30. Beta Adrenergic Receptor Blocking Agents Acebutolol Carteolol (Cartrol) February 12, 2003 Penbutolol (Levatol) Propranolol (Inderal LA)
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1 #03-01 Prior Authorization PDL Implementation Schedule UPDATES Drugs on PDL Drugs which Require PA Implementation Date 26. Bone Resorption Suppression Agents Alendronate (Fosamax) Etidronate (Didronel) February 12, 2003 Calcitonin-salmon (Miacalcin) Raloxifene (Evista) Risendronate (Actonel) Tiludronate (Skelid) 30. Beta Adrenergic Receptor Blocking Agents Acebutolol Carteolol (Cartrol) February 12, 2003 Atenolol Penbutolol (Levatol) Betaxolol Propranolol (Inderal LA) Bisoprolol Sotalol (Betapace AF) Carvedilol (Coreg) Labetalol Metoprolol Metoprolol XL (Toprol XL) Nadolol Pindolol Propanolol Sotalol Timolol #03-01 Prior Authorization PDL Implementation Schedule 41. Antihyperlipidemic Agents- Non Statins Cholestyramine Colesevelam (Welchol) February 12, 2003 Clofibrate Colestipol (Colestid) Fenofibrate (Tricor) Gemfibrozil Niacin ER (Niaspan) Niacin ER/Lovastatin (Advicor) Cholestyramine/Aspartane 42. Combination Estrogen Agents 17β-Estradiol/Norgestimate (Ortho-Prefast) 17β-Estradiol/Norethindrone Acetate (Activella) February 19, 2003 Conjugated Estrogens (CE)/ 17β-Estradiol/Norethindrone Acetate (CombiPatch) Medroxyprogesterone Acetate (MPA) (Premphase) Conjugated Estrogens (CE)/ Medroxyprogesterone Acetate (MPA) (Prempro) Ethinyl Estradiol/Norethindrone Acetate (Femhrt) 43. Alzheimer's Drugs - Cholinesterase Inhibitors Donepezil (Aricept) Tacrine (Cognex) February 19, 2003 Galantamine (Reminyl) Rivastigmine (Exelon) PDL and NPDL provider notification Page 1
2 #03-01 Prior Authorization PDL Implementation Schedule Drugs on PDL Drugs which Require PA Implementation Date 44. Antiparkinson Agents - Anticholinergic and Other Amantadine Hcl Biperiden (Akineton) February 19, 2003 Benztropine Mesylate Procyclidine (Kemadrin) Bromocriptine Mesylate Tolcapone (Tasmar) Diphenhydramine Entacapone (Comtan) Levodopa (Larodopa) Levodopa/Carbidopa Pergolide (Permax) Pramipexole (Mirapex) Ropinirole (Requip) Selegiline Trihexyphenidyl 45. Allergic Conjunctivitis Azelastine Hydrochloride (Optivar) Emedastine Difumarate (Emadine) February 26, 2003 Cromolyn Sodium Ketorolac Tromethamine (Acular) Ketotifen Fumarate (Zaditor) Levocabastine (Livostin) Lodoxamide Tromethamine (Alomide) Loteprednol (Alrex) Nedocromil Sodium (Alocril) Olopatadine Hydrochloride (Patanol) Pemirolast Potassium (Alamast) 46. Intraocular Pressure (IOP) Reducers Brimonidine (Alphagan P) NONE February 26, 2003 Brinzolamide (Azopt) Dipivefrin Dorzolamide (Trusopt) Dorzolamide/Timolol (Cosopt) Epinephrine 47. Fluoroquinolones, Otic Ciprofloxacin/Hydrocortisone (Cipro HC Otic) NONE February 26, 2003 Ofloxacin (Floxin Otic) PDL and NPDL provider notification Page 2
3 #03-01 Prior Authorization PDL Implementation Schedule Drugs on PDL Drugs which Require PA Implementation Date 48. Erythropoietins Epoetin alfa (Epogen; Procrit) Darbepoetin alfa (Aranesp) March 5, 2003 Darbepoetin alfa (Aranesp) - Pediatrics only (Under 21 years old) 49. Growth Hormones Somatropin (Nutropin) Somatrem (Protropin) March 5, 2003 Somatropin (Nutropin AQ) Somatropin (Genotropin) Somatropin (Nutropin Depot) Somatropin (Humatrope) Somatropin (Serostim) Somatropin (Norditropin) Somatropin (Saizen) 50. Multiple Sclerosis Agents (Immunomodulatory Agents) Interferon beta-1a (Avonex) Glatiramer (Copaxone) March 5, 2003 Interferon beta-1b (Betaseron) Interferon beta-1a (Rebif) 51. Ulcerative Colitis Agents Mesalamine (Asacol) Balsalazide (Colazal) Mesalamine (Pentasa) - Pediatric only (Under 21 years old) Mesalamine (Pentasa) Olsalazine (Dipentum) Mesalamine (Rowasa) Sulfasalazine (Generic) 52. Phosphate Binders Calcium Acetate (PhosLo) NONE March 19, 2003 Magnesium Carbonate, Calcium Carbonate, Folic Acid (Magnebind 400 Rx) Sevelamer (RenaGel) 53. Atopic Dermatitis Immunomodulators Pimecrolimus (Elidel) Tacrolimus (Protopic) March 19, 2003 PDL and NPDL provider notification Page 3
4 PDL and NPDL provider notification Page 4
5 PDL and NPDL provider notification Page 5
6 PDL and NPDL provider notification Page 6
7 PDL and NPDL provider notification Page 7
8 PDL and NPDL provider notification Page 8
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