Division of Health Care Financing and Policy Nevada Medicaid Preferred Drug List Effective January 1, 2015
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- Wilfrid Nelson
- 8 years ago
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1 ACNE AGENTS: Topical, Retinoid Agents and Combinations... 3 ACNE AGENTS: Topical, Benzoyl Peroxide, Antibiotics and Combination Products... 3 ALZHEIMER'S AGENTS... 3 ANALGESICS: Long Acting Narcotics... 3 ANALGESICS/ANESTHETICS: Topical... 3 ANALGESICS: Tramadol and Related Drugs... 3 ANAPHYLAXIS: Self-Injectable Epinephrine... 4 ANDROGENIC AGENTS: Topical... 4 ANTIBIOTICS: Cephalosporins 2nd Generation... 4 ANTIBIOTICS: Cephalosporins 3rd Generation... 4 ANTIBIOTICS: Macrolides... 4 ANTIBIOTICS: Quinolones 2nd Generation... 4 ANTIBIOTICS: Quinolones 3rd Generation... 4 ANTICOAGULANTS: Injectable... 4 ANTICOAGULANTS: Oral... 4 ANTIDEPRESSANTS: Other... 4 ANTIDEPRESSANTS: SSRIs... 5 ANTIEMETICS: Oral, 5-HT3s... 5 ANTIFUNGALS: Onychomycosis Agents... 5 ANTIHISTAMINES: 2nd Generation... 5 ANTIHYPERURICEMICS: Xanthine Oxidase Inhibitors for Gout... 5 ANTI-MIGRAINE AGENTS: Triptans... 5 ANTIPARKINSON'S AGENTS: Non-ergot Dopamine Agonists... 5 ANTIPSYCHOTICS: Oral, Atypical... 5 ANTIVIRAL AGENTS: Influenza... 5 BENIGN PROSTATIC HYPERPLASIA (BPH) AGENTS: Alpha-blockers... 6 BENIGN PROSTATIC HYPERPLASIA (BPH) AGENTS: 5-alpha-reductase Inhibitors... 6 BONE OSSIFICATION AGENTS: Bisphosphonates... 6 CARDIOVASCULAR: ACE Inhibitors and Diuretic Combinations... 6 CARDIOVASCULAR: Angiotensin II Receptor Blockers and Diuretic Combinations... 6 CARDIOVASCULAR: Antihyperlipidemics, Bile Acid Sequestrants... 6 CARDIOVASCULAR: Antihyperlipidemics, Cholesterol Absorption Inhibitors... 6 CARDIOVASCULAR: Antihyperlipidemics, Niacin Agents... 6 CARDIOVASCULAR: Antihyperlipidemics, Statins and Statin Combinations... 7 CARDIOVASCULAR: Antihyperlipidemics, Triglyceride Lowering Agents... 7 CARDIOVASCULAR: Beta blockers... 7 CARDIOVASCULAR: Calcium Channel Blockers and Combinations... 7 CARDIOVASCULAR: Direct Renin Inhibitors and Combinations... 7 CENTRAL NERVOUS SYSTEM: ADHD/Stimulants... 8 CENTRAL NERVOUS SYSTEM: Anticonvulsants, Barbiturates... 8 CENTRAL NERVOUS SYSTEM: Anticonvulsants,Benzodiazepines... 8 CENTRAL NERVOUS SYSTEM: Oral Anticonvulsants, Hydantoins... 8 CENTRAL NERVOUS SYSTEM: Oral Anticonvulsants, Misc... 9 CENTRAL NERVOUS SYSTEM: Sedative Hypnotics... 9 DIABETIC AGENTS: Biguanides... 9 DIABETIC AGENTS: Insulin Products... 9 DIABETIC AGENTS: DPP-4 Inhibitors and Combinations DIABETIC AGENTS: Incretin Mimetics DIABETIC AGENTS: Meglitinides and Combinations
2 DIABETIC AGENTS: Other Agents DIABETIC AGENTS: SGLT-2 Inhibitors DIABETIC AGENTS: Sulfonylureas DIABETIC AGENTS: Thiazolidinediones ELECTROLYTE DEPLETERS ERYTHROPOIESIS STIMULATING PROTEINS FIBROMYALGIA AGENTS GASTROINTESTINAL AGENTS: H2RAs GASTROINTESTINAL AGENTS: Pancreatic Enzymes GASTROINTESTINAL AGENTS: PPIs GASTROINTESTINAL AGENTS: Ulcerative Colitis GROWTH HORMONE AGENTS HEPATITIS C AGENTS - Antivirals: Hepatitis C Pegylated Interferons HEPATITIS C AGENTS - Antivirals: Hepatitis C Polymerase Inhibitors HEPATITIS C AGENTS - Antivirals: Hepatitis C Protease Inhibitors HEPATITIS C AGENTS - Antivirals: Hepatitis C Ribavirins HERPETIC ANTIVIRAL AGENTS HERPETIC ANTIVIRAL AGENTS: Topical IMMUNOMODULATORS: Injectable IMMUNOMODULATORS: Topical IMPETIGO AGENTS: Topical LEUKOTRIENE MODIFIERS MULTIPLE SCLEROSIS AGENTS: Injectable Disease Modifying MULTIPLE SCLEROSIS AGENTS: Oral Disease Modifying MULTIPLE SCLEROSIS AGENTS: Specific Symptomatic Treatment NASAL CALCITONINS NEUROPATHIC PAIN AGENTS OPHTHALMIC ANTIBIOTICS: Macrolides OPHTHALMIC ANTIHISTAMINES OPHTHALMIC GLAUCOMA AGENTS OPHTHALMIC GLAUCOMA AGENTS: PROSTAGLANDINS OPHTHALMIC NON-STEROIDAL ANTI-INFLAMMATORY AGENTS OPHTHALMIC QUINOLONES OPHTHALMIC STEROIDS OTIC FLUOROQUINOLONES PEDICULOCIDES / SCABICIDES PLATELET AGGREGATION INHIBITORS PROGESTINS FOR CACHEXIA PSORIASIS AGENTS: Topical PULMONARY ARTERIAL HYPERTENSION AGENTS: Inhaled Agents PULMONARY ARTERIAL HYPERTENSION: Oral Agents RESPIRATORY: Inhaled Anticholinergic Agents RESPIRATORY: Inhaled Corticosteroid/Beta- Adrenergic Combinations RESPIRATORY: Inhaled Corticosteroids/Nebs RESPIRATORY: Intranasal Rhinitis Agents RESPIRATORY: Intranasal Steroid RESPIRATORY: Long Acting Beta Adrenergics RESPIRATORY: ORAL COPD AGENTS RESPIRATORY: Short Acting Beta Adrenergics-Inhalers/Nebs RESTLESS LEG SYNDROME AGENTS SKELETAL MUSCLE RELAXANTS URINARY TRACT ANTISPASMODICS
3 PREFERRED AGENTS ACNE AGENTS: TOPICAL, RETINOID AGENTS AND COMBINATIONS Payable only for recipients up to age 21. RETIN-A MICRO (Pump and Tube) ADAPALENE GEL AND CREAM EPIDUO TAZORAC ATRALIN TRETINOIN ZIANA AVITA TRETIN-X DIFFERIN ACNE AGENTS: TOPICAL, BENZOYL PEROXIDE, ANTIBIOTICS AND COMBINATION PRODUCTS AZELEX 20% cream BENZACLIN BENZOYL PEROXIDE (2.5, 5 and 10% only) CLINDAMYCIN ERYTHROMYCIN/BENZOYL PEROXIDE SODIUM SULFACETAMIDE ALZHEIMER'S AGENTS Payable only for recipients up to age 21. ACANYA DUAC CS ERYTHROMYCIN VELTIN CLINDAMYCIN/BENZOYL PEROXIDE GEL SODIUM SULFACETAMIDE/SULFUR DONEPEZIL NAMENDA TABS ARICEPT 23mg GALANTAMINE ER DONEPEZIL ODT NAMENDA XR TABS ARICEPT RAZADYNE EXELON PATCH RIVASTIGMINE CAPS GALANTAMINE RAZADYNE ER EXELON SOLN ANALGESICS: LONG ACTING NARCOTICS FENTANYL PATCH (PA required) AVINZA MS CONTIN MORPHINE SULFATE SA TABS (ALL GENERIC EXTENDED RELEASE) NEW BUTRANS NUCYNTA ER DOLOPHINE OPANA ER DURAGESIC PATCHES (PA required) OXYCODONE SR EMBEDA OXYCONTIN ANALGESICS/ANESTHETICS: TOPICAL EXALGO KADIAN METHADONE METHADOSE OXYMORPHONE SR XARTEMIS XR NEW ZOHYDRO ER NEW LIDOCAINE LIDOCAINE VISCOUS EMLA LIDAMANTLE LIDOCAINE HC VOLTAREN GEL FLECTOR PENNSAID ANALGESICS: TRAMADOL AND RELATED DRUGS LIDODERM TRAMADOL CONZIPR TRAMADOL ER TRAMADOL/APAP NUCYNTA ULTRACET RYZOLT RYBIX ODT ULTRAM ULTRAM ER 3
4 PREFERRED AGENTS ANAPHYLAXIS: SELF-INJECTABLE EPINEPHRINE AUVI-Q EPIPEN ADRENACLICK QL EPINEPHRINE EPIPEN JR. ANDROGENIC AGENTS: TOPICAL ANDROGEL AXIRON TESTOSTERONE GEL NEW ANDRODERM FORTESTA VOGELXO NEW TESTIM ANTIBIOTICS: CEPHALOSPORINS 2ND GENERATION CEFACLOR CAPS and SUSP CEFUROXIME TABS and SUSP CEFTIN CECLOR CD CEFACLOR ER CEFPROZIL SUSP CECLOR CEFZIL ANTIBIOTICS: CEPHALOSPORINS 3RD GENERATION CEFDINIR CAPS and SUSP CEDAX CAPS and SUSP SPECTRACEF CEFPODOXIME TABS and SUSP CEFDITOREN SUPRAX NEW ANTIBIOTICS: MACROLIDES OMNICEF AZITHROMYCIN TABS/SUSP ERYTHROMYCIN STEARATE BIAXIN CLARITHROMYCIN TABS/SUSP ERYTHROMYCIN BASE ERYTHROMYCIN ESTOLATE ERYTHROMYCIN ETHYLSUCCINATE ANTIBIOTICS: QUINOLONES 2ND GENERATION CIPROFLOXACIN TABS CIPRO SUSP ANTIBIOTICS: QUINOLONES 3RD GENERATION DIFICID ZITHROMAX ZMAX FLOXIN OFLOXACIN AVELOX LEVOFLOXACIN LEVAQUIN AVELOX ABC PACK ANTICOAGULANTS: INJECTABLE VANTIN ARIXTRA FRAGMIN FONDAPARINUX LOVENOX NEW ENOXAPARIN NEW ANTICOAGULANTS: ORAL COUMADIN ELIQUIS PRADAXA WARFARIN JANTOVEN XARELTO ANTIDEPRESSANTS: OTHER INNOHEP BUPROPION MIRTAZAPINE RAPID TABS APLENZIN NEW FETZIMA BUPROPION SR PRISTIQ BRINTELLIX FORFIVO XL NEW BUPROPION XL TRAZODONE DULOXETINE KHEDEZLA NEW CYMBALTA (PA not required for ICD-9 code or 250.6) MIRTAZAPINE VENLAFAXINE (ALL FORMS) NEW DESVENLAFAXINE FUMARATE NEW EFFEXOR (ALL FORMS) NEW VIIBRYD WELLBUTRIN NEW 4
5 ANTIDEPRESSANTS: SSRIS CITALOPRAM PAROXETINE CELEXA PAXIL ESCITALOPRAM NEW PEXEVA FLUVOXAMINE QL PROZAC FLUOXETINE SERTRALINE LEXAPRO SARAFEM ANTIEMETICS: ORAL, 5-HT3S LUVOX ZOLOFT GRANISETRON ANZEMET ZOFRAN ONDANSETRON KYTRIL ZUPLENZ ANTIFUNGALS: ONYCHOMYCOSIS AGENTS CICLOPIROX SOLN SANCUSO Prior authorization is required for all drugs in this class. TERBINAFINE TABS ANTIHISTAMINES: 2ND GENERATION A two week trial of one of these drugs is required before a non- preferred drug will be authorized. CETIRIZINE D OTC LORATADINE D OTC ALLEGRA FEXOFENADINE CETIRIZINE OTC LORATADINE OTC CLARITIN SEMPREX ANTIHYPERURICEMICS: XANTHINE OXIDASE INHIBITORS FOR GOUT ALLOPURINOL ANTI-MIGRAINE AGENTS: TRIPTANS CLARINEX DESLORATADINE XYZAL RELPAX AMERGE MAXALT MLT SUMATRIPTAN NASAL SPRAY AXERT NARATRIPTAN SUMATRIPTAN INJECTION FROVA SUMAVEL SUMATRIPTAN TABLET IMITREX TREXIMET ZOMIG ZMT MAXALT TABS ZOMIG ANTIPARKINSON'S AGENTS: NON-ERGOT DOPAMINE AGONISTS PRAMIPEXOLE ROPINIROLE ER MIRAPEX REQUIP ROPINIROLE MIRAPEX ER REQUIP XL ANTIPSYCHOTICS: ORAL, ATYPICAL NEUPRO ABILIFY QUETIAPINE CLOZARIL RISPERDAL CLOZAPINE RISPERIDONE FAZACLO SEROQUEL FANAPT SAPHRIS GEODON ZYPREXA LATUDA SEROQUEL XR INVEGA OLANZAPINE ANTIVIRAL AGENTS: INFLUENZA AMANTADINE TAMIFLU ZIPRASIDONE RIMANTADINE RELENZA 5
6 PREFERRED AGENTS BENIGN PROSTATIC HYPERPLASIA (BPH) AGENTS: ALPHA-BLOCKERS DOXAZOSIN ALFUZOSIN PRAZOSIN TAMSULOSIN CARDURA RAPAFLO TERAZOSIN FLOMAX UROXATRAL MINIPRESS BENIGN PROSTATIC HYPERPLASIA (BPH) AGENTS: 5-ALPHA-REDUCTASE INHIBITORS AVODART FINASTERIDE JALYN NEW PROSCAR BONE OSSIFICATION AGENTS: BISPHOSPHONATES ALENDRONATE TABS ACTONEL DIDRONEL FOSAMAX PLUS D ALENDRONATE SOLUTION NEW ETIDRONATE ATELVIA IBANDRONATE CARDIOVASCULAR: ACE INHIBITORS AND DIURETIC COMBINATIONS BINOSTO NEW BONIVA SKELID BENAZEPRIL ENALAPRIL HCTZ ACCURETIC QUINAPRIL BENAZEPRIL HCTZ EPANED EPANED ǂ QUINARETIC CAPTOPRIL LISINOPRIL FOSINOPRIL TRANDOLAPRIL CAPTOPRIL HCTZ LISINOPRIL HCTZ MAVIK UNIVASC ENALAPRIL RAMIPRIL MOEXIPRIL PREFERRED FOR AGES 10 AND UNDER ǂ NONPREFERRED FOR OVER 10 YEARS OLD CARDIOVASCULAR: ANGIOTENSIN II RECEPTOR BLOCKERS AND DIURETIC COMBINATIONS DIOVAN LOSARTAN ATACAND EPROSARTAN DIOVAN HCTZ LOSARTAN HCTZ AVAPRO IRBESARTAN BENICAR EDARBI CARDIOVASCULAR: ANTIHYPERLIPIDEMICS, BILE ACID SEQUESTRANTS EDARBYCLOR COLESTIPOL WELCHOL QUESTRAN CHOLESTYRAMINE CARDIOVASCULAR: ANTIHYPERLIPIDEMICS, CHOLESTEROL ABSORPTION INHIBITORS ZETIA CARDIOVASCULAR: ANTIHYPERLIPIDEMICS, NIACIN AGENTS NIASPAN (Brand only) NIACIN ER (ALL GENERICS) NEW NIACOR MICARDIS TELMISARTAN TEVETEN 6
7 CARDIOVASCULAR: ANTIHYPERLIPIDEMICS, STATINS AND STATIN COMBINATIONS ATORVASTATIN LOVASTATIN ADVICOR LIPTRUZET CRESTOR PRAVASTATIN ALTOPREV LIVALO FLUVASTATIN SIMVASTATIN AMLODIPINE/ATORVASTATIN MEVACOR CADUET LESCOL LESCOL XL LIPITOR CARDIOVASCULAR: ANTIHYPERLIPIDEMICS, TRIGLYCERIDE LOWERING AGENTS PRAVACHOL SIMCOR VYTORIN ZOCOR FENOFIBRATE NEW ANTARA NEW TRICOR NEW FENOFIBRIC ACID NEW FENOGLIDE NEW TRIGLIDE NEW GEMFIBROZIL FIBRICOR NEW TRILIPIX NEW LIPOFEN NEW CARDIOVASCULAR: BETA BLOCKERS ACEBUTOLOL ATENOLOL ATENOLOL/CHLORTH BETAXOLOL BISOPROLOL BISOPROLOL/HCTZ BYSTOLIC * CARVEDILOL LABETALOL METOPROLOL (Regular Release) NADOLOL PINDOLOL PROPRANOLOL PROPRANOLOL/HCTZ SOTALOL TIMOLOL LOFIBRA NEW *Restricted to ICD-9 codes CARDIOVASCULAR: CALCIUM CHANNEL BLOCKERS AND COMBINATIONS AFEDITAB CR AMLODIPINE CARTIA XT DILTIA XT DILTIAZEM ER DILTIAZEM HCL DYNACIRC CR EXFORGE EXFORGE HCT FELODIPINE ER ISRADIPINE LOTREL NICARDIPINE NIFEDIAC CC NIFEDICAL XL NIFEDIPINE ER NISOLDIPINE ER TAZTIA XT VERAPAMIL VERAPAMIL ER CARDIOVASCULAR: DIRECT RENIN INHIBITORS AND COMBINATIONS TEKAMLO TEKTURNA HCT AMTURNIDE TEKTURNA VALTURNA 7
8 CENTRAL NERVOUS SYSTEM: ADHD/STIMULANTS AMPHETAMINE SALT COMBO XR NEW METHYLIN ADDERALL MODAFINIL AMPHETAMINE SALT COMBO METHYLIN ER ADDERALL XR NEW NUVIGIL DEXMETHYLPHENIDATE METHYLPHENIDATE CONCERTA METADATE ER DEXTROAMPHETAMINE SA METHYLPHENIDATE ER (All forms generic extended release DAYTRANA PROVIGIL * NEW) DEXTROAMPHETAMINE TAB METHYLPHENIDATE SOL DESOXYN PROCENTRA DEXTROSTAT QUILLIVANT XR SUSP DEXEDRINE RITALIN FOCALIN XR RITALIN LA FOCALIN INTUNIV STRATTERA KAPVAY METADATE CD NEW VYVANSE * (No PA required for ICD-9 codes , , , , and ) CENTRAL NERVOUS SYSTEM: ANTICONVULSANTS, BARBITURATES LUMINAL MEBARAL MEPHOBARBITAL SOLFOTON PHENOBARBITAL MYSOLINE PRIMIDONE CENTRAL NERVOUS SYSTEM: ANTICONVULSANTS,BENZODIAZEPINES CLONAZEPAM DIAZEPAM rectal soln ONFI CLORAZEPATE DIASTAT DIAZEPAM KLONOPIN TRANXENE T-TAB VALIUM CENTRAL NERVOUS SYSTEM: ORAL ANTICONVULSANTS, HYDANTOINS CEREBYX DILANTIN ETHOTOIN FOSPHENYTOIN PEGANONE PHENYTEK PHENYTOIN PRODUCTS 8
9 CENTRAL NERVOUS SYSTEM: ORAL ANTICONVULSANTS, MISC. BANZEL LAMICTAL APTIOM CARBAMAZEPINE LAMOTRIGINE FYCOMPA CARBAMAZEPINE XR LEVETIRACETAM OXTELLAR XR CARBATROL ER LYRICA POTIGA CELONTIN NEURONTIN QUDEXY XR NEW DEPAKENE OXCARBAZEPINE TROKENDI XR NEW DEPAKOTE ER DEPAKOTE DIVALPROEX SODIUM DIVALPROEX SODIUM ER EPITOL ETHOSUXIMIDE FELBATOL GABAPENTIN GABITRIL KEPPRA KEPPRA XR LAMICTAL ODT LAMICTAL XR SABRIL STAVZOR DR TEGRETOL TEGRETOL XR TOPAMAX TOPIRAGEN TOPIRAMATE (IR AND ER) NEW TRILEPTAL VALPROATE ACID VIMPAT ZARONTIN ZONEGRAN ZONISAMIDE CENTRAL NERVOUS SYSTEM: SEDATIVE HYPNOTICS ESTAZOLAM TEMAZEPAM AMBIEN SILENOR FLURAZEPAM TRIAZOLAM AMBIEN CR SOMNOTE ROZEREM * ZOLPIDEM DORAL SONATA EDLUAR ZALEPLON *(PA not required for ICD-9 code ) INTERMEZZO ZOLPIDEM CR DIABETIC AGENTS: BIGUANIDES FORTAMET GLUCOPHAGE GLUCOPHAGE XR METFORMIN EXT-REL GLUMETZA METFORMIN RIOMET DIABETIC AGENTS: INSULIN PRODUCTS APIDRA LEVEMIR HUMALOG HUMULIN LANTUS LUNESTA All types, mixes and pens containing these insulins are preferred. NOVOLIN NOVOLOG ZOLPIMIST 9
10 DIABETIC AGENTS: DPP-4 INHIBITORS AND COMBINATIONS JANUMET JUVISYNC KAZANO JANUMET XR KOMBIGLYZE XR NESINA JANUVIA ONGLYZA OSENI JENTADUETO NEW TRADJENTA NEW DIABETIC AGENTS: INCRETIN MIMETICS BYDUREON VICTOZA TANZEUM NEW BYETTA DIABETIC AGENTS: MEGLITINIDES AND COMBINATIONS NATEGLINIDE (Starlix ) PRANDIMET PRANDIN STARLIX DIABETIC AGENTS: OTHER AGENTS ACARBOSE (Precose ) GLYSET PRECOSE SYMLIN (PA required) DIABETIC AGENTS: SGLT-2 INHIBITORS FARXIGA NEW INVOKANA INVOKAMET NEW JARDIANCE NEW DIABETIC AGENTS: SULFONYLUREAS AMARYL CHLORPROPAMIDE DIABETA GLIMEPIRIDE GLIPIZIDE GLUCOTROL GLUCOVANCE GLIPIZIDE EXT-REL GLIPIZIDE/METFORMIN GLYBURIDE MICRONIZED GLYBURIDE/METFORMIN GLUCOTROL XL GLYBURIDE GLYNASE METAGLIP TOLAZAMIDE TOLBUTAMIDE DIABETIC AGENTS: THIAZOLIDINEDIONES ACTOPLUS MET XR ACTOS ACTOPLUS MET AVANDAMET ELECTROLYTE DEPLETERS AVANDARYL AVANDIA DUETACT CALCIUM ACETATE RENAGEL PHOSLO NEW VELPHORO NEW ELIPHOS RENVELA PHOSLYRA NEW FOSRENOL NEW SEVELAMER CARBONATE NEW 10
11 ERYTHROPOIESIS STIMULATING PROTEINS Prior authorization is required for all drugs in this class. ARANESP PROCRIT EPOGEN OMONTYS FIBROMYALGIA AGENTS CYMBALTA LYRICA SAVELLA GASTROINTESTINAL AGENTS: H2RAS FAMOTIDINE RANITIDINE No PA required for drugs in this class if ICD-9 code= RANITIDINE SYRUP (PA not required for < 12 years) GASTROINTESTINAL AGENTS: PANCREATIC ENZYMES CREON PANCREAZE ULTRESA ZENPEP PANCRELIPASE VIOKACE GASTROINTESTINAL AGENTS: PPIS PERTZYE Prior authorization is required for all drugs in this class. NEXIUM CAPSULES PANTOPRAZOLE ACIPHEX PREVACID NEXIUM POWDER FOR SUSP* DEXILANT PRILOSEC LANSOPRAZOLE PRILOSEC OTC TABS *for children 12 yrs. OMEPRAZOLE OTC TABS PROTONIX GASTROINTESTINAL AGENTS: ULCERATIVE COLITIS ASACOL SUPP PENTASA APRISO CANASA SULFASALAZINE DR ASACOL HD DELZICOL SULFASALAZINE IR LIALDA MESALAMINE ENEMA SUSP GROWTH HORMONE AGENTS Prior authorization is required for all drugs in this class. GENOTROPIN NORDITROPIN HUMATROPE SEROSTIM NUTROPIN AQ OMNITROPE NUTROPIN SAIZEN HEPATITIS C AGENTS - ANTIVIRALS: HEPATITIS C PEGYLATED INTERFERONS PEGASYS PEGASYS CONVENIENT PACK PEGINTRON Vials and REDIPEN HEPATITIS C AGENTS - ANTIVIRALS: HEPATITIS C POLYMERASE INHIBITORS SOVALDI SOMAVERT TEV-TROPIN ZORBTIVE 11
12 PREFERRED AGENTS HEPATITIS C AGENTS - ANTIVIRALS: HEPATITIS C PROTEASE INHIBITORS INCIVEK OLYSIO VICTRELIS HEPATITIS C AGENTS - ANTIVIRALS: HEPATITIS C RIBAVIRINS RIBAVIRIN RIBASPHERE RIBAPAK REBETOL NEW HERPETIC ANTIVIRAL AGENTS ACYCLOVIR FAMVIR VALACYCLOVIR HERPETIC ANTIVIRAL AGENTS: TOPICAL ABREVA DENAVIR ZOVIRAX, OINTMENT IMMUNOMODULATORS: INJECTABLE MODERIBA NEW Prior authorization is required for all drugs in this class. ENBREL HUMIRA ACTEMRA NEW SIMPONI IMMUNOMODULATORS: TOPICAL ELIDEL IMPETIGO AGENTS: TOPICAL PROTOPIC CIMZIA NEW KINERET REMICADE Prior authorization is required for all drugs in this class. ORENCIA STELARA MUPIROCIN OINT ALTABAX MUPIROCIN CREAM LEUKOTRIENE MODIFIERS CENTANY MONTELUKAST ZAFIRLUKAST ACCOLATE SINGULAIR MULTIPLE SCLEROSIS AGENTS: INJECTABLE DISEASE MODIFYING AVONEX AVONEX ADMIN PACK BETASERON COPAXONE Trial of only one agent is required before moving to a non-preferred agent EXTAVIA REBIF TYSABRI MULTIPLE SCLEROSIS AGENTS: ORAL DISEASE MODIFYING AUBAGIO Trial of only one agent is required before moving to a non-preferred agent TECFIDERA GILENYA MULTIPLE SCLEROSIS AGENTS: SPECIFIC SYMPTOMATIC TREATMENT AMPYRA (PA required) 12
13 NASAL CALCITONINS MIACALCIN NEUROPATHIC PAIN AGENTS CYMBALTA LYRICA GRALISE HORIZANT GABAPENTIN OPHTHALMIC ANTIBIOTICS: MACROLIDES ERYTHROMYCIN OINTMENT OPHTHALMIC ANTIHISTAMINES LIDODERM ALAWAY ZADITOR OTC NEW ELESTAT OPTIVAR BEPREVE NEW EMADINE PATANOL PATADAY OPHTHALMIC GLAUCOMA AGENTS LASTACRAFT ALPHAGAN P DORZOLAM ALPHAGAN OCUPRESS AZOPT DORZOLAM / TIMOLOL BETAGAN OPTIPRANOLOL BETAXOLOL LEVOBUNOLOL BETOPTIC TIMOPTIC BETOPTIC S METIPRANOLOL COSOPT TIMOPTIC XE BRIMONIDINE SIMBRINZA COSOPT PF TRUSOPT CARTEOLOL TIMOLOL DROPS/ GEL SOLN COMBIGAN OPHTHALMIC GLAUCOMA AGENTS: PROSTAGLANDINS LATANOPROST TRAVATAN Z LUMIGAN TRAVATAN ZIOPTAN XALATAN OPHTHALMIC NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACULAR DICLOFENAC ACUVAIL ILEVRO ACULAR LS FLURBIPROFEN BROMDAY PROLENSA ACULAR PF NEVANAC BROMFENAC OPHTHALMIC QUINOLONES BESIVANCE OFLOXACIN CILOXAN CIPROFLOXACIN VIGAMOX ZYMAXID MOXEZA OPHTHALMIC STEROIDS ALREX FLUOROMETHOLONE FLAREX OMNIPRED DEXAMETHASONE LOTEMAX FML PRED FORTE DUREZOL PREDNISOLONE FML FORTE PRED MILD OTIC FLUOROQUINOLONES CIPRODEX OFLOXIN MAXIDEX VEXOL 13
14 PEDICULOCIDES / SCABICIDES NATROBA PERMETHRIN EURAX OVIDE NIX RID LINDANE ULESFIA SKLICE PLATELET AGGREGATION INHIBITORS MALATHION AGGRENOX CILOSTAZOL EFFIENT ANAGRELIDE CLOPIDOGREL PLAVIX ASPIRIN DIPYRIDAMOLE ZONTIVITY NEW BRILINTA PROGESTINS FOR CACHEXIA MEGESTROL ACETATE, SUSP PSORIASIS AGENTS: TOPICAL TICLOPIDINE MEGACE ES CALCIPOTRIENE CALCITRENE NEW TACLONEX NEW DOVONEX CREAM NEW SORILUX NEW PULMONARY ARTERIAL HYPERTENSION AGENTS: INHALED AGENTS VENTAVIS TYVASO PULMONARY ARTERIAL HYPERTENSION: ORAL AGENTS VECTICAL NEW ADCIRCA SILDENAFIL ADEMPAS REVATIO LETAIRIS TRACLEER OPSUMIT RESPIRATORY: INHALED ANTICHOLINERGIC AGENTS ANORO ELLIPTA NEW ATROVENT HFA INHALER IPRATROPIUM/ALBUTEROL NEBS IPRATROPIUM NEBS SPIRIVA RESPIMAT NEW COMBIVENT RESPIMAT SPIRIVA NEW RESPIRATORY: INHALED CORTICOSTEROID/BETA- ADRENERGIC COMBINATIONS ADVAIR DISKUS DULERA BREO ELLIPTA ADVAIR HFA SYMBICORT RESPIRATORY: INHALED CORTICOSTEROIDS/NEBS ASMANEX PULMICORT FLEXHALER ALVESCO BUDESONIDE NEBS* PULMICORT RESPULES * FLOVENT DISKUS FLOVENT HFA *No PA required if < 4 years old QVAR RESPIRATORY: INTRANASAL RHINITIS AGENTS ASTEPRO PATANASE AZELASTINE DYMISTA TUDORZA 14
15 RESPIRATORY: INTRANASAL STEROID FLUTICASONE NASONEX BECONASE AQ QNASL RESPIRATORY: LONG ACTING BETA ADRENERGICS FLONASE FLUNISOLIDE NASACORT AQ OMNARIS ARCAPTA NEOHALER SEREVENT DISKUS BROVANA FORADIL RESPIRATORY: ORAL COPD AGENTS DALIRESP RESPIRATORY: SHORT ACTING BETA ADRENERGICS-INHALERS/NEBS ALBUTEROL NEB/SOLN XOPENEX HFA (PA req) MAXAIR AUTOHALER PROVENTIL HFA XOPENEX Solution(PA req) VENTOLIN HFA PROAIR HFA RESTLESS LEG SYNDROME AGENTS LEVALBUTEROL RHINOCORT AQUA TRIAMCINOLONE ACETONIDE VERAMYST ZETONNA PRAMIPEXOLE ROPINIROLE HORIZANT MIRAPEX ER REQUIP XL MIRAPEX REQUIP SKELETAL MUSCLE RELAXANTS BACLOFEN CHLORZOXAZONE CYCLOBENZAPRINE DANTROLENE METHOCARBAMOL/ASPIRIN ORPHENADRINE CITRATE ORPHENADRINE COMPOUND TIZANIDINE METHOCARBAMOL URINARY TRACT ANTISPASMODICS OXYBUTYNIN TABS/SYRUP/ER DETROL GELNIQUE SANCTURA XR DETROL LA OXYTROL TOVIAZ DITROPAN XL SANCTURA VESICARE ENABLEX TOLTERODINE FLAVOXATE TROSPIUM 15
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