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 />
STEROIDS, TOPICAL<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
Low Potency<br />
DERMA‐SMOOTHE/FS (fluocinolone)<br />
desonide cream and ointment<br />
hydrocortisone lotion (OTC)<br />
hydrocortisone cream & ointment<br />
(OTC & RX)<br />
hydrocortisone/aloe cream &<br />
ointiment (OTC)<br />
hydrocortisone/mineral oil ointment<br />
hydrocortisone butyrate<br />
hydrocortisone valerate<br />
fluticasone propionate<br />
mometasone furoate cream &<br />
ointment<br />
ACLOVATE (alclometasone)<br />
Alclometasone<br />
AQUA GLYCOLIC HC (hydrocortisone)<br />
CAPEX (fluocinolone)<br />
DESONATE (desonide)<br />
desonide lotion<br />
DESOWEN (desonide)<br />
fluocinolone oil<br />
hydrocortisone acetate/urea<br />
hydrocortisone lotion (RX)<br />
hydrocortisone/aloe gel<br />
NUZON (hydrocortisone/aloe)<br />
PEDIADERM HC (hydrocortisone)<br />
PEDIADERM TA (triamcinolone)<br />
TEXACORT (hydrocortisone sol)<br />
VERDESO (desonide)<br />
Medium Potency<br />
CLODERM (clocortolone)<br />
CORDRAN (flurandrenolide)<br />
CUTIVATE (fluticasone)<br />
DERMATOP (prednicarbate)<br />
ELECON (mometasone)<br />
flucinolone acetonide<br />
LUXIQ (betamethasone)<br />
mometasone furoate solution<br />
MOMEXIN (mometasone)<br />
P<strong>AND</strong>EL (hydrocortisone probutate)<br />
Prednicarbate<br />
WESTCORT (hydrocortisone valerate)<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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