HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

More documents

Recommendations

Info

HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 ANTIBIOTICS, TOPICAL Preferred Agents Non‐Preferred Agents PA Criteria bacitracin bacitracin/polymyxin DOUBLE ANTIBIOTIC (bacitracin/polymyxin b) gentamicin mupirocin neomycin/polymyxin/pramoxine triple antibiotic ALTABAX (retapamulin) BACTROBAN (mupirocin) CENTANY (mupirocin) NEOSPORIN(bacitracin/neomycin/ polymyxin b) NEOSPORIN PLUS PAIN RELIEF (bacitracin/neomycin/polyxyxin b/pramoxine) POLYSPORIN (bacitracin/polymyxin) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ANTIBIOTICS, VAGINAL Preferred Agents Non‐Preferred Agents PA Criteria clindamycin metronidazole CLEOCIN (clindamycin) CLINDESSE (clindamycin) VANDAZOLE (metronidazole) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ANTICOAGULANTS Preferred Agents Non‐Preferred Agents PA Criteria ARIXTRA (fondaparinux) LOVENOX (enoxaparin) PRADAXA (dabigatran) warfarin XARELTO (rivaroxaban) COUMADIN (warfarin) Enoxaparin fondaparinux FRAGMIN (dalteparin) ■ 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 Page 8 of 47
HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective January 23, 2013 ANTIDEPRESSANTS, OTHER Preferred Agents Non‐Preferred Agents PA Criteria bupropion MARPLAN (isocarboxazid) mirtazapine NARDIL (phenelzine) PRISTIQ (desvenlafaxine) trazodone Venlafaxine ER capsules APLENZIN (bupropion) EFFEXOR (venlafaxine) EFFEXOR XR (venlafaxine) EMSAM (selegiline) nefazodone OLEPTRO ER (trazodone) PARNATE (tranylcypromine) phenelzin REMERON (mirtazapine) tranylcypromine venlafaxine IR venlafaxine ER tablets VIIBRYD (vilazodone) WELLBUTRIN (bupropion) ZYBAN SR (bupropion) ■ Treatment failure with preferred drugs within any subclass ■ Contraindication to preferred drugs ■ Allergic reaction to preferred drugs ANTIDEPRESSANTS, SSRIS Preferred Agents Non‐Preferred Agents PA Criteria citalopram fluoxetine fluvoxamine LEXAPRO (escitalopram) paroxetine sertraline CELEXA (citalopram) escitalopram fluoxetine capsule DR LUVOX CR (fluvoxamine) paroxetine CR PAXIL (paroxetine) PAXIL CR (paroxetine) PEXEVA (paroxetine) PROZAC (fluoxetine) SARAFEM (fluoxetine) ZOLOFT (sertraline) ■ 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 Page 9 of 47
Page 1 and 2: HEALTH AND HUMAN SERVICES COMMISSIO
Page 7: HEALTH AND HUMAN SERVICES COMMISSIO
Page 49 and 50: Cough and Cold Drugs (Oral Only) Co
Page 51 and 52: Cough and Cold Drugs - Narcotic PRE
Page 53 and 54: IRON AGENTS Preferred Agents Non-Pr
Page 55: PRENATAL VITAMINS PREFERRED DRUGS N

HEALTH AND HUMAN SERVICES COMMISSION TEXAS ...

Create successful ePaper yourself

Delete template?

Save as template?