Medicaid Preferred Drug List Summary of Changes Effective February by amd51223

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									                                           Medicaid Preferred Drug List
                                    Summary of Changes Effective February 2, 2010
                                                 Drug Class Order

                                                                                PDL Status       Prior Authorization Status
           Therapeutic Drug Class                         Brand Name          February 2, 2010    No PA         PA Required
ACNE AGENTS, TOPICAL                      ACZONE (TOPICAL)                          PDL             √
                                          CLARIFOAM EF (TOPICAL)                           NPD                      √
                                          EPIDUO (TOPICAL)                          PDL             √
                                          LAVOCLEN (TOPICAL)                               NPD                      √
                                          SODIUM SULFA-SULFUR-MERATAN (TOP)                NPD                      √
                                          SULFACETAMIDE / SULFUR (TOPICAL)          PDL             √
                                          ZACLIR (TOPICAL)                          PDL             √
ANALGESICS, NARCOTICS LONG                RYZOLT (ORAL)                                    NPD                      √
                                          NUCYNTA (ORAL)                                   NPD                      √
                                          LEVORPHANOL (ORAL)                               NPD                      √
ANGIOTENSIN MODULATORS                    RAMIPRIL (ORAL)                           PDL             √
ANGIOTENSIN MODULATORS/CCB COMBINATIONS   AMLODIPINE / BENAZEPRIL (ORAL)                   NPD                      √
ANTICOAGULANTS, INJECTABLE                INNOHEP (SUBCUTANE.)                             NPD                      √
ANTIDEPRESSANTS, OTHER                    APLENZIN (ORAL)                                  NPD                      √
ANTIFUNGALS, TOPICAL                      BENSAL HP (TOPICAL)                              NPD                      √
                                          CNL 8 (TOPICAL)                                  NPD                      √
ANTIHYPERURICEMICS                        ALLOPURINOL (ORAL)                        PDL             √
                                          COLCHICINE (ORAL)                         PDL             √
                                          PROBENECID (ORAL)                         PDL             √
                                          PROBENECID / COLCHICINE (ORAL)            PDL             √
                                          ULORIC (ORAL)                                    NPD                      √
ANTIMIGRAINE AGENTS, TRIPTANS             FROVA (ORAL)                                     NPD                      √
                                          TREXIMET (ORAL)                           PDL             √
                                          ZOMIG / ZOMIG ZMT (ORAL)                         NPD                      √
ANTIPARASITICS, TOPICAL                   EURAX (TOPICAL)                           PDL             √
                                          OVIDE (TOPICAL)                                  NPD                      √
                                          ULESFIA (TOPICAL)                         PDL             √
ANTIPARKINSON'S AGENTS                    BROMOCRIPTINE (ORAL)                      PDL             √
                                          MIRAPEX (ORAL)                                   NPD                      √
BETA-BLOCKERS                             METOPROLOL XL (ORAL)                             NPD                      √

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                                                                                   PDL Status       Prior Authorization Status
            Therapeutic Drug Class                          Brand Name           February 2, 2010    No PA         PA Required
BLADDER RELAXANT PREPARATIONS              DETROL LA (ORAL)                                   NPD                      √
                                           GELNIQUE (TRANSDERM.)                              NPD                      √
                                           TOVIAZ (ORAL)                               PDL             √
                                           VESICARE (ORAL)                             PDL             √
BONE RESORPTION SUPPRESSION AND RELATED    CALCITONIN SALMON (NASAL)                          NPD                      √
AGENTS
BPH TREATMENTS                             RAPAFLO (ORAL)                                     NPD                      √
CALCIUM CHANNEL BLOCKERS                   NISOLDIPINE (ORAL)                                 NPD                      √
CEPHALOSPORINS & RELATED ANTIBIOTICS       CEDAX (ORAL)                                       NPD                      √
                                          CEFPODOXIME (ORAL)                           PDL             √
                                          CEFTIN SSUSPENSION (Oral)                           NPD                      √
CYTOKINE AND CAM ANTAGONISTS               AMEVIVE (INJECTION)                                NPD                      √
                                           CIMZIA (INJECTION)                          PDL             √
                                           SIMPONI (INJECTION)                                NPD                      √
HYLOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS ONGLYZA (ORAL)                              PDL             √
HYPOGLYCEMICS, INSULIN ANALOGS             LEVEMIR (SUBCUTANE.)                               NPD                      √
                                           LEVEMIR PENS (SUBCUTANE.)                          NPD                      √
                                           NOVOLOG (SUBCUTANE.)                               NPD                      √
                                           NOVOLOG MIX 70/30 (SUBCUTANE.)                     NPD                      √
                                           NOVOLOG MIX 70/30 PENS (SUBCUTANE.)                NPD                      √
                                           NOVOLOG PENS (SUBCUTANE.)                          NPD                      √
HYPOGLYCEMICS, MEGLITINIDES                PRANDIN (ORAL)                                     NPD                      √
NSAIDS                                     IBUPROFEN OTC (ORAL)                        PDL             √
                                           INDOMETHACIN (ORAL/RECTAL)                  PDL             √
OPHTHALMIC ANTIBIOTICS                     BESIVANCE (OPHTHALMIC)                             NPD                      √
OTIC ANTIBIOTICS                           CETRAXAL (OTIC)                                    NPD                      √
PAH AGENTS, ORAL                           ADCIRCA (ORAL)                                     NPD                      √
PHOSPHATE BINDERS                          ELIPHOS (ORAL)                              PDL             √
                                           RENVELA (ORAL)                              PDL             √
PLATELET AGGREGATION INHIBITORS            EFFIENT (ORAL)                                     NPD                      √
SEDATIVE HYPNOTICS                         EDLUAR (SUBLINGUAL)                                NPD                      √
                                           AMBIEN CR (ORAL)                            PDL             √
STEROIDS, TOPICAL HIGH                     DESOXIMETASONE (TOPICAL)                           NPD                      √
STEROIDS, TOPICAL MEDIUM                   CORDRAN (TOPICAL)                                  NPD                      √
                                           MOMEXIN (TOPICAL)                                  NPD                      √
STIMULANTS AND RELATED AGENTS              NUVIGIL (ORAL)                                     NPD                      √
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                                                                         PDL Status       Prior Authorization Status
             Therapeutic Drug Class                   Brand Name       February 2, 2010    No PA         PA Required
TETRACYCLINE                          ADOXA CK (ORAL)                               NPD                      √
                                      ADOXA TT (ORAL)                               NPD                      √
                                      DEMECLOCYCLINE (ORAL)                  PDL             √
                                      DOXYCYCLINE (ORAL)                     PDL             √
                                      MINOCYCLINE (ORAL)                     PDL             √
                                      MINOCYCLINE ER (ORAL)                         NPD                      √
                                      NUTRIDOX (ORAL)                               NPD                      √
                                      ORACEA (ORAL)                                 NPD                      √
                                      SOLODYN (ORAL)                                NPD                      √
                                      TETRACYCLINE (ORAL)                    PDL             √
ULCERATIVE COLITIS AGENTS             APRISO (ORAL)                                 NPD                      √
                                      CANASA (RECTAL)                        PDL             √
                                      SFROWASA (RECTAL)                      PDL             √

NPD = Non-Preferred Drug
PDL = Preferred Drug




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