| Document Date: 2013-03-04 08:40:35
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Company BP / COGNEX / 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 / 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 / / Product FLAGYL / DEPAKOTE ER / LOVENOX / acetaminophen / PRINZIDE / DURAGESIC / EMLA / EVOCLIN / VICOPROFEN / ZESTRIL / AZOR / CLINDAGEL / ANDROGEL / TYLENOL / FANATREX SUSPENSION / OPANA / TALWIN NX / erythromycin / tretinoin / BENZACLIN / CAPOTEN / RAZADYNE ER / KADIAN / losartan / rivastigmine / UNIVASC / FENTORA / KLARON / telmisartan / VOLTAREN / 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 / sulfacetamide sodium / ACEON / FRAGMIN / fentanyl / MAVIK / captopril / ciprofloxacin / ALTACE / EXELON / AVITA / trandolapril / HYZAAR / ARICEPT / DEMEROL / LOTREL / clindamycin phosphate / AVINZA / ZESTORETIC / CARBATROL / valsartan / TAZORAC / irbesartan / ULTRAM / BENZAMYCIN PAK / FIORINAL / COGNEX / CLEOCIN / ARIXTRA / GI PREFERRED AGENTS / LOTENSIN / FLAGYL ER / FIORICET / ULTRAM ER / carbamazepine / ALINIA / ACTIQ / TARKA / RAZADYNE / VASOTEC / NORCO / TEVETEN / EXFORGE / ANDRODERM / TINDAMAX / divalproex / ACZONE / ER capsules / VICODIN / ATACAND / MONOPRIL / dapsone / AVAPRO / tobramycin / ORAMORPH SR / LORTAB / naloxone / AZELEX / DIOVAN / MS CONTIN / CAPOZIDE / OPANA ER / LEXXEL / ramipril / COMBUNOX / COUMADIN / NEO-FRADIN / ZYDONE / ACCUPRIL / EQUETRO / REPREXAIN / COZAAR / ATRALIN / PERCODAN / xylocaine / ACCURETIC / ZIANA / ULTRACET / INNOHEP / testosterone / BENICAR / NAMENDA / valproic acid / butalbital / UNIRETIC / donepezil / chlorthalidone / TYLOX / DIFFERIN / SYNERA / felodipine / MICARDIS / lactulose / TEKTURNA / OXYCONTIN / Aricept 23mg / hydrocortisone / FLECTOR / EPITOL / TALACEN / DEPAKOTE / AVALIDE / DILAUDID / EFFECTIVE / PA CRITERIA Voltaren Gel / PREFERRED DRUG / PA / 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