HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 CEPHALOSPORINS AND RELATED ANTIBIOTICS (ORAL) Preferred Agents Non‐Preferred Agents PA Criteria Beta Lactam/Beta‐Lactamase Inhibitor Combinations amoxicillin/clavulanate suspension amoxicillin/clavulanate IR tablets cefadroxil cephalexin cefaclor IR capsules, suspension cefprozil cefuroxime tablets Cefdinir SUPRAX (cefixime) amoxicillin/clavulanate XR amoxicillin/clavulanate chew tabs AUGMENTIN Suspension (amoxicillin/clavulanate) AUGMENTIN (amoxicillin/clavulanate) tablets AUGMENTIN XR (amoxicillin/clavulanate) Cephalosporins – First Generation KEFLEX (cephalexin) PANIXINE (cephalexin) Cephalosporins – Second Generation cefaclor ER CEFTIN tablets (cefuroxime) CEFTIN suspension (cefuroxime) cefuroxime suspension Cephalosporins – Third Generation CEDAX (ceftibuten) cefditoren cefpodoxime SPECTRACEF (cefditoren) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs COLONY STIMULATING FACTORS LEUKINE (sargramostim, GM‐CSF) NEULASTA (pegfilgrastim) NEUPOGEN (filgrastim, G‐CSF) Preferred Agents Non‐Preferred Agents PA Criteria Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. January 23, 2013 Page 22 of 47
HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 COPD AGENTS Preferred Agents Non‐Preferred Agents PA Criteria Anticholinergics ATROVENT HFA (ipratropium) ipratropium inhalation solution SPIRIVA (tiotropium) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Anticholinergic‐Beta Agonist Combinations COMBIVENT (albuterol/ipratropium) albuterol/ipratropium DUONEB (albuterol/ipratropium) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs Phosphodiesterase Inhibitors DALIRESP (roflumilast) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs COUGH AND COLD AGENTS See Separate Preferred Cough and Cold Agent Listing. CYTOKINE AND CAM ANTAGONISTS Preferred Agents Non‐Preferred Agents PA Criteria CIMZIA (certolizumab) ENBREL (etanercept) HUMIRA (adalimumab) ACTEMRA (tocilizumab) KINERET (anakinra) ORENCIA SC (abatacept) SIMPONI (golimumab) STELARA (ustekinumab) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction 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 Page 23 of 47
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Page 51 and 52: Cough and Cold Drugs - Narcotic PRE
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Page 55: PRENATAL VITAMINS PREFERRED DRUGS N

HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

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