Iowa Rdl * 11/24/2004 3:40:03Pm
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IOWA RDL * 11/24/2004 3:40:03PM DRAFT Explanation: * - Color highlighted drugs are draft recommendations to be voted on at the December 2, 2004 P & T meeting . If approved by the P&T Committee, the highlighted drugs will be become part of the PDL with preferred and non-preferred designations. This means that nonpreferred brands (designated as N) and nonpreferrerd generics (also designated as N) will require prior authorization. Drugs described as recommended (R) or non-recommended (NR) will not require prior authorization. Please note that the Atypical and Special Atypical Antipsychotics will not be discussed until the March, 2005 P&T meeting. The Antihemophilic Agents, some of the Antineoplastic categories, and all of the Antiretrovirals will not be discussed until the June, 2005 P&T meeting. RDL Category Dec. 2 Dec. 2 PDL RDL Review of Review brand/generics ANTIDEPRESSANTS - MAO INHIBITORS YES YES ANTIDEPRESSANTS - SELECTED SSRI'S YES YES ANTIDEPRESSANTS - TRI-CYCLICS YES YES ANTIHEMOPHILIC AGENTS ANTINEOPLASTICS - ALKYLATING AGENTS YES ANTINEOPLASTICS - ANTIADRENALS ANTINEOPLASTICS - ANTIANDROGENS YES ANTINEOPLASTICS - ANTIBIOTICS YES ANTINEOPLASTICS - ANTIESTROGENS YES ANTINEOPLASTICS - ANTIMETABOLITES YES ANTINEOPLASTICS - AROMATASE INHIBITORS ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS ANTINEOPLASTICS - COMBINATIONS ANTINEOPLASTICS - ESTROGEN RECEPTOR ANTAGONIST ANTINEOPLASTICS - ESTROGENS ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS RESCUE AGENTS YES ANTINEOPLASTICS - IMIDAZOTETRAZINES ANTINEOPLASTICS - INTERLEUKINS ANTINEOPLASTICS - LHRH ANALOGS ANTINEOPLASTICS - MISC. YES ANTINEOPLASTICS - MITOTIC INHIBITORS YES ANTINEOPLASTICS - NITROGEN MUSTARDS YES ANTINEOPLASTICS - NITROSOUREAS ANTINEOPLASTICS - PROGESTINS YES ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE INHIBITORS ANTINEOPLASTICS - RETINOIDS ANTINEOPLASTICS - SELECTIVE RETINOID X RECEPTOR AGONISTS ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS ANTINEOPLASTICS - URINARY TRACT PROTECTIVE AGENTS ANTIPSYCHOTICS - ATYPICALS ANTIPSYCHOTICS - SPECIAL ATYPICALS ANTIPSYCHOTICS - TYPICAL ANTIRETROVIRAL COMBINATIONS ANTIRETROVIRALS - FUSION INHIBITORS ANTIRETROVIRALS - PROTEASE INHIBITORS ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES ANXIOLYTICS - BENZODIAZEPINES YES YES ANXIOLYTICS - LONG ACTING YES YES ANXIOLYTICS - MISC. YES YES IMMUNOSUPPRESSANTS YES LITHIUM YES YES PSYCHOTHERAPEUTIC COMBINATION YES SEDATIVE/HYPNOTICS - BARBITURATE YES YES SEDATIVE/HYPNOTICS - BENZODIAZEPINES YES YES STIMULANTS - AMPHETAMINES - LONG ACTING YES YES STIMULANTS - AMPHETAMINES - SHORT ACTING YES YES STIMULANTS - METHYLPHENIDATE YES YES STIMULANTS - METHYLPHENIDATE - LONG ACTING YES YES STIMULANTS - OTHER STIMULANTS / LIKE STIMULANTS YES YES Drug Name P , Drug Name P , RDL Category B N, RDL Category B N, Therapeutic Category or R, Therapeutic Category or R, G or G or Labeler NR Labeler NR ANTIDEPRESSANTS - MAO INHIBITORS ELI LILLY AND COMPANY B PROZAC TAB 10MG N Fluoxetine HCl Tab 20 MG Phenelzine Sulfate Tab 15 MG G Fluoxetine HCl Tab 20 MG N WARNER-LAMBERT COMPANY - P B NARDIL TAB 15MG R PAR PHARMACEUTICAL INC B RAPIFLUX TAB 20MG N Tranylcypromine Sulfate Tab 10 MG Fluvoxamine Maleate Tab 100 MG GLAXOSMITHKLINE B PARNATE TAB 10MG R G Fluvoxamine Maleate Tab 100 M P ANTIDEPRESSANTS - SELECTED SSRI'S Fluvoxamine Maleate Tab 25 MG G Fluvoxamine Maleate Tab 25 M P Bupropion HCl Tab 100 MG Fluvoxamine Maleate Tab 50 MG G Bupropion HCl Tab 100 MG N G Fluvoxamine Maleate Tab 50 M P GLAXOSMITHKLINE B WELLBUTRIN TAB 100MG P Maprotiline HCl Tab 25 MG Bupropion HCl Tab 75 MG G Maprotiline HCl Tab 25 MG R G Bupropion HCl Tab 75 MG N Maprotiline HCl Tab 50 MG GLAXOSMITHKLINE B WELLBUTRIN TAB 75MG P Bupropion HCl Tab SR 12HR 100 MG MYLAN PHARMACEUTICALS, INC. B MAPROTILINE TAB 50MG R Maprotiline HCl Tab 75 MG G Bupropion HCl Tab SR 12HR 1 N GLAXOSMITHKLINE B WELLBUTRIN TAB 100MG S P MYLAN PHARMACEUTICALS, INC. B MAPROTILINE TAB 75MG R Bupropion HCl Tab SR 12HR 150 MG Mirtazapine Orally Disintegrating Tab 15 MG G Bupropion HCl Tab SR 12HR 1 N G Mirtazapine Orally Disintegrati N GLAXOSMITHKLINE B WELLBUTRIN TAB 150MG S P ORGANON INC. B REMERON SLTB TAB 15MG N Bupropion HCl Tab SR 12HR 200 MG Mirtazapine Orally Disintegrating Tab 30 MG GLAXOSMITHKLINE B WELLBUTRIN TAB 200MG S R G Mirtazapine Orally Disintegrati N Bupropion HCl Tab SR 24HR 150 MG ORGANON INC. B REMERON SLTB TAB 30MG N Mirtazapine Orally Disintegrating Tab 45 MG GLAXOSMITHKLINE B WELLBUTRIN TAB XL 150 R Bupropion HCl Tab SR 24HR 300 MG ORGANON INC. B REMERON SLTB TAB 45MG N Mirtazapine Tab 15 MG GLAXOSMITHKLINE B WELLBUTRIN TAB XL 300 R Citalopram Hydrobromide Oral Soln 10 MG/5ML G Mirtazapine Tab 15 MG N ORGANON INC. B REMERON TAB 15MG P FOREST LABORATORIES, INC. B CELEXA SOL 10MG/5ML R Mirtazapine Tab 30 MG Citalopram Hydrobromide Tab 10 MG (Base Equiv) G Mirtazapine Tab 30 MG N FOREST LABORATORIES, INC. B CELEXA TAB 10MG R ORGANON INC. B REMERON TAB 30MG P Citalopram Hydrobromide Tab 20 MG (Base Equiv) Mirtazapine Tab 45 MG FOREST LABORATORIES, INC. B CELEXA TAB 20MG R G Mirtazapine Tab 45 MG N Citalopram Hydrobromide Tab 40 MG (Base Equiv) ORGANON INC. B REMERON TAB 45MG P FOREST LABORATORIES, INC. B CELEXA TAB 40MG R Nefazodone HCl Tab 100 MG Duloxetine HCl Enteric Coated Pellets Cap 30 MG G Nefazodone HCl Tab 100 MG P ELI LILLY AND COMPANY B CYMBALTA CAP 30MG NR Nefazodone HCl Tab 150 MG Duloxetine HCl Enteric Coated Pellets Cap 60 MG G Nefazodone HCl Tab 150 MG P ELI LILLY AND COMPANY B CYMBALTA CAP 60MG NR Nefazodone HCl Tab 200 MG Escitalopram Oxalate Soln 5 MG/5ML (Base Equiv) G Nefazodone HCl Tab 200 MG P FOREST LABORATORIES, INC. B LEXAPRO SOL 5MG/5ML R Nefazodone HCl Tab 250 MG Escitalopram Oxalate Tab 10 MG (Base Equiv) G Nefazodone HCl Tab 250 MG P FOREST LABORATORIES, INC. B LEXAPRO TAB 10MG R Nefazodone HCl Tab 50 MG Escitalopram Oxalate Tab 20 MG (Base Equiv) G Nefazodone HCl Tab 50 MG P FOREST LABORATORIES, INC. B LEXAPRO TAB 20MG R Paroxetine HCl Oral Susp 10 MG/5ML (Base Equiv) Escitalopram Oxalate Tab 5 MG (Base Equiv) GLAXOSMITHKLINE B PAXIL SUS 10MG/5ML R FOREST LABORATORIES, INC. B LEXAPRO TAB 5MG R Paroxetine HCl Tab 10 MG Fluoxetine HCl Cap 10 MG G Paroxetine HCl Tab 10 MG N G Fluoxetine HCl Cap 10 MG P GLAXOSMITHKLINE B PAXIL TAB 10MG P DISTA PRODUCTS CO DIV OF ELI L B PROZAC CAP 10MG N Paroxetine HCl Tab 20 MG WARNER CHILCOTT LABORATORI B SARAFEM CAP 10MG N G Paroxetine HCl Tab 20 MG N Fluoxetine HCl Cap 20 MG GLAXOSMITHKLINE B PAXIL TAB 20MG P G Fluoxetine HCl Cap 20 MG P Paroxetine HCl Tab 30 MG DISTA PRODUCTS CO DIV OF ELI L B PROZAC CAP 20MG N G Paroxetine HCl Tab 30 MG N WARNER CHILCOTT LABORATORI B SARAFEM CAP 20MG N GLAXOSMITHKLINE B PAXIL TAB 30MG P Fluoxetine HCl Cap 40 MG Paroxetine HCl Tab 40 MG G Fluoxetine HCl Cap 40 MG N G Paroxetine HCl Tab 40 MG N DISTA PRODUCTS CO DIV OF ELI L B PROZAC CAP 40MG N GLAXOSMITHKLINE B PAXIL TAB 40MG P Fluoxetine HCl Cap Delayed Release 90 MG Paroxetine HCl Tab SR 24HR 12.5 MG ELI LILLY AND COMPANY B PROZAC WEEKL CAP 90MG N GLAXOSMITHKLINE B PAXIL CR TAB 12.5MG R Fluoxetine HCl Solution 20 MG/5ML Paroxetine HCl Tab SR 24HR 25 MG G Fluoxetine HCl Solution 20 MG/5 N GLAXOSMITHKLINE B PAXIL CR TAB 25MG R DISTA PRODUCTS CO DIV OF ELI L B PROZAC LIQ 20MG/5ML P Paroxetine HCl Tab SR 24HR 37.5 MG Fluoxetine HCl Tab 10 MG GLAXOSMITHKLINE B PAXIL CR TAB 37.5MG R G Fluoxetine HCl Tab 10 MG P 997- WEB Labeler Level RDL (eam) (915) Copyright GHS Data Management 2004 11/24/2004 Page 1 of 12 Drug Name P , Drug Name P , RDL Category B N, RDL Category B N, Therapeutic Category or R, Therapeutic Category or R, G or G or Labeler NR Labeler NR ANTIDEPRESSANTS - SELECTED SSRI'S Amoxapine Tab 25 MG Sertraline HCl Oral Conc 20 MG/ML WATSON PHARMA B AMOXAPINE TAB 25MG R Amoxapine Tab 50 MG PFIZER-ROERIG B ZOLOFT CON 20MG/ML R Sertraline HCl Tab 100 MG WATSON PHARMA B AMOXAPINE TAB 50MG R Clomipramine HCl Cap 25 MG PFIZER-ROERIG B ZOLOFT TAB 100MG R Sertraline HCl Tab 25 MG MALLINCKRODT INC. B ANAFRANIL CAP 25MG N G Clomipramine HCl Cap 25 MG P PFIZER-ROERIG B ZOLOFT TAB 25MG R Clomipramine HCl Cap 50 MG Sertraline HCl Tab 50 MG MALLINCKRODT INC. B ANAFRANIL CAP 50MG N PFIZER-ROERIG B ZOLOFT TAB 50MG R PHYSICIANS TOTAL CARE B ANAFRANIL CAP 50MG N Trazodone HCl Tab 100 MG G Clomipramine HCl Cap 50 MG P BRISTOL-MYERS SQUIBB COMPAN B DESYREL TAB 100MG N Clomipramine HCl Cap 75 MG G Trazodone HCl Tab 100 MG P MALLINCKRODT INC. B ANAFRANIL CAP 75MG N Trazodone HCl Tab 150 MG G Clomipramine HCl Cap 75 MG P BRISTOL-MYERS SQUIBB COMPAN B DESYREL TAB 150MG N Desipramine HCl Tab 10 MG G Trazodone HCl Tab 150 MG P G Desipramine HCl Tab 10 MG P Trazodone HCl Tab 300 MG AVENTIS PHARMACEUTICALS B NORPRAMIN TAB 10MG N BRISTOL-MYERS SQUIBB COMPAN B DESYREL TAB 300MG N Desipramine HCl Tab 100 MG G Trazodone HCl Tab 300 MG N G Desipramine HCl Tab 100 MG P Trazodone HCl Tab 50 MG AVENTIS PHARMACEUTICALS B NORPRAMIN TAB 100MG N BRISTOL-MYERS SQUIBB COMPAN B DESYREL TAB 50MG N Desipramine HCl Tab 150 MG G Trazodone HCl Tab 50 MG P G Desipramine HCl Tab 150 MG P Venlafaxine HCl Cap SR 24HR 150 MG AVENTIS PHARMACEUTICALS B NORPRAMIN TAB 150MG N WYETH LABORATORIES B EFFEXOR XR CAP 150MG NR Desipramine HCl Tab 25 MG Venlafaxine HCl Cap SR 24HR 37.5 MG G Desipramine HCl Tab 25 MG P WYETH LABORATORIES B EFFEXOR XR CAP 37.5MG NR AVENTIS PHARMACEUTICALS B NORPRAMIN TAB 25MG N Venlafaxine HCl Cap SR 24HR 75 MG Desipramine