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 />
ANGIOTENSIN MODULATORS<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
Direct Renin Inhibitor/Diuretic Combinations<br />
TEKTURNA HCT (aliskerin/HCTZ) ■ Treatment failure with preferred<br />
drugs within any subclass<br />
■ Contraindication to preferred drugs<br />
■ Allergic reaction to preferred drugs<br />
ANGIOTENSIN MODULATOR COMBINATIONS<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
EXFORGE (valsartan/amlodipine)<br />
EXFORGE HCT<br />
(valsartan/amlodipine/HCTZ)<br />
TARKA (trandolapril/verapamil)<br />
AZOR (olmesartan/amlodipine)<br />
benazepril/amlodipine<br />
LOTREL (benazepril/amlodipine)<br />
TEKAMLO (aliskerin/amlodipine)<br />
trandolapril/verapamil<br />
TRIBENZOR<br />
(olmesartan/amlodipine/HCTZ)<br />
TWYNSTA (telmisartan/amlodipine)<br />
VALTURNA (valsartan/aliskerin)<br />
■ Treatment failure with preferred<br />
drugs within any subclass<br />
■ Contraindication to preferred drugs<br />
■ Allergic reaction to preferred drugs<br />
ANTIMICROBIALS, GASTROINTESTINAL<br />
Preferred Agents Non‐Preferred Agents PA Criteria<br />
metronidazole tablet<br />
TINDAMAX (tinidazole)<br />
vancomycin<br />
ALINIA(nitazoxanide)<br />
DIFICID (fidaxomicin)<br />
FLAGYLl, FLAGYL ER(metronidazone)<br />
metronidazole capsule<br />
NEO‐FRADIN (neomycin)<br />
neomycin<br />
tinidazole<br />
VANCOCIN (vancomycin)<br />
XIFAXIN (rifaximin)<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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