| Document Date: 2011-12-02 13:25:27
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Company COGNEX / EXELON / / Event FDA Phase / / IndustryTerm requested non-preferred product / pharmaceutical samples / chemical entities / chemical entity / long acting chemical entities / generic equivalent products / / MedicalCondition fibromyalgia / post herpetic neuralgia / injury / cancer / seizure disorder / unnecessary breakthrough pain / severe chronic pain requiring / seizure / non-valvular atrial fibrillation / moderate-to-severe Alzheimer’s Disease / chronic pain / strain / chronic pain therapy / MS / Acne / post-herpetic neuralgia / / Organization BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA EFFECTIVE / / Person EPITOL (carbamazepine) FELBATOL / / Product topiramate / DEPAKOTE ER / LOVENOX / acetaminophen / PRINZIDE / DURAGESIC / EMLA / NEURONTIN / EVOCLIN / VICOPROFEN / ZESTRIL / EFFEXOR XR / AZOR / ANDROGEL / TYLENOL / CYMBALTA / NR FANATREX SUSPENSION / OPANA / zonisamide / clonazepam / TALWIN NX / ethosuximide / erythromycin / tretinoin / KLONOPIN / BENZACLIN / CAPOTEN / RAZADYNE ER / KADIAN / losartan / rivastigmine / UNIVASC / FENTORA / diazepam / KLARON / phenytoin / telmisartan / LIDODERM / VOLTAREN / ER tablets / DEPAKENE / KEPPRA / lisinopril / DUAC / ibuprofen / PERCOCET / LOTENSIN HCT / PRINIVIL / TEKTURNA HCT / DILANTIN / lamotrigine / AKNE-MYCIN / TESTIM / ROXICET / gabapentin / GABITRIL / quinapril / VASERETIC / lidocaine / sulfacetamide sodium / ACEON / PEGANONE / CEREBYX / FRAGMIN / fentanyl / MAVIK / captopril / ALTACE / EXELON / AVITA / trandolapril / HYZAAR / ARICEPT / LAMICTAL / DEMEROL / venlafaxine / LOTREL / clindamycin phosphate / EFFEXOR / mirtazapine / AVINZA / ZESTORETIC / CARBATROL / valsartan / TAZORAC / irbesartan / primidone / ULTRAM / BENZAMYCIN PAK / FIORINAL / PHENYTEK / MYSOLINE / COGNEX / DESYREL / CLEOCIN / ARIXTRA / ZONEGRAN / LOTENSIN / FIORICET / ULTRAM ER / carbamazepine / ACTIQ / TARKA / RAZADYNE / VASOTEC / CELONTIN / RETIN-A / TOPAMAX / TEVETEN / EXFORGE / ANDRODERM / divalproex / ACZONE / ER capsules / VICODIN / ATACAND / MONOPRIL / dapsone / AVAPRO / ORAMORPH SR / LORTAB / sodium sulfacetamide / EMSAM / naloxone / AZELEX / DIOVAN / MS CONTIN / CAPOZIDE / OPANA ER / LEXXEL / ramipril / COMBUNOX / TEGRETOL / ZYDONE / ACCUPRIL / DIASTAT / EQUETRO / COZAAR / PERCODAN / xylocaine / ACCURETIC / FELBATOL / ULTRACET / ZIANA / PRISTIQ / INNOHEP / testosterone / BENICAR / NAMENDA / butalbital / valproic acid / UNIRETIC / donepezil / ARICEPT ODT / oxcarbazepine / LYRICA / DIFFERIN / SYNERA / TRILEPTAL / felodipine / MICARDIS / TEKTURNA / OXYCONTIN / Aricept 23mg / hydrocortisone / FLECTOR / ZARONTIN / TALACEN / DEPAKOTE / EPITOL / AVALIDE / DILAUDID / ER / / ProgrammingLanguage EC / / 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