HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...
HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...
HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...
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<strong>HEALTH</strong> <strong>AND</strong> <strong>HUMAN</strong> <strong>SERVICES</strong> <strong>COMMISSION</strong><br />
<strong>TEXAS</strong> MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA<br />
Effective January 23, 2013<br />
BETA BLOCKERS (ORAL)<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
Beta Blocker Combinations<br />
atenolol/chlorthalidone<br />
bisoprolol/HCTZ<br />
metoprolol/HCTZ<br />
nadolol/bendroflumethiazide<br />
propranolol/HCTZ<br />
Carvedilol<br />
labetalol<br />
CORZIDE<br />
(nadolol/bendroflumethiazide)<br />
DUTOPROL (metoprolol succinate<br />
ER/HCTZ)<br />
INDERIDE (propranolol/HCTZ)<br />
LOPRESSOR HCT (metoprolol/HCTZ)<br />
TENORETIC (atenolol/HCTZ)<br />
ZIAC (bisoprolol/HCTZ)<br />
Beta‐ and Alpha‐Blockers<br />
COREG (carvedilol)<br />
COREG CR (carvedilol)<br />
TR<strong>AND</strong>ATE (labetalol)<br />
■ Treatment failure with preferred<br />
drugs within any subclass<br />
■ Contraindication to preferred drugs<br />
■ Allergic reaction to preferred drugs<br />
■ Treatment failure with preferred<br />
drugs within any subclass<br />
■ Contraindication to preferred drugs<br />
■ Allergic reaction to preferred drugs<br />
BILE SALTS<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
ursodiol ACTIGALL (ursodiol)<br />
CHENODAL (chenodiol)<br />
URSO (ursodiol)<br />
URSO FORTE (urosodiol)<br />
■ Treatment failure with preferred<br />
drug<br />
■ Contraindication to preferred drug<br />
■ Allergic reaction to preferred drug<br />
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. January 23, 2013<br />
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