diclofenac potassiumdiclofenac epolamine - PDF document

diclofenac potassiumdiclofenac epolamine ( s diclofenac/misoprostol ( A rthrote c )naproxen/lansoprazole (Prevacid NapraPAC)Immediate-Release OPIOID Analgesics/CENTRALLY ACTING butalbital/codeine/APAP/caffeinebuprenorphine (Subutex)butalbital/codeine/ASA/caffeinecodeine/APAP ( V opac)codeinecodeine/APAP dihydrocodeine/APAP/caffeinedihydrocodeine/APAP/caffeine (Panlor DC, Synalgos DCfentanyl (lozenges, patches)fentanyl citrate buccal/transmucosal (Fentora/ Actiq)hydrocodone/APAPhydrocodone/APAP (Zydone, Xodol)hydrocodone/ibuprofenhydrocodone/ibuprofen (Reprexain)hydromorphonenaloxone/buprenorphine (Suboxone)levorphanoloxycodone/APAP (Lynox, Magnace t )meperidineoxycodone/ibuprofen (Combuno x )methadoneoxymorphone-plain and ER (Opana,Opana E R )morphine sulfate IRtramadol (Ultram ER)oxycodone IRoxycodone IR/APAPpentazocine/APAPpentazocine/naloxonetramadol IRtramadol/APAPSustained-Release OPIOID Analgesicsfentanyl transdermaloxycodone SA (generic & Oxycontin)morphine sulfate Avinza, Kadian)Effective JULY 1, 2007Therapeutic Drug Class 1 ANTI-INFECTIVE AGENTSANTI-FUNGA L fluconazol

eflucytosine ( A ncobon)griseofulvin microsize (Grifulvin V ) itraconazole (Sporanox Kit & Soln.)griseofulvin ultramicrosize (Gris-PEG) voriconazole ( V fend)itraconazoleLamisil) ANTI-PROTOZOA L metronidazoleatovaquone (Mepron)nitazoxanide (Alinia)metronidazole (Flagyl E R )tinadazole (Tindamax)ANTI-VIRA L acyclovirfamciclovir (Famvi r )adefovir (Hepsera)ganciclovir Copegus, Rebetol)valacyclovir ( V altrex)valgancyclovir ( V alcyte)CEPHALOSPORINScefditoren (Spectrace f cefadroxil ceftibuten ( V CiproSuspension , Proquin XR x )gatifloxacin (Tequin)ofloxacingemifloxacin (Factive)levofloxacin (Levaquin)lomefloxacin (Maxaquin)naldixic acid (Neggram)norfloxacin (Noroxin)sparfloxacin (Zagam)KETOLIDEStelithromycin (Ketek)MACROLIDESazithromycin (Zmax)clarithromycin (& Biaxin XL)erythromycin (ERYC 250,PCE 333, PCE 500)erythromycincarbenicillin (Geocillin)amoxicillin/potassium clav (Augmentin / Augmentin XR)Gantrisin Ped. Susp)TETRACYLINES 2 demeclocyclinedoxycycline (Adoxa,Doryx,Monodox, Oracea, Vibramycin Syrup)doxycyclineminocycline (Dynacin, Solodyn ) )linezolid ( x )vancomycin ( V anc

ocin)OTIC ANTI-INFECTIVESacetic acid/ acetic acid + hydrocortisoneciprofloxacin/hydrocortisone(Cipro HC)ciprofloxacin/dexamethasone (Ciprodex)neomycin/polymyxin B/buffers/hc (Pediotic)neomycin/polymyxin B/hydrocortisoneneomycin/colistin/hc (Coly-Mycin S,CortisporinT C )pramoxine/chloroxylenol A )enalapril/felodipine ( s spironolactoneeplerenone (Inspra)ARBs & ARB/Diuretic Combination s irbesartan (Avapro/Avalid e ) candesartan ( A tacand/Atacand HC T ) olmesartan (Benicar/Benicar HCT)eprosartan (Teveten/Teveten HC T ) valsartan (Diovan/Diovan HC T )losartan (Cozaar/Hyzaa r cholestyraminecolesevalam ( s fenofibrate generics (& Tricor)fenofibrate (Antara, Lofibra, Triglide)gemfibrozilNiacorOmega-3 Fatty Aci d omega-3 acid ethyl esters(Lovaza formerly Omacor)Selective Cholesterol Absorption Inhibitor Zetia)Statins (Lipito r )fluvastatin (Lescol)lovastatinlovastatin ER ( A ltopre v )pravastatinrosuvastatin (Crestor)simvastatin 3 Statin Combinationsezetimibe/simvastatin ( V )pravastatin/ASA ( S diltiazem IR & ERdiltiazem ( r felodipineisradipine (nicardipinenicardipine (nifedipine ERni

soldipine ( c amlodipine/atorvastatin (Caduet)DIURETICSamiloride & amiloride/HCTZclorothiazide (Diuril Oral Susp)bumetanideclonidine/chlorthalidone (Clorpres)chlorothalidonedeserpidine/methyclothiazide (Enduronyl-Forte)chlorothiazideethacrynic acid (Edecrin)furosemidehydroflumethiazide (Saluron)hydrochlorothiazidepolythiazide (Renese)indapamideprazosin/polythiazide (Minizide)methyclothiazidereserpine/methyclothiazide (Diutensin- R )metolazonespironolactone/hctz ( A ldactazide 50/50)torsemidetrichlormethazide (Naqua)triamterene & triamterene/HCTZRENIN INHIBITORSaliskiren (Tekturna)CENTRAL NERVOUS SYSTEM AGENTSADHD AGENT S )amphetamine mixture ( V yvans e )methamphetamine (dextroamphetamine (generics)methylphendidate ( A )methylphendidate (generics, Concerta, Daytrana Patch, Metadate CD, Methylin Chewable & Soln) ALZHEIMERS AGENT S donepezil (Aricept)galantamine (Razadyne, Reminyl)memantine (Namenda)tacrine (Cognex)rivastigmine (Exelon)ANTICONVULSANT S carbamazepine(Carbatrol, Equetro, Tegretol XRcarbamazepine (Tegretol) NTI rules apply- see Pharm. Manual Section 31.11divalproex sod

ium(Depakote,Depakote E R )ethotoin ( 4 gabapentinmethsuximide (Celontin)lamotrigine (Lamictal)levetiracetam (Keppra)oxcarbazepine (Trileptal)phenytoin (Dilantin, Phenyte k )pregabalin (Lyrica)primidonetiagabine (Gabitril)topiramate (Topamax)valproic acidANTIDEPRESSANT S AminoketonesWellbutrin XL)MAOIsphenelzine (Nardil)selegeline (Emsam Patch)tranylcypromine(Parnate)SNRIsduloxetine (Cymbalta)venlafaxine XR (Effexor XR)SSRIsescitalopram (Lexapro)fluoxetinefluoxetine(Prozac Weekly, Sarafem)paroxetineparoxetine (Paxil & Paxil CR) sertralineparoxetine mesylate (Pexeva)TCAsprotriptyline ( V desipraminetrimipramine ( * meclizineaprepitant (Emend)ondansetron (& brand Zofran) dolasetron ( A promethazinedronabinol ()*aripiprazole ( A bilif y )ziprasidone (Geodon)*olanzapine (Zyprexa)olanzapine/fluoxetine (Symbya x )palperidone (Invega)quetiapine (Seroquel)* injectable forms require PA (except for beneficiaries residing in a long term care facilityFirst Generation Antipsychotics & Misc.chlorpromazinemolindone (Moban)fluphenazinepimozide (Orap)haloperidol 5 thiothixeneANXIOLYTICSalprazolamh

ydroxyzine pamoate ( V istaril Suspension)buspironechlordiazepoxideNote:SingleSource Brand Benzodiazepines and Barbiturates are NOT covered. No PA s will be issued.MIGRAINE AGENT S )almotriptan( A xer t )eletriptan( A merge)zolmitriptan(Zomig)SEDATIVE/HYPNOTICSestazolamzaleplon(Sonata)eszopiclone (Lunesta) flurazepamlorazepamRozerem)temazepam (& brand Ambien CR) Note:SingleSource Brand Benzodiazepines and Barbiturates are NOT covered. No PA s will be issued.SKELETAL MUSCLE RELAXANT S baclofencyclobenzaprine (Fexmid)cyclobenzaprinemetalaxone (Skelaxin) dantrolenetizanidine caps (Zanaflex)tizanidine tabsENDOCRINE & METABOLIC AGENTSANTIDIABETIC S noneacarbose ( t ) Amylin Analo g pramlintide acetates (Symlin)Biguanidesmetformin (Fortamet, Glumetza, Riomet Liq)DPP-4 InhibitorsJanuvia)DPP-4 Inhibitor/Biguanide Combinations (Janumet)Incretin MimeticsByetta)InsulinApidra (insulin glulisine)Exubera (human regular insulin powder for inhalation)Lantus (insulin glargine)Humalog(human insulin lispro (rDNA)Levemi r Humalog MixNovolin N, Novolin R, Novolin 70/3 0 repaglinide( 6 acetohexamidec

hlorpropamide (Actos)rosiglitazone (Avandi a ) Combination Products(Duetact)pioglitazone/metformin(Actoplus Me t )rosiglitazone/metformin (Avandame t )rosiglitazone/glimeperide(Avandary l )estradiol/noreth. ( A ctivell a )estradiol/norgestimate A lora,Climara, Esclim,Estraderm, Menostar,Vivelle, Vivelle Do t )estradiol/levonorgestrel (ClimaraPro)estradiol/norethindrone (CombiPatch) V medroxyprogesterone acetateprogesterone,micronized ( % progesterone in oilDepo-Provera 400mg/ml(150mg/ml does not require PA),somatropin ( e )Nutropin,Nutropin A Q ,mecasermin ( A ctonel/Actonel w/Calcium)ibandronate (Boniva)teriparatide (Forteo)raloxifene (Evista)THYROID/ANTI-THYROID AGENTS 7 All Brand and Generic AgentsNoneGASTROINTESTINAL AGENTSH2- Antagonistsfamotidine (Pepcid RPD,Pepcid Susp)famotidinenizatidine ( A xid Solution)nizatidineranitidine (generic capsules, Zantac EFFERdose, Zantac Syrup)ranitidine generic tablets & syrupInflammatory Bowel Diseasemesalamine (generic enema,Asacol, Canasa, Lialda, Pentasa)balsalazode (Colazal)olsalazine(Dipentum)budesonide (Entocort EC)mesalamine(Row

asa)LAXATIVE S lactulose (Constulose,Enulose)lactulose (Kristalose Packet)lubiprostone (Amitiza)PEG Combinations (Colyte, Golytely, Halflytely, Miralax, Moviprep, Nulytely. OCL, Trilyte)PEG 3350/Electrolyte Solutionsodium phosphate salts (Osmoprep, V )esomeprazole ( A ciphe x )HEMATOLOGICAL AGENTSANTICOAGULANTS-INJECTABL E )dalteparin ( x )epoetin alfa()filgrastim( x )clopidogrelIMMUNOLOGIC AGENTSadalimumab (Humira)abatacept (Orencia)*efalizumab (Raptiva)alefacept ( A meviv e )*etanercept (Enbrel)anakinra (Kineret)infliximab (Remicade)*leflunomide ( A rav a )*administer in hospital or clinic setting-Prior Auth will not be issued for Point of Sale without justificationNEPHROLOGIC AGENTScalcium acetate (PhosLo)calcium/magnesium/FA (Magnebind Rx)lanthanum(Fosrenol)sevelamer(Renagel)RESPIRATORY ALLERGY-ANTIHISTAMINE S 8 antihist/decong combinationsfexofenadine/pseudoephedrine ( y )brompheniramine ( V azol, Vazol D)carbinoxamine (Palgic)cetirizine (Zyrtec) desloratadine (Clarinex)fexofenadineloratadine OTC (tabs,D-12hr,D-24hr syrup)ALLERGY- NASAL CORTICOSTEROID S flunisolidebeclometha

sone (Beconase A Q )fluticasone (& brand Flonase)budesonide (Rhinocort Aqu a )ciclesonide ( V eramys t )triamcinolone (Nasacort A Q )ANTIASTHMATIC S ipratropium solution for inhalationipratropium( A trovent MDI)tiotropium (Spiriva)Inhaled Corticosteroidsbudesonide (Pulmicort Flexhaler/ Respules/Turbuhaler)beclomethasone (QVAR)fluticasone (Flovent HFA & Disku s )flunisolide ( A erobid, A erobid M)mometasone (Asmane x )triamcinolone ( A zmacor t )Leukotriene Modifiersmontelukast (Singulair )zafirlukast ( A cromolyn sodium solution for inhalationnedocromil (TiladeInhaleralbuterol (soln.for inhal., syrup, tabs IR & ER) albuterol ( A )arformoterol soln.for inhalation ( A )metaproterenol ( A lupent Aerosol)metaproterenol tabs,soln,syrupsalmeterol (Serevent Diskus)pirbuterol (Maxair)terbutalineCombiven t )formoterol/budesonide (Symbicor t )albuterol/ipratropium (DuoNeb) salmeterol/fluticasone (Advair ) TOPICAL AGENTSAcne Preparations ( )adapalene ( A zele x )Duac)benzoyl peroxide/erythromycin (BenzamycinPak)benzoyl peroxide/sulfur (Nuox)benzoyl peroxide/sulfur (Sulfoxyl)clindamycin (

& Evoclin)clindamycin (Clindagel),clinadmycin/tretinoin (Ziana Gel)erythromycinerythromycin ( A kne-Mycinoint)sodium sulfacetamide (Klaron)sodium sulfacetamide/sulfur (Suphera) 9 tazarotene (Tazorac)tretinointretinoin (Retin-A Micr o )Antibacterial Agent s bacitracin ointmupirocin (Bactroban) 2% Cr & Nasalbacitracin/polymyxin ointpolymixin B/neomycin/HC (Cortisporin) Cr & Ointgentamicin 0.1% cr & ointmupirocin 2% ointclindamycin 2 % vaginal cream (Clindamax, Clindesse) clindamycin (Cleocin Vaginal Ovules)metronidazole 0.75% vaginal geltriple sulfa vaginal cream s clotrimazole/betamethasone cream & lotionoxiconazole ( V ) ointterbinafine 1% soln ( r clotrimazole 1 & 2% vaginal cream butoconazole ( s All Generics - Too numerous to listAll Brands not listed - Too numerous to listAntipruritic Agent s doxepin generic (Prudoxin)doxepin (Zonalon)Antiviral Agent s Nonepenciclovir (Denavi r ) 1% Creamacyclovir (Zovira x fluorouracil 5% cr, 2 % & 5% Solnalitretinoin ( s )anthralin ( x )calcipotriene/betamet.diprop. (Taclonex)Diabetic Ulcer Prepsbecaplermin (Regranex)ImmunomodulatorsAldara

)Immunosuppressive Agent s )tacrolimus(podofilox 0.5% Top.Solnpodofilox ( x )salicylic acid podophyllum resin (Podocon-25)urea cream, gel, lotion genericresorcinol/phenol (Derma-Cas) 10 salicylic acid ( A kurza, Keralyt Gel, Salex)urea (Hydro 40 Foam, Kerafoam, Keralac, Keralac Nail, Umecta)Mucous Membr/Subcut Enzymespapain/urea generics collegenase (Santyl Ointmen t )papain/urea/chlorophylin generics acemannan (Salicept, OramagicRx))Oral Agents Amnesteem,Claravis, Sotre t ) isotretinoin ( A ccutane) acitretin (Soriatane) Scabicides and PediculicidesEurax)lindane 1% lotion , shampoo (generic)malathion (Ovide)permethrin (1% lotion, 1% cream rinse-OTC, 5% cream)piperonyl/pyrethrins OTCUROLOGICAL AGENTSAnticholinergic/Antispasmodic s darifenacin (Enablex)oxybutynin (Oxytrol Patch)flavoxatesolifenacin ( V ESIcare)oxybutynintolterodine (Detrol, Detrol L A )trospium (Sanctura)BPH Agents (Uroxatral)dutasteride ( A vodart ) doxazosin (& brand Floma x *In some cases, Medicaid may opt to prefer a brand name drug over its generic equivalent. This occurs when the net price is deemed to be