HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

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HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 TETRACYCLINES Preferred Agents Non‐Preferred Agents PA Criteria doxycycline hyclate IR doxycycline monohydrate capsules (except 75 mg and 150 mg) doxycycline monohydrate tablets minocycline capsules tetracycline VIBRAMYCIN suspension (doxycycline) ADOXA (doxycycline) demeclocycline DORYX (doxycycline) doxycycline hyclate DR doxycycline monohydrate capsules75 mg and 150 mg minocycline ER minocycline tablets NUTRIDOX (doxycycline) ORACEA (doxycycline) SOLODYN (minocycline) VIBRAMYCIN capsule and syrup (doxycycline) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ULCERATIVE COLITIS Preferred Agents Non‐Preferred Agents PA Criteria Oral ASACOL (mesalamine) balsalazide sulfasalazine sulfasalazine DR SFROWASA (mesalamine) mesalamine APRISO (mesalamine) ASACOL HD (mesalamine) AZULFIDINE (sulfasalazine) COLAZAL (balsalazide) DIPENTUM (olsalazine) LIALDA (mesalamine) PENTASA (mesalamine) Rectal CANASA (mesalamine) mesalamine kit ROWASA (mesalamine) ■ Treatment failure with preferred drugs within any subclass of same route ■ Contraindication to preferred drugs of same route ■ Allergic reaction to preferred drugs of same route ■ Treatment failure with preferred drugs within any subclass of same route ■ Contraindication to preferred drugs of same route ■ Allergic reaction to preferred drugs of same route Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. January 23, 2013 Page 46 of 47
HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 PREMIUM PREFERRED GENERIC () MANUFACTURERS: These manufacturers have offered Supplemental Rebates to the state for their PDL drugs dispensed to Medicaid recipients. Pharmacists will receive an additional $0.50 dispensing fee when they dispense the PDL drugs of these manufacturers. Generic Manufacturer Mallinckrodt 00406 Labeler Code(s) Sun Pharma Glob 41616 Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug. January 23, 2013 Page 47 of 47
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