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 />
OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
cromolyn<br />
PATADAY (olopatadine)<br />
ALAMAST (pemirolast)<br />
ALOMIDE (lodoxamide)<br />
ALREX (loteprednol)<br />
ALOCRIL (nedocromil)<br />
azelastine<br />
BEPREVE (bepotastine)<br />
CROLOM (cromolyn)<br />
ELESTAT (epi EMADINE (emedastine)<br />
Epinastine<br />
ketotifen<br />
LASTACAFT (alcaftadine)<br />
OPTIVAR (azelastine)<br />
PATANOL (olopatadine)<br />
ZADITOR (ketotifen)nastine)<br />
■ Treatment failure with preferred<br />
drugs within any subclass<br />
■ Contraindication to preferred drugs<br />
■ Allergic reaction to preferred drugs<br />
OPHTHALMIC ANTIBIOTICS<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
Aminoglycosides<br />
gentamicin<br />
tobramycin<br />
TOBREX Ointment (tobramycin)<br />
BESIVANCE (besifloxacin)<br />
MOXEZA (moxifloxacin)<br />
ciprofloxacin<br />
ofloxacin<br />
VIGAMOX (moxifloxacin)<br />
GARAMYCIN<br />
TOBREX Solution (tobramycin)<br />
Quinolones<br />
CILOXAN (ciprofloxacin)<br />
IQUIX (levofloxacin)<br />
Levofloxacin<br />
OCUFLOX (ofloxacin)<br />
QUIXIN (levofloxacin)<br />
ZYMAR (gatifloxacin)<br />
ZYMAXID (gatifloxacin)<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 />
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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