| Document Date: 2013-03-26 15:57:39
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Company BP / HP / EXELON / / Event FDA Phase / / IndustryTerm requested non-preferred product / pharmaceutical samples / peroxide sulfacetamide solution / chemical entities / chemical entity / long acting chemical entities / / MedicalCondition injury / THERAPEUTIC DRUG CLASS PREFERRED AGENTS NON-PREFERRED AGENTS PA CRITERIA disease / traveller’s diarrhea / 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 / strain / C. difficile infections / chronic pain therapy / pulmonary embolism / MS / Acne / / MedicalTreatment knee replacement surgeries / ANTIBIOTICS / hip replacement surgeries / / Organization BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA EFFECTIVE / / Product FLAGYL / DEPAKOTE ER / LOVENOX / acetaminophen / PRINZIDE / DURAGESIC / EMLA / EVOCLIN / VICOPROFEN / ZESTRIL / AZOR / CLINDAGEL / ANDROGEL / TYLENOL / FANATREX SUSPENSION / OPANA / erythromycin / tretinoin / BENZACLIN / RAZADYNE ER / KADIAN / losartan / rivastigmine / UNIVASC / FENTORA / KLARON / telmisartan / VOLTAREN / ER tablets / DEPAKENE / KEPPRA / TOBI / lisinopril / DUAC / metronidazole / ibuprofen / PERCOCET / LOTENSIN HCT / PRINIVIL / TEKTURNA HCT / lamotrigine / AKNE-MYCIN / TESTIM / ROXICET / gabapentin / GABITRIL / quinapril / VASERETIC / ROXICODONE / SYNALGOS-DC / lidocaine / sulfacetamide sodium / ACEON / FRAGMIN / fentanyl / MAVIK / captopril / ciprofloxacin / ALTACE / EXELON / AVITA / trandolapril / GI / HYZAAR / ARICEPT / LAMICTAL / DEMEROL / LOTREL / 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 / NORCO / TEVETEN / EXFORGE / ANDRODERM / TINDAMAX / divalproex / ACZONE / ER capsules / VICODIN / ATACAND / dapsone / AVAPRO / tobramycin / ORAMORPH SR / LORTAB / naloxone / AZELEX / DIOVAN / MS CONTIN / CAPOZIDE / OPANA ER / ramipril / COUMADIN / TEGRETOL / NEO-FRADIN / ZYDONE / ACCUPRIL / EQUETRO / REPREXAIN / COZAAR / ATRALIN / PERCODAN / xylocaine / ACCURETIC / FELBATOL / ZIANA / ULTRACET / INNOHEP / testosterone / BENICAR / NAMENDA / valproic acid / butalbital / UNIRETIC / donepezil / Aricept ODT / chlorthalidone / TYLOX / oxcarbazepine / DIFFERIN / SYNERA / MICARDIS / lactulose / TEKTURNA / OXYCONTIN / Aricept 23mg / hydrocortisone / FLECTOR / DEPAKOTE / EPITOL / AVALIDE / DILAUDID / PREFERRED DRUG / NR / Xifaxin / / 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