| Document Date: 2013-12-16 08:52:17
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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 / moderate-to-severe Alzheimer’s Disease / E. coli diarrhea / chronic pain / THERAPEUTIC PREFERRED AGENTS DRUG CLASS ACNE AGENTS / C. difficile infections / chronic pain therapy / angina / MS / Alzheimer’s disease / cancer / Acne / C. difficile infection / hepatic encephalopathy / unnecessary breakthrough pain / severe chronic pain requiring / non-valvular atrial fibrillation / / MedicalTreatment ANTIBIOTICS / / Organization BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA EFFECTIVE / / Product LOTREL / sulfanilamide / FLAGYL / clindamycin phosphate / AVINZA / ZESTORETIC / LOVENOX / acetaminophen / PRINZIDE / valsartan / irbesartan / TAZORAC / DURAGESIC / EMLA / CENTANY / ULTRAM / RETIN-A MICRO / EVOCLIN / BENZAMYCIN PAK / FIORINAL / CLEOCIN / ARIXTRA / VICOPROFEN / ZESTRIL / LOTENSIN / FLAGYL ER / AZOR / CLINDAGEL / ULTRAM ER / FIORICET / ANDROGEL / TYLENOL / ALINIA / ACTIQ / mupirocin / OPANA / TARKA / RAZADYNE / VANDAZOLE / VASOTEC / RETIN-A / NORCO / METROGEL / TEVETEN / EXFORGE / CORTISPORIN / TINDAMAX / ANDRODERM / erythromycin / ACZONE / ER capsules / CLINDESSE / tretinoin / VICODIN / BENZACLIN / ATACAND / RAZADYNE ER / losartan / KADIAN / dapsone / rivastigmine / UNIVASC / AVAPRO / FENTORA / tobramycin / sodium sulfacetamide / KLARON / LORTAB / bacitracin / AZELEX / naloxone / telmisartan / DIOVAN / CAPOZIDE / MS CONTIN / OPANA ER / ramipril / ER tablets / COUMADIN / TOBI / ZYDONE / lisinopril / ACCUPRIL / metronidazole / DUAC / ibuprofen / LOTENSIN HCT / REPREXAIN / PERCOCET / COZAAR / ATRALIN / PERCODAN / TEKTURNA HCT / xylocaine / ACCURETIC / PRINIVIL / ULTRACET / AKNE-MYCIN / ZIANA / TESTIM / INNOHEP / ROXICET / BENICAR / testosterone / NAMENDA / butalbital / quinapril / VASERETIC / UNIRETIC / ROXICODONE / lidocaine / SYNALGOS-DC / donepezil / ALTABAX / sulfacetamide sodium / ACEON / AVC / chlorthalidone / TYLOX / XIFAXAN / gentamicin sulfate / RANEXA / FRAGMIN / SYNERA / DIFFERIN / MAVIK / fentanyl / captopril / ciprofloxacin / MICARDIS / BACTROBAN / lactulose / TEKTURNA / ALTACE / AVITA / EXELON / trandolapril / OXYCONTIN / hydrocortisone / Aricept 23mg / HYZAAR / ARICEPT / AVALIDE / DEMEROL / DILAUDID / / ProvinceOrState 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