| Document Date: 2014-09-08 09:44:58
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Company BP / HP / EXELON / / IndustryTerm requested non-preferred product / pharmaceutical samples / preferred unique long acting chemical entities / chemical entities / chemical entity / / MedicalCondition traveler’s diarrhea / angina / THERAPEUTIC DRUG PREFERRED AGENTS CLASS ACNE AGENTS / cancer / C. difficile infection / seizure disorder / hepatic encephalopathy / unnecessary breakthrough pain / severe chronic pain requiring / non-valvular atrial fibrillation / Deep vein thrombosis / moderate-to-severe Alzheimer’s Disease / E. coli diarrhea / chronic pain / C. difficile infections / chronic pain therapy / pulmonary embolism / MS / Alzheimer’s disease / Acne / / MedicalTreatment knee replacement surgeries / ANTIBIOTICS / hip replacement surgeries / / Product FLAGYL / DEPAKOTE ER / LOVENOX / acetaminophen / PRINZIDE / DURAGESIC / EMLA / CENTANY / RETIN-A MICRO / EVOCLIN / VICOPROFEN / ZESTRIL / AZOR / CLINDAGEL / ANDROGEL / TYLENOL / OPANA / mupirocin / METROGEL / CORTISPORIN / erythromycin / CLINDESSE / tretinoin / BENZACLIN / RAZADYNE ER / KADIAN / losartan / ER FANATREX SUSPENSION / rivastigmine / UNIVASC / FENTORA / KLARON / bacitracin / telmisartan / ER tablets / DEPAKENE / TOBI / lisinopril / DUAC / metronidazole / ibuprofen / PERCOCET / LOTENSIN HCT / PRINIVIL / TEKTURNA HCT / AKNE-MYCIN / TESTIM / ROXICET / gabapentin / quinapril / VASERETIC / ROXICODONE / SYNALGOS-DC / lidocaine / ALTABAX / sulfacetamide sodium / ACEON / XIFAXAN / RANEXA / gentamicin sulfate / FRAGMIN / fentanyl / MAVIK / captopril / ciprofloxacin / ALTACE / EXELON / AVITA / trandolapril / HYZAAR / ARICEPT / DEMEROL / LOTREL / sulfanilamide / clindamycin phosphate / AVINZA / ZESTORETIC / CARBATROL / valsartan / TAZORAC / irbesartan / ULTRAM / BENZAMYCIN PAK / FIORINAL / CLEOCIN / ARIXTRA / LOTENSIN / FLAGYL ER / FIORICET / ULTRAM ER / carbamazepine / ALINIA / ACTIQ / TARKA / RAZADYNE / VASOTEC / VANDAZOLE / RETIN-A / NORCO / TEVETEN / EXFORGE / ANDRODERM / TINDAMAX / divalproex / ER capsules / ACZONE / VICODIN / ATACAND / dapsone / AVAPRO / tobramycin / sodium sulfacetamide / naloxone / AZELEX / DIOVAN / MS CONTIN / CAPOZIDE / OPANA ER / ramipril / COUMADIN / ZYDONE / ACCUPRIL / EQUETRO / REPREXAIN / COZAAR / ATRALIN / PERCODAN / ACCURETIC / ZIANA / ULTRACET / INNOHEP / testosterone / BENICAR / NAMENDA / butalbital / valproic acid / UNIRETIC / donepezil / AVC / chlorthalidone / TYLOX / DIFFERIN / SYNERA / MICARDIS / lactulose / BACTROBAN / TEKTURNA / OXYCONTIN / Aricept 23mg / hydrocortisone / DEPAKOTE / AVALIDE / DILAUDID / / ProvinceOrState Prince Edward Island / Pennsylvania / / Region WEST VIRGINIA / / URL http /
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BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover p