PDL Comparison of Select Therapeutic Classes OPEN (No Restrictions on Access) Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
benzonatate, dextromethorphan, generics,
aspirin (RX & OTC products), choline
aspirin, salsalate, choline & magnesium
nitrofurantoin, nitrofurantoin monohydrate
amoxicillin, ampicillin, dicloxacillin, pen vk
metaproterenol solution, syrup & tablet,
albuterol syrup, tablet & inhalation solution,
albuterol syrup, tablet & inhalation
albuterol solution for inhalation, tablets,
metaproterenol solution, syrup & tablet,
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
atenolol, bisoprolol, metoprolol, nadolol,
atenolol, labetalol, metoprolol, nadolol,
benazepril, captopril, enalapril maleate,
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
glimepiride, glipizide, glipizide/metformin,
glyburide, glyburide micronized, glyburide
clotrimazole (otc), miconazole (otc), nystatin
flucinonide, clobetasol, desoxymetasone,
neomycin/bacitracin/polymixin/lidocaine,
polyethylene glycol electrolye solution, propantheline, sucralfate, sulfasalzine,
cimetidine (RX & OTC), famotidine (RX
& OTC), nizatidine, ranitidine (RX &
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
spironolactone w/hctz, triamterene w/hctz
meclizine, metoclopramide, promethazine,
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
apap/butalbital, apap/caffeine/butalbital,
asa/caffeine/butalbital, ergotamine/caffeine,
bacitracin, bacitracin/neomycin/polymyxin
gentamicin, gramicidin/neomycin/polymyxin
B, polymyxin B/bacitracin, sulfacetamide
betaxolol, levobunolol, timolol, carteol,
metipranolol, epinephrine, physostigmine,
see products covered with quantity limits
dexamethasone, flurbiprofen, prednisolone,
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
diclofenac K 50mg, diclofenac 50mg &
RECEPTOR ANTAGONISTANTI-ARTHRITIC, FOLATE
**Note: In accordance with Indiana law, all antianxiety, antidepressant, antipsychotic, and "cross indicated" drugs are considered as being preferred. Drugs that are (1) classified in a central nervous system drug category or classification (according to Drug Facts and Comparisons) created after March 12, 2002, and (2)
prescribed for the treatment of a mental illness (as defined by the most recent publication of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders) are also considered as being preferred.
When a brand name drug having generic equivalent is included in the "Non-Preferred Drug List" listing, please note that the generic equivalents for the brand name drug are considered as preferred medications on the Fee-for Service PDL, unless otherwise specified.
Prior authorization for Brand Medically Necessary is not required for the drugs specifically exempted by the DUR Board from a prior authorization for Brand Medically Necessary requirement for the Fee-for Service PDL (those drugs being what are typically referred to as "narrow therapeutic index"). Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description PDL Comparison of Select Therapeutic Classes CLINICAL EDITS (Restrictions) CLINICAL EDITS: PA - Prior Authorization QLL - Quantity Level Limits ST - Step Therapy AGE - Age Limit
oxycodone with APAP (5/325 only) or and ibuprofen QLL)
analgesics containing acetaminophen day supply; limited
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
ALLEGRA/fexofenadine 30mg day; ST - must fail a
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
QLL - Limit 1 tablet per day; Step Edit -
ALLEGRA-D/fexofenadine-pse loratadine/pse within
albuterol inhaler, albuterol HFA (ProAir)
benazepril, captopril, enalapril, lisinopril,
benazepril, captopril, enalapril, lisinopril,
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
AVANDAMET 500mg/4mg. 1 gram/2mg QLL - 2 tablets
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
cimetidine, famotidine, nizatidine, ranitidine
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
buproption HCL for smoking cessation therapy every 365
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
levobunolol, LUMIGAN, metipranolol, available package
ISOPTO HOMATROPINE, tropicamide available package
Fee For Service Clinical Clinical Clinical Clinical Categories Drug Class Name/Description Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Drug Name/Nomenclature Edits and Description Description Description Description
RECEPTOR ANTAGONISTANTI-ARTHRITIC, FOLATE
Medication Strength Utilization Edit Medication Strength Utilization Edit Medication Strength Utilization Edit Medication Strength Utilization Edit
nefazodone tablet 50, 100, 150, 200, 250MG
Medication Strength Utilization Edit
Les effets secondaires du vaccin antivariolique Les effets secondaires du vaccin antivariolique - Documentation - Les différents effets secondaires des vaccins - Le vaccin antivariolique - Date de mise en ligne : vendredi 4 juin 2010 Description : Quels sont les effets secondaires du vaccin antivariolique ? Info-vaccination.be Les effets secondaires du vac
Concert Schedule until August 2010 Wednesday 28 October 2009 Concert, National Arts Centre, OTTAWA ROSSINI William Tell Overture BERLIOZ Romeo and Juliet: Scene for orchestra / excerpt PROKOFIEV Piano Concerto No 1 - interval - SHOSTAKOVICH Hamlet Suite Op 32 BRIDGE There is a willow grows aslant a brook STRAUSS Don Juan NATIONAL ARTS CENTRE ORCHESTRA SIMON TRPCESKI Thursday 29