norethindrone Acetate (Femhrt) |
|
| |
|
|
|
|
| 43 |
Alzheimer's Drugs
- |
Donepezil
(Aricept�) |
Tacrine
(Cognex�) |
February
19, 2003 |
| |
Cholinesterase
Inhibitors |
Galantamine
(Reminyl�) |
|
|
| |
|
Rivastigmine
(Exelon�) |
|
|
| |
|
|
|
|
| 44 |
Antiparkinson
Agents - |
Amantadine
HcI |
Biperiden
(Akineton�) |
February
19, 2003 |
| |
Anticholinergic
and Other |
Benztropine
Mesylate |
Procyclidine
(Kemadrin�) |
|
| |
|
Bromocriptine
Mesylate |
Tolcapone
(Tasmar�) |
|
| |
|
Diphenhydramine |
|
|
| |
|
Entacapone
(Comtan�) |
|
|
| |
|
Levodopa
(Larodopa�) |
|
|
| |
|
Levodopa/Carbidopa |
|
|
| |
|
Pergolide
(Permax�) |
|
|
| |
|
Pramipexole
(Mirapex�) |
|
|
| |
|
Ropinirole
(Requip�) |
|
|
| |
|
Selegiline |
|
|
| |
|
Trihexyphenidyl |
|
|
| |
|
|
|
|
| 45 |
Allergic
Conjunctivitis |
Azelastine
Hydrochloride (Optivar�) |
Emedastine
Difumarate (Emadine�) |
February
26, 2003 |
| |
|
Cromolyn
Sodium |
Ketorolac
Tromethamine (Acular�) |
|
| |
|
Ketotifen
Fumarate (Zaditor�) |
|
|
| |
|
Levocabastine
(Livostin�) |
|
|
| |
|
Lodoxamine
Tromethamine (Alomide�) |
|
|
| |
|
Loteprednol
(Alrex�) |
|
|
| |
|
Nedocromil
Sodium (Alocril�) |
|
|
| |
|
Olopatadine
Hydrochloride (Patanol�) |
|
|
| |
|
Pemirolast
Potassium (Alamast�) |
|
|
| |
|
|
|
|
| 46 |
Intraocular
Pressure (IOP) |
Brimonidine
(Alphagan P�) |
NONE |
February
26, 2003 |
| |
Reducers |
Brinzolamide
(Azopt�) |
|
|
| |
|
Dipivefrin |
|
|
| |
|
Dorzolamide
(Trusopt�) |
|
|
| |
|
Dorzolamide/Timolol
(Cosopt�) |
|
|
| |
|
Epinephrine |
|
|
| |
|
|
|
|
| 47 |
Fluoroquinolones,
Otic |
Ciprofloxacin/Hydrocortisone
(Cipro HC Otic) |
NONE |
February
26, 2003 |
| |
|
Ofloxacin
(Floxin Otic) |
|
|
| |
|
|
|
|
| 48 |
Erythropoietins |
Epoetin
alfa (Epogen;Procrit�) |
Darbepoetin
alfa (Aranesp�) |
March
5, 2003 |
| |
|
Darbepoetin
alfa (Aranesp�) - Pediatrics only (Under 21 years old) |
|
|
| |
|
|
|
|
| 49 |
Growth Hormones |
Somatropin
(Nutropin�) |
Somatrem
(Protropin�) |
March
5, 2003 |
| |
|
Somatropin
(Nutropin AQ�) |
Somatropin
(Genotropin�) |
|
| |
|
Somatropin
(Nutropin Depot) |
Somatropin
(Humatrope�) |
|
| |
|
Somatropin
(Serostim�) |
Somatropin
(Norditropin�) |
|
| |
|
|
Somatropin
(Saizen�) |
|
| |
|
|
|
|
| 50 |
Multiple Sclerosis
Agents |
Interferon
beta - 1a (Avonex�) |
Glatiramer
(Copaxone�) |
March
5, 2003 |
| |
(Immunomodulatory
Agents) |
Interferon
beta - 1a (Betaseron�) |
Interferon
beta - 1a (Rebif�) |
|
| |
|
|
|
|
| 51 |
Ulcerative Colitis
Agents |
Mesalamine
(Asacol�) |
Balsalazide
(Colazal�) |
March
12, 2003 |
| |
|
Mesalamine
(Pentasa�) - Pediatric only (Under 21 years old) |
Mesalamine
(Pentasa�) |
|
| |
|
Olsalazine
(Dipentum�) |
Mesalamine
(Rowasa�) |
|
| |
|
Sulfasalazine
(Generic) |
|
|
| |
|
|
|
|
| 52 |
Phosphate Binders |
Calcium
Acetate (PhosLo�) |
NONE |
March
19, 2003 |
| |
|
Magnesium
Carbonate, Calcium Carbonate, Folic Acid (Magnebind 400 Rx) |
|
|
| |
|
Sevelamer
(RenaGel�) |
|
|
| |
|
|
|
|
| 53 |
Atopic Dermatitis |
|
|
|
| |
Immunomodulators |
Pimecrolimus
(Elidel�) |
Tacrolimus
(Protopic�) |
March
19, 2003 |
| |
|
|
|
|
| 55 |
Anticoagulants,
Injectable |
Dalteparin (Fragmin) |
Enoxaparin (Lovenox) |
March 26, 2003 |
| |
|
Fondaparinux (Arixtra) |
Tinzaparin (Innohep) |
|
| |
|
Enoxaparin (Lovenox)
- Pediatric use only |
|
|
| |
|
(Under 21
years old) |
|
|
| |
|
|
|
|
| 56 |
H. Pylori
Agents |
Bismuth |
|
March 26, 2003 |
| |
|
Subsalicylate/Metronidazole/Tetracycline |
Lansoprazole/Amoxicillin/ |
|
| |
|
(Helidac) |
Clarithromycin (Prevpac) |
|
| |
|
Amoxicillin |
|
|
| |
|
Prevacid |
|
|