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PDL Comparison of Select Therapeutic Classes
OPEN (No Restrictions on Access)
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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
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atenolol, bisoprolol, metoprolol, nadolol, atenolol, labetalol, metoprolol, nadolol, benazepril, captopril, enalapril maleate, Fee For Service
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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
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spironolactone w/hctz, triamterene w/hctz meclizine, metoclopramide, promethazine, Fee For Service
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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
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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").
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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
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ALLEGRA/fexofenadine 30mg day; ST - must fail a Fee For Service
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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
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AVANDAMET 500mg/4mg. 1 gram/2mg QLL - 2 tablets Fee For Service
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cimetidine, famotidine, nizatidine, ranitidine Fee For Service
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buproption HCL for smoking cessation therapy every 365 Fee For Service
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levobunolol, LUMIGAN, metipranolol, available package ISOPTO HOMATROPINE, tropicamide available package Fee For Service
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RECEPTOR ANTAGONISTANTI-ARTHRITIC, FOLATE Medication
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nefazodone tablet 50, 100, 150, 200, 250MG Medication
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Source: http://provider.indianamedicaid.com/media/18515/2007%20mco-ffs%20pdl%20comparison%20final%20update.pdf

Microsoft word - detailed ingredient information - 3.3.14.docx

Detailed Ingredient Information for U.S. Stores Thin Crust deLITE Dough Mix [Enriched Bleached Wheat Flour (Wheat Flour, Malted Barley Flour, Niacin, Ferrous Sulfate, Thiamine Mononitrate, Riboflavin, Folic Acid), Salt, Sugar], Water , Pomace Olive Oil , Yeast (Yeast, Sorbitan Monostearate, Ascorbic Acid), Soybean Oil. Original Crust Original Dough Mix [Enriched Whe

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