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
PRENATAL VITAMINS
See Separate Preferred Prenatal Vitamin Listing.
PA Criteria:
■ Prenatal vitamins are covered only for females less than 50 years of age.
PROTON PUMP INHIBITORS (ORAL)
Preferred Agents Non‐Preferred Agents PA Criteria
pantoprazole
PROTONIX suspension (pantoprazole)
NEXIUM (esomeprazole)
ZEGERID OTC (omeprazole/sodium
bicarbonate)
ACIPHEX (rabeprazole)
DEXILANT (dexlansoprazole)
Lansoprazole
omeprazole
PREVACID (lansoprazole)
PRILOSEC (omeprazole)
PROTONIX (pantoprazole)
■ Treatment failure after no less than
a 30 day trial of each preferred
drug
■ Contraindication to preferred drugs
■ Allergic reaction to preferred drugs
■ Prevacid Solutabs will be approved
for children 10 years of age and
under
SEDATIVE HYPNOTICS
Preferred Agents Non‐Preferred Agents PA Criteria
Benzodiazepines
flurazepam
temazepam 15, 30 mg
triazolam
DORAL (quazepam)
estazolam
HALCION (triazola)
RESTORIL (temazepam)
temazepam 7.5, 22.5 mg
■ 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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