drug class

HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ACNE AGENTS, TOPICAL
ANTIBIOTICS
CLINDAGEL (clindamycin)
clindamycin
erythromycin
AKNE-MYCIN (erythromycin)
CLEOCIN-T (clindamycin)
CLINDAREACH (clindamycin)
EVOCLIN (clindamycin)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
RETINOIDS
DIFFERIN (adapalene)
RETIN-A MICRO (tretinoin)
tretinoin
adapalene
ATRALIN (tretinoin)
TAZORAC (tazarotene)
OTHERS
ACZONE (dapsone)
AZELEX (azelaic acid)
BENZACLIN
(benzoyl peroxide/ clindamycin)
benzoyl peroxide
benzoyl peroxide/sulfur
CLARIFOAM EF
(sodium sulfacetamide/sulfur)
CLINAC BPO (benzoyl peroxide)
EPIDUO (benzoyl peroxide/adapalene)
NUOX (benzoyl peroxide/sulfur)
ACANYA (benzoyl peroxide/clindamycin)
AVAR-E (sodium sulfacetamide/sulfur)
BENZAMYCIN (benzoyl peroxide/erythromycin)
BREVOXYL (benzoyl peroxide)
DELOS (benzoyl peroxide)
DUAC (benzoyl peroxide/clindamycin)
erythromycin/benzoyl peroxide
INOVA (benzoyl peroxide)
INOVA 4/1 (benzoyl peroxide/salicylic acid)
KLARON (sodium sulfacetamide)
LAVOCLEN (benzoyl peroxide)
NEOBENZ MICRO (benzoyl peroxide)
SE BPO (benzoyl peroxide)
sodium sulfacetamide
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur/meratan
VELTIN (clindamycin/tretinoin)
TRIAZ (benzoyl peroxide)
ZIANA (clindamycin/tretinoin)
ZODERM (benzoyl peroxide)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
1
PA CRITERIA
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ALZHEIMER’S AGENTS
CHOLINESTERASE INHIBITORS
ARICEPT (donepezil)
ARICEPT ODT (donepezil)
EXELON (rivastigmine)
donepezil
donepezil ODT
galantamine
galantamine ER
RAZADYNE (galantamine)
RAZADYNE ER (galantamine)
PA CRITERIA
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
NMDA RECEPTOR ANTAGONIST
NAMENDA (memantine)
ANALGESICS, NARCOTIC – LONG
ACTING
EMBEDA (morphine/naltrexone)
fentanyl patchPPG
KADIAN (morphine)
morphinePPG
OPANA ER (oxymorphone)
AVINZA (morphine)
BUTRANS (buprenorphine)
DURAGESIC (fentanyl)
EXALGO (hydromorphone)
MS CONTIN (morphine)
oxycodone ER
OXYCONTIN (oxycodone)
oxymorphone ER
RYZOLT (tramadol)
tramadol ER
ULTRAM ER (tramadol)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
2
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ANALGESICS, NARCOTIC – SHORT
ACTING
(Non-parenteral)
PPG
ABSTRAL (fentanyl)
ACTIQ (fentanyl)
DEMEROL (meperidine)
DILAUDID (hydromorphone)
fentanyl
FENTORA (fentanyl)
FIORICET W/CODEINE
(butalbital/APAP/caffeine/codeine)
FIORINAL W/CODEINE
(butalbital/ASA/caffeine/codeine)
IBUDONE (hydrocodone/ibuprofen)
levorphanol
LORCET (hydrocodone/APAP)
LORTAB (hydrocodone/APAP)
meperidine
NORCO (hydrocodone/APAP)
NUCYNTA (tapentadol)
ONSOLIS (fentanyl)
OPANA (oxymorphone)
oxycodone/APAP
oxycodone/ASA
oxycodone/ibuprofen
OXYFAST (oxycodone)
PERCOCET (oxycodone/APAP)
propoxyphene
propoxyphene/APAP
REPREXAIN (hydrocodone/ibuprofen)
RYBIX ODT (tramadol)
SYNALGOS-DC (dihydrocodeine/ASA/caffeine)
TALACEN (pentazocine/APAP)
TALWIN NX (pentazocine/naloxone)
TYLENOL W/CODEINE (APAP/codeine)
ULTRACET (tramadol/APAP)
ULTRAM (tramadol)
VICODIN (hydrocodone/APAP)
VICOPROFEN (hydrocodone/ibuprofen)
XODOL (hydrocodone/APAP)
Unless otherwise specified, the listing of a particular brand or generic name includes all ZAMICET
dosage forms
of that drug.
(hydrocodone/APAP)
3
ZOLVIT (hydrocodone/APAP)
APAP/codeine
ASA/codeine
butalbital/APAP/caffeine/codeine
butalbital/ASA/caffeine/codeine
codeine
dihydrocodeine/APAP/caffeine
hydrocodone/APAPPPG
hydrocodone/ibuprofen
hydromorphonePPG
morphinePPG
oxycodonePPG
pentazocine/APAP
pentazocine/naloxone
tramadol
tramadol/APAP
PA CRITERIA
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ANALGESICS/ANESTHETICS,
TOPICAL
capsaicin OTC
LIDODERM (lidocaine)
PENNSAID (diclofenac)
VOLTAREN (diclofenac)
FLECTOR (diclofenac)
QUTENZA (capsacin)
ANDROGENIC AGENTS, TOPICAL
ANDRODERM (testosterone)
ANDROGEL (testosterone)
TESTIM (testosterone)
FORTESTA (testosterone)
ANGIOTENSIN MODULATORS
ACE INHIBITORS
benazepril
captopril
enalapril
fosinopril
lisinopril
quinapril
ramipril
ACCUPRIL (quinapril)
ACEON (perindopril)
ALTACE (ramipril)
CAPOTEN (captopril)
LOTENSIN (benazepril)
MAVIK (trandolapril)
moexepril
MONOPRIL (fosinopril)
perindopril
PRINIVIL (lisinopril)
trandolapril
UNIVASC (moexepril)
VASOTEC (enalapril)
ZESTRIL (lisinopril)
• Treatment failure with preferred
products.
• Contraindication to preferred
products.
• Allergic reaction to preferred
products
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/HCTZ
captopril/HCTZ
enalapril/HCTZ
fosinopril/HCTZ
lisinopril/HCTZ
quinapril/HCTZ
ACCURETIC (quinapril/HCTZ)
CAPOZIDE (captopril/HCTZ)
LOTENSIN HCT (benazepril/HCTZ)
moxepril/HCTZ
MONOPRIL HCT (fosinopril/HCTZ)
PRINZIDE (lisinopril/HCTZ)
UNIRETIC (moexepril/HCTZ)
VASERETIC (enalapril/HCTZ)
ZESTORETIC (lisinopril/HCTZ)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
4
PA CRITERIA
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ANGIOTENSIN MODULATORS
(cont)
PA CRITERIA
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)
ATACAND (candesartan)
AVAPRO (irbesartan)
COZAAR (losartan)
EDARBI (azilsartan)
TEVETEN (eprosartan)
BENICAR (olmesartan)
DIOVAN (valsartan)
losartan
MICARDIS (telmisartan)
ARB/DIURETIC COMBINATIONS
BENICAR-HCT (olmesartan/HCTZ)
DIOVAN-HCT (valsartan/HCTZ)
losartan/HCTZ
MICARDIS-HCT (telmisartan/HCTZ)
ATACAND-HCT (candesartan/HCTZ)
AVALIDE (irbesartan/HCTZ)
HYZAAR (losartan/HCTZ)
TEVETEN-HCT (eprosartan/HCTZ)
DIRECT RENIN INHIBITORS
TEKTURNA (aliskerin)
DIRECT RENIN INHIBITOR/DIURETIC COMBINATIONS
TEKTURNA HCT (aliskerin/HCTZ)
ANGIOTENSIN MODULATOR
COMBINATIONS
AZOR (olmesartan/amlodipine)
EXFORGE (valsartan/amlodipine)
EXFORGE HCT
(valsartan/amlodipine/HCTZ)
LOTREL (benazepril/amlodipine)
TRIBENZOR
(olmesartan/amlodipine/HCTZ)
TWYNSTA (telmisartan/amlodipine)
benazepril/amlodipine
TARKA (trandolapril/verapamil)
TEKAMLO (aliskerin/amlodipine)
trandolapril/verapamil
VALTURNA (valsartan/aliskerin)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIBIOTICS, TOPICAL
bacitracin
gentamicin
mupirocin
ALTABAX (retapamulin)
BACTROBAN (mupirocin)
CENTANY (mupirocin)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIBIOTICS, VAGINAL
clindamycin
METROGEL (metronidazole)
metronidazole
CLEOCIN (clindamycin)
CLINDAMAX (clindamycin)
CLINDESSE (clindamycin)
VANDAZOLE (metronidazole)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
5
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
PA CRITERIA
ANTICOAGULANTS
ARIXTRA (fondaparinux)
LOVENOX (enoxaparin)
PRADAXA (dabigatran) – for patients
meeting clinical criteria
warfarin
COUMADIN (warfarin)
fondaparinux
FRAGMIN (dalteparin)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIDEPRESSANTS, OTHER
bupropion
CYMBALTA (duloxetine)
MARPLAN (isocarboxazid)
mirtazapine
NARDIL (phenelzine)
PRISTIQ (desvenlafaxine)
trazodone
venlafaxine ER tabletsPPG
Venlafaxine ER tablets
APLENZIN (bupropion)
DESYREL (trazodone)
EFFEXOR (venlafaxine)
EFFEXOR XR (venlafaxine)
EMSAM (selegiline)
nefazodone
OLEPTRO ER (trazodone)
phenelzine
REMERON (mirtazapine)
tranylcypromine
venlafaxine IR
venlafaxine ER capsules
WELLBUTRIN (bupropion)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
• Patients on a non-preferred product
will be authorized to continue on that
product.
ANTIDEPRESSANTS, SSRIs
citalopram
fluoxetine
fluvoxamine
LEXAPRO (escitalopram)
paroxetine
sertraline
CELEXA (citalopram)
LUVOX CR (fluvoxamine)
paroxetine CR
PAXIL (paroxetine)
PAXIL CR (paroxetine)
PEXEVA (paroxetine)
PROZAC (fluoxetine)
SARAFEM (fluoxetine)
ZOLOFT (sertraline)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
6
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ANTIEMETIC-ANTIVERTIGO
AGENTS
(excludes injectables)
ANTICHOLINERGICS, ANTIHISTAMINES, DOPAMINE ANTAGONISTS
dimenhydrinate
meclizine
metoclopramide
prochlorperazine
promethazine
SCOPACE (scopolamine)
trimethobenzamide
TRANSDERM-SCOP (scopolamine)
METOZOLV ODT (metoclopramide)
PA CRITERIA
• Treatment failure with preferred
product
• Contraindication to preferred
product
• Allergic reaction to preferred product
CANNABINOIDS
CESAMET (nabilone)
dronabinol
MARINOL (dronabinol)
5-HT3 RECEPTOR ANTAGONISTS
ondansetron
SANCUSO (granisetron)
ANZEMET (dolasetron)
granisetron
KYTRIL (granisetron)
ZOFRAN (ondansetron)
ZUPLENZ (ondansetron)
SUBSTANCE P ANTAGONISTS
EMEND (aprepitant)
ANTIFUNGALS, ORAL
clotrimazole
fluconazole
griseofulvin
GRIS-PEG (griseofulvin)
ketoconazole
nystatin
terbinafine
ANCOBON (flucytosine)
DIFLUCAN (fluconazole)
GRIFULVIN V (griseofulvin)
itraconazole
LAMISIL (terbinafine)
MYCELEX (clotrimazole)
MYCOSTATIN (nystatin)
NIZORAL (ketoconazole)
NOXAFIL (posaconazole)
SPORANOX (itraconazole)
TERBINEX (terbinafine)
VFEND (voriconazole)
voriconazole
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
7
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ANTIFUNGALS, TOPICAL
ANTIFUNGALS
NAFTIN (naftifine)
OXISTAT (oxiconazole)
ciclopirox solution
clotrimazole
ketoconazole
miconazole
nystatin
terbinafine
tolnaftate
BENSAL HP (benzoic acid/salicylic acid)
ciclopirox cream/gel/shampoo/suspension
CNL 8 (ciclopirox)
econazole
ERTACZO (sertaconazole)
EXELDERM (sulconazole)
EXTINA (ketoconazole)
LAMISIL (terbinafine)
LOPROX (ciclopirox)
LOTRIMIN (clotrimazole)
MENTAX (butenafine)
MONISTAT (miconazole)
MYCELEX (clotrimazole)
MYCOSTATIN (nystatin)
NIZORAL (ketoconazole)
PENLAC (ciclopirox)
TINACTIN (tolnaftate)
VUSION (miconazole/zinc/petrolatum)
XOLEGEL (miconazole)
PA CRITERIA
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIFUNGAL/STEROID COMBINATIONS
nystatin/triamcinolone
ANTIHISTAMINES, MINIMALLY
SEDATING
clotrimazole/betamethasone
LOTRISONE (clotrimazole/betamethasone)
ANTIHISTAMINES
cetirizine syrup, tablets
loratadine
ALLEGRA (fexofenadine)
cetirizine chewable
CLARINEX (desloratadine)
CLARITIN (loratadine)
fexofenadine
levocetirizine
XYZAL (levocetirizine)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
8
• Treatment failure after no less than
a 30-day trial of preferred product
• Contraindication to preferred
product
• Allergic reaction to preferred product
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ANTIHISTAMINES, MINIMALLY
SEDATING
(continued)
PA CRITERIA
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
cetirizine/pseudoephedrine
loratadine/pseudoephedrine
ALLEGRA-D (fexofenadine/pseudoephedrine)
CLARINEX-D (desloratadine/pseudoephedrine)
CLARITIN-D (loratadine/pseudoephedrine)
fexofenadine/pseudoephedrine
SEMPREX-D (acrivastine/pseudoephedrine)
ANTIHYPERURICEMICS
allopurinol
probenecid
probenecid/colchicine
COLCRYS (colchicine)
ULORIC (febuxostat)
ZYLOPRIM (allopurinol)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIMIGRAINE AGENTS
IMITREX injection, nasal (sumatriptan)
RELPAX (eletriptan)
TREXIMET (sumatriptan/naproxen)
AMERGE (naratriptan)
AXERT (almotriptan)
CAMBIA (diclofenac)
FROVA (frovatriptan)
IMITREX tablets (sumatriptan)
MAXALT (rizatriptan)
sumatriptan
ZOMIG (zolmitriptan)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIPARASITICS, TOPICAL
EURAX (cromtamiton)
permethrin
ULESFIA (benzyl alcohol)
ACTICIN (permethrin)
ELIMITE (permethrin)
lindane
malathion
OVIDE (malathion)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products.
ANTIPARKINSON’S AGENTS
(Oral)
ANTICHOLINERGICS
benztropine
trihexyphenidyl
COMT INHIBITORS
COMTAN (entacapone)
TASMAR (tolcapone)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
9
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ANTIPARKINSON’S AGENTS
(continued)
PA CRITERIA
DOPAMINE AGONISTS
bromocriptine
REQUIP XL (ropinirole)
ropinirole
MIRAPEX (pramipexole)
MIRAPEX ER (pramipexole)
PARLODEL (bromocriptine)
pramipexole
REQUIP (ropinirole)
MAO-B INHIBITORS
selegiline
AZILECT (rasagiline)
ELDEPRYL (selegiline)
ZELAPAR (selegiline)
OTHERS
levodopa/carbidopa
STALEVO
(levodopa/carbidopa/entacapone)
ANTIPSYCHOTICS
(Oral)
PARCOPA (levodopa/carbidopa)
SINEMET (levodopa/carbidopa)
ANTIPSYCHOTICS
ABILIFY (aripiprazole)
chlorpromazine
FANAPT (iloperidone)
fluphenazine
GEODON (ziprasidone)
haloperidol
INVEGA (paliperidone)
perphenazine
risperidone
SAPHRIS (asenapine)
SEROQUEL (quetiapine)
SEROQUEL XR (quetiapine)
thiothixene
trifluoperazine
ZYPREXA (olanzapine)
clozapine
CLOZARIL (clozapine)
FAZACLO (clozapine)
LATUDA (lurasidone)
MOBAN (molindone)
NAVANE (thiothixene)
ORAP (pimozide)
RISPERDAL (risperidone)
thioridazine
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIPSYCHOTIC/SSRI COMBINATIONS
perphenazine/amitriptyline
SYMBYAX (olanzapine/fluoxetine)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
10
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
PA CRITERIA
ANTIVIRALS, ANTIHERPETIC
(Oral)
acyclovir
VALTREX (valacyclovir)
FAMVIR (famciclovir)
valacyclovir
ZOVIRAX (acyclovir)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ANTIVIRALS, TOPICAL
ABREVA (docosanol)
DENAVIR (penciclovir)
ZOVIRAX OINTMENT (acyclovir)
XERESE (acyclovir/hydrocortisone)
ZOVIRAX CREAM (acyclovir)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
BETA BLOCKERS
(Oral)
BETA BLOCKERS
acebutolol
atenolol
betaxolol
bisoprolol
BYSTOLIC (nebivolol)
INNOPRAN XL (propranolol)
LEVATOL (penbutolol)
metoprolol IR
nadolol
pindolol
propranolol IR
sotalol
timolol
TOPROL XL (metoprolol)
BETAPACE (sotalol)
CORGARD (nadolol)
INDERAL (propranolol)
KERLONE (betaxolol)
LOPRESSOR (metoprolol)
metoprolol XL
propranolol ER
SECTRAL (acebutolol)
TENORMIN (atenolol)
ZEBETA (bisoprolol)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
BETA BLOCKER COMBINATIONS
atenolol/chlorthalidone
bisoprolol/HCTZ
metoprolol/HCTZ
nadolol/bendroflumethiazide
propranolol/HCTZ
CORZIDE (nadolol/bendroflumethiazide)
INDERIDE (propranolol/HCTZ)
LOPRESSOR HCT (metoprolol/HCTZ)
TENORETIC (atenolol/HCTZ)
ZIAC (bisoprolol/HCTZ)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
11
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
BETA BLOCKERS
(continued)
PA CRITERIA
BETA- AND ALPHA- BLOCKERS
carvedilol
labetalol
COREG (carvedilol)
COREG CR (carvedilol)
TRANDATE (labetalol)
BILE SALTS
ursodiol
ACTIGALL (ursodiol)
CHENODAL (chenodiol)
URSO (ursodiol)
URSO FORTE (urosodiol)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
BLADDER RELAXANT
PREPARATIONS
ENABLEX (darifenacin)
oxybutynin IR
VESICARE (solifenacin)
DETROL (tolterodine)
DETROL LA (tolterodine)
DITROPAN (oxybutynin)
DITROPAN XL (oxybutynin)
GELNIQUE (oxybutynin)
oxybutynin ER (oxybutynin)
OXYTROL (oxybutynin)
SANCTURA (trospium)
SANCTURA XR (trospium)
TOVIAZ (fesoterodine)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
BONE RESORPTION
SUPPRESSION AND RELATED
AGENTS
BISPHOSPHONATES
PPG
alendronate
ACTONEL (risedronate)
ACTONEL W/ CALCIUM (risedronate/calcium)
ATELVIA (risedronate)
BONIVA (ibandronate)
DIDRONEL (etidronate)
etidronate
FOSAMAX (alendronate)
FOSAMAX PLUS D (alendronate/vitamin D)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
OTHER BONE RESORPTION SUPPRESSION AND RELATED AGENTS
MIACALCIN (calcitonin)
calcitonin nasal
EVISTA (raloxifene)
FORTEO (teriparatide)
FORTICAL (calcitonin)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
12
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
BPH AGENTS
ALPHA BLOCKERS
alfuzosin
CARDURA (doxazosin)
CARDURA XL (doxazosin)
HYTRIN (terazosin)
tamsulosin
doxazosin
FLOMAX (tamsulosin)
terazosin
UROXATRAL (alfuzosin)
PA CRITERIA
• Treatment failure with preferred
product
• Contraindication to preferred
product
• Allergic reaction to preferred product
5-ALPHA-REDUCTASE (5AR) INHIBITORS
finasteride
AVODART (dutasteride)
PROSCAR (finasteride)
ALPHA BLOCKER/5AR INHIBITOR COMBINATIONS
JALYN (dutasteride/tamsulosin)
BRONCHODILATORS, BETA
AGONIST
INHALERS, SHORT-ACTING
PROVENTIL HFA (albuterol)
XOPENEX HFA (levalbuterol)
MAXAIR (pirbuterol)
PROAIR HFA (albuterol)
VENTOLIN HFA (albuterol)
INHALERS, LONG-ACTING
FORADIL (formoterol)
SEREVENT (salmeterol)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
• History of intolerable side effects to
preferred product
INHALATION SOLUTION
XOPENEX (levalbuterol)
albuterol
ACCUNEB (albuterol)
BROVANA (arformoterol)
levalbuterol
PERFOROMIST (formoterol)
ORAL
albuterol
terbutaline
BRETHINE (terbutaline)
metaproterenol
VOSPIRE ER (albuterol)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
13
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
CALCIUM CHANNEL BLOCKERS
(Oral)
SHORT-ACTING
diltiazem ER
nifedipine
verapamil
CALAN (verapamil)
CARDENE (nicardipine)
CARDIZEM (diltiazem)
diltiazem LA
DYNACIRC (isradipine)
isradipine
nicardipine
nimodipine
NIMOTOP (nimodipine)
PROCARDIA (nifedipine)
VERELAN (verapamil)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
LONG-ACTING
amlodipine
diltiazem
felodipine
nifedipine
verapamil ER
ADALAT CC (nifedipine)
CALAN SR (verapamil)
CARDENE SR (nicardipine)
CARDIZEM CD (diltiazem)
CARDIZEM LA (diltiazem)
COVERA-HS (verapamil)
DILACOR XR (diltiazem)
DYNACIRC CR (isradipine)
ISOPTIN SR (verapamil)
nisoldipine
NORVASC (amlodipine)
PLENDIL (felodipine)
PROCARDIA XL (nifedipine)
SULAR (nisoldipine)
TIAZAC (diltiazem)
verapamil ER PM
VERELAN PM (verapamil)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
14
PA CRITERIA
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
CEPHALOSPORINS AND RELATED
ANTIBIOTICS
(Oral)
BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS
amoxicillin/clavulanate IR
AUGMENTIN 125 and 250 suspension
only (amoxicillin/clavulanate)
AUGMENTIN XR (amoxicillin/clavulanate)
amoxicillin/clavulanate XR
AUGMENTIN (amoxicillin/clavulanate) – except 125
and 250 suspension
PA CRITERIA
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
CEPHALOSPORINS – First Generation
cefadroxil
cephalexin
KEFLEX (cephalexin)
PANIXINE (cephalexin)
CEPHALOSPORINS – Second Generation
cefaclor
cefprozil
cefuroxime
CEFTIN (cefuroxime)
CEPHALOSPORINS – Third Generation
cefditoren
OMNICEF (cefdinir)
SPECTRACEF (cefditoren)
VANTIN (cefpodoxime)
CEDAX (ceftibuten)
cefdinir
cefpodoxime
SUPRAX (cefixime)
COLONY STIMULATING FACTORS
LEUKINE (sargramostim, GM-CSF)
NEULASTA (pegfilgrastim)
NEUPOGEN (filgrastim, G-CSF)
COPD AGENTS
ANTICHOLINERGICS
ATROVENT HFA (ipratropium)
ipratropium inhalation solution
SPIRIVA (tiotropium)
ANTICHOLINERGIC-BETA AGONIST COMBINATIONS
COMBIVENT (albuterol/ipratropium)
COUGH AND COLD AGENTS
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
albuterol/ipratropium
DUONEB (albuterol/ipratropium)
See Separate Preferred Cough and Cold Agent Listing
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
15
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
CYTOKINE AND CAM
ANTAGONISTS
CIMZIA (certolizumab)
ENBREL (etanercept)
HUMIRA (adalimumab)
KINERET (anakinra)
SIMPONI (golimumab)
ERYTHROPOIESIS STIMULATING
PROTEINS
EPOGEN (RhUEPO)
PROCRIT (RhUEPO)
ARANESP (darbepoetin)
FIBROMYALGIA AGENTS
CYMBALTA (duloxetine)
LYRICA (pregabalin)
SAVELLA (milnacipran)
FLUROQUINOLONES, ORAL
AVELOX (moxifloxacin)
ciprofloxacin IR
LEVAQUIN (levofloxacin)
levofloxacin
GLUCOCORTICOIDS, INHALED
CIPRO (ciprofloxacin)
ciprofloxacin ER
FACTIVE (gemifloxacin)
NOROXIN (norfloxacin)
ofloxacin
PROQUIN XR (ciprofloxacin)
GLUCOCORTICOIDS
ASMANEX (mometasone)
budesonide
FLOVENT (fluticasone)
QVAR (beclomethasone)
AEROBID (flunisolide)
AEROBID-M (flunisolide)
ALVESCO (ciclesonide)
AZMACORT (triamcinolone)
PULMICORT (budesonide)
GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS
GROWTH HORMONE
ADVAIR (fluticasone/salmeterol)
SYMBICORT (budesonide/formoterol)
DULERA (mometasone/formoterol)
GENOTROPIN (somatropin)
NORDITROPIN (somatropin)
NUTROPIN AQ (somatropin)
HUMATROPE (somatropin)
NUTROPIN (somatropin)
OMNITROPE (somatropin)
SAIZEN (somatropin)
SEROSTIM (somatropin)
TEV-TROPIN (somatropin)
ZORBTIVE (somatropin)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
16
PA CRITERIA
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
• Cipro Suspension will be authorized
for patients 10 years of age and under.
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
• Pulmicort Respules will be
authorized for patients 8 years of age
and under.
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
HEPATITIS C AGENTS
HYPOGLYCEMICS, INCRETIN
MIMETICS/ENHANCERS
PEGASYS (pegylated IFN alfa-2a)
PEG-INTRON (pegylated IFN alfa-2b)
INFERGEN (consensus IFN)
AMYLIN ANALOGS
PA CRITERIA
• Treatment failure with preferred
product of same type
• Contraindication to preferred
product of same type
• Allergic reaction to preferred product
of same type
Patient must meet all of the following
criteria:
o Diagnosis of diabetes mellitus
o Age >18 years
o HbA1C in past 6 months
o No history of gastroparesis,
neurologic manifestations of
diabetes or recent treatment of
hypoglycemia
SYMLIN (pramlintide)
INCRETIN ENHANCERS
JANUMET (sitagliptin/metformin)
JANUVIA (sitagliptin)
KOMBIGLYZE XR (saxagliptin/metformin)
ONGLYZA (saxagliptin)
INCRETIN MIMETICS
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
BYETTA (exenatide)
VICTOZA (liraglutide)
HYPOGLYCEMICS, INSULIN
HUMALOG Vials (insulin lispro)
LANTUS (insulin glargine)
NOVOLIN (insulin)
NOVOLOG (insulin aspart)
NOVOLOG MIX
(insulin aspart/aspart protamine)
APIDRA (insulin glulisine)
HUMALOG Pens (insulin lispro/lispro protamine)
HUMALOG MIX (insulin lispro/lispro protamine)
HUMULIN (insulin)
LEVEMIR (insulin detemir)
• Treatment failure with preferred
products
• Contraindication to preferred
products
HYPOGLYCEMICS, MEGLITINIDES
nateglinide
PRANDIN (repaglinide)
PRANDIMET (repaglinide/metformin)
STARLIX (nateglinide)
• Separate prescriptions for the
individual components should be used
instead of the combination product.
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
17
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
HYPOGLYCEMICS, TZD
PA CRITERIA
• Separate prescriptions for the
individual components should be used
instead of the combination product.
THIAZOLINEDIONES
ACTOS (pioglitazone)
AVANDIA (rosiglitazone)
TZD COMBINATIONS
ACTOPLUS MET (pioglitazone/metformin)
AVANDAMET (rosiglitazone/metformin)
AVANDARYL (rosiglitazone/glimepiride)
DUETACT (pioglitazone/glimepiride)
IMMUNOMODULATORS, ATOPIC
DERMATITIS
ELIDEL (pimecrolimus)
PROTOPIC (tacrolimus)
INTRANASAL RHINITIS AGENTS
GLUCOCORTICOIDS
BECONASE AQ (beclomethasone)
NASONEX (mometasone)
FLONASE (fluticasone propionate)
flunisolide
fluticasone
NASACORT AQ (triamcinolone)
NASAREL (flunisolide)
OMNARIS (ciclesonide)
RHINOCORT AQUA (budesonide)
triamcinolone
VERAMYST (fluticasone furoate)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
OTHERS
ASTEPRO (azelastine)
PATANASE (olopatadine)
IRON, ORAL
LEUKOTRIENE MODIFIERS
ASTELIN (azelastine)
ATROVENT nasal spray (ipratropium)
ipratropium nasal spray
See Separate Listing Of Preferred Oral Iron Products
ACCOLATE (zafirlukast)
SINGULAIR (montelukast)
zafirlukast
ZYFLO CR (zileuton)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
18
• Treatment failure with preferred
product
• Contraindication to preferred
product
• Allergic reaction to preferred product
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
LIPOTROPICS, OTHER
BILE ACID SEQUESTRANTS
cholestyramine
COLESTID (colestipol)
colestipol
QUESTRAN (cholestyramine)
WELCHOL (colesevalam)
CHOLESTEROL ABSORPTION INHIBITORS
PA CRITERIA
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ZETIA (ezetimibe)
FIBRIC ACID DERIVATIVES
gemfibrozil
TRICOR (fenofibrate)
TRILIPIX (fenofibric acid)
ANTARA (fenofibrate)
fenofibrate
fenofibric acid
FENOGLIDE (fenofibrate)
FIBRICOR (fenofibric acid)
LIPOFEN (fenofibrate)
LOFIBRA (fenofibrate)
LOPID (gemfibrozil)
TRIGLIDE (fenofibrate)
NIACIN
niacin
NIACOR (niacin)
NIASPAN (niacin)
OMEGA-3 FATTY ACIDS
LOVAZA (omega-3 fatty acids)
LIPOTROPICS, STATINS
STATINS
CRESTOR (rosuvastatin)
LESCOL (fluvastatin)
LESCOL XL (fluvastatin)
LIPITOR (atorvastatin)
pravastatin
simvastatin
ALTOPREV (lovastatin)
LIVALO (pitavastatin)
lovastatin
MEVACOR (lovastatin)
PRAVACHOL (pravastatin)
ZOCOR (simvastatin)
• Treatment failure with at least two
preferred products accounting for no
less than 120 days of therapy
combined
• Contraindication to preferred
products
• Allergic reaction to preferred
products
STATIN COMBINATIONS
SIMCOR (simvastatin/niacin)
ADVICOR (lovastatin/niacin)
CADUET (atorvastatin/amlodipine)
VYTORIN (simvastatin/ezetimibe)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
19
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
MACROLIDES/KETOLIDES
(Oral)
KETOLIDES
KETEK (telithromycin)
MACROLIDES
azithromycin
clarithromycin IR
EES (erythromycin)
ERYTHROCIN (erythromycin)
ERY-TAB (erythromycin)
ERYPED (erythromycin)
erythromycin
PCE (erythromycin)
Z-MAX (azithromycin)
NSAIDS
BIAXIN (clarithromycin)
BIAXIN XL (clarithromycin)
clarithromycin ER
ZITHROMAX (azithromycin)
NONSPECIFIC
diclofenac
etodolac
fenoprofen
flurbiprofen
ibuprofen (except Rx suspension)
INDOCIN suspension (indomethacin)
indomethacin
ketoprofen
ketorolac
meclofenamate
nabumetone
naproxen
oxaprozin
piroxicam
sulindac
ANAPROX (naproxen)
ANSAID (flurbiprofen)
CATAFLAM (diclofenac)
CLINORIL (sulindac)
DAYPRO (oxaprozin)
FELDENE (piroxicam)
ibuprofen Rx suspension
INDOCIN (indomethacin) (excluding suspension)
mefenamic acid
MOTRIN (ibuprofen)
NALFON (fenoprofen)
NAPRELAN (naproxen)
NAPROSYN (naproxen)
PONSTEL (meclofenamate)
tolmetin
VOLTAREN (diclofenac)
ZIPSOR (diclofenac)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
NSAID/GI PROTECTANT COMBINATIONS
VIMOVO (naproxen/ esomeprazole)
ARTHROTEC (diclofenac/misoprostol)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
20
PA CRITERIA
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
NSAIDs
continued
PA CRITERIA
COX-II SELECTIVE
meloxicam
CELEBREX (celecoxib)
MOBIC (meloxicam)
OPHTHALMICS, ANTIBIOTIC –
STEROID COMBINATIONS
neomycin/polymyxin/dexamethasone
sulfacetamide/prednisolone
TOBRADEX (tobramycin/dexamethasone)
ZYLET (tobramycin/loteprednol)
BLEPHAMIDE (sulfacetamide/prednisolone)
CORTISPORIN Ointment
(neomycin/bacitracin/polymyxin/hydrocortisone
CORTISPORIN Suspension
(neomycin/polymyxin/hydrocortisone)
MAXITROL
(neomycin/polymyxin/dexamethasone)
neomycin/bacitracin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
POLY-PRED (neomycin/polymyxin/prednisolone)
PRED-G (gentamicin/prednisolone)
TOBRADEX ST (tobramycin/dexamethasone)
tobramycin/dexamethasone
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
OPHTHALMICS FOR ALLERGIC
CONJUNCTIVITIS
ALREX (loteprednol)
BEPREVE (bepotastine)
cromolyn
ketotifen
OPTIVAR (azelastine)
PATADAY (olopatadine)
PATANOL (olopatadine)
ALAMAST (pemirolast)
ALOCRIL (nedocromil)
ALOMIDE (lodoxamide)
azelastine
CROLOM (cromolyn)
ELESTAT (epinastine)
EMADINE (emedastine)
epinastine
LASTACAFT (alcaftadine)
VOLTAREN (ketotifen)
ZADITOR (ketotifen)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
OPHTHALMIC ANTIBIOTICS
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
AMINOGLYCOSIDES
gentamicin
tobramycin
TOBREX Ointment
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
21
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
OPHTHALMIC ANTIBIOTICS
continued
PA CRITERIA
QUINOLONES
CILOXAN (ciprofloxacin)
ciprofloxacin
IQUIX (levofloxacin)
levofloxacin
OCUFLOX (ofloxacin)
QUIXIN (levofloxacin)
ZYMAXID (gatifloxacin)
ZYMAR (gatifloxacin)
BESIVANCE (besifloxacin)
MOXEZA (moxifloxacin)
ofloxacin
VIGAMOX (moxifloxacin)
MACROLIDES
erythromycin
AZASITE (azithromycin)
OTHER
bacitracin/polymyxin
neomycin/polymyxin/gramicidin
polymyxin/trimethoprim
sulfacetamide
OPHTHALMICS, GLAUCOMA
AGENTS
bacitracin
bacitracin/neomycin/polymyxin
NATACYN (natamycin)
SYMPATHOMIMETICS
ALPHAGAN P (brimonidine)
brimonidine
dipivefrin
pilocarpine
ISOPTO CARPINE (pilocarpine)
PROPINE (dipivefrin)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
BETA BLOCKERS
betaxolol
BETIMOL (timolol)
BETOPTIC S (betaxolol)
carteolol
ISTALOL (timolol)
levobunolol
metipranolol
timolol
BETAGAN (levobunolol)
OPTIPRANOLOL (metipranolol)
TIMOPTIC (timolol)
CARBONIC ANHYDRASE INHIBITORS
AZOPT (brinzolamide)
dorzolamide
TRUSOPT (dorzolamide)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
22
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
OPHTHALMICS, GLAUCOMA
AGENTS
continued
PA CRITERIA
PROSTAGLANDIN ANALOGS
TRAVATAN-Z (travoprost)
XALATAN (latanoprost)
latanoprost
LUMIGAN (bimatoprost)
COMBINATION AGENTS
COMBIGAN (brimonidine/timolol)
dorzolamide/timolol
OPHTHALMICS, ANTIINFLAMMATORIES
COSOPT (dorzolamide/timolol)
NSAIDS
flurbiprofen
NEVANAC (nepafenac)
ACULAR (ketorolac)
ACULAR LS (ketorolac)
ACULAR PF (ketorolac)
ACUVAIL (ketorolac)
bromfenac
diclofenac
ketorolac
OCUFEN (flurbiprofen)
VOLTAREN (diclofenac)
XIBROM (bromfenac)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
STEROIDS
OTIC ANTIBIOTICS
dexamethasone
FLAREX (fluorometholone)
fluorometholone
FML FORTE (fluorometholone)
FML S.O.P. (fluorometholone)
LOTEMAX (loteprednol)
MAXIDEX (dexamethasone)
PRED MILD (prednisolone)
prednisolone
DUREZOL (difluprednate)
VEXOL (rimexolone)
CIPRODEX
(ciprofloxacin/dexamethasone)
neomycin/polymyxin/hydrocortisone
ofloxacin
CETRAXAL (ciprofloxacin)
CIPRO HC (ciprofloxacin/hydrocortisone)
COLY-MYCIN S
(colistin/neomycin/thonzonium/hydrocortisone)
CORTISPORIN-TC
(colistin/neomycin/thonzonium/hydrocortisone)
FLOXIN (ofloxacin)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
23
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
PAH AGENTS
(Oral, Inhalation)
ADCIRCA (tadalafil)
LETAIRIS (ambrisentan)
REVATIO (sildenafil)
TRACLEER (bosentan)
PANCREATIC ENZYMES
CREON (pancrelipase)
PANCREAZE (pancrelipase)
pancrelipase
ZENPEP (pancrelipase)
PHOSPHATE BINDERS
FOSRENOL (lanthanum)
PHOSLO (calcium acetate)
RENAGEL (sevelamer HCl)
calcium acetate
ELIPHOS (calcium acetate)
RENVELA (sevelamer carbonate)
PA CRITERIA
Diagnosis of ESRD and
hyperphosphatemia despite dietary
phosphorous restrictions and at least
one of the following:
• hypercalcemia (corrected serum
calcium >10.2 mg/dL)
• plasma PTH levels <150 pg/mL on
two consecutive measurements
• dialysis patients with severe
vascular and/or soft tissue
calcifications
• allergic reaction to preferred product
• treatment failure with preferred
product
PLATELET AGGREGATION
INHIBITORS
PRENATAL VITAMINS
AGGRENOX (dipyridamole/aspirin)
PLAVIX (clopidogrel)
dipyridamole
EFFIENT (prasugrel)
PERSANTINE (dipyridamole)
ticlopidine
See Separate Preferred Prenatal Vitamin Listing
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
24
• Treatment failure with preferred
product.
• Contraindication to preferred
product.
• Allergic reaction to preferred
product.
• Prenatal vitamins are covered only
for females less than 50 years of age.
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
PROTON PUMP INHIBITORS
(Oral)
ACIPHEX (rabeprazole)
NEXIUM (esomeprazole)
SEDATIVE HYPNOTICS
DEXILANT (dexlansoprazole)
lansoprazole
omeprazole
pantoprazole
PREVACID (lansoprazole)
PRILOSEC (omeprazole)
PROTONIX (pantoprazole)
ZEGERID OTC (omeprazole/sodium bicarbonate)
BENZODIAZEPINES
flurazepam
temazepam 15, 30 mgPPG
triazolam
DORAL (quazepam)
estazolam
HALCION (triazolam)
PROSOM (estazolam)
RESTORIL (temazepam)
temazepam 7.5, 22.5 mg
PA CRITERIA
• Treatment failure after no less than
a 30 day trial of each preferred product
• Contraindication to preferred
products
• Allergic reaction to preferred
products
• Prevacid Solutabs will be approved
for children 10 years of age and under
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
OTHERS
SKELETAL MUSCLE RELAXANTS
chloral hydrate
LUNESTA (eszopiclone)
zaleplon
zolpidem
AMBIEN (zolpidem)
AMBIEN CR (zolpidem)
EDLUAR (zolpidem)
ROZEREM (ramelteon)
SILENOR (doxepin)
SONATA (zaleplon)
ZOLPIMIST (zolpidem)
baclofen
carisoprodol
carisoprodol/ASA
chlorzoxazone
cyclobenzaprine
methocarbamol
orphenadrine
orphenadrine compound
tizanidine
AMRIX (cyclobenzaprine ER)
cyclobenzaprine ER
dantrolene
FEXMID (cyclobenzaprine)
FLEXERIL (cyclobenzaprine)
metaxolone
NORFLEX (orphenadrine)
PARAFON FORTE (chlorzoxazone)
ROBAXIN (methocarbamol)
SKELAXIN (metaxolone)
SOMA (carisoprodol)
ZANAFLEX (tizanidine)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
25
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
STEROIDS, TOPICAL
LOW POTENCY
alclometasone
DERMA-SMOOTHE/FS (fluocinolone)
desonide
hydrocortisone
DESONATE (desonide)
DESOWEN (desonide)
PEDIADERM HC (hydrocortisone)
VERDESO (desonide)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
MEDIUM POTENCY
hydrocortisone valerate
mometasone
CLODERM (clocortolone)
CORDRAN (flurandrenolide)
CUTIVATE (fluticasone)
fluticasone propionate
hydrocortisone butyrate
LUXIQ (betamethasone)
MOMEXIN (mometasone)
PANDEL (hydrocortisone probutate)
prednicarbate
HIGH POTENCY
betamethasone valerate
fluocinolone
fluocinonide
triamcinolone
amcinonide
betamethasone dipropionate
CAPEX (fluocinolone)
desoximetasone
diflorasone
HALOG (halcinonide)
KENALOG aerosol (triamcinolone)
VANOS (fluocinonide)
VERY HIGH POTENCY
clobetasol
halobetasol
CLOBEX (clobetasol)
HALONATE (halobetasol)
OLUX (clobetasol)
ULTRAVATE (halobetasol)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
26
PA CRITERIA
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
STIMULANTS AND RELATED
AGENTS
STIMULANTS
ADDERALL XR
(amphetamine salt combination)
amphetamine salt combination IR
CONCERTA (methylphenidate)
DAYTRANA (methylphenidate)
dexmethylphenidate
dextroamphetamine
FOCALIN XR (dexmethylphenidate)
METHYLIN (methylphenidate)
methylphenidatePPG
VYVANSE (lisdexamfetamine)
ADDERALL (amphetamine salt combination)
amphetamine salt combination ER
DEXEDRINE (dextroamphetamine)
DEXEDRINE SPANSULES (dextroamphetamine)
FOCALIN (dexmethylphenidate)
METADATE CD (methylphenidate)
METHYLIN (methylphenidate) chewable tablets
methylphenidate SA (equivalent to Concerta)
NUVIGIL (armodafinil)
PROCENTRA (dextroamphetamine)
PROVIGIL (modafinil)
RITALIN (methylphenidate)
PA CRITERIA
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
NON-STIMULANTS
INTUNIV (guanfacine ER)
KAPVAY (clonidine ER)
STRATTERA (atomoxetine)
TETRACYCLINES
doxycycline hyclate
minocycline capsules
tetracycline
VIBRAMYCIN suspension (doxycycline)
ULCERATIVE COLITIS
ASACOL (mesalamine)
COLAZAL (balsalazide)
LIALDA (mesalamine)
PENTASA (mesalamine)
sulfasalazine
ADOXA CK (doxycycline)
ADOXA TT (doxycycline)
demeclocycline
doxycycline hyclate DR
doxycycline monohydrate
DYNABAC (dirithromycin)
minocycline ER
minocycline tablets
NUTRIDOX (doxycycline)
ORACEA (doxycycline)
SOLODYN (minocycline)
• Treatment failure with preferred
products
• Contraindication to preferred
products
• Allergic reaction to preferred
products
ORAL
• Treatment failure with preferred
products of same route
• Contraindication to preferred
products of same route
• Allergic reaction to preferred
products of same route
APRISO (mesalamine)
ASACOL HD (mesalamine)
AZULFIDINE (sulfasalazine)
balsalazide
DIPENTUM (olsalazine
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
27
7/25/11
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
THERAPEUTIC DRUG CLASS
PREFERRED
NON-PREFERRED
ULCERATIVE COLITIS
(continued)
RECTAL
CANASA (mesalamine)
SFROWASA (mesalamine)
mesalamine
ROWASA (mesalamine)
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
28
7/25/11
PA CRITERIA
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Highlighted PDL changes effective July 27, 2011
PREMIUM PREFERRED GENERIC () MANUFACTURERS: These manufacturers have offered Supplemental Rebates to the state for their PDL products dispensed to Medicaid
recipients. Pharmacists will receive an additional $0.50 dispensing fee when they dispense the PDL products of these manufacturers.
Generic Manufacturer
Labeler Code(s)
Mallinckrodt
00406
Sun Pharma Glob
41616
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
29
7/25/11
January 20, 2011
PRENATAL VITAMINS
PREFERRED DRUGS
CAVAN-ALPHA KIT
CAVAN-EC SOD DHA
CITRANATAL 90 DHA
CITRANATAL ASSURE
CITRANATAL B-CALM
CITRANATAL DHA
CITRANATAL RX
COMPLETE NATAL DHA
COMPLETENATE
COMPLETE-RF PRENATAL
DUALVIT OB
ED CYTE F
FE C
FEMECAL OB
FOLBECAL
FOLTABS
FOLTABS 90 PLUS DHA
FOLTABS PRENATAL PLUS DHA
ICAR-C PLUS
ICAR-C PLUS SR
INATAL ADVANCE
INATAL GT
INATAL ULTRA
LACTOCAL-F
MARNATAL-F
MARNATAL-F PLUS
MATERNITY
MAXINATE
MISSION PRENATAL FA OTC
MISSION PRENATAL HP OTC
MISSION PRENATAL OTC
MULTIFOL PLUS
MULTI-NATE 30
MULTI-NATE 30 DHA
MULTI-NATE DHA EXTRA
M-VIT
NATACAPS
NATAFORT
NATALCARE PLUS
NATALVIT
NUTRISPIRE
OB + DHA
OB 90 + DHA
NON-PREFERRED DRUGS
ADVANCED CARE PLUS
CAVAN ONE OMEGA
CITRANATAL HARMONY
CONCEPT DHA
CONCEPT OB
DOCOSAVIT
DUET DHA
DUET DHA COMPLETE
DUET DHA EC
DUET DHA WITH FERRAZONE
DUET STUARTNATAL
EDGE OB
ELITE OB DHA
ELITE-OB
FOLCAL DHA
FOLCAPS CARE ONE
FOLINATAL PLUS B
FOLIVANE-EC CALCIUM DHA NF
FOLIVANE-OB
FOLIVANE-PRX DHA NF
GESTICARE
GESTICARE DHA
MULTINATAL PLUS
NATACHEW
NATELLE
NATELLE ONE
NATELLE PLUS
NATELLE PREFER
NATELLE-EZ
NEEVO
NEEVO DHA
OB COMPLETE
OB COMPLETE 400
OB COMPLETE DHA
OB-NATAL ONE
PNV-DHA
PNV-DHA + DOCUSATE
PNV-SELECT
PRECARE CONCEIVE
PRECARE PREMIER
PREFERA-OB ONE
PRENATE DHA
PRENATE DHA
1 of 3
January 20, 2011
PRENATAL VITAMINS
PREFERRED DRUGS
O-CAL FA
O-CAL PRENATAL
POLY IRON PN
POLY IRON PN FORTE
PR NATAL 400
PR NATAL 400 EC
PR NATAL 430
PR NATAL 430 EC
PR NATAL 440 EC
PREFERA OB
PREFERA-OB PLUS DHA
PRENACARE
PRENAFIRST
PRENAPLUS
PRENATABS FA
PRENATABS RX
PRENATAL 1-1
PRENATAL 19
PRENATAL AD
PRENATAL LOW IRON
PRENATAL MR 90 FE
PRENATAL MULTIVITAMIN W-IRON
PRENATAL PLUS
PRENATAL VITAMINS OTC
PRENATAL Z
PRENATAL-U
PRENAVITE OTC
PREVITE RX
PRUET DHA
PRUET DHA EC
RE-NATA 29
RE-NATA 29 OB
SELECT-OB
SELECT-OB + DHA
SE-NATAL 19
SE-NATAL 90
SE-NATAL ONE
SE-TAN DHA
SETONET
SETONET-EC
STUART PRENATAL OTC
TRI RX
TRIADVANCE
NON-PREFERRED DRUGS
PRENATE ELITE
PRENATE ESSENTIAL
PRENATE PLUS
PRENEXA
PREQUE 10
PRIMACARE ONE
RENATE DHA EXTRA
ROVIN-NV
ROVIN-NV DHA
SE-CARE
SE-CARE CONCEIVE
SE-CARE GESTURE
SE-PLETE DHA
TANDEM DHA
TANDEM OB
TARON EC CALCIUM
TARON-C DHA
TARON-EC CAL
TARON-PREX PRENATAL
TRICARE DHA
TRIMESIS RX
TRIVEEN-ONE
TRIVEEN-PRX RNF
ULTIMATECARE ADVANTAGE
ULTIMATECARE COMBO
ULTIMATECARE ONE
ULTIMATECARE ONE NF
VINACAL
VIVA DHA
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
2 of 3
January 20, 2011
PRENATAL VITAMINS
PREFERRED DRUGS
TRICARE
TRINATAL RX 1
TRINATE
VINATE AZ
VINATE AZ EXTRA
VINATE C
VINATE CALCIUM
VINATE CARE
VINATE GT
VINATE IC
VINATE II
VINATE III
VINATE ONE
VINATE PN CARE
VINATE ULTRA
VINATE-M
VITAFOL-OB
VITAFOL-OB+DHA
VITAFOL-PN
VITAPHIL
VITAPHIL + DHA
VITASPIRE
NON-PREFERRED DRUGS
3 of 3
IRON AGENTS, ORAL
PREFERRED DRUGS
NON-PREFERRED DRUGS
BIFERA RX
CENTRATEX
DUALVIT F
DUALVIT PLUS
FEROCON
FEROTRINSIC
FERRALET 90 DUAL-IRON
FERRAPLUS 90
FERREX 28
FERROCITE PLUS
FERROGELS FORTE
FETRIN
FOLITAB 500
FOLIVANE-F
FOLIVANE-PLUS
FOLTRIN
FUMATINIC
HEMATINIC PLUS
HEMATINIC WITH FOLIC ACID
HEMATOGEN
HEMATOGEN FA
HEMATOGEN FORTE
HEMOCYTE PLUS
HEMOCYTE-F
IFEREX 150 FORTE
INTEGRA F
INTEGRA PLUS
IRON
MYKIDZ IRON 10
NEPHRON FA
NOVAFERRUM
POLY-IRON 150 FORTE
POLYSACCHARIDE IRON FORTE
REOCYTE PLUS
SE-TAN PLUS
SE-VATE 21-7
TANDEM F
TANDEM PLUS
TARON FORTE
TRICON
TRIGELS-F FORTE
CORVITA 150
CORVITE 150
CORVITE FE
FERRALET 90
FERREX 150 FORTE PLUS
MAXARON FORTE
MULTIGEN
MULTIGEN FOLIC
MULTIGEN PLUS
NIFEREX-150 FORTE
PRUVATE 21-7
TL ICON
VITAFOL
COUGH AND COLD, NON-ANTITUSSIVE
PREFERRED DRUGS
NON-PREFERRED DRUGS
ALAHIST LQ (ORAL)
ALA-HIST PE OTC (ORAL)
ALLANTAN (ORAL)
ALLERFRIM OTC (ORAL)
ALLERGY & SINUS HEADACHE OTC (ORAL)
ALLERGY & SINUS OTC (ORAL)
ALLERGY MULTI-SYMPTOM (ORAL)
ALLERGY MULTI-SYMPTOM OTC (ORAL)
ALLERGY RELIEF OTC (ORAL)
APRODINE OTC (ORAL)
BPM PE (ORAL)
BROMALINE OTC (ORAL)
BROTAPP OTC (ORAL)
CERON (ORAL)
CHEST CONGESTION & SINUS OTC (ORAL)
CHEST CONGESTION RELIEF D OTC (ORAL)
CHEST CONGESTION RELIEF OTC (ORAL)
CHEST CONGESTION RELIEF PE OTC (ORAL)
CHEST-SINUS CONGESTION RELIEF OTC (ORAL)
CHILDREN'S COLD & ALLERGY (ORAL)
CHILDREN'S COLD & ALLERGY OTC (ORAL)
CHILDREN'S MUCUS RELIEF (ORAL)
CHILDREN'S MUCUS RELIEF OTC (ORAL)
CHILDRENS TYLENOL PLUS COLD OTC (ORAL)
CHILD'S MUCINEX OTC (ORAL)
CHILDS PLUS COLD & ALLERGY OTC (ORAL)
CHILDS TRIACTING COLD & COUGH (ORAL)
CHILDS TRIACTING COLD & COUGH OTC (ORAL)
COLD & ALLERGY (ORAL)
COLD & ALLERGY OTC (ORAL)
COLD & ALLERGY PE OTC (ORAL)
COLD RELIEF PLUS OTC (ORAL)
COLD, ALLERGY & SINUS OTC (ORAL)
COMPLETE SINUS RELIEF OTC (ORAL)
10PEH-4CPM OTC (ORAL)
60PSE-400GFN OTC (ORAL)
60PSE-4CPM OTC (ORAL)
ACCUHIST (ORAL)
ALDEX-CT (ORAL)
ALERSULE (ORAL)
ALLFEN OTC (ORAL)
BIDEX OTC (ORAL)
BROMAX D (ORAL)
BROMHIST (ORAL)
BROMHIST-NR (ORAL)
BROVEX PSE (ORAL)
CENHIST (ORAL)
COUGH AND COLD, COLD FDA LIST
CPM-PE (ORAL)
CPM-PSE (ORAL)
CPM-PYR-PE (ORAL)
CRANTEX (ORAL)
DICEL (ORAL)
DONATUSSIN (ORAL)
DRYMAX (ORAL)
ED BRON GP (ORAL)
ED CHLORPED D (ORAL)
ENTEX LQ (ORAL)
ENTRE-B (ORAL)
FLU & SEVERE COLD OTC (ORAL)
FLU & SORE THROAT (ORAL)
FLU-SEVERE COLD & COUGH (ORAL)
HISTEX SR (ORAL)
HIST-PSE (ORAL)
J-TAN D PD (ORAL)
LIQUIBID D-R OTC (ORAL)
LIQUIBID OTC (ORAL)
LIQUIBID PD-R OTC (ORAL)
1 of 5
COUGH AND COLD, NON-ANTITUSSIVE
PREFERRED DRUGS
NON-PREFERRED DRUGS
COMTREX FLU THERAPY OTC (ORAL)
COMTREX SEVERE COLD & SINUS OTC (ORAL)
CONEX OTC (ORAL)
CONGESTAC OTC (ORAL)
CONGEST-EZE OTC (ORAL)
CONGEST-EZE PE OTC (ORAL)
CONTAC OTC (ORAL)
COUGH CONTROL OTC (ORAL)
COUGHTAB 400 OTC (ORAL)
COUGHTAB OTC (ORAL)
DALLERGY (ORAL)
DALLERGY-JR (ORAL)
DECONEX IR OTC (ORAL)
DECONEX OTC (ORAL)
DELSYM COUGH & COLD (ORAL)
DIABETIC TUSSIN EX OTC (ORAL)
DIABETIC TUSSIN MUCUS RELIEF OTC (ORAL)
DIMAPHEN OTC (ORAL)
DIMETAPP COLD & CONGESTION OTC (ORAL)
DIMETAPP OTC (ORAL)
DRISTAN COLD OTC (ORAL)
DRIXORAL OTC (ORAL)
EFFERVESCENT COLD RELIEF OTC (ORAL)
EXPECTORANT OTC (ORAL)
FLU RELIEF THERAPY (ORAL)
FLU RELIEF THERAPY NIGHTTIME (ORAL)
FLU RELIEF THERAPY OTC (ORAL)
GENAC OTC (ORAL)
GENAPHED PLUS OTC (ORAL)
G-FENESIN OTC (ORAL)
GUAIFENESIN OTC (ORAL)
GUAIFENESIN/PHENYLEPHRINE HCL OTC (ORAL)
HISTAFED OTC (ORAL)
INTENSE COLD & FLU OTC (ORAL)
LORTUSS LQ (ORAL)
MAXICHLOR PEH (ORAL)
MAXICHLOR PSE (ORAL)
MEDENT-PEI OTC (ORAL)
MYCI CHLORPED D (ORAL)
NASOHIST (ORAL)
NEUTRAHIST (ORAL)
NOREL SR (ORAL)
NY-TANNIC (ORAL)
PE-CPM-MSN (ORAL)
PEDIATEX PS (ORAL)
PEDIATEX TD (ORAL)
PHENA-PLUS (ORAL)
PHENA-S (ORAL)
PHENYLEPHRINE/CHLOR-TAN (ORAL)
POLY HIST FORTE (ORAL)
POLY HIST PD (ORAL)
PYRICHLOR PE (ORAL)
PYRIL D (ORAL)
PYRIL-CHLOR-PHEN (ORAL)
RELHIST (ORAL)
RESPA A.R. (ORAL)
RESPAHIST (ORAL)
R-TANNA (ORAL)
R-TANNA PEDIATRIC (ORAL)
RU-HIST FORTE (ORAL)
RU-HIST-D OTC (ORAL)
RU-TUSS (ORAL)
RYDEX G (ORAL)
RYNATAN (ORAL)
RYNATAN PEDIATRIC (ORAL)
SINA-12X (ORAL)
SONAHIST (ORAL)
TEKRAL (ORAL)
2 of 5
COUGH AND COLD, NON-ANTITUSSIVE
PREFERRED DRUGS
NON-PREFERRED DRUGS
IOPHEN NR (ORAL)
LOHIST-D (ORAL)
LUSAIR (ORAL)
MEDIFIN EXPECTORANT OTC (ORAL)
MEDI-TUSSIN OTC (ORAL)
MUCINEX COLD OTC (ORAL)
MUCINEX D MAXIMUM STRENGTH OTC (ORAL)
MUCINEX D OTC (ORAL)
MUCINEX OTC (ORAL)
MUCOSA OTC (ORAL)
MUCUS ER (ORAL)
MUCUS RELIEF OTC (ORAL)
MUCUS RELIEF SINUS OTC (ORAL)
MYHIST-PD (ORAL)
NASOPEN (ORAL)
NIGHTTIME SINUS OTC (ORAL)
ORGAN-I NR (ORAL)
PAIN RELIEF ALLERGY OTC (ORAL)
PE HCL-CPM-MSN (ORAL)
PHENYLEPHRINE HCL/PROMETH HCL (ORAL)
PHENYLTOLOXAMINE PE CPM (ORAL)
POLY-VENT IR OTC (ORAL)
PRIMATENE ASTHMA OTC (ORAL)
PROHIST LQ (ORAL)
PSEUDO PLUS COLD & ALLERGY OTC (ORAL)
Q-TAPP OTC (ORAL)
Q-TUSSIN OTC (ORAL)
RESCON (ORAL)
RESCON-GG OTC (ORAL)
RESCON-JR. (ORAL)
RHINACON A (ORAL)
ROBAFEN OTC (ORAL)
ROBITUSSIN COUGH & COLD OTC (ORAL)
ROBITUSSIN OTC (ORAL)
THERAFLU COLD-SORE THROAT OTC (ORAL)
THERAFLU OTC (ORAL)
THERAFLU SINUS & COLD (ORAL)
TIBAMINE LA (ORAL)
TRIP-PSE (ORAL)
TRYMINE D (ORAL)
VAZOTAB (ORAL)
V-HIST (ORAL)
ZOTEX-PE (ORAL)
3 of 5
COUGH AND COLD, NON-ANTITUSSIVE
PREFERRED DRUGS
NON-PREFERRED DRUGS
RYMED OTC (ORAL)
RYNEX PSE (ORAL)
SILAFED OTC (ORAL)
SILDEC (ORAL)
SILTUSSIN DAS OTC (ORAL)
SILTUSSIN SA OTC (ORAL)
SINUS & ALLERGY OTC (ORAL)
SINUS & ALLERGY PE (ORAL)
SINUS & ALLERGY PE OTC (ORAL)
SINUS CONGESTION & PAIN (ORAL)
SINUS CONGESTION & PAIN OTC (ORAL)
SINUS NIGHTTIME OTC (ORAL)
SINUTROL PE OTC (ORAL)
SUDOGEST COLD & ALLERGY OTC (ORAL)
SUDOGEST SINUS & ALLERGY (ORAL)
TRIACTIN OTC (ORAL)
TRIACTING COLD AND ALLERGY OTC (ORAL)
TRIAMINIC CHEST NASAL CONGESTION OTC (ORAL)
TRIAMINIC COLD & ALLERGY OTC (ORAL)
TRIAMINIC COLD & COUGH OTC (ORAL)
TRIAMINIC COLD-ALLERGY PE OTC (ORAL)
TRIAMINIC SOFTCHEWS OTC (ORAL)
TRIAMINICIN OTC (ORAL)
TRIGOFEN (ORAL)
TRIPOHIST D (ORAL)
TRIPTIFED OTC (ORAL)
TUSSANIL (ORAL)
TUSSIN COLD SEVERE CONGESTION OTC (ORAL)
TUSSIN HONEY OTC (ORAL)
TUSSIN OTC (ORAL)
TUSSIN PE OTC (ORAL)
TYLENOL ALLERGY COMPLETE OTC (ORAL)
TYLENOL ALLERGY M-S NIGHTTIME OTC (ORAL)
TYLENOL ALLERGY MULTI-SYMPTOM OTC (ORAL)
4 of 5
COUGH AND COLD, NON-ANTITUSSIVE
PREFERRED DRUGS
NON-PREFERRED DRUGS
TYLENOL SINUS NIGHTTIME OTC (ORAL)
VALU-TAPP OTC (ORAL)
ZODEN PD (ORAL)
5 of 5
COUGH AND COLD, NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
NON-PREFERRED DRUGS
ALA-HIST AC (ORAL)
ALAHIST DHC (ORAL)
BALTUSSIN (ORAL)
CAPCOF (ORAL)
CHERATUSSIN AC OTC (ORAL)
CHERATUSSIN DAC OTC (ORAL)
CODAL-DH (ORAL)
CODEINE/PROMETHAZINE HCL (ORAL)
COLDCOUGH PD (ORAL)
CYTUSS HC (ORAL)
EXECLEAR-C (ORAL)
GANI-TUSS NR (ORAL)
GUAIFENESIN/CODEINE PHOS (ORAL)
HYCODAN (ORAL)
HYPHED (ORAL)
IOPHEN-C NR (ORAL)
M-CLEAR (ORAL)
M-CLEAR WC (ORAL)
MYTUSSIN AC OTC (ORAL)
MYTUSSIN DAC OTC (ORAL)
PHENYLEPHRINE HCL/COD/PROMETH (ORAL)
PHENYLHISTINE DH OTC (ORAL)
POLY-TUSSIN AC (ORAL)
POLY-TUSSIN DHC (ORAL)
POLY-TUSSIN EX (ORAL)
PRO-CLEAR AC (ORAL)
PRO-CLEAR CAPS (ORAL)
PRO-RED AC (ORAL)
PSEUDOEPHEDRINE HCL/CODEINE (ORAL)
ROBAFEN AC (ORAL)
SU-TUSS HD (ORAL)
TUSNEL C (ORAL)
TUSNEL PED-C (ORAL)
TUSSIONEX (ORAL)
AIRACOF (ORAL)
ALLFEN CD (ORAL)
ALLFEN CDX (ORAL)
AMBIFED CD (ORAL)
AMBIFED CDX (ORAL)
AMBIFED-G CD (ORAL)
AMBIFED-G CDX (ORAL)
BROMPHENIRAM/PE/DIHYDROCODEINE (ORAL)
BRONTEX (ORAL)
CENTUSSIN DHC (ORAL)
CHLORPHENIRAMINE/CODEINE PHOS (ORAL)
CODEINE-GUAIFENESIN (ORAL)
COTAB A (ORAL)
COTAB AX (ORAL)
COTABFLU (ORAL)
COUGH AND COLD, NARCOTIC FDA LIST
DEXPHEN W-C (ORAL)
DEX-TUSS (ORAL)
DIHYDROCODEINE-BPM-PE (ORAL)
DIHYDRO-CP (ORAL)
DIHYDRO-GP (ORAL)
DIHYDRO-PE (ORAL)
DONATUSS DC (ORAL)
DUOHIST DH (ORAL)
ENDACOF AC (ORAL)
ENDACOF-C (ORAL)
ENDACOF-DC (ORAL)
ENDAL CD (ORAL)
HYDROCODONE/HOMATROPINE (ORAL)
HYDROCODONE-CHLORPHENIRAMINE (ORAL)
HYDROMET (ORAL)
J-COF DHC (ORAL)
J-MAX DHC (ORAL)
LEXUSS 210 (ORAL)
1 of 3
COUGH AND COLD, NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
NON-PREFERRED DRUGS
LORTUSS EX (ORAL)
MAR-COF BP (ORAL)
MAR-COF CG (ORAL)
MAXIFED CD (ORAL)
MAXIFED CDX (ORAL)
MAXIFED-G CD (ORAL)
MAXIFED-G CDX (ORAL)
MAXIFLU CD (ORAL)
MAXIFLU CDX (ORAL)
MAXIPHEN CD (ORAL)
MAXIPHEN CDX (ORAL)
M-END PE (ORAL)
M-END WC (ORAL)
MESEHIST WC (ORAL)
MYCI-GC (ORAL)
NASOTUSS (ORAL)
NEO AC (ORAL)
NOTUSS AC (ORAL)
NOTUSS DC (ORAL)
NOTUSS-NX (ORAL)
NOTUSS-NXD (ORAL)
NOTUSS-PE (ORAL)
PHENFLU CD (ORAL)
PHENFLU CDX (ORAL)
POLY HIST DHC (ORAL)
POLY HIST NC (ORAL)
RYDEX (ORAL)
TL-HIST CD (ORAL)
TL-HIST CM (ORAL)
TUSSCOUGH DHC (ORAL)
TUSSICAPS (ORAL)
TUSSIGON (ORAL)
TUSSO-C (ORAL)
ZODRYL AC 25 OTC (ORAL)
2 of 3
COUGH AND COLD, NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
NON-PREFERRED DRUGS
ZODRYL AC 30 OTC (ORAL)
ZODRYL AC 35 OTC (ORAL)
ZODRYL AC 40 OTC (ORAL)
ZODRYL AC 50 OTC (ORAL)
ZODRYL AC 60 OTC (ORAL)
ZODRYL AC 80 OTC (ORAL)
ZODRYL DAC 25 OTC (ORAL)
ZODRYL DAC 30 OTC (ORAL)
ZODRYL DAC 35 OTC (ORAL)
ZODRYL DAC 40 OTC (ORAL)
ZODRYL DAC 50 OTC (ORAL)
ZODRYL DAC 60 OTC (ORAL)
ZODRYL DAC 80 OTC (ORAL)
ZODRYL DEC 25 OTC (ORAL)
ZODRYL DEC 30 OTC (ORAL)
ZODRYL DEC 35 OTC (ORAL)
ZODRYL DEC 40 OTC (ORAL)
ZODRYL DEC 50 OTC (ORAL)
ZODRYL DEC 60 OTC (ORAL)
ZODRYL DEC 80 OTC (ORAL)
ZOTEX-C (ORAL)
Z-TUSS AC (ORAL)
3 of 3
COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
ADULT ROBITUSSIN COUGH-COLD D OTC (ORAL)
ADULT ROBITUSSIN OTC (ORAL)
ALA-HIST DM (ORAL)
ALLANHIST PDX (ORAL)
ALLANVAN-DM (ORAL)
ANAPLEX DMX (ORAL)
BENZONATATE (ORAL)
BROMALINE DM OTC (ORAL)
BROMDEX D (ORAL)
BROMPHENEX DM OTC (ORAL)
BROMPLEX DM (ORAL)
BROTAPP DM OTC (ORAL)
CAPMIST DM OTC (ORAL)
CHERACOL D OTC (ORAL)
CHEST CONGESTION RELIEF DM OTC (ORAL)
CHEST CONGESTION-COUGH RELIEF OTC (ORAL)
CHILD MUCINEX MULTI-SYMPTOM (ORAL)
CHILD MUCUS RELIEF COUGH (ORAL)
CHILD MUCUS RELIEF COUGH OTC (ORAL)
CHILD TRIACTING COLD-COUGH (ORAL)
CHILD TRIAMINIC-D MT-SYM COLD OTC (ORAL)
CHILDREN'S COLD & COUGH (ORAL)
CHILDREN'S COLD & COUGH DM OTC (ORAL)
CHILDREN'S COLD & COUGH OTC (ORAL)
CHILDREN'S MUCINEX COUGH OTC (ORAL)
CHLO TUSS OTC (ORAL)
CODAL-DM OTC (ORAL)
CODITUSS DM OTC (ORAL)
COLD & COUGH DM OTC (ORAL)
COLD & COUGH OTC (ORAL)
COLD HEAD CONGESTION (ORAL)
COLD HEAD CONGESTION OTC (ORAL)
COLD MULTI-SYMPTOM (ORAL)
COLD MULTI-SYMPTOM DAYTIME (ORAL)
COLD MULTI-SYMPTOM SEVERE (ORAL)
NON-PREFERRED DRUGS
10PEH-4CPM-20DM OTC (ORAL)
20DM-4CPM OTC (ORAL)
40PSE-400GFN-20DM OTC (ORAL)
60PSE-4CPM-20DM OTC (ORAL)
ALLRES PD (ORAL)
ATUSS DS (ORAL)
BROMFED DM (ORAL)
BROMFED-DM (ORAL)
BROMHIST PDX (ORAL)
BROMPHENIRAMIN/PE/DEXTROMETHOR (ORAL)
CARBATUSS-12 (ORAL)
CENTUSS DM (ORAL)
CLOFERA (ORAL)
CLOFERA OTC (ORAL)
CORZALL PLUS (ORAL)
COUGH AND COLD, NON-NARCOTIC FDA LIST
CPM-PSE DM (ORAL)
DECONSAL DM (ORAL)
DICEL CD (ORAL)
DICEL DM (ORAL)
D-METHORPHAN HB/P-EPD HCL/BPM (ORAL)
D-METHORPHAN HB/P-EPHED HCL/CP (ORAL)
DONATUSSIN DM (ORAL)
ENDACOF-PD (ORAL)
ENDACON OTC (ORAL)
ENTRE-S (ORAL)
FLU-SEVERE COLD-COUGH (ORAL)
FLUTABS (ORAL)
INDAMIX DM (ORAL)
LIVETAN DM (ORAL)
LORTUSS DM (ORAL)
MAXIFED DM OTC (ORAL)
MAXIPHEN DMX (ORAL)
M-END DM (ORAL)
NASOHIST DM (ORAL)
1 of 5
COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
COLD SEVERE CONGESTION OTC (ORAL)
COMTREX COLD & COUGH OTC (ORAL)
CORFEN-DM (ORAL)
CORICIDIN HBP OTC (ORAL)
COUGH & COLD OTC (ORAL)
COUGH & RUNNY NOSE OTC (ORAL)
COUGH & SORE THROAT OTC (ORAL)
COUGH CONTROL DM (ORAL)
COUGH CONTROL DM MAX (ORAL)
COUGH CONTROL DM OTC (ORAL)
COUGH RELIEF (ORAL)
COUGH RELIEF OTC (ORAL)
COUGH SUPPRESSANT OTC (ORAL)
DALLERGY DM (ORAL)
DAY TIME COUGH (ORAL)
DAYTIME (ORAL)
DAYTIME COLD & FLU RELIEF (ORAL)
DAYTIME COLD-FLU RELIEF (ORAL)
DAYTIME COUGH (ORAL)
DAYTIME MUCUS RELIEF DM (ORAL)
DECONEX DM OTC (ORAL)
DECONEX DMX OTC (ORAL)
DELSYM MULTI-SYMPTOM (ORAL)
DELSYM OTC (ORAL)
DIABETIC TUSSIN DM OTC (ORAL)
DIABETIC TUSSIN MAX-STRENGTH OTC (ORAL)
DIMAPHEN DM OTC (ORAL)
DIMETAPP DM OTC (ORAL)
DIMETAPP LONG-ACTING OTC (ORAL)
D-METHORPHAN HB/PROMETH HCL (ORAL)
DURAFLU (ORAL)
EXECLEAR-DM (ORAL)
EXPECTORANT DM (ORAL)
EXPECTORANT DM OTC (ORAL)
FLU RELIEF THERAPY DAYTIME OTC (ORAL)
NON-PREFERRED DRUGS
NEO DM (ORAL)
NEUTRAHIST PDX (ORAL)
PEDIAHIST DM (ORAL)
PHENYLEPHRINE COMPLEX (ORAL)
POLY HIST CB (ORAL)
PYRIL DM (ORAL)
PYRILAMINE/PE/DEXTROMETHORPHAN (ORAL)
RE DCP (ORAL)
RESPERAL-DM (ORAL)
RYDEX DM (ORAL)
RYNATUSS (ORAL)
SIMUC-DM (ORAL)
TANAFED DMX (ORAL)
THERAFLU COLD & COUGH OTC (ORAL)
THERAFLU MAX-D SEVERE COLD-FLU (ORAL)
THERAFLU NIGHTTIME OTC (ORAL)
TL-HIST DM (ORAL)
TREXBROM (ORAL)
TRYMINE CD (ORAL)
TUSDEC-DM (ORAL)
TUSSALL (ORAL)
TUSSALL-ER (ORAL)
TUSSI-12 S (ORAL)
TUSSO-XR (ORAL)
VANACOF DX OTC (ORAL)
VANACOF G (ORAL)
VANACOF OTC (ORAL)
VANATAB DX OTC (ORAL)
VAZOTAN (ORAL)
V-COF (ORAL)
Z-COF 12DM (ORAL)
Z-DEX (ORAL)
ZONATUSS (ORAL)
ZOTEX-D (ORAL)
ZOTEX-EX (ORAL)
2 of 5
COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
G-FENESIN DM OTC (ORAL)
GUAIFENESIN DM (ORAL)
GUAIFENESIN/D-METHORPHAN HB OTC (ORAL)
HOLD OTC (ORAL)
INTENSE COUGH OTC (ORAL)
INTENSE COUGH RELIEVER OTC (ORAL)
IOPHEN DM (ORAL)
KIDCARE OTC (ORAL)
MEDI-TUSSIN DM DIABETIC OTC (ORAL)
MEDI-TUSSIN DM OTC (ORAL)
MUCINEX COUGH OTC (ORAL)
MUCINEX DM OTC (ORAL)
MUCOSA DM OTC (ORAL)
MUCUS RELIEF COUGH OTC (ORAL)
MUCUS RELIEF DM OTC (ORAL)
MULTI-SYMPTOM COLD OTC (ORAL)
NIGHT TIME COUGH OTC (ORAL)
NIGHTTIME COUGH OTC (ORAL)
NITE TIME COUGH (ORAL)
NITE TIME COUGH OTC (ORAL)
NOHIST-PDX (ORAL)
NON-ASPIRIN SEVERE CONGESTION OTC (ORAL)
PAIN RELIEF COLD OTC (ORAL)
PBM ALLERGY (ORAL)
PEDIA RELIEF COUGH-COLD OTC (ORAL)
PEDIATRIC COUGH-COLD OTC (ORAL)
POLY-VENT DM OTC (ORAL)
PSE BROM (ORAL)
Q-TAPP DM OTC (ORAL)
Q-TUSSIN DM OTC (ORAL)
RESCON-DM OTC (ORAL)
ROBAFEN CF OTC (ORAL)
ROBAFEN COUGH OTC (ORAL)
ROBAFEN DM MAX (ORAL)
ROBAFEN-DM CLEAR OTC (ORAL)
NON-PREFERRED DRUGS
3 of 5
COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
ROBAFEN-DM OTC (ORAL)
ROBITUSSIN COUGH & COLD CF OTC (ORAL)
ROBITUSSIN COUGH-COLD OTC (ORAL)
ROBITUSSIN COUGHGELS OTC (ORAL)
ROBITUSSIN DM MAX OTC (ORAL)
ROBITUSSIN DM TO GO (ORAL)
ROBITUSSIN LONG-ACTING OTC (ORAL)
ROBITUSSIN PEDIATRIC COUGH OTC (ORAL)
ROBITUSSIN-COUGH-CHEST-CONG OTC (ORAL)
ROBITUSSIN-DM COUGH OTC (ORAL)
RYNEX DM (ORAL)
SILDEC-DM (ORAL)
SILPHEN DM OTC (ORAL)
SILTUSSIN DM DAS COUGH FORMULA OTC (ORAL)
SILTUSSIN DM OTC (ORAL)
SIMPLY COUGH OTC (ORAL)
SUPER TROCHE DM OTC (ORAL)
TESSALON (ORAL)
TESSALON PERLE (ORAL)
TRIACTING COLD & COUGH (ORAL)
TRIACTING OTC (ORAL)
TRIAMINIC COLD & COUGH LIQUID OTC (ORAL)
TRIAMINIC NIGHT TIME OTC (ORAL)
TRIAMINIC OTC (ORAL)
TUSNEL DIABETIC OTC (ORAL)
TUSNEL-A OTC (ORAL)
TUSSIN CF (ORAL)
TUSSIN CF OTC (ORAL)
TUSSIN COLD-CONGESTION OTC (ORAL)
TUSSIN COUGH (ORAL)
TUSSIN COUGH OTC (ORAL)
TUSSIN DM (ORAL)
TUSSIN DM CLEAR OTC (ORAL)
TUSSIN DM MAX (ORAL)
TUSSIN DM MAX OTC (ORAL)
NON-PREFERRED DRUGS
4 of 5
COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES
PREFERRED DRUGS
TUSSIN DM OTC (ORAL)
TYLENOL COLD M-S SEVERE DAY OTC (ORAL)
TYLENOL COLD SEVERE CONGESTION OTC (ORAL)
ULTRA DM FREE & CLEAR OTC (ORAL)
VICKS 44 OTC (ORAL)
VICKS 44D COUGH & HEAD OTC (ORAL)
VICKS 44E COUGH & CHEST OTC (ORAL)
VICKS CHILDREN'S NYQUIL OTC (ORAL)
VICKS DAYQUIL COUGH OTC (ORAL)
VICKS DAYQUIL OTC (ORAL)
VICKS FORMULA 44 D OTC (ORAL)
VICKS PEDIATRIC 44E OTC (ORAL)
VICKS PEDIATRIC 44M OTC (ORAL)
Y-COF DM (ORAL)
NON-PREFERRED DRUGS
5 of 5