NEW Plan Year 2007 Preferred Drug List Goes Into Effect January 1, 2007
Following is a list of the most commonly prescribed drugs on the West Virginia Preferred Drug List. It is an abbreviated version of the drug list that is at the core of the PEIA pharmacy benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you're encouraged to ask your doctor to prescribe generic drugs whenever possible. THIS LIST WILL BE EFFECTIVE January 1, 2007 and IS SUBJECT TO CHANGE. KEY Following is a list symbols used on this list, as well as the explanation for each: [G] indicates that a generic is available for at least one or more strengths of the brand medication. [PA] indicates Prior Authorization is required. [PA*] indicates Step Therapy. [PA**] indicates Prior Authorization is required for dependents for medical necessity. [QLL] indicates Quantity Level Limits. [SP] indicates specialty product with $50 copay per 30 days supply [PA$] indicates that Step Therapy and $30 copay apply For the member: Generic medications contain the same active ingredients as their corresponding brand name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. PLEASE NOTE: the * next to a drug signifies the drug is subject to non-preferred status when generic becomes available throughout the year. Brand name drugs are listed in CAPITAL letters.
ABILIFY ACTIVELLA ACTONEL ACTONEL W/CA ACTOS ACTOPLUS MET acyclovir ADDERALL XR* [G] ADVANCED NATALCARE ADVAIR DISKUS ADVICOR [PA*] ALDARA ALINIA ALKERAN allopurinol ALPHAGAN P ALORA alprazolam AMBIEN*[QLL] AMBIEN PAK [QLL] aminophylline amitriptyline amox tr/potassium clavulanate amoxicillin amphetamine salt ANDRODERM ANDROGEL ANTABUSE ARANESP [PA], [SP] ARICEPT ASACOL ASTELIN atenolol atenolol/chlorthalidone ATROVENT/ HFA AVANDAMET AVANDARYL AVANDIA
AVELOX, ABC PACK AVODART azithromycin B BAYER ASCENSIA ELITE TEST STRIPS BAYER ASCENSIA AUTODISC TEST STRIPS BAYER MICROFILL TEST STRIPS benazepril/ hctz benzonatate BENICAR/HCT [PA*] BETASERON [SP] bisoprolol fumarate/hctz bimonidine tartrate bromfenex,-PD bumetanide bupropion bupropion sr buspirone hcl butalbital/apap/caffeine BYETTA C CAPITAL W/CODEINE captopril CARAFATE SUSP carbamazepine CARBATROL carisoprodol cartia xt CASODEX cefaclor cefuroxime CELLCEPT CELONTIN CETROTIDE [SP] choline mag trisalicylate cimetidine ciprofloxacin CIPRODEX CIPRO HC citalopram clarithromycin clidinium/chlordiazepoxide CLIMARA PRO clindamycin phosphate clobetasol proprionate clonidine hcl clotrimazole clotrimazole/betamethasone COLAZAL* COMBIVENT CONCERTA* COREG* [PA*] CREON [G] CRESTOR [PA*] cromolyn sodium cyclobenzaprine cyclosporine, modified CYMBALTA[PA*] D dantrolene sodium DAPSONE DEPAKOTE desmopressin acetate desogestrel- ethinyl estradiol [PA**] desoximetasone DESOXYN dextroampehtamine sulfate DIAMOX SEQUELS
dicyclomine hcl diclofenac sodium diflunisal diltiazem, er DIOVAN/HCT [PA*] DITROPAN XL* [G][PA*] DOVONEX E EFFEXOR XR [PA*] EMEND [QLL] enalapril maleate, hctz erythromycin erythromycin/benzoyl perox ESTINYL estradiol ESTRING estropipate ethinyl estradiol [PA**] ethinyl estradiol-levonorgestrel [PA**] EVISTA EXELON F FEMARA fentanyl citrate [PA] FINACEA finasteride FLOMAX FLOVENT*, ROTADISK FLOVENT HFA fluocinonide fluconazole [PA] fluorouracil fluoxetine hcl flurazepam [QLL] flutamide fluticasone fluvoxamine FOLTX FORADIL FORTEO [PA],[SP] FOSAMAX/Plus D G gabapentin GABITRIL GANTRISIN SUSP. gemfibrozil gentamicin sulfate glipizide glyburide GRIFULVIN V TAB guaifenesin la H haloperidol homatropine hydrobromide HUMALOG (vials only) HUMATROPE [PA],[SP] HUMULIN (vials only) hydrochlorothiazide hydrocodone w/guaifenesin hydrocodone/ acetaminophen hydrocortisone
acetate hyoscyamine sulfate I ibuprofen IMITREX* [QLL] INDERAL LA [PA*] indomethacin INNOPRAN XL [PA*] INTAL ipratropium bromide K ketoconazole KEPPRA L lactulose LAMICTAL LAMISIL* [PA] LANTUS (vials only) leucovorin levothyroxine sodium LEVAQUIN LEVEMIR LEXAPRO[PA*] LEVOXYL] lidocaine hcl viscous LIDODERM lisinopril/ hctz lithium carbonate, er LIVOSTIN* LOTREL [PA*] lovastatin LUMIGAN M MALARONE MATULANE medroxyprogesterone megestrol MENEST MEPHYTON mephobarbital MEPRON mercaptopurine MESTINON SA METANX metformin, extended release methocarbamol methotrexate methylphenidate hcl methylprednisolone metolazone metoprolol metronidazole microgestin fe [PA**] migergot MIRAPEX mirtazapine soltab misoprostol MOBAN MONUROL morphine sulfate sa tab MSIR [G] mupirocin MYCOBUTIN N nabumetone nadolol naproxen NARDIL NASCOBAL NASONEX [PA*] NATALCARE NEBUPENT NEXIUM [PA$] NIASPAN *[G] nifedipine, er NIMOTOPnitrofurantoin macrocrystal nizatidine norethindrone- ethinyl estradiol [PA**] norethindrone- mestranol [PA**] norgestrel ethinyl estradiol [PA**] NOVOFINE 30 NOVOLIN (vials only) NOVOLOG (vials only) NUTROPIN , AQ excluding Depot [PA], [SP] nystatin nystatin w/triamcinolone O omeprazole OMNICEF* ORTHO EVRA[PA**] ORTHO TRI-CYCLEN LO [PA**] OXSORALEN/ULTRA oxybutynin chloride o OXYCONTIN [PA] oxycodone/ acetaminophen OXYTROL [PA*] P PANCREASE MT 4 paroxetine hcl PEGANONE PEGASYS [SP] penicillin v potassium PENTASA perphenazine PHOSLO PLAVIX podofilox solution potassium chloride potassium citrate er PRANDIN PRECOSE PRED G PRED MILD prednisolone acetate prednisone PREMARIN PREMARIN LOW DOSE PREMPHASE PREMPRO PREMPRO LOW DOSE PRENATE
ADVANCE [G] PREVACID [PA$] PRIMSOL prochlorperazine PROCRIT [PA], [SP] proctozone – HC PROGRAF promethazine promethazine/codeine promethazine vc PROMETRIUM propranolol PROTOPIC PULMICORT Q quetiapine fumarate QVAR R RAZADYNE (not ER) REBIF [SP] REGRANEX [PA] RENACIDIN RENAGEL REQUIP* RESTASIS ribasphere [SP] ribavirin [SP] RIDAURA RILUTEK RISPERDAL (excluding M-tabs) ROZEREM[PA*][QLL] S SAIZEN [PA],[SP] salsalate selenium sulfide SEREVENT, DISKUS SEROQUEL simvastatin SINGULAIR [PA*] SKELAXIN* SPIRIVA STALEVO STARLIX STIMATE STRATTERA [ PA*] STROMECTOL SUBUXONE SUBUTEX SULAR [PA*] SYNAREL T TAMIFLU [QLL] tamoxifen TARGRETIN TASMAR TAZORAC [PA] TEGRETOL XR temazepam [QLL] theophylline anhydrous thioguanine
thioridazine hcl thyroid ticlopidine hcl TIKOSYN TILADE timolol hcl tobramcyin sulfate TOPAMAX [PA] TOPROL XL* [G] [PA*] TRACLEER tretinoin TREXALL TRICOR trazodone hcl triamcinolone acetonide triamterene/hctz triazolam [QLL] trifluoperazine hcl TRILEPTAL TRUSOPT U UNIPHYL [G] UNITHROID URSO/FORTE V VAGIFEM VALCYTE VANCOCIN HCL venlafaxine VENTAVIS VENTOLIN HFA verapamil hcl VESANOID VFEND [PA] VIGAMOX VINATE II VOLTAREN OPHTH. VYTORIN [PA*] W WELLBUTRIN XL* [PA*] X XALATAN XYREM Y
Patient Contact Information Single Married Domestic Partner Whom may we thank for referring you to our office ? Person responsible for payment of this account: Dental Insurance Information As dental care providers, we want to emphasize that our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend t
Mangosteen Documented Health Benefits The Mangosteen, if scientific research is any indication, is perhaps the most important fruit on earth. The potent effects on human health of the Mangosteen have been observed for centuries in Southeast Asia. As a powerful anti-inflammatory and anti- oxidant, Mangosteen has a wide range of health benefits, well documented in reliable sources.