Dchpharmacyexpandedpalist120601r.pdf

Michigan Department of Community Health
Changes to the Michigan Pharmaceutical Product List
Effective January 14, 2002
Bolded Drugs do not require prior authorization

Morphine Sulfate
Piroxicam
Morphine Sulfate Solution
Oxaprozin
Allegra D®
Morphine Sulfate ER
Sulindac
Allegra
Tolmetin Sodium
Claritin®
Nalbuphine HCL
Toradol®
Claritin D 12 hour®
Nubain®
Claritin D 24 hour®
Claritin Syrup®
Oxycodone HCL
Claritin Redi-Tab®
Oxycodone/ APAP
Oxycodone/ ASA
Panlor DC®
Phenaphen W/Codeine®
Propoxyphene HCL Compound
Propoxyphene HCL/ APAP
Propoxyphene Napsylate/ APAP
Roxicet®
Butalbital Compound W/Codeine
Roxilox®
Capital W/Codeine®
Zydone®
Codeine Phosphate
Codeine/ APAP
Codeine/ASA
Diclofenac Potassium
Darvon-N®
Diclofenac Sodium
Dolophine HCL®
Etodolac
Fiorinal W/Codeine #3®
Fenoprofen Calcium
Fiortal W/Codeine # 3®
Flurbiprofen
Hydrocodone/APAP
Ibuprofen
Hydromorphone
Indomethacin
Kadian®
Ketoprofen
Meperidine
Ketorolac Trimethamine
Methadone
Meclofenamate Sodium
Methadone HCL
Naproxen
Methadose®
Naproxen Sodium
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12 2 Prior Authorization Not Required for Beneficiaries Over the Age of 60 3 Prior Authorization Required if Beneficiary is over the age of 65 Michigan Department of Community Health
Changes to the Michigan Pharmaceutical Product List
Effective January 14, 2002
Bolded Drugs do not require prior authorization

Antibiotics Broad Spectrum Cephalosporin Valcyte® Monopril HCT®
Monopril®
Cephalexin
Unirectic®
Cefadroxil
Univasc®
Cinobac®
Zestoretic®
Levaquin®
Maxaquin®
Zestril®
Cholestyramine
Neggram®
Cholestyramine Light
Noroxin®
Colestid®
Tequin®
Gemfibrozil
Lescol XL®
Lescol®
Niacor®
Cefaclor
Niaspan®
Cefaclor ER
Pravachol®
Ceftin®
Cefzil®
Ceptaz®
Actonel®
Rocephin®
Evista®
Fosamax®
Atacand HCT ®
Atacand®
Micardis HCT®
Antibiotics & Antiviral - Antivirals Micardis®
Captopril
Captopril/Hydrochlorothiazide
Teveten®
Acyclovir
Enalapril
Valtrex®
Enalapril/Hydrochlorothiazide
Lotensin HCT®
Acebutolol
Lotensin®
Atenolol
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12 2 Prior Authorization Not Required for Beneficiaries Over the Age of 60 3 Prior Authorization Required if Beneficiary is over the age of 65 Michigan Department of Community Health
Changes to the Michigan Pharmaceutical Product List
Effective January 14, 2002
Bolded Drugs do not require prior authorization

Atenolol/HCT
Plavix®
Betaxolol
Cardene®
Pletal®
Psychiatric Anti-Depressants – Other Bisoprolol Fumarate
Diltiazem
Ticlopidine
Remeron® [sol tab]
Bisoprolol HCT
Diltiazem-SR
Trazodone
Dynacirc®
Wellbutrin SR®
Metoprolol
Nicardipine
Nifedical XL®
Pindolol
Nifedipine
Propranolol
Norvasc®
Gastrointestinal Proton Pump Inhibitors Propranolol/HCT
Verapamil
Prevacid®
Verapamil SR
Protonix®
Histamine-2 Receptor Antagonists (H- Cimetidine
Fluoxetine
Famotidine
Ranitidine
Aggrenox®
Dipyridamole
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12 2 Prior Authorization Not Required for Beneficiaries Over the Age of 60 3 Prior Authorization Required if Beneficiary is over the age of 65 Michigan Department of Community Health
Changes to the Michigan Pharmaceutical Product List
Effective January 14, 2002
Bolded Drugs do not require prior authorization

Central Nervous System Stimulants Amitriptyline3
Concerta®
Amoxapine 3
Chlorpromazine
Dexedrine®
Clomipramine
Fluphenazine
Dextrostat®
Desipramine
Haloperidol
Dextroamphetamine Sulfate
Doxepin3
Loxapine
Methylin®
Elavil®
Methylphenidate
Imipramine 3
Perphenazine
Methylphenidate SR
Nortriptyline
Thiothixene
Protriptyline
Trifluperazine
Sinequan®
Sedative Hypnotic Non-Barbiturates Chloral Hydrate
Chloral Hydrate Syrup
Diphenhydramine3
Estazolam
Flurazepam3
Alprazolam
Temazepam3
Buspar®
Triazolam3
Buspirone
Chlordiazepoxide 3
Clorazepate
Risperdal®
Diazepam3
Eskalith®
Seroquel®
Doxepin3
Lithobid®
Zyprexa®
Hydroxyzine HCL
Lithium Carbonate
Hydroxyzine Pamoate
Lithium Citrate
Lorazepam
Meprobamate
Oxazepam
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12 2 Prior Authorization Not Required for Beneficiaries Over the Age of 60 3 Prior Authorization Required if Beneficiary is over the age of 65 Michigan Department of Community Health
Changes to the Michigan Pharmaceutical Product List
Effective January 14, 2002
Bolded Drugs do not require prior authorization

Respiratory Beta Adrenergic Inhalers Nystantin W/Triamcinolone
Clobevate
Advair Diskus®
Tri-Statin II
Desonide
Albuterol
Desoximetasone
Albuterol Sulfate
Diflorasone Diacetate
Brethine®
Fluocinolone Acetate
Maxair®
Fluocinonide
Metaproterenol
Fluocinonide-E
Serevent®
FS Shampoo®
Volmax®
Halog-E®
Hydrocortisone Acetate
Hydrocortisone Valerate
Acetohexamide
Pandel®
Chlorpropamide
Trimacinolone Acetonide
Glipizide
Glucovance®
Glyburide
Glyburide Micronized
Prandin®
Amphosin®
Precose®
Amphotericin B
Tolazamide
Anti-Fungal
Tolbutamide
Carrington Antifungal®
Clotrim Antifungal®
Clotrimazole
Clotrimazole/Betamethasone
Fungizone®
Fungoid®
Griseofulvin Ultramicrosize
Ketoconazole
Augmented Betamethasone
Dipropionate
Micaderm®
Betamethasone Dipropionate
Miconazole Nitrate
Betamethasone Valerate
Micro-Guard®
Capex Shampoo®
N.T.A.®
Clobetasol Propionate
Nystantin
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12 2 Prior Authorization Not Required for Beneficiaries Over the Age of 60 3 Prior Authorization Required if Beneficiary is over the age of 65 Michigan Department of Community Health
Changes to the Michigan Pharmaceutical Product List
Effective January 14, 2002
Bolded Drugs do not require prior authorization

Erythrocin Stearate
Erythromycin Base
Amantadine
Beconase®
Erythromycin Estolate
Flumadine®
Flonase®
Erythromycin Ethylsuccinate
Tamiflu®
Nasarel®
Erythromycin Stearate
Relenza®
Nasonex®
Erythromycin w/Sulfisoxazole
Tri-Nasal®
Zithromax®
Cytovene® (CMV Retinitis)
Dilatrate-SR®
Isosorbide Dinitrate
Isosorbide Mononitrate
Agenerase®
Isotrate ER
Crixivan®
Monoket®
Exelon®
Fortovase®
Nitroglycerin
Reminyl®
Invirase®
Nitroglyn
Kaletra®
Nitroquick®
Autoplex T®
Norvir®
Nitrostat®
Bioclate®
Viracept®
Nitrotab®
Feiba Vh Immuno®
Nitro-Time
Helixate®
Hemofil-M®
Cortisone Acetate
Humate-P®
Azathioprine
Dexamethasone
Kogenate®
Cellcept®
Methylprednisolone
Monoclate-P®
Cyclosporine
Prednisolone
Recombinate®
Gengraf®
Aristocort®
Refacto®
Imuran®
Celestone®
Neoral®
Hydrocortisone
Prograf®
Orapred®
Biaxin®
Rapamune®
Pediapred®
Biaxin XL®
Sandimmune®
Prednisone
Dynabac®
Simulect®
Prelone®
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12 2 Prior Authorization Not Required for Beneficiaries Over the Age of 60 3 Prior Authorization Required if Beneficiary is over the age of 65 Michigan Department of Community Health
Changes to the Michigan Pharmaceutical Product List
Effective January 14, 2002
Bolded Drugs do not require prior authorization

Coronary Vasodilators (Topical)
Deponit®
Nitrek®
Nitroglycerin Patches

NTG

Prior Authorized Drugs
Minitran®
Transderm -Nitro®
Hypoglycemics Insulin Response
Actos®
Avandia®
Inhaled Systemic Glucocorticoids
Beclovent®
Flovent®
Vanceril®
Prior Authorized Drugs
Aerobid®

Oral Hypoglecemic Agents CG’s (Non-
Sulfonylureas)
Glucophage®

1 Prior Authorization Not Required for Beneficiaries Under the Age of 12 2 Prior Authorization Not Required for Beneficiaries Over the Age of 60 3 Prior Authorization Required if Beneficiary is over the age of 65

Source: http://www.mdch.state.mi.us/dchpharmacyexpandedpalist120601r.pdf

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