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
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