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 />
High Potency<br />
betamethasone valerate<br />
fluocinonide<br />
triamcinolone<br />
clobetasol propionate cream,<br />
ointment, gel, emollient, solution<br />
halobetasol<br />
amcinonide<br />
betamethasone dipropionate<br />
betamethasone dipropionat/<br />
propylene glycol<br />
BETA‐VAL (betamethasone valerate)<br />
desoximetasone<br />
diflorasone<br />
DIPROLENE (betamethasone<br />
dipropionate)<br />
HALOG (halcinonide)<br />
KENALOG aerosol (triamcinolone)<br />
TOPICORT (desoximetasone)<br />
VANOS (fluocinonide)<br />
Very High Potency<br />
APEXICON E (diflorasone)<br />
clobetasol lotion, foam, shampoo<br />
CLOBEX (clobetasol)<br />
HALAC (halobetasol)<br />
HALONATE (halobetasol)<br />
OLUX‐E (clobetasol)<br />
TEMOVATE (clobetasol)<br />
ULTRAVATE (halobetasol)<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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