BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA PA-Prior Authorization REVISED 4/7/03 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA PROTON PUMP lansoprazole (Prevacid)** esomeprazole (Nexium) PA Criteria: Both of the preferred INHIBITORS rabeprazole (AcipHex)** omeprazole (Prilosec) drugs must be tried before a non- Effective 10/1/02 pantoprazole (Protonix) preferred agent will be approved, Implement 1/7/03 unless one of the exceptions on the PA form is present. MINIMALLY SEDATING desloratadine (Clarinex) cetirizine (Zyrtec) PA Criteria: Both Claritin (or a ANTIHISTAMINES AND loratadine (Claritin) cetirizine/pseudoephedrine (Zyrtec-D) decongestant combination) and COMBINATIONS loratadine/pseudoephedrine (Claritin-D fexofenadine (Allegra) Clarinex must be tried before a Effective 10/1/02 12 hour, Claritin-D 24 hour) fexofenadine/pseudoephedrine non-preferred agent will be Implement 1/7/03 (Allegra-D) authorized, unless one of the exceptions on the PA form is present for each agent. LEUKOTRIENE montelukast (Singulair) zafirlukast (Accolate) PA Criteria: The preferred agent RECEPTOR AGONISTS zileuton (Zyflo) must be tried before the non- Effective 10/1/02 preferred agents will be approved, Implement 1/7/03 unless one of the exceptions on the PA form is present. BETA AGONISTS albuterol/ipratropium MDI (Combivent) albuterol/ipratropium inhalation solution PA Criteria: The preferred agents (INHALED & PERORAL) albuterol HFA MDI (Proventil HFA) (Duoneb) must be tried before non- Effective 10/1/02 albuterol syrup, tablets, CFC MDI, albuterol HFA MDI (Ventolin HFA) preferred agents will be Implement 1/7/03 inhalation solution # albuterol inhalation solution (Accuneb) authorized, unless one of the metaproterenol syrup, tablets, inhalation albuterol SR tablets (Volmax) exceptions on the PA form is solution # formoteral MDI (Foradil) present. pirbuterol MDI (Maxair, Maxair metaproterenol MDI (Alupent) Autohaler) salmeterol (Serevent, Serevent Diskus) terbutaline # levalbuterol inhalation solution (Xopenex)

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 1 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA HISTAMINE 2 (Tagamet)# famotidine orally disintegrating (Pepcid PA Criteria: The preferred agents ANTAGONISTS famotidine (Pepcid)# RPD) must be tried before a non- Effective 10/1/02 nizatidine (Axid)# famotidine suspension (Pepcid) preferred agent will be authorized, Implement 1/7/03 ranitidine (Zantac)# ranitidine 150mg (Zantac EFFERdose) unless one of the exceptions on ranitidine syrup (Zantac) the PA form is present. ANTIMIGRAINE almotriptan (Axert) frovatriptan (Frova) PA Criteria: All of the preferred (TRIPTANS) sumatriptan (Imitrex) all forms naratriptan (Amerge) agents must be tried before a Effective 10/1/02 rizatriptan (Maxalt) non-preferred agent will be Implement 1/7/03 zolmitriptan (Zomig) approved, unless one of the eletriptan (Relpax)<> exceptions on the PA form is present. (Quantity limits still apply in this category) ANTIINCONTINENCE flavoxate (Urispas) oxybutynin XL (Ditropan XL) PA Criteria: All of the preferred AGENTS oxybutynin (Ditropan)# agents in this category must be Effective 10/1/02 tolterodine (Detrol) tried before a non-preferred agent Implement 1/7/03 tolterodine LA (Detrol LA) will be authorized, unless one of the exceptions on the PA form is present. GLUCOCORTICOIDS, beclomethasone CFC (Vanceril) beclomethasone HFA (QVAR) PA Criteria: All of the preferred INHALED flunisolide (Aerobid, Aerobid M) budesonide (Pulmicort Turbuhaler) agents (in one dosage form) must Effective 10/1/02 fluticasone (Flovent, Flovent Rotadisk) budesonide (Pulmicort Respules)*** be tried before a non-preferred Implement 1/7/03 fluticasone/salmeterol (Advair) triamcinolone (Azmacort) agent will be authorized, unless one of the exceptions on the PA form is present. LIPOTROPICS, OTHER cholestyramine (Questran)# colesevelam (WelChol) PA Criteria: The preferred agents Effective 10/1/02 cholestyramine light (Questran Light)# niacin ER/lovastatin (Advicor) must be tried before a non- Implement 1/7/03 colestipol (Colestid) ezetimibe (Zetia)(Implement 2/5/03) preferred agent will be authorized, gemfibrozil (Lopid)# unless one of the exceptions on niacin ER (Niaspan) the PA form is present. Zetia, as fenofibrate (Tricor) monotherapy, will only be approved for patients who cannot take statins or other available agents. Zetia and Welchol will be approved for add-on therapy only after an insufficient response to the maximum tolerable dose of a statin for 12 weeks of therapy and failure of a binding agent.

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 2 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA BETA-ADRENERGIC acebutolol (Sectral)# carteolol (Cartrol) PA Criteria: If one of the RECEPTOR BLOCKING atenolol (Tenormin)# penbutolol (Levatol) exceptions on the PA form is AGENTS betaxolol (Kerlone)# sotalol (Betapace AF) present or if the physician feels Effective 10/1/02 bisoprolol (Zebeta)# that the patient cannot be Implement 1/7/03 carvedilol (Coreg) stabilized with any of the labetalol (Normodyne, Trandate)# preferred agents, one of the non- metoprolol (Lopressor)# preferred agents will be approved. metoprolol XL (Toprol XL) nadolol (Corgard)# pindolol (Visken)# propranolol (Inderal)# propranolol LA (Inderal LA) sotalol (Betapace)# timolol (Blocadren)# CORTICOSTEROIDS, flunisolide (Nasalide)# flunisolide (Nasarel) PA Criteria: All of the preferred NASAL fluticasone (Flonase) beclomethasone (Beconase, Vancenase) agents must be tried before a Effective 10/1/02 mometasone (Nasonex) beclomethasone AQ (Beconase AQ, non-preferred agent will be Implement 1/7/03 Vancenase AQ) authorized, unless one of the budesonide (Rhinocort) exceptions on the PA form is budesonide aqua (Rhinocort Aqua) present. triamcinolone (Nasacort) triamcinolone AQ (Nasacort AQ) CHANNEL diltiazem (Cardizem)# amlodipine (Norvasc) PA Criteria: If one of the BLOCKERS diltiazem SR ( Cardizem SR, Cardizem bepridil (Vascor) preferred agents on the list has Effective 10/1/02 CD, Dilacor XR)# nicardipine SR (Cardene SR) already been tried or if one of the Implement 2/5/03 felodipine (Plendil) nifedipine (Adalat, Procardia) generic and exceptions on the PA form is isradipine (Dynacirc) brand present, a non-preferred agent isradipine SR (Dynacirc CR) verapamil ER (Covera-HS) will be authorized. nicardipine (Cardene)# verapamil SR (Verelan) nifedipine SR (Adalat CC, Procardia diltiazem SR (Tiazac) XL)# nimodipine (Nimotop) nisoldipine (Sular) verapamil (Calan, Isoptin)# verapamil ER (Verelan PM) verapamil SR (Calan SR, Isoptin SR)#

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 3 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA HMG-CoA REDUCTASE fluvastatin (Lescol) atorvastatin (Lipitor) PA Criteria: One of the preferred INHIBITORS fluvastatin XL (Lescol XL) pravastatin (Pravachol) agents must be tried before a Effective 10/1/02 lovastatin (Mevacor)# non-preferred agent will be Implement 2/5/03 lovastatin ER (Altocor) authorized, unless one of the simvastatin (Zocor) exceptions on the PA form is present. NARCOTIC all generics aspirin/caffeine/dihydrocodeine bitartrate PA Criteria: Three of the ANALGESICS acetaminophen/caffeine/dihydrocodeine (Synalgos-DC) preferred agents must be tried, Effective 12/1/02 bitartrate (Panlor) fentanyl citrate (Actiq) for at least 72 hours, before a Implement 2/5/03 fentanyl transdermal (Duragesic) hydrocodone bitartrate/ibuprofen non-preferred agent will be hydrocodone/acetaminophen (Vicoprofen) authorized, unless one of the (Maxidone) oxycodone (Roxicodone Intensol) exceptions on the PA form is morphine sulfate ER (Kadian) oxycodone CR (OxyContin) present. morphine sulfate ER (Avinza) propoxyphene napsylate (Darvon-N) oxycodone (Roxicodone) tablets oxycodone/acetaminophen (Roxicet) tramadol/acetaminophen (Ultracet)† NSAIDS all generics celecoxib (Celebrex) PA Criteria: A two-week trial of Effective 12/1/02 rofecoxib (Vioxx)** diclofenac/misoprostol (Arthrotec) Vioxx and Bextra is required Implement 2/5/03 valdecoxib (Bextra)** meloxicam (Mobic) before Celebrex will be meclofenamic acid (Ponstel) authorized, unless one of the exceptions on the PA form is present. HYPOGLYCEMICS, glipizide/metformin (Metaglip) (Effective BIGUANIDES 2/1/03) Effective 12/1/02 rosiglitazone/metformin (Avandamet) Implement 2/5/03 (Effective 2/1/03) metformin (Glucophage)# metformin XR (Glucophage XR) metformin/glyburide (Glucovance) HYPOGLYCEMICS, human insulin (Novolin, Novolog) human insulin (Humulin, Humalog) PA Criteria: Lilly products will be INSULINS human insulin (Relion) all insulin pens and devices available for pediatric patients Effective 12/1/02 insulin glargine (Lantus) requiring diluted doses. Non- Implement 2/5/03 preferred insulins will only be authorized with documented proof of an allergic reaction to the preferred insulins.

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 4 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA HYPOGLYCEMICS, nateglinide (Starlix) POST-PRANDIAL repaglinide (Prandin) Effective 12/1/02 Implement 2/5/03 HYPOGLYCEMICS, glimepiride (Amaryl) glipizide XL (Glucotrol XL) PA Criteria: A two-month trial of SULFONYLUREAS glipizide (Glucotrol)# acetohexamide (Dymelor and generics) the maximum dose of glimepiride, Effective 12/1/02 glyburide (Micronase, DiaBeta)# chlorpropamide (Diabinese and generics) glipizide, and glyburide is Implement 2/5/03 glyburide extended release (Glynase)# tolazamide (Tolinase and generics) required before an authorization tolbutamide (Orinase and generics) will be given for a non-preferred product. Requests for acetohexamide, tolazamide, tolbutamide, and chlorpropamide must be reviewed by the BMS Medical Director. HYPOGLYCEMICS, rosiglitazone (Avandia) THIAZOLIDINEDIONES pioglitazone (Actos) Effective 12/1/02 Implement 2/5/03 MACROLIDES azithromycin (Zithromax) dirithromycin (Dynabac) PA Criteria: No non-preferred Effective 12/1/02 clarithromycin (Biaxin) troleandomycin (Tao) agents will be authorized unless Implement 2/5/03 clarithromycin (Biaxin XL) erythromycin estolate one of the exceptions on the PA erythromycin# (excluding erythromycin cinoxacin (Cinobac) form is present for all of the estolate) preferred agents. BONE RESORPTION alendronate (Fosamax) SUPPRESSION AGENTS calcitonin-salmon (Miacalcin) Effective 12/1/02 etidronate (Didronel) Implement 2/5/03 risedronate (Actonel) raloxifene (Evista) (Effective 2/1/03) ANGIOTENSIN II eprosartan (Teveten) candesartan (Atacand) PA Criteria: Five of the agents RECEPTOR BLOCKERS losartan (Cozaar) candesartan/HCTZ (Atacand HCT) must be tried, for at least two Effective 12/1/02 losartan/HCTZ (Hyzaar) irbesartan (Avapro) weeks each, before one of the Implement 2/5/03 olmesartan (Benicar) irbesartan/HCTZ (Avalide) non-preferred agents will be telmisartan (Micardis) authorized. Exceptions to this telmisartan/HCTZ (Micardis HCT) criteria are those listed on the PA valsartan (Diovan) form. valsartan/HCTZ (Diovan HCT)

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 5 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA ANTIFUNGALS, clotrimazole/betamethasone (Lotrisone)# butenafine (Mentax) PA Criteria: Three of the TOPICAL (Nizoral)# ciclopirox (Penlac) preferred agents must be tried for Effective 12/1/02 naftifine (Naftin) econazole (Spectazole) at least two weeks each before Implement 2/5/03 nystatin (Mycostatin)# oxiconazole (Oxistat) one of the non-preferred agents nystatin/triamcinolone (Mycolog)# terbinafine (Lamisil) will be authorized, unless one of sulconazole (Exelderm) the exceptions on the PA form is ciclopirox (Loprox) present. ANTIFUNGALS, ORAL clotrimazole (Mycelex Troche) flucytosine (Ancobon) PA Criteria: Non-preferred agents Effective 12/1/02 fluconazole (Diflucan) (Quantity limits itraconazole (Sporanox) will be authorized only if one of Implement 2/5/03 still apply)† griseofulvin (brand & generic) the exceptions on the PA form is ketoconazole (Nizoral)#** present for the appropriate nystatin# preferred agent’s use. terbinafine (Lamisil)** ACE amlodipine/benazepril (Lotrel) felodipine/enalapril (Lexxel) PA Criteria: A thirty day trial of INHIBITOR/CALCIUM verapamil SR/trandolapril (Tarka) both of the preferred agents is CHANNEL BLOCKER, required before a non-preferred COMBINATIONS agent will be authorized. Effective 12/1/02 Implement 2/5/03 ESTROGEN AGENTS, Transdermal patch (All brands, Vivelle, synthetic conjugated estrogens PA Criteria: The preferred agents ORAL AND Vivelle DOT, Esclim, Alora, Climara, (Cenestin) must be tried, for at least 90 days, TRANSDERMAL Estraderm and generics) before a non-preferred agent will Effective 12/1/02 conjugated estrogens (Premarin) be authorized, unless one of the Implement 2/5/03 esterified estrogens (Menest) exceptions on the PA form is (Estrace)# present. estropipate (Ortho-Est, Ogen)# ESTROGEN AGENTS, 17$-estradiol/norethindrone acetate conjugated estrogens/ PA Criteria: A trial of each of the COMBINATION (Activella) medroxyprogesterone acetate preferred agents, for at least 90 Effective 12/1/02 17$-estradiol/norethindrone acetate (Prempro) days, is required before a non- Implement 2/5/03 (Combipatch) esterified estrogens/ ethyltestosterone preferred agent will be authorized. 17$-estradiol/ (Ortho- (Estratest, HS) Requests for Estratest will be Prefast) ethinyl estradiol/norethindrone acetate handled on a case-by-case basis. conjugated estrogens/ Femhrt) edroxyprogesterone acetate (Premphase)

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 6 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA SKELETAL MUSCLE baclofen# dantrolene (Dantrium) PA Criteria: All of the preferred RELAXANTS carisoprodol# metaxolone (Skelaxin) agents must be tried, for a Effective 1/1/03 carisoprodol compound# minimum of 14 days, before a Implement 3/5/03 carisoprodol compound with codeine# non-preferred agent will be chlorzoxazone# authorized, unless one of the cyclobenzaprine# exceptions on the PA form is methocarbamol# present. Patients with chronic methocarbamol with ASA# spasticity will be exempted from orphenadrine# these trials. orphenadrine/ASA/caffeine# tizanidine# QUINOLONES ciprofloxacin (Cipro) cinoxacin (Cinobac) PA Criteria: The preferred agents Effective 1/1/03 moxifloxacin (Avelox) gatifloxacin (Tequin) must be tried before a non- Implement 3/5/03 levofloxacin (Levaquin) preferred agent will be authorized, lomefloxacin (Maxaquin) unless one of the exceptions on norfloxacin (Noroxin) the PA form is present. ofloxacin (Floxin) ciprofloxacin extended-release (Cipro XL)<> SELECTED brimonidine (Alphagan P) INTRAOCULAR brinzolamide (Azopt) PRESSURE REDUCERS dipivefrin# Effective 1/1/03 dorzolamide (Trusopt) Implement 3/5/03 dorzolamide/timolol (Cosopt) epinephrine # epinephryl borate# pilocarpine# pilocarpine/epinephrine# PROSTAGLANDIN bimatoprost (Lumigan) 2.5 ml bimatoprost (Lumigan) 5 ml PA Criteria: Authorization for a INHIBITORS, latanoprost (Xalatan) unoprostone (Rescula) non-preferred agent will only be OPHTHALMIC travoprost (Travatan) given if there is an allergy to the Effective 1/1/03 preferred agents. Implement 3/5/03 BENIGN PROSTATIC doxazosin (Cardura)# dutasteride (Avodart)<> PA Criteria: The preferred agents HYPERPLASIA finasteride (Proscar) must be tried before the non- (BPH)/MICTURITION tamsulosin (Flomax) preferred agent will be approved, AGENTS terazosin (Hytrin)# unless one of the exceptions on Effective 1/1/03 the PA form is present. Implement 3/5/03

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 7 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA ATOPIC DERMATITIS pimecrolimus (Elidel) tacrolimus (Protopic) PA Criteria: The preferred agent IMMUNE MODULATORS must be tried, for at least 30 days, Effective 1/1/03 before a non-preferred agent will Implement 3/5/03 be authorized. AMINOSALICYLATES/ balsalazide (Colazal) mesalamine (Pentasa) PA Criteria: The preferred agents ULCERATIVE COLITIS mesalamine (Asacol) must be tried before a non- AGENTS mesalamine (Rowasa) preferred agent will be authorized, Effective 1/1/03 olsalazine (Dipentum) unless one of the exceptions on Implement 3/5/03 sulfasalazine# the PA form is present. sulfasalazine EC# ANTIEMETIC/ ANTIEMETIC ANTIEMETIC PA Criteria: A trial of the ANTIVERTIGO AGENTS hydroxyzine# dolasetron (Anzemet) preferred agents (with Effective 1/1/03 metoclopramide# dronabinol (Marinol) corresponding routes of Implement 3/5/03 ondansetron (Zofran) (Quantity limits granisetron (Kytril) administration and for still apply) thiethylperazine maleate (Torecan) appropriate diagnoses) is ondansetron (Zofran) ODT (Quantity required before non-preferred limits still apply) agents will be approved, unless prochlorperazine# one of the exceptions on the PA promethazine# form is present. For chemotherapy or radiation- ANTIVERTIGO induced nausea, a trial of Zofran meclizine# is adequate for approval of the 5 scopolamine, oral (Scopace) HT-3 agents. scopolamine, transdermal (Transderm Scop) ACE INHIBITORS benazepril (Lotensin) perindopril (Aceon) PA Criteria: Four of the preferred Effective 1/1/03 benazepril/HCTZ (Lotensin HCT) ramipril (Altace) agents must be tried, for at least Implement 3/5/03 captopril (Capoten)# 30 days each, before a non- captopril/HCTZ (Capozide)# preferred agent will be authorized, enalapril (Vasotec)# unless one of the exceptions on enalapril/HCTZ (Vasoretic)# the PA form is present. fosinopril (Monopril) fosinopril/HCTZ (Monopril HCT) lisinopril (Prinivil/Zestril)# lisinopril/HCTZ (Prinzide/Zestoretic) moexipril (Univasc) moexipril/HCTZ (Uniretic) quinapril (Accupril) quinapril/HCTZ (Accuretic) trandolapril (Mavik)

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 8 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA CEPHALOSPORIN AND FIRST GENERATION PA Criteria: Preferred drugs must RELATED ANTIBIOTICS cefadroxil (Duricef)# be tried before non- preferred Effective 1/1/03 cephalexin (Keflex)# drugs will be approved, unless Implement 3/5/03 cephradine (Velosef)# one of the exceptions on the PA form is present. SECOND GENERATION SECOND GENERATION cefaclor (Ceclor)# cefprozil (Cefzil) cefuroxime axetil (Ceftin)# loracarbef (Lorabid) THIRD GENERATION THIRD GENERATION cefdinir (Omnicef) cefpodoxime proxetil (Vantin) cefditoren pivoxil (Spectracef) ceftibuten (Cedax) cefixime (Suprax) PENICILLIN/BETA LACTAMASE INHIBITOR amoxicillin/clavulanate (Augmentin)# amoxicillin/clavulanate (Augmentin ES- 600) amoxicillin/clavulanate (Augmentin XR) PLATELET aspirin#(OTC) AGGREGATION aspirin/dipyridamole ER (Aggrenox) INHIBITORS clopidogrel (Plavix) Effective 1/1/03 dipyridamole (Persantine)# Implement 3/5/03 ticlopidine (Ticlid)# INTERMITTENT pentoxifylline (Trental)# CLAUDICATION cilostazol (Pletal) Effective 1/1/03 Implement 3/5/03 SEDATIVES/ estazolam (ProSom)# quazepam (Doral) PA Criteria: Each of the HYPNOTICS temazepam (Restoril)# zaleplon (Sonata) preferred agents must be tried Effective 1/1/03 temazepam (Restoril 7.5mg) chloral hydrate before non-preferred agents will Implement 3/5/03 zolpidem (Ambien) flurazepam (Dalmane) be authorized. Prior authorization triazolam (Halcion) is required for these agents for patients over 65 years of age.

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 9 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA ANTIDEPRESSANTS, bupropion (Wellbutrin)# venlafaxine (Effexor) PA Criteria: A non-preferred OTHER bupropion XR (Wellbutrin SR) venlafaxine (Effexor XR) agent will only be prior authorized Effective 1/1/03 mirtazapine (Remeron) nefazodone (Serzone) if there has been a six-week trial Implement 3/5/03 mirtazapine (Remeron SolTab) of an SSRI and a preferred agent trazodone (Desyrel)# in this class, unless one of the exceptions on the PA form is present. STIMULANTS++ desmethylphenidate (Focalin)++ methamphetamine (Desoxyn) PA Criteria: One of the preferred Effective 1/1/03 dextroamphetamine#++ modafinil (Provigil) agents in each group Implement 3/5/03 methylphenidate#++ methylphenidate ER (Ritalin LA) (methylphenidates and methylphenidate ER#++ atomoxetine (Strattera)<> amphetamines) must be tried methylphenidate ER (Concerta)++ before a non-preferred agent will methylphenidate ER (Metadate CD)++ be authorized. Ritalin LA will only methylphenidate ER (Methylin ER)++ be approved if there is an allergy mixed salt amphetamines#++ to all of the preferred long-acting mixed salt amphetamines (Adderall agents on the list. XR)++ pemoline#++ Phase IV OPHTHALMICS, azelastine hydrochloride (Optivar) lodoxamide tromethamine PA Criteria: All of the preferred ALLERGIC cromolyn sodium (Opticrom)# (Alomide) agents must be tried before non- CONJUNCTIVITIS emedastine difumarate (Emadine) nedocromil sodium (Alocril) preferred agents will be Effective 2/1/03 ketorolac tromethamine (Acular) pemirolast potassium (Alamast) authorized, unless one of the Implement 4/9/03 ketotifen fumarate (Zaditor) exceptions on the PA form is levocabastine (Livostin) present. loteprednol (Alrex) olopatadine hydrochloride (Patanol) ANTIVIRALS, GENERAL acyclovir (Zovirax)# famciclovir (Famvir)* PA Criteria: All of the Effective 2/1/03 amantadine (Symmetrel)# valganciclovir (Valcyte) appropriate preferred agents Implement 4/9/03 ganciclovir (Cytovene) zanamivir (Relenza) must be tried before the non- rimantadine (Flumadine)# oseltamivir (Tamiflu) preferred agents will be prior valacyclovir (Valtrex) authorized, unless one of the exceptions on the PA form is present.

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 10 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA NASAL ipratropium nasal 0.03% (Atrovent Nasal PA Criteria: One of the non- PREPARATIONS, Spray) preferred nasal sprays will be OTHER ipratropium nasal 0.06% (Atrovent Nasal approved only if the patient fails Effective 2/1/03 Spray) on a nasal spray and and Implement 4/9/03 azelastine (Astelin) a non-sedating antihistamine and is still complaining of rhinorrhea. ERYTHROPOIESIS rHuEPO (Epogen)** darbepoetin (Aranesp) PA Criteria: Prior approval for STIMULATING rHuEPO (Procrit)** Aranesp will be given only in PROTEINS cases where administration is an Effective 2/1/03 issue. Implement 4/9/03 PHOSPHATE BINDERS calcium acetate (PhosLo) sevelamer (RenaGel)* PA Criteria: A trial of one of the Effective 2/1/03 carbonate, calcium preferred agents is required Implement 4/9/03 carbonate, folic acid (Magnebind 400 before a non-preferred agent will Rx) be approved, unless one of the exceptions on the PA form is present. HYPOGLYCEMICS, miglitol (Glyset) acarbose (Precose) PA Criteria: The preferred agent ALPHA-GLUCOSIDASE must be tried before the non- INHIBITORS preferred agent will be prior Effective 2/1/03 authorized. Implement 4/9/03 IMMUNOMODULATORY interferon beta-1a (Rebif)** glatiramer (Copaxone) PA Criteria: Patients starting AGENTS FOR interferon beta-1b (Betaseron)** interferon beta-1a (Avonex) therapy in this class will be MULTIPLE SCLEROSIS required to try the preferred Effective 2/1/03 agents, unless one of the Implement 4/9/03 exception criteria on the PA form is present. Patients already on non-preferred agents will receive prior authorization for that agent for one year. ANTICOAGULANTS, dalteparin (Fragmin)** tinzaparin (Innohep) PA Criteria: All of the preferred INJECTABLES fondaparinux (Arixtra)** agents must be tried before Effective 2/1/03 enoxaparin (Lovenox)** approval of the non-preferred Implement 4/9/03 agent will be approved, unless one of the exceptions on the PA form is present.

Bureau for Medical Services West Virginia Medicaid Preferred Drug List Page 11 of 12 DRUG CLASS PREFERRED NON-PREFERRED CRITERIA ANTIDEPRESSANTS, citalopram (Celexa) escitalopram (Lexapro) PA Criteria: None of the non- SELECTIVE fluoxetine (Prozac)# fluoxetine ER (Prozac Weekly) preferred agents will be SEROTONIN REUPTAKE fluvoxamine (Luvox)# fluoxetine (Sarafem) authorized unless there is a INHIBITORS (SSRIs) paroxetine (Paxil) documented allergic reaction to Effective 2/1/03 paroxetine CR (Paxil CR) all of the preferred agents. Implement 4/9/03 sertraline (Zoloft) ANTIPSYCHOTICS, clozapine (Clozaril)# aripiprazole (Abilify) PA Criteria: Patients already on ATYPICAL quetiapine (Seroquel) olanzapine (Zyprexa) non-preferred agents will receive Effective 2/1/03 risperidone (Risperdal) olanzapine (Zyprexa Zydis) authorization to continue these Implement 4/9/03 ziprasidone (Geodon) drugs. New patients for this class of therapy will be required to try a preferred agent for 2 weeks, unless one of the exceptions on the PA form is present. ALZHEIMER’S AGENTS donepezil (Aricept) tacrine (Cognex) PA Criteria: Patients already on a Effective 2/1/03 galantamine (Reminyl) non-preferred agent will receive Implement 4/9/03 rivastigmine (Exelon) authorization to continue therapy on that agent. Patients starting therapy in this class must show a documented allergy to all of the preferred agents before a non- preferred agent will be prior authorized.

# Generic forms only. * Status pending. ** Prior authorization required. *** No prior authorization required for children through 8 years of age. † Prior authorization required after limits exceeded. ++ Prior authorization required for adults > age 18 years. <> New drug, not yet reviewed.

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