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NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. ANALGESICS
Cyclooxygenase II (COX II) Inhibitors
Cyclooxygenase II (COX II) Inhibitors
Non-Steroidal Anti-Inflammatory Drugs
Non-Steroidal Anti-Inflammatory Drugs
(NSAIDS) – Prescription
(NSAIDS) – Prescription
TTP://NE
Opioids – Long-Acting
Opioids – Long-Acting
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Opioids – Short-Acting
Opioids – Short-Acting
NON-PREFERRED AGENTS (PA EFFECTIVE 8/25/2011) FERRE II. ANTI-INFECTIVES
Anti-Fungals – Oral for Onychomycosis
Anti-Fungals – Oral for Onychomycosis
Anti-Virals - Oral
Anti-Virals - Oral
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Cephalosporins – Third Generation
Cephalosporins – Third Generation
Fluoroquinolones – Oral
Fluoroquinolones – Oral
Hepatitis B Agents
Hepatitis B Agents
Hepatitis C Agents - Injectabl
Hepatitis C Agents - Injectabl
Hepatitis C Agents - Oral
Hepatitis C Agents - Oral
Victrelis
Tetracyclines
Tetracyclines
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. III. CARDIOVASCULAR
Angiotensin Converting Enzyme Inhibitors
Angiotensin Converting Enzyme Inhibitors
ACEIs + Calcium Channel Blockers
ACEIs + Calcium Channel Blockers
ACEIs + Diuretics
ACEIs + Diuretics
TTP://NE
Angiotensin Receptor Blockers (ARBs)
Angiotensin Receptor Blockers (ARBs)
ARBs + Calcium Channel Blockers
ARBs + Calcium Channel Blockers
ARBs + Diuretics
ARBs + Diuretics
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Beta Blockers
Beta Blockers
Beta Blockers + Diuretics
Beta Blockers + Diuretics
TTP://NE
Bile Acid Sequestrants
Bile Acid Sequestrants
Calcium Channel Blockers
Calcium Channel Blockers
(Dihydropyridine)
(Dihydropyridine)
Cholesterol Absorption Inhibitors
Cholesterol Absorption Inhibitors
Direct Renin Inhibitors
Direct Renin Inhibitors
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Endothelin Receptor Antagonists for
Endothelin Receptor Antagonists for
Pulmonary Arterial Hypertension (PAH)
Pulmonary Arterial Hypertension (PAH)
HMG-CoA Reductase Inhibitors (Statins)
HMG-CoA Reductase Inhibitors (Statins)
Niacin Derivatives
Niacin Derivatives
Phosphodiesterase type-5 (PDE-5)
Phosphodiesterase type-5 (PDE-5)
Inhibitors for PA
Inhibitors for PA
TTP://NE
Triglyceride Lowering Agents
Triglyceride Lowering Agents
IV. CENTRAL NERVOUS SYSTEM
Alzheimer’s Agents
Alzheimer’s Agents
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Anticonvulsants – Second Generation
Anticonvulsants – Second Generation
Atypical Antipsychotics
Atypical Antipsychotics
NON-PREFERRED AGENTS (PA REQUIREMENTS EFFECTIVE Benzodiazepines - Rectal
Benzodiazepines - Rectal
Carbamazepine Derivatives
Carbamazepine Derivatives
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Central Nervous System (CNS)
Central Nervous System (CNS)
Stimulan
Stimulan
Multiple Sclerosis Agents
Multiple Sclerosis Agents
Non-Ergot Dopamine Receptor Agonists
Non-Ergot Dopamine Receptor Agonists
Other Agents for Attention Deficit
Other Agents for Attention Deficit
Hyperactivity Disorder (ADHD)
Hyperactivity Disorder (ADHD)
Sedative Hypnotics/Sleep Agents
Sedative Hypnotics/Sleep Agents
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Selective Serotonin Reuptake Inhibitors
Selective Serotonin Reuptake Inhibitors
Serotonin-Norepinephrine Reuptake
Serotonin-Norepinephrine Reuptake
Inhibitors (SNRIs)
Inhibitors (SNRIs)
Serotonin Receptor Agonists (Triptans
Serotonin Receptor Agonists (Triptan
P V. DERMATOLOGIC AGENTS
Agents for Actinic Keratosis
Agents for Actinic Keratosis
Antibiotics – Topical
Antibiotics – Topical
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Anti-Fungals - Topical
Anti-Fungals – Topica
NON-PREFERRED AGENTS (PA EFFECTIVE 8/25/2011) Anti-Virals – Topical
Anti-Virals – Topical
Immunomodulators – Topica
Immunomodulators – Topica
Psoriasis Agents – Topical
Psoriasis Agents – Topical
Steroids, Topical – Low Potency
Steroids, Topical – Low Potenc
NON-PREFERRED AGENTS (PA EFFECTIVE 8/25/2011) CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Steroids, Topical – Medium Potency
Steroids, Topical – Medium Potenc
NON-PREFERRED AGENTS (PA EFFECTIVE 8/25/2011) Steroids, Topical – High Potency
Steroids, Topical – High Potenc
NON-PREFERRED AGENTS (PA EFFECTIVE 8/25/2011) Steroids, Topical – Very High Potency
Steroids, Topical – Very High Potenc
NON-PREFERRED AGENTS (PA EFFECTIVE 8/25/2011) D VI. ENDOCRINE AND METABOLIC AGENTS
Amylin Analogs
Amylin Analogs
Anabolic Steroids – Topica
Anabolic Steroids – Topica
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Biguanides
Biguanides
Bisphosphonates – Ora
Bisphosphonates – Ora
Calcitonins – Intranasal
Calcitonins – Intranasal
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
Glucagon-like Peptide-1 (GLP-1) Agonists
Glucagon-like Peptide-1 (GLP-1) Agonists
Growth Hormone
Growth Hormone
PREFERRED AGENTS (SUBJECT TO CDRP FOR AGE 21 YEARS & NON-PREFERRED AGENTS (SUBJECT TO CDRP FOR AGE 21 Insulin – Long-Acting
Insulin – Long-Acting
Insulin – Mixes
Insulin – Mixes
Insulin – Rapid-Acting
Insulin – Rapid-Acting
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Pancreatic Enzymes
Pancreatic Enzymes
Thiazolidinediones (TZDs)
Thiazolidinediones (TZDs)
C VII. GASTROINTESTINAL
Anti-Emetics
Anti-Emetics
Helicobacter pylori Agents
Helicobacter pylori Agents
TTP://NE
Proton Pump Inhibitors (PPIs
Proton Pump Inhibitors (PPIs
Sulfasalazine Derivatives
Sulfasalazine Derivatives
VIII. HEMATOLOGICAL AGENTS
Anticoagulants – Injectable
Anticoagulants – Injectable
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Anticoagulants – Oral
Anticoagulants – Oral
Erythropoiesis Stimulating Agents (ESAs)
Erythropoiesis Stimulating Agents (ESAs)
Platelet Inhibitors
Platelet Inhibitors
IX. IMMUNOLOGIC AGENTS
Immunomodulators – Injectable
Immunomodulators – Injectable
TTP://NE
MISCELLANEOUS
Progestins (for Cachexia)
Progestins (for Cachexia)
P XI. MUSCULOSKELETAL AGENTS
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
orphenadrine comp. forte carisoprodol compound N XII. OPHTHALMICS
Alpha-2 Adrenergic Agonists (for
Alpha-2 Adrenergic Agonists (for
Glaucoma) – Ophthalmic
Glaucoma) – Ophthalmic
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Antihistamines – Ophthalmic
Antihistamines – Ophthalmic
Beta Blockers – Ophthalmics
Beta Blockers – Ophthalmics
Fluoroquinolones – Ophthalm
Fluoroquinolones – Ophthalm
TTP://NE
Non-Steroidal Anti-Inflammatory Drugs
Non-Steroidal Anti-Inflammatory Drugs
(NSAIDS) – Ophthalmic
(NSAIDS) – Ophthalmic
Prostaglandin Agonists – Ophthalmic
Prostaglandin Agonists – Ophthalmic
N XIII. OTICS
Fluoroquinolones – Otic
Fluoroquinolones – Otic
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. XIV. RENAL AND GENITOURINARY
Alpha Reductase Inhibitors for BPH
Alpha Reductase Inhibitors for BPH
Phosphate Binders/Regulators
Phosphate Binders/Regulators
Selective Alpha Adrenergic Blockers
Selective Alpha Adrenergic Blockers
Urinary Tract Antispasmodics
Urinary Tract Antispasmodics
Xanthine Oxidase Inhibitors
Xanthine Oxidase Inhibitors
D XV. RESPIRATORY
Anticholinergics – Inhaled
Anticholinergics – Inhaled
Antihistamines – Intranasal
Antihistamines – Intranasal
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Antihistamines – Second Generation
Antihistamines – Second Generation
Beta2 Adrenergic Agents – Inhaled Long
Beta2 Adrenergic Agents – Inhaled Long
Beta2 Adrenergic Agents – Inhaled Short
Beta2 Adrenergic Agents – Inhaled Short
TTP://NE
Corticosteroids – Inhale
Corticosteroids – Inhale
Corticosteroid/Beta
Corticosteroid/Beta
2 Adrenergic Agent
2 Adrenergic Agent
(Long-Acting) Combinations – Inhale
(Long-Acting) Combinations – Inhale
Corticosteroids – Intranasa
Corticosteroids – Intranasa
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See: NEW YORK STATE MEDICAID
PREFERRED DRUG LIST
Non-preferred drugs in these classes require prior authorization (PA), unless indicated otherwise. Preferred drugs that require prior authorization are indicated by footnote. Leukotriene Modifiers
Leukotriene Modifiers
CDRP All drugs in class are subject to Clinical Drug Review Program PA requirements (See: DUR Please see Drug Utilization Review (DUR) recommendations for drug class or specific drugs noted. (See:

Source: http://www.coalitionny.org/news_resources/prescription_drug_benefits/documents/NYRx_PDP_PDL.pdf

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