Microsoft word - nv_pdl o080508-n082008.doc

STATE OF NEVADA
DIVISION OF HEALTH CARE FINANCING AND POLICY
Nevada Medicaid Preferred Drug List
ANALGESICS: Long Acting
ANTIBIOTICS:
ANTIHISTAMINES: 2nd Generation
CARDIOVASCULAR:
CARDIOVASCULAR: Beta Blockers
Narcotics
Quinolones 3rd Generation
A two week trial of one of these drugs is Angiotensin II Receptor Blockers &
ACEBUTOLOL (generic Sectral®)
DURAGESIC® PATCHES (PA required)
AVELOX®
required before a non-preferred drug will Diuretic Combination
ATENOLOL (generic Tenormin®)
KADIAN®
AVELOX ABC PACK®
COZAAR®
ATENOLOL/CHLORTHALIDONE
MORPHINE SULFATE SA TABS
ANTICOAGULANTS: Injectable
CETIRIZINE D OTC
DIOVAN®
(generic Tenoretic®)
(generic MS Contin®)
(generic Zyrtec D®) (new)
ARIXTRA®
DIOVAN HCTZ®
BETAXOLOL (generic Kerlone®)
ORAMORPH SR®
CETIRIZINE OTC TABS, CHEW TABS
FRAGMIN®
HYZAAR®
BISOPROLOL (generic Zebeta®)
AND SYRUP (generic Zyrtec®) (new)
ANTIBIOTICS:
LOVENOX®
BISOPROLOL/HCTZ (generic Ziac®)
CLARINEX® SYRUP
CARDIOVASCULAR:
Cephalosporins 2nd Generation
BYSTOLIC®
ANTIDEPRESSANTS: Other
(PA not required for < 2 years)
Antihyperlipidemics: Cholesterol
(Restricted to
CEFACLOR CAPS & SUSP
BUPROPION (generic Wellbutrin®)
LORATADINE OTC TABS, SYRUP, &
Absorption Inhibitors
ICD-9 codes 490-496)
(generic Ceclor®)
BUPROPION SR
RAPID DISINTEGRATING TABS
CARVEDILOL
CEFACLOR ER
are effective
(generic Wellbutrin SR®)
(generic Claritin®) Class changes
(generic Coreg®)
(generic Ceclor CD®) 09/25/08.
CARDIOVASCULAR:
CYMBALTA® (PA not
LORATADINE D OTC are effective
LABETALOL
CEFUROXIME SUSP (generic Ceftin®) (new)
09/25/08.
Antihyperlipidemics: Niacin Agents
required for
(generic Claritin D®)
(generic Normodyne®, Trandate®)
CEFUROXIME TABS (generic Ceftin®)
ICD-9-CM code 356.9)
ANTI-MIGRAINE AGENTS: Triptans
NIASPAN®
METOPROLOL (generic Lopressor®)
CEFPROZIL SUSP (generic Cefzil®)
MIRTAZAPINE (generic Remeron®)
IMITREX® INJECTION
NIACIN ER
NADOLOL (generic Corgard®)
ANTIBIOTICS:
MIRTAZAPINE RAPID TABS
IMITREX® TABS & NASAL SPRAY
CARDIOVASCULAR:
PINDOLOL (generic Visken®)
(generic Remeron Soltabs®)
Antihyperlipidemics: Statins & Statin
Cephalosporins 3rd Generation
MAXALT® TABS
PROPRANOLOL (generic Inderal®)
TRAZODONE (generic Desyrel®)
CEDAX® CAPS & SUSP
MAXALT® MLT
WELLBUTRIN XL 150MG®
ADVICOR®
PROPRANOLOL/HCTZ
CEFDINIR CAPS & SUSP
RELPAX®
Class changes
(generic Inderide®)
WELLBUTRIN XL 300MG®
CRESTOR®
are effective
(generic Omnicef®)
BONE OSSIFICATIONS AGENTS:
09/25/08.
LESCOL®
CEFPODOXIME TABS
ANTIDEPRESSANTS: SSRIs
Bisphosphonates
(generic Betapace®, Sorine®)
(generic Vantin®)
CITALOPRAM (generic Celexa®)
LESCOL XL®
FOSAMAX® TABS & SOLUTION
TIMOLOL (generic Blocadren®)
FLUOXETINE (generic Prozac®)
LIPITOR® (new)
ANTIBIOTICS: Macrolides
FOSAMAX PLUS D®
PAROXETINE (generic Paxil®)
LOVASTATIN (generic Mevacor®)
AZITHROMYCIN TABS & SUSP
CARDIOVASCULAR: ACE Inhibitors
PRAVASTATIN (generic Pravachol®)
(generic for Zithromax)
PEXEVA®
& Diuretic Combinations
SIMCOR® (new)
CLARITHROMYCIN TABS & SUSP
SERTRALINE (generic Zoloft®)
ALTACE® (PA is required)
(generic Biaxin®)
ANTIEMETICS: Oral, 5-T3s
SIMVASTATIN (generic Zocor®)
BENAZEPRIL (generic Lotensin®)
ERYTHROMYCIN BASE
GRANISETRON (generic Kytril®) (new)
VYTORIN®
BENAZEPRIL HCTZ
(generic E-Mycin®, Ery-Tab®, PCE®) ONDANSETRON
Class changes are
(generic Lotensin HCT®)
CARDIOVASCULAR:
ERYTHROMYCIN ESTOLATE
(generic Zofran®) effective 09/25/08. CAPTOPRIL (generic Capoten®)
Antihyperlipidemics:
ERYTHROMYCIN ETHYLSUCCINATE
ANTIFUNGALS:
CAPTOPRIL HCTZ (generic Capozide®)
Triglyceride Lowering Agents
(generic EES®)
Onychomycosis Agents
ENALAPRIL (generic Vasotec®)
GEMFIBROZIL (generic Lopid®)
ERYTHROMYCIN STEARATE
Prior authorization is required for all ENALAPRIL HCTZ
TRICOR®
ANTIBIOTICS:
(generic Vaseretic®)
Quinolones 2nd Generation
TERBINAFINE TABS
LISINOPRIL
Class changes
CIPROFLOXACIN TABS
(generic Lamisil®) are effective
(generic Prinivil®, Zestril®)
(generic Cipro®)
CIDOPIROX SOLN
09/25/08.
LISINOPRIL HCTZ
CIPRO® SUSP
(generic Penlac®) (new)
(generic Prinzide®, Zestoretic®)
This list contains “preferred” drugs for each Class shown above. Prior authorization is required for non-listed drugs within these Classes and as otherwise noted. Unlisted Classes are free from PDL requirements at this time.
Questions? Contact First Health Services’ Clinical Call Center. Phone: (800) 505-9185 Fax: (800) 229-3928 Website: http://nevada.fhsc.com
STATE OF NEVADA
DIVISION OF HEALTH CARE FINANCING AND POLICY
Nevada Medicaid Preferred Drug List
CARDIOVASCULAR: Calcium
METHYLPHENIDATE ER
GROWTH HORMONE AGENTS
NASAL CALCITONINS
RESPIRATORY:
Channel Blockers & Combinations
(generic Ritalin SR®)
Prior authorization is required for all MIACALCIN®
Inhaled Corticosteroids/Nebs
AFEDITAB CR® (generic Adalat CC®)
PROVIGIL® (No PA required for
OPHTHALMIC ANTIHISTAMINES
ADVAIR DISKUS®
AMLODIPINE (generic Norvasc®)
ICD-9-CM codes 347.00, 347.01,
GENOTROPIN®
ALAWAY®
ADVAIR HFA®
CARTIA XT®
347.10, 347.11, 780.53 and 780.57)
NORDITROPIN®
NUTROPIN®
PATADAY®
ASMANEX®
DILTIA XT®
RITALIN LA®
NUTROPIN AQ®
PATANOL®
AZMACORT®
DILTIAZEM HCL (generic Cardizem®)
STRATTERA®
SAIZEN®
ZADITOR OTC®
FLOVENT HFA®
DILTIAZEM EXTENDED RELEASE
VYVANSE®
OPHTHALMIC GLAUCOMA AGENTS
PULMICORT RESPULES®
DYNACIRC CR®
CENTRAL NERVOUS SYSTEM:
HEPATITIS C AGENTS
ALPHAGAN P® Class changes are
(No PA required < 4 years)
FELODIPINE ER (generic Plendil®)
Sedative Hypnotics
PEGASYS®
effective 09/25/08.
ISRADIPINE (generic for Dynacirc®)
ESTAZOLAM (generic ProSom®)
PEGASYS® CONVENIENT PACK
BETAXOLOL (generic Betoptic®)
RESPIRATORY: Long Acting Beta
LOTREL®
FLURAZEPAM (generic Dalmane®)
PEG-INTRON® & REDIPEN
BETOPTIC S®
Adrenergics
NICARDIPINE (generic Cardene®)
ROZEREM® (PA not required for
RIBAVIRIN
BRIMONIDINE (generic Alphagan®)
FORADIL®
ICD-9-CM code 307.42)
CARTEOLOL (generic Ocupress®)
NIFEDIAC CC (generic Adalat CC®)
HERPETIC ANTIVIRAL AGENTS
SEREVENT DISKUS®
TEMAZEPAM
COMBIGAN® (new)
NIFEDICAL XL (generic Procardia XL®)
(generic Restoril®)
ACYCLOVIR (generic Zovirax®)
COSOPT®
RESPIRATORY: Nasal Corticosteroids
NIFEDIPINE ER (generic Procardia XL®)
TRIAZOLAM
FAMVIR®
LEVOBUNOLOL
FLUTICASONE (generic Flonase®)(new)
(generic Halcion®)
VALTREX®
(generic Betagan®)
NASONEX® Class changes are
TAZTIA XT®
ZOLPIDEM
IMMUNOMODULATORS: Injectable
LUMIGAN®
effective 09/25/08.
VERAPAMIL (generic Calan®, Isoptin®)
(generic Ambien®)
METIPRANOLOL
Prior authorization is required for all RESPIRATORY: Short Acting Beta
VERAPAMIL ER
(generic Optipranolol®)
ELECTROLYTE DEPLETERS
Adrenergics-Inhalers/Nebs
TIMOLOL DROPS & GEL SOLUTION
ALBUTEROL MDI/NEB/SOLN
CENTRAL NERVOUS SYSTEM:
PHOSLO®
ENBREL®
(generic Timoptic® & Timoptic XE®)
(generic Proventil®, Ventolin®)
ADHD/Stimulants -- Prior authorization
RENAGEL®
HUMIRA®
TRAVATAN®
is required for all drugs in this Class. MAXAIR®
ERYTHROPOIESIS STIMULATING
IMMUNOMODULATORS: Topical
TRUSOPT®
METAPROTERENOL NEB
ADDERALL XR®
PROTEINS -- Prior authorization is
XALATAN® (new)
Prior authorization is required for all (generic Alupent® Nebs)
AMPHETAMINE SALT COMBINATION
required for all drugs in this Class. OPHTHALMIC QUINOLONES
PROVENTIL® HFA
(generic Adderall®)
ARANESP®
ELIDEL®
CIPROFLOXACIN (generic Ciloxan®)
VENTOLIN® HFA
CONCERTA®
PROCRIT®
PROTOPIC®
VIGAMOX®
XOPENEX® HFA
DEXTROAMPHETAMINE SA
GASTROINTESTINAL AGENTS: H2RAs
OTIC FLUOROQUINOLONES
XOPENEX® NEBS
(generic Dexedrine SA®)
FAMOTIDINE (generic Pepcid®)
LEUKOTRIENE MODIFIERS
CIPRODEX®
Class changes are
(No PA required for < 12 years)
DEXTROAMPHETAMINE TAB
RANITIDINE (generic Zantac®)
ACCOLATE®
effective 09/25/08.
(generic Dexedrine®)
ZANTAC SYRUP
SINGULAIR®
(generic Floxin®)
URINARY TRACT ANTISPAMODICS
DEXTROSTAT®
(PA not required for < 12 years)
MULTIPLE SCLEROSIS AGENTS
RESPIRATORY:
DETROL LA®
FOCALIN®
GASTROINTESTINAL AGENTS: PPIs
AVONEX®
Inhaled Anticholinergic Agents
ENABLEX®
FOCALIN XR®
Prior authorization is required for all AVONEX® ADMINSTRATION PACK
ATROVENT® HFA INHALER
OXYBUTYNIN TABS & SYRUP
METADATE CD®
(generic Ditropan®)
BETASERON®
COMBIVENT® INHALER
METADATE ER®
NEXIUM® CAPSULES
VESICARE
COPAXONE®
DUONEB® SOLUTION
METHYLIN®
OMEPRAZOLE OTC TABS (new)
IPRATROPIUM NEBS
METHYLIN ER®
PREVACID® CAPSULES Class changes
(generic Atrovent® Nebs)
are effective
METHYLPHENIDATE (generic Ritalin®)
PRILOSEC® OTC TABS
09/25/08.
SPIRIVA®
This list contains “preferred” drugs for each Class shown above. Prior authorization is required for non-listed drugs within these Classes and as otherwise noted. Unlisted Classes are free from PDL requirements at this time.
Questions? Contact First Health Services’ Clinical Call Center. Phone: (800) 505-9185 Fax: (800) 229-3928 Website: http://nevada.fhsc.com

Source: http://calderonmed.com/formulary/medicaid.pdf