HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

HEALTH AND HUMAN SERVICES COMMISSION
TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA
Effective January 23, 2013
BPH AGENTS
Preferred Agents Non‐Preferred Agents PA Criteria
Alpha Blockers
Doxazosin
tamsulosin
terazosin
UROXATRAL (alfuzosin)
alfuzosin
CARDURA (doxazosin)
CARDURA XL (doxazosin)
Flomax (tamsulosin)
RAPAFLO (silodosin)
tamsulosin
5‐Alpha‐Reductase (5AR) Inhibitors
■ Treatment failure with preferred
drugs within any subclass
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
finasteride AVODART (dutasteride)
PROSCAR (finasteride)
■ Treatment failure with preferred
drugs within any subclass
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
Alpha Blocker/5AR Inhibitor Combinations
JALYN (dutasteride/tamsulosin) ■ Treatment failure with preferred
drugs within any subclass
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
BRONCHODILATORS, BETA AGONIST
Preferred Agents Non‐Preferred Agents PA Criteria
Inhalers, Short‐Acting
PROVENTIL HFA (albuterol)
XOPENEX HFA (levalbuterol)
MAXAIR (pirbuterol)
PROAIR HFA (albuterol)
VENTOLIN HFA (albuterol)
■ Treatment failure with preferred
drugs within any subclass
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
■ History of intolerable side effects
to preferred drugs
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. January 23, 2013
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