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
INTRANASAL RHINITIS AGENTS
Preferred Agents Non‐Preferred Agents PA Criteria
Others
ASTEPRO (azelastine)
PATANASE (olopatadine)
ASTELIN (azelastine)
ATROVENT nasal spray (ipratropium)
Azelastine
DYMISTA (azelastine/fluticasone)
ipratropium nasal spray
ZETONNA (ciclesonide)
■ Treatment failure with preferred
drugs within any subclass
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
See Separate Listing Of Preferred Oral Iron Drugs.
IRON, ORAL
LEUKOTRIENE MODIFIERS
Preferred Agents Non‐Preferred Agents PA Criteria
ACCOLATE (zafirlukast)
montelukast tab and chew tab
SINGULAIR GRANULES (montelukast)
SINGULAIR tab and chew tab
(montelukast)
zafirlukast
ZYFLO, ZYFLO CR (zileuton)
■ Treatment failure with preferred
drugs within any subclass
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
LIPOTROPICS, OTHER
Preferred Agents Non‐Preferred Agents PA Criteria
Bile Acid Sequestrants
cholestyramine
Colestipol tablet
COLESTID granules (colestipol)
COLESTID tablets (colestipol)
Colestipol granules
QUESTRAN (cholestyramine)
WELCHOL (colesevalam)
Cholesterol Absorption Inhibitors
■ Treatment failure with preferred
drugs within any subclass
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
ZETIA (ezetimibe) ■ 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
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