NEW YORK STATE MEDICAID PREFERRED DRUG LIST by vbf10124

VIEWS: 10 PAGES: 10

									                                                                                                                                                                      Revised 11/18/2009
                                                                                               NEW YORK STATE MEDICAID
                                                                                                 PREFERRED DRUG LIST
                                                                             All non-preferred drugs in these classes require prior authorization (PA)
                                                                            Preferred drugs that require prior authorization are indicated by footnote
                                                           I.    ANALGESICS
                                                                 Cyclooxygenase II (COX II) Inhibitors                      Cyclooxygenase II (COX II) Inhibitors
                                                                 PREFERRED AGENTS                                           NON-PREFERRED AGENTS
                                                                          ®
                                                                 Celebrex                                                   None
                                                                 Narcotics – Long Acting                                    Narcotics – Long Acting
                                                                 PREFERRED AGENTS                                           NON-PREFERRED AGENTS




                                                                                                                                                                                    NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                 Duragesic  ®2
                                                                                                morphine sulfate SR         Avinza®                     oxycodone HCL CR
                                                                 fentanyl patch                 Opana ER®                   Embeda®                     Oxycontin®
                                                                 Kadian®                        Oramorph SR®                MS Contin®
                                                                 Non-Steroidal Anti-Inflammatory Drugs                      Non-Steroidal Anti-Inflammatory Drugs
                                                                 (NSAIDS) – Prescription                                    (NSAIDS) – Prescription
                                                                 PREFERRED AGENTS                                           NON-PREFERRED AGENTS

                                                                 diclofenac potassium           ketorolac                   Anaprox®                    Nalfon®
                                                                 diclofenac sodium              meclofenamate               Anaprox® DS                 Naprelan®
                                                                 diclofenac sodium XR           mefenamic acid              Arthrotec®                  Naprosyn®
                                                                 diflunisal                     meloxicam                   Cataflam®                   Naprosyn® EC
                                                                 etodolac                       nabumetone                  Clinoril®                   Ponstel®
                                                                 etodolac SA                    naproxen                    Daypro®                     Voltaren®
                                                                 fenoprofen                     naproxen sodium             Feldene®                    Voltaren® Gel
                                                                 flurbiprofen                   naproxen EC                 Flector® patch              Voltaren® XR
                                                                 ibuprofen                      oxaprozin                   Indocin®                    Zipsor®
                                                                 indomethacin                   piroxicam                   Mobic®
                                                                 indomethacin SR                sulindac
                                                                 ketoprofen                     tolmetin
                                                                 ketoprofen SA
                                                           II.   ANTI-INFECTIVES
                                                                 Anti-Fungals                                               Anti-Fungals
                                                                 PREFERRED AGENTS                                           NON-PREFERRED AGENTS

                                                                 ciclopirox (lacquer)           griseofulvin (suspension)   Grifulvin V® (suspension)   Lamisil® (tablet)
                                                                 Gris-PEG®                      terbinafine (tablet)        Grifulvin V® (tablet)2      Penlac®
                                                                                                                            itraconazole                Sporanox®
                                                                 Anti-Virals - Oral                                         Anti-Virals - Oral
                                                                 PREFERRED AGENTS                                           NON-PREFERRED AGENTS

                                                                 acyclovir (capsule, suspension, tablet)                    Famvir®                     Zovirax® (capsule,
                                                                 Valtrex®                                                   famciclovir2                  suspension, tablet)
                                                                                                                            valacyclovir
                                                                 Cephalosporins – Third Generation                          Cephalosporins – Third Generation
                                                                 PREFERRED AGENTS                                           NON-PREFERRED AGENTS

                                                                 cefdinir                       Suprax ®
                                                                                                                            Cedax®                      Spectracef®
                                                                 cefpodoxime proxetil                                       Omnicef®                    Vantin®


2
                                           Non-Preferred as of 1/12/2010
CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                            Page 1 of 10
                                                                                                                                                                  Revised 11/18/2009
                                                                                              NEW YORK STATE MEDICAID
                                                                                                PREFERRED DRUG LIST
                                                                              All non-preferred drugs in these classes require prior authorization (PA)
                                                                             Preferred drugs that require prior authorization are indicated by footnote

                                                                  Fluoroquinolones – Oral                              Fluoroquinolones – Oral
                                                                  PREFERRED AGENTS                                     NON-PREFERRED AGENTS

                                                                  Avelox®
                                                                                              ciprofloxacin (tablet)   Cipro® (tablet)              Levaquin®
                                                                  Avelox ABC Pack®            ofloxacin (tablet)       Cipro XR®                    Noroxin®
                                                                  Cipro® (suspension)                                  ciprofloxacin ER             Proquin XR®
                                                                                                                       Factive®
                                                                  Pegylated Interferons                                Pegylated Interferons




                                                                                                                                                                                NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                  PREFERRED AGENTS                                     NON-PREFERRED AGENTS
                                                                             ®
                                                                  PegIntron                                            None
                                                                  PegIntron Redipen®
                                                                  Pegasys®
                                                                  Pegasys Convenience Pack®
                                                           III.   CARDIOVASCULAR
                                                                  Angiotensin Converting Enzyme Inhibitors             Angiotensin Converting Enzyme Inhibitors
                                                                  (ACEIs)                                              (ACEIs)
                                                                  PREFERRED AGENTS                                     NON-PREFERRED AGENTS

                                                                  benazepril                  moexipril                Accupril®                    Monopril®
                                                                  captopril                   ramipril (capsule)       Aceon®                       perindopril
                                                                  enalapril maleate           trandolapril             Altace® (capsule)            Prinivil®
                                                                  lisinopril                                           Altace® (tablet)             quinapril
                                                                                                                       Capoten®                     Univasc®
                                                                                                                       fosinopril sodium            Vasotec®
                                                                                                                       Lotensin®                    Zestril®
                                                                                                                       Mavik®
                                                                  ACEIs + Calcium Channel Blockers                     ACEIs + Calcium Channel Blockers
                                                                  PREFERRED AGENTS                                     NON-PREFERRED AGENTS

                                                                  benazepril/amlodipine       Tarka ®
                                                                                                                       Lexxel®
                                                                  Lotrel®
                                                                  ACEIs + Diuretics                                    ACEIs + Diuretics
                                                                  PREFERRED AGENTS                                     NON-PREFERRED AGENTS

                                                                  benazepril/HCTZ             lisinopril/HCTZ          Accuretic®                   quinapril/HCTZ
                                                                  captopril/HCTZ              moexipril/HCTZ           Capozide®                    Quinaretic®
                                                                  enalapril maleate/HCTZ                               fosinopril/HCTZ              Uniretic®
                                                                                                                       Lotensin HCT®                Vaseretic®
                                                                                                                       Monopril HCT®                Zestoretic®
                                                                                                                       Prinzide®
                                                                  Angiotensin Receptor Blockers (ARBs)                 Angiotensin Receptor Blockers (ARBs)
                                                                  PREFERRED AGENTS                                     NON-PREFERRED AGENTS

                                                                  Avapro®
                                                                                              Diovan  ®
                                                                                                                       Atacand®                     Twynsta®
                                                                  Benicar®                    Exforge®                 Azor®                        Valturna®
                                                                  Cozaar®                     Micardis®                Teveten®


CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                       Page 2 of 10
                                                                                                                                                                 Revised 11/18/2009
                                                                                            NEW YORK STATE MEDICAID
                                                                                              PREFERRED DRUG LIST
                                                                            All non-preferred drugs in these classes require prior authorization (PA)
                                                                           Preferred drugs that require prior authorization are indicated by footnote

                                                           ARBs + Diuretics                                         ARBs + Diuretics
                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                           Avalide     ®
                                                                                            Hyzaar®
                                                                                                                    Atacand HCT®                    Teveten HCT®
                                                           Benicar HCT®                     Micardis HCT®           Exforge HCT®
                                                           Diovan HCT®
                                                           Beta Blockers                                            Beta Blockers
                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS




                                                                                                                                                                               NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                           acebutolol                       metoprolol tartrate     Bystolic®                       Lopressor®
                                                           atenolol                         nadolol                 Coreg®                          metoprolol succinate XL
                                                           betaxolol                        pindolol                Coreg CR®                       Sectral®
                                                           bisoprolol fumarate              propranolol             Corgard®                        Tenormin®
                                                           carvedilol                       propranolol ER/SA       Inderal LA®                     Toprol XL®
                                                           labetalol                        timolol maleate         InnoPran XL®                    Trandate®
                                                                                                                    Kerlone®                        Zebeta®
                                                                                                                    Levatol®
                                                           Beta Blockers + Diuretics                                Beta Blockers + Diuretics
                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                           atenolol/chlorthalidone                                  Corzide®                        Tenoretic®
                                                           bisoprolol fumarate/HCTZ                                 Lopressor HCT®                  Ziac®
                                                           metoprolol tartrate/HCTZ
                                                           nadolol/bendroflumethiazide
                                                           propranolol/HCTZ
                                                           Calcium Channel Blockers                                 Calcium Channel Blockers
                                                           (Dihydropyridine)                                        (Dihydropyridine)
                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                           Afeditab CR         ®
                                                                                            nicardipine HCl         Adalat CC®                      Plendil®
                                                           amlodipine                       Nifediac CC®            Cardene SR®                     Procardia®
                                                           DynaCirc CR®                     Nifedical XL®           nisoldipine                     Procardia XL®
                                                           felodipine ER                    nifedipine              Norvasc®                        Sular®
                                                           isradipine                       nifedipine ER/SA
                                                           Cholesterol Absorption Inhibitors                        Cholesterol Absorption Inhibitors
                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS
                                                                   ®
                                                           Zetia                                                    None
                                                           Direct Renin Inhibitors                                  Direct Renin Inhibitors
                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS
                                                                           ®                               ®
                                                           Tekturna                         Tekturna HCT            None




CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                      Page 3 of 10
                                                                                                                                                                   Revised 11/18/2009
                                                                                                NEW YORK STATE MEDICAID
                                                                                                  PREFERRED DRUG LIST
                                                                                All non-preferred drugs in these classes require prior authorization (PA)
                                                                               Preferred drugs that require prior authorization are indicated by footnote

                                                                 HMG-CoA Reductase Inhibitors (Statins)                 HMG-CoA Reductase Inhibitors (Statins)
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 Crestor®
                                                                                                lovastatin              Advicor®                      Pravachol®
                                                                 Lescol®                        pravastatin             Altoprev®                     Vytorin®
                                                                 Lescol XL®                     Simcor®                 Caduet®                       Zocor®
                                                                 Lipitor®                       simvastatin             Mevacor®
                                                                 Niacin Derivatives                                     Niacin Derivatives




                                                                                                                                                                                 NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS
                                                                           ®
                                                                 Niaspan                                                None
                                                                 Triglyceride Lowering Agents                           Triglyceride Lowering Agents
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 gemfibrozil                    Tricor®
                                                                                                                        Antara®                       Lipofen®
                                                                 Lovaza®                        Trilipix®               fenofibrate                   Lofibra®
                                                                                                                        Fenoglide®                    Lopid®
                                                                                                                        Fibricor®                     Triglide®
                                                           IV.   CENTRAL NERVOUS SYSTEM
                                                                 Alzheimer’s Agents                                     Alzheimer’s Agents
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS (PA required as of 01/12/2010)
                                                                       ®
                                                                 Aricept (ODT, tablet)          galantamine ER          Cognex®                       Razadyne ER®
                                                                 Exelon®                        Namenda®                Razadyne®
                                                                 galantamine
                                                                 Carbamazepine Derivatives                              Carbamazepine Derivatives
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 carbamazepine (chewable,       oxcarbazepine           None
                                                                   suspension, tablet)          Tegretol® (chewable,
                                                                 carbamazepine XR                 suspension, tablet)
                                                                 Carbatrol®                     Tegretol XR®
                                                                 Epitol®                        Trileptal®
                                                                 Equetro®

                                                                 Central Nervous System (CNS) Stimulants                Central Nervous System (CNS) Stimulants
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 Adderall XR    ®
                                                                                                Focalin XR  ®
                                                                                                                        Adderall®                     Metadate CD®
                                                                 amphetamine salt combo         Metadate ER®            amphetamine salt combo        Nuvigil™CC
                                                                   immediate release            Methylin®                 extended release            Procentra®
                                                                 Concerta®                      Methylin ER®            Daytrana®                     Provigil®CC
                                                                 dexmethylphenidate             methylphenidate         Desoxyn®                      Ritalin®
                                                                 dextroamphetamine              methylphenidate ER/SA   Dexedrine Spansule®           Ritalin LA®
                                                                 dextroamphetamine SR           Vyvanse®                Dextrostat®                   Ritalin SR®
                                                                 Focalin®




CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                        Page 4 of 10
                                                                                                                                                                Revised 11/18/2009
                                                                                               NEW YORK STATE MEDICAID
                                                                                                 PREFERRED DRUG LIST
                                                                              All non-preferred drugs in these classes require prior authorization (PA)
                                                                             Preferred drugs that require prior authorization are indicated by footnote

                                                                Multiple Sclerosis Agents                             Multiple Sclerosis Agents
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS

                                                                Avonex   ®
                                                                                               Copaxone     ®
                                                                                                                      Extavia®
                                                                Betaseron®                     Rebif®

                                                                Non-Ergot Dopamine Receptor Agonists                  Non-Ergot Dopamine Receptor Agonists
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS

                                                                Mirapex  ®
                                                                                               ropinirole             Requip®                       Requip® XL™




                                                                                                                                                                              NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                Sedative Hypnotics/Sleep Agents                       Sedative Hypnotics/Sleep Agents
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS

                                                                chloral hydrate                temazepam              Ambien®                       Prosom®
                                                                estazolam                      triazolam              Ambien CR®                    Restoril®
                                                                flurazepam                     zolpidem               Dalmane®                      Rozerem®
                                                                                                                      Doral®                        Somnote®
                                                                                                                      EdluarTM                      Sonata®
                                                                                                                      Halcion®                      zaleplon
                                                                                                                      Lunesta®
                                                                Serotonin Receptor Agonists (Triptans)                Serotonin Receptor Agonists (Triptans)
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS

                                                                Imitrex®                       sumatriptan            Amerge®                       Frova®
                                                                Maxalt®                        Treximet®              Axert®                        Zomig®
                                                                Relpax®
                                                           V.   DERMATOLOGIC AGENTS
                                                                Antibiotics – Topical                                 Antibiotics – Topical
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS

                                                                Altabax  ®
                                                                                               mupirocin ointment     Bactroban® ointment           Centany™ ointment
                                                                Bactroban® cream                                      Bactroban Nasal® ointment
                                                                Anti-Virals – Topical                                 Anti-Virals – Topical
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS

                                                                Abreva   ®                             ®
                                                                                               Zovirax ointment       Denavir®                      Zovirax® cream
                                                                Immunomodulators – TopicalCDRP                        Immunomodulators – Topical
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS
                                                                     ®                                 ®
                                                                Elidel                         Protopic               None
                                                                Psoriasis Agents – Topical                            Psoriasis Agents – Topical
                                                                PREFERRED AGENTS                                      NON-PREFERRED AGENTS

                                                                calcipotriene scalp solution                          Dovonex® scalp solution       Taclonex Scalp®
                                                                Dovonex® cream                                        Taclonex®                     Vectical™




CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                      Page 5 of 10
                                                                                                                                                                         Revised 11/18/2009
                                                                                               NEW YORK STATE MEDICAID
                                                                                                 PREFERRED DRUG LIST
                                                                              All non-preferred drugs in these classes require prior authorization (PA)
                                                                             Preferred drugs that require prior authorization are indicated by footnote
                                                           VI.   ENDOCRINE AND METABOLIC AGENTS
                                                                 Bisphosphonates – Oral                                      Bisphosphonates – Oral
                                                                 PREFERRED AGENTS                                            NON-PREFERRED AGENTS

                                                                 alendronate                              ®
                                                                                                Fosamax (solution)           Actonel®1                     Fosamax® (tablet)
                                                                                                                             Actonel® with Calcium         Fosamax® Plus D
                                                                                                                             Boniva®
                                                                 Calcitonins – Intranasal                                    Calcitonins – Intranasal




                                                                                                                                                                                       NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                 PREFERRED AGENTS                                            NON-PREFERRED AGENTS

                                                                 calcitonin-salmon              Miacalcin     ®
                                                                                                                             Fortical®
                                                                 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors                   Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
                                                                 PREFERRED AGENTS                                            NON-PREFERRED AGENTS

                                                                 Janumet  ®
                                                                                                Januvia   ®
                                                                                                                             Onglyza®
                                                                 Growth HormonesCDRP                                         Growth HormonesCDRP
                                                                 PREFERRED AGENTS (Subject to CDRP as of 3/10/2010 for Age   NON-PREFERRED AGENTS (Subject to CDRP as of 3/10/2010
                                                                 21 Years & Older)                                           for Age 21 Years & Older)

                                                                 Genotropin   ®
                                                                                                Nutropin AQ       ®
                                                                                                                             Humatrope®                    Tev-Tropin®
                                                                 Nutropin®                      Saizen®                      Norditropin®                  Zorbtive®
                                                                                                                             Omnitrope®
                                                                 Thiazolidinediones (TZDs)                                   Thiazolidinediones (TZDs)
                                                                 PREFERRED AGENTS                                            NON-PREFERRED AGENTS

                                                                 Actoplus Met     ®
                                                                                                Duetact   ®
                                                                                                                             Avandamet®2                   Avandia®2
                                                                 Actos®                                                      Avandaryl®2
                                                           VII. GASTROINTESTINAL
                                                                 Anti-Emetics                                                Anti-Emetics
                                                                 PREFERRED AGENTS                                            NON-PREFERRED AGENTS

                                                                 ondansetron (ODT, solution, tablet)                         Anzemet®                      Sancuso®
                                                                                                                             granisetron (tablet)          Zofran® (ODT, solution,
                                                                                                                             Granisol®                     tablet)
                                                                                                                             Kytril® (tablet)
                                                                 Proton Pump Inhibitors (PPIs)                               Proton Pump Inhibitors (PPIs)
                                                                 PREFERRED AGENTS                                            NON-PREFERRED AGENTS
                                                                         ®
                                                                 Nexium (capsule)                                            Aciphex®                      Prevacid® (packet,
                                                                 omeprazole OTC                                              Kapidex™                        solutab)
                                                                 Prevacid® OTC                                               lansoprazole                  Prilosec® Rx
                                                                 Prevacid® Rx (capsule)                                      Nexium Packet®                Protonix®
                                                                 Prilosec® OTC                                               omeprazole Rx
                                                                                                                             pantoprazole




2
     Non-Preferred as of 1/12/2010
CC
     Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
     All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                               Page 6 of 10
                                                                                                                                                                      Revised 11/18/2009
                                                                                               NEW YORK STATE MEDICAID
                                                                                                 PREFERRED DRUG LIST
                                                                               All non-preferred drugs in these classes require prior authorization (PA)
                                                                              Preferred drugs that require prior authorization are indicated by footnote

                                                                 Sulfasalazine Derivatives                                Sulfasalazine Derivatives
                                                                 PREFERRED AGENTS                                         NON-PREFERRED AGENTS (PA required as of 01/12/2010)

                                                                 Asacol   ®
                                                                                               sulfasalazine IR           Asacol HD®                    balsalazide
                                                                 Dipentum®                     sulfasalazine DR/EC        Apriso®                       Colazal®
                                                                 Pentasa®                                                 Azulfidine®                   Lialda®
                                                                                                                          Azulfidine Entab®


                                                           VIII. HEMATOLOGICAL AGENTS




                                                                                                                                                                                    NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                 Anticoagulants – Injectable                              Anticoagulants – Injectable
                                                                 PREFERRED AGENTS                                         NON-PREFERRED AGENTS
                                                                          ®                                  ®
                                                                 Arixtra                       Innohep                    None
                                                                 Fragmin®                      Lovenox®

                                                                 Erythropoiesis Stimulating Agents (ESAs)                 Erythropoiesis Stimulating Agents (ESAs)
                                                                 PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                                 Aranesp      ®
                                                                                               Procrit   ®
                                                                                                                          Epogen®
                                                           IX.   IMMUNOLOGIC AGENTS
                                                                 Immunomodulators – Injectable                            Immunomodulators – Injectable
                                                                 PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                                 Enbrel®
                                                                                               Humira    ®
                                                                                                                          Cimzia®                       Simponi™
                                                                                                                          Kineret®
                                                           X.    MISCELLANEOUS
                                                                 Progestins (for Cachexia)                                Progestins (for Cachexia)
                                                                 PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                                 megestrol acetate (suspension)                           Megace® (suspension)          Megace ES®
                                                           XI.   MUSCULOSKELETAL AGENTS
                                                                 Skeletal Muscle Relaxants                                Skeletal Muscle Relaxants
                                                                 PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                                 baclofen                      orphenadrine               Amrix®                        Skelaxin®
                                                                 chlorzoxazone                 orphenadrine compound      carisoprodol                  Soma®
                                                                 cyclobenzaprine               orphenadrine comp. forte   carisoprodol compound         Soma® 250
                                                                 dantrolene                    tizanidine                 carisoprodol compound-        Soma® Compound
                                                                 methocarbamol                                              codeine                     Soma® Compound with
                                                                                                                          Dantrium®                       codeine
                                                                                                                          Fexmid®                       Zanaflex® capsule
                                                                                                                          Parafon Forte® DSC            Zanaflex® tablet
                                                                                                                          Robaxin®




CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                           Page 7 of 10
                                                                                                                                                                Revised 11/18/2009
                                                                                            NEW YORK STATE MEDICAID
                                                                                              PREFERRED DRUG LIST
                                                                            All non-preferred drugs in these classes require prior authorization (PA)
                                                                           Preferred drugs that require prior authorization are indicated by footnote
                                                           XII. OPHTHALMICS
                                                                Alpha-2 Adrenergic Agonists (for                    Alpha-2 Adrenergic Agonists (for
                                                                Glaucoma) – Ophthalmic                              Glaucoma) – Ophthalmic
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS

                                                                Alphagan P     ®
                                                                                            brimonidine             apraclonidine                   Iopidine®
                                                                Antihistamines – Ophthalmic                         Antihistamines – Ophthalmic
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS




                                                                                                                                                                              NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                Pataday   ®
                                                                                            Patanol®
                                                                                                                    Bepreve®                        Emadine®
                                                                                                                    Elestat®                        Optivar®
                                                                Fluoroquinolones – Ophthalmic                       Fluoroquinolones – Ophthalmic
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS

                                                                ciprofloxacin               Vigamox   ®
                                                                                                                    Besivance™                      Ocuflox®
                                                                ofloxacin                                           Ciloxan®                        Quixin®
                                                                                                                    IQUIX®                          Zymar®
                                                                Non-Steroidal Anti-Inflammatory Drugs               Non-Steroidal Anti-Inflammatory Drugs
                                                                (NSAIDS) – Ophthalmic                               (NSAIDS) – Ophthalmic
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS

                                                                Acular®
                                                                                            diclofenac              Acuvail®                        Voltaren®
                                                                Acular LS®                  flurbiprofen            Nevanac®                        Xibrom®
                                                                Acular PF®                  ketorolac               Ocufen®
                                                                Prostaglandin Agonists – Ophthalmic                 Prostaglandin Agonists – Ophthalmic
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS

                                                                Travatan   ®
                                                                                            Xalatan   ®
                                                                                                                    Lumigan®
                                                                Travatan Z®
                                                           XIII. OTICS
                                                                Fluoroquinolones – Otic                             Fluoroquinolones – Otic
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS

                                                                Ciprodex   ®
                                                                                            ofloxacin               Cetraxal®                       Floxin®
                                                                                                                    Cipro HC®
                                                           XIV. RENAL AND GENITOURINARY
                                                                Phosphate Binders/Regulators                        Phosphate Binders/Regulators
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS

                                                                calcium acetate (capsule)   Renagel   ®
                                                                                                                    Eliphos™                        Renvela® (oral powder)
                                                                Fosrenol®                   Renvela® (tablet)
                                                                Phoslo®

                                                                Selective Alpha Adrenergic Blockers                 Selective Alpha Adrenergic Blockers
                                                                PREFERRED AGENTS                                    NON-PREFERRED AGENTS
                                                                       ®                                  ®
                                                                Flomax                      Uroxatral               Rapaflo™




CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                     Page 8 of 10
                                                                                                                                                                   Revised 11/18/2009
                                                                                                NEW YORK STATE MEDICAID
                                                                                                  PREFERRED DRUG LIST
                                                                                All non-preferred drugs in these classes require prior authorization (PA)
                                                                               Preferred drugs that require prior authorization are indicated by footnote

                                                                 Urinary Tract Antispasmodics                           Urinary Tract Antispasmodics
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 Detrol LA     ®
                                                                                                Sanctura  ®
                                                                                                                        Detrol®                     Gelnique™
                                                                 Enablex®                       Sanctura XR®            Ditropan®                   oxybutynin ER
                                                                 oxybutynin                     Vesicare®               Ditropan XL®                Toviaz™
                                                                 Oxytrol®
                                                           XV.   RESPIRATORY




                                                                                                                                                                                 NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                                 Anticholinergics – Inhaled                             Anticholinergics – Inhaled
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 Atrovent HFA      ®
                                                                                                ipratropium/albuterol   Duoneb®
                                                                 Combivent®                     Spiriva®
                                                                 ipratropium

                                                                 Antihistamines – Intranasal                            Antihistamines – Intranasal
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 Astelin   ®
                                                                                                Astepro™
                                                                                                                        Patanase®
                                                                 Antihistamines – Second Generation                     Antihistamines – Second Generation
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 OTC   cetirizine                                       Allegra® CC                 fexofenadine
                                                                 OTC   cetirizine-D                                     Allegra-D®                  fexofenadine-D
                                                                 OTC   loratadine                                       Clarinex® CC                Semprex-D®
                                                                 OTC   loratadine-D                                     Clarinex-D®                 Xyzal®
                                                                 Beta2 Adrenergic Agents – Inhaled Long                 Beta2 Adrenergic Agents – Inhaled Long
                                                                 Acting                                                 Acting
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 Foradil   ®
                                                                                                Serevent Diskus     ®
                                                                                                                        Brovana®                    Perforomist®
                                                                 Beta2 Adrenergic Agents – Inhaled Short                Beta2 Adrenergic Agents – Inhaled Short
                                                                 Acting                                                 Acting
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 albuterol                      Proventil HFA ®1
                                                                                                                        Accuneb®                    ProAir HFA®
                                                                 Maxair Autohaler®              Ventolin HFA®           Alupent®                    Xopenex® (solution)
                                                                                                                        levalbuterol (solution)     Xopenex HFA®
                                                                                                                        metaproterenol


                                                                 Corticosteroids – Inhaled                              Corticosteroids – Inhaled
                                                                 PREFERRED AGENTS                                       NON-PREFERRED AGENTS

                                                                 Advair Diskus     ®
                                                                                                Flovent Diskus  ®
                                                                                                                        Aerobid®
                                                                 Advair HFA®                    Flovent HFA®            Aerobid-M®
                                                                 Asmanex®                       QVAR®                   Alvesco®
                                                                 Azmacort®                      Symbicort®              Pulmicort® (Flexhaler) CC



1
                                           Preferred as of 1/12/2010
CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                        Page 9 of 10
                                                                                                                                                               Revised 11/18/2009
                                                                                       NEW YORK STATE MEDICAID
                                                                                         PREFERRED DRUG LIST
                                                                       All non-preferred drugs in these classes require prior authorization (PA)
                                                                      Preferred drugs that require prior authorization are indicated by footnote

                                                           Corticosteroids – Intranasal                             Corticosteroids – Intranasal
                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS

                                                           fluticasone                 Nasonex ®
                                                                                                                    Beconase AQ®                    Nasarel®
                                                                                                                    Flonase®                        Omnaris®
                                                                                                                    flunisolide                     Rhinocort Aqua®
                                                                                                                    Nasacort AQ®                    Veramyst®
                                                           Leukotriene Modifiers                                    Leukotriene Modifiers




                                                                                                                                                                               NYS MEDICAID PHARMACY CLINICAL CALL CENTER 877‐309‐9493 
     NYS PREFERRED DRUG PROGRAM HTTP://NEWYORK.FHSC.COM 




                                                           PREFERRED AGENTS                                         NON-PREFERRED AGENTS
                                                                      ®                          ®
                                                           Accolate                    Singulair                    None




CC
                                           Subject to Clinical Criteria (See: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_clinical_criteria.pdf)
CDRP
                                           All drugs in class are subject to Clinical Drug Review Program PA requirements (See: https://newyork.fhsc.com)

                                                                                                                                                                      Page 10 of 10

								
To top