ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL
Table of Contents
Antihistamines
Anti-infective Agents
Behavioral Health
Cardiovascular Health
Diabetic Agents
Eye, Ear Nose, and Throat (EENT) Preparations
Gastrointestinal Agents
Genitourinary Agents
Pain Management & Autonomic Agents
Allergy and Respiratory Agents
Skin & Mucous Membrane Agents
Women’s Health
Page 2
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Page 10
Page 14
Page 16
Page 18
Page 19
Page 20
Page 22
Page 23
Page 27
1
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Antihistamines
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
none
phenylephrine and chlorpheniramine
phenylephrine and brompheniramine
phenylephrine and brompheniramine
phenylephrine and chlorpheniramine
pseudoephedrine and chlorpheniramine
pseudoephedrine and brompheniramine
brompheniramine
pseudoephedrine and brompheniramine
First Generation
Antihistamine
Agents
chlorpheniramine
phenylephrine, phenyltoloxamine, and
chlorpheniramine
phenylephrine and chlorpheniramine
carbinoxamine
pseudoephedrine and triprolidine
phenylephrine, pyrilamine, and chlorpheniramine
phenylephrine, pyrilamine, and chlorpheniramine
phenylephrine and chlorpheniramine
phenylephrine and brompheniramine
phenylephrine and chlorpheniramine
phenylephrine and chlorpheniramine
phenylephrine and brompheniramine
brompheniramine
PA REQUIRED for NAME
Non-Preferred Brand
AccuHist*
Aldex AN
Aldex-CT
Aldex D
Alersule*
Bromax
Bromfed*
Bromfed-PD*
Brovex ADT
Brovex PD
Brovex PSE
Dallergy*
Dallergy JR
Deconsal CT
Duratuss DA
Histex*
Histex SR
J-Tan D PD*
J-Tan PD*
Lodrane*
Lodrane 24
Lodrane 24D
Lodrane D
Myci Chlor-Tan*
Nalex-A*
Nasohist*
Palgic*
Pediatex TD*
Phena-Plus
Phena-S*
Phena-S 12
Poly Hist PD*
Relhist
Rescon-Jr*
Rescon-MX SR
Respahist-II*
Ryna-12
Ryna-12 S
Rynatan*
Rynatan Pediatric*
Rynesa 12S
Sudal-12
Tekral
Tripohist*
Tripohist D
Tussanil
Vazobid*
VaZol*
Vazotab
Viravan-P
Zotex-PE*
phenylephrine and brompheniramine
brompheniramine and diphenhydramine
First Generation Antihistamines continued on next page
2
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
First Generation Antihistamines continued from previous page
none
First Generation
Antihistamine
Agents
(continued)
brompheniramine, diphenhydramine, and
phenylephrine
dexchlorpheniramine
diphenhydramine
phenylephrine and diphenhydramine
phenylephrine, pyrilamine, and
dexbrompheniramine
pseudoephedrine and dexbrompheniramine
pyrilamine and dexbrompheniramine
3
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Anti-infective Agents
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
Adamantanes
Amebicides
NO PA REQUIRED
Preferred Brand
none
none
none
Aminoglycosides
none
NO PA REQUIRED
Preferred Generic or OTC
rimantadine
amantadine
paromomycin
PA REQUIRED for NAME
Non-Preferred Brand
Flumadine*
none
TOBI
amikacin
gentamicin
kanamycin
neomycin
streptomycin
tobramycin
Reese Pinworm
Albenza
Biltricide
Stromectol
Anthelmintics
mebendazole
Gris-Peg
fluconazole
griseofulvin microsize
terbinafine
Antifungals
nystatin
itraconazole
voriconazole
amphotericin B
ketoconazole
Abelcet
Ambisome
Amphotec
Ancobon
Cancidas
Diflucan*
Eraxis
Grifulvin V*
Lamisil*
Mycamine
Mycostatin*
Noxafil
Sporanox*
Vfend*
Daraprim
chloroquine
Antimalarials
mefloquine
atovaquone/proguanil
hydroxychloroquine
Aralen Phosphate*
Coartem
Fansidar
Lariam*
Malarone*
Plaquenil*
Qualaquin
primaquine
none
Capastat Sulfate
Myambutol*
Mycobutin
Paser
Priftin
rifampin
Rifadin*
Rifamate*
rifampin and isoniazid
Rifater
cycloserine
Seromycin*
Trecator
Antituberculosis Agents continued on next page
ethambutol
Antituberculosis Agents
4
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
Antituberculosis Agents continued from previous page
Antituberculosis Agents
(continued)
none
isoniazid
pyrazinamide
none
cefuroxime
cefotaxime
ceftazidime
cephalexin
ceftriaxone
cefditoren
ceftazidime
Cephalosporins
Chloramphenicol
none
Infergen
PegIntron
cefuroxime
cefaclor
cefadroxil
cefazolin
cefdinir
cefepime
cefpodoxime
cefprozil
chloramphenicol
none
Interferons
none
clarithromycin
clarithromycin ER
erythromycin ethylsuccinate
Macrolides
azithromycin
none
erythromycin base
erythromycin ethylsuccinate
and sulfisoxazole
bacitracin
clindamycin
colistimethate
Miscellaneous Antibacterials
Cedax
Ceftin*
Claforan*
Fortaz*
Keflex*
Rocephin*
Spectracef*
Suprax
Tazicef*
Teflaro
Zinacef *
none
Alferon N
Intron A
Pegasys
Biaxin*
Biaxin XL*
Dificid
E.E.S.*
EryPed
Erythrocin Lactobionate
Ketek
PCE
Zithromax*
Zmax
Baciim*
Cleocin*
Coly-Mycin M*
Cubicin
Helidac
Lincocin
Pylera
Synercid
Vancocin
Vibativ
Xifaxan
Zyvox
polymyxin B sulfate
vancomycin
5
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
Miscellaneous Antimycobacterials
NO PA REQUIRED
Preferred Brand
none
none
NO PA REQUIRED
Preferred Generic or OTC
dapsone
metronidazole
Miscellaneous Antiprotozoals
none
pentamidine
tinidazole
foscarnet
none
aztreonam
Miscellaneous Antivirals
Miscellaneous β-Lactams
Neuraminidase Inhibitors
†The preferred status of this product is
contingent upon statewide influenza
epidemiology status as reported by the CDC.
Relenza
†
Tamiflu
†
meropenem
imipenem and cilastatin
cefotetan
cefoxitin
none
none
ribavirin
ganciclovir
famciclovir
ribavirin
Nucleosides and Nucleotides
valacyclovir
none
acyclovir
amoxicillin and clavulanate
amoxicillin and clavulanate
penicillin G
Penicillins
ampicillin and sulbactam
piperacillin and tazobactam
amoxicillin
ampicillin
dicloxacillin
nafcillin
oxacillin
penicillin V
piperacillin
PA REQUIRED for NAME
Non-Preferred Brand
none
Alinia
Flagyl*
Flagyl ER
Mepron
Nebupent
Pentam 300*
Tindamax*
Foscavir*
Incivek**
Victrelis**
Azactam*
Cayston
Doribax
Invanz
Mefoxin
Merrem*
Primaxin*
none
Baraclude
Copegus*
Cytovene*
Famvir*
Hepsera
Rebetol*
Tyzeka
Valcyte
Valtrex*
Virazole
Vistide
Zovirax*
Augmentin*
Augmentin XR*
Bicillin C-R
Bicillin L-A
Moxatag
Pfizerpen*
Timentin
Unasyn*
Zosyn*
6
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
none
ciprofloxacin
ciprofloxacin ER
Quinolones
levofloxacin
none
Sulfonamides
none
ofloxacin
sulfasalazine
sulfamethoxazole and trimethoprim
sulfamethoxazole and trimethoprim
sulfamethoxazole and trimethoprim
sulfadiazine
doxycycline
doxycycline
minocycline
doxycycline
Tetracyclines
none
Urinary Anti-infectives
doxycycline
demeclocycline
tetracycline
nitrofurantoin
methenamine
nitrofurantoin and nitrofurantoin
macrocrystals
nitrofurantoin macrocrystals
methenamine, methylene blue,
benzoic acid, phenyl salicylate,
hyoscyamine
methenamine, methylene blue,
phenyl salicylate, sodium
phosphate, hyoscyamine
methenamine
methenamine and sodium
phosphate
methenamine, methylene blue,
phenyl salicylate, sodium
phosphate, hyoscyamine
methenamine and sodium
phosphate
methenamine, methylene blue,
phenyl salicylate, sodium
phosphate, hyoscyamine
trimethoprim
PA REQUIRED for NAME
Non-Preferred Brand
Avelox
Cipro*
Cipro XR*
Factive
Levaquin*
Noroxin
ProQuin XR
Azulfidine*
Bactrim*
Bactrim DS*
Septra DS*
Adoxa*
Doryx*
Dynacin*
Morgidox*
Terramycin
Tygacil
Vibramycin*
Furadantin*
Hiprex*
Macrobid*
Macrodantin*
Monurol
Primsol
Prosed/DS*
Urelle*
Urex*
Urimar-T
Urin D.S.
Uroqid-Acid No. 2*
Uta*
Utac*
Utira C*
7
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Behavioral Health
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
Aricept*
Aricept ODT*
Alzheimer’s Agents
NO PA REQUIRED
Preferred Generic
PA REQUIRED for NAME
Non-Preferred Brand
donepezil
donepezil
rivastigmine
galantamine
galantamine
Cognex
Exelon*
Namenda
Razadyne*
Razadyne ER*
Lexapro
clomipramine
citalopram
venlafaxine
venlafaxine
amitriptyline and chlordiazepoxide
desipramine
nortriptyline
tranylcypromine
paroxetine
paroxetine
Antidepressants
fluoxetine
fluoxetine
mirtazapine
fluoxetine
fluoxetine
trimipramine
imipramine
imipramine
protriptyline
bupropion
bupropion
bupropion
sertraline
amitriptyline
amoxapine
doxepin
fluvoxamine
maprotiline
nefazodone
trazodone
venlafaxine ER
Anafranil*
Aplenzin
Celexa*
Cymbalta
Effexor*
Effexor XR *
Emsam
Limbitrol*
Luvox CR
Marplan
Nardil
Norpramin*
Oleptro ER
Pamelor*
Parnate*
Paxil*
Paxil CR*
Pexeva
Pristiq
Prozac*
Prozac Weekly*
Remeron*
Sarafem*
Selfemra*
Silenor**
Surmontil*
Tofranil*
Tofranil-PM*
Viibryd**
Vivactil*
Wellbutrin*
Wellbutrin SR*
Wellbutrin XL*
Zoloft*
8
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic
none
Anxiolytics, Sedatives, and
Hypnotics: Barbiturates
mephobarbital
PA REQUIRED for NAME
Non-Preferred Brand
Amytal Sodium
Butisol Sodium
Luminal Sodium
Mebaral*
Nembutal Sodium
Seconal Sodium
phenobarbital
Diastat*
Anxiolytics, Sedatives, and
Hypnotics: Benzodiazepines
‡Brand named benzodiazepines
(excluding Diastat) are non-covered by
Alabama Medicaid.
none
diazepam
alprazolam
alprazolam ER
chlordiazepoxide
clonazepam
clorazepate
diazepam
flurazepam
lorazepam
midazolam
oxazepam
temazepam
triazolam
zolpidem
zolpidem
buspirone
droperidol
Anxiolytics, Sedatives, and
Hypnotics:
Miscellaneous Agents
zaleplon
hydroxyzine
N/A
‡
Ambien*
Ambien CR*
BuSpar*
Edluar
Inapsine*
Lunesta
Precedex
Rozerem
Sonata*
Vistaril*
Zolpimist**
chloral hydrate
meprobamate
Ritalin*
Ritalin-SR*
Cerebral Stimulants/
Agents Used for ADHD
(Short- and IntermediateActing)
Cerebral Stimulants/
Agents Used for ADHD
(Long-Acting)
methylphenidate
methylphenidate
amphetamine-dextroamphetamine
dextroamphetamine
dexmethylphenidate
methylphenidate
methylphenidate
Adderall XR*
Concerta*
Daytrana
Focalin XR
Vyvanse
Adderall*
Desoxyn
Dexedrine*
Focalin*
Metadate ER*
Methylin*
ProCentra
amphetamine-dextroamphetamine
methylphenidate
methylphenidate
Intuniv
Kapvay ER**
Metadate CD
Nuvigil
Provigil
Ritalin LA*
Strattera
9
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Cardiovascular Health
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
none
ACE Inhibitors
none
Alpha-Adrenergic Blocking
Agents
NO PA REQUIRED
Preferred Generic
perindopril
quinapril
quinapril and HCTZ
ramipril
benazepril
benazepril and HCTZ
trandolapril
lisinopril
lisinopril and HCTZ
trandolapril and verapamil
moexipril and HCTZ
moexipril
enalapril and HCTZ
enalapril
lisinopril and HCTZ
lisinopril
captopril
captopril and HCTZ
fosinopril
fosinopril and HCTZ
doxazosin
prazosin
terazosin
losartan
Angiotensin II Receptor
Antagonists
losartan and HCTZ
eprosartan
none
Antiarrhythmic Agents
amiodarone
disopyramide
disopyramide
amiodarone
propafenone
flecainide
PA REQUIRED for NAME
Non-Preferred Brand
Aceon*
Accupril*
Accuretic*
Altace*
Lotensin*
Lotensin HCT*
Mavik*
Prinivil*
Prinzide*
Tarka*
Uniretic*
Univasc*
Vaseretic*
Vasotec*
Zestoretic*
Zestril*
Cardura*
Cardura XL
Minipress*
Atacand
Atacand HCT
Avalide
Avapro
Benicar
Benicar HCT
Cozaar*
Diovan
Diovan HCT
Edarbi**
Edarbyclor**
Hyzaar*
Micardis
Micardis HCT
Teveten*
Teveten HCT
Twynsta
Cordarone*
Multaq
Norpace*
Norpace CR*
Pacerone*
Rythmol*
Rythmol SR
Tambocor*
Tikosyn
mexiletine
quinidine
10
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
none
NO PA REQUIRED
Preferred Generic
sotalol
sotalol
carvedilol
nadolol
nadolol and bendroflumethiazide
propranolol
betaxolol
Beta-Adrenergic Blocking Agents
none
metoprolol
metoprolol and HCTZ
acebutolol
atenolol and chlorthalidone
atenolol
metoprolol
labetalol
bisoprolol
bisoprolol and HCTZ
pindolol
propranolol and HCTZ
timolol
nifedipine
verapamil
verapamil
diltiazem
diltiazem
diltiazem
diltiazem
verapamil
amlodipine and benazepril
Calcium-Channel Blocking
Agents
nimodipine
amlodipine
nifedipine
nifedipine
diltiazem
Cardiotonic Agents
none
verapamil
verapamil
felodipine
isradipine
nicardipine
nisoldipine
digoxin
PA REQUIRED for NAME
Non-Preferred Brand
Betapace*
Betapace AF*
Bystolic
Coreg*
Coreg CR
Corgard*
Corzide*
Dutoprol**
Inderal LA*
InnoPran XL
Kerlone*
Levatol
Lopressor*
Lopressor HCT*
Sectral*
Tenoretic*
Tenormin*
Toprol XL*
Trandate*
Zebeta*
Ziac*
Adalat CC*
Azor
Calan*
Calan SR*
Cardene SR
Cardizem*
Cardizem CD*
Cardizem LA*
Covera-HS
Dilacor XR*
DynaCirc CR
Exforge
Exforge HCT
Isoptin SR*
Lotrel*
Matzim LA**
Nimotop*
Norvasc*
Procardia*
Procardia XL*
Sular
Tiazac*
Tribenzor**
Verelan*
Verelan PM*
Lanoxin*
Lanoxin Pediatric
11
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
none
NO PA REQUIRED
Preferred Generic
clonidine
clonidine
guanfacine
clonidine and chlorthalidone
guanabenz
methyldopa
methyldopa and HCTZ
Central Alpha-Agonists
none
Direct Vasodilators
none
Mineralocorticoid (Aldosterone)
Receptor Antagonists
hydralazine
minoxidil
torsemide
furosemide
triamterene and HCTZ
hydrochlorothiazide (HCTZ)
amiloride
Miscellaneous Cardiac Drugs
none
none
Catapres*
Catapres-TTS*
Nexiclon**
Tenex*
BiDil
Proglycem
chlorothiazide
triamterene and HCTZ
Diuretics
PA REQUIRED for NAME
Non-Preferred Brand
metolazone
amiloride and HCTZ
bumetanide
chlorthalidone
indapamide
methyclothiazide
spironolactone and HCTZ
spironolactone
eplerenone
none
Demadex*
Diuril
Diuril Sodium*
Dyazide*
Edecrin
Lasix*
Maxzide*
Microzide*
Midamor*
Samsca
Thalitone
Zaroxolyn*
Aldactazide*
Aldactone*
Inspra*
Ranexa
Nitro-Bid
isosorbide mononitrate
isosorbide mononitrate
isosorbide dinitrate
nitroglycerin
isosorbide mononitrate
nitroglycerin
nitroglycerin
Nitrates and Nitrites
Peripheral Adrenergic Inhibitors
none
nitroglycerin
amyl nitrite
reserpine
none
Platelet-Aggregation Inhibitors
dipyridamole
cilostazol
Dilatrate-SR
Imdur*
Ismo*
Isordil*
Minitran*
Monoket*
Nitro-Dur*
Nitrolingual*
NitroMist
Nitrostat*
none
Aggrenox
Brilinta**
Effient
Persantine*
Plavix
Pletal*
Zorprin CR
ticlopidine
12
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic
none
none
Amturnide**
Tekamlo**
Tekturna
Tekturna HCT
Valturna
none
colestipol
cholestyramine
cholestyramine
Colestid*
Questran*
Questran Light *
Welchol
none
none
Zetia
Renin Inhibitors
Bile Acid Sequestrants
Cholesterol Absorption Inhibitors
PA REQUIRED for NAME
Non-Preferred Brand
none
fenofibric acid
Fibric Acid Derivatives
fenofibrate
gemfibrozil
none
amlodipine/atorvastatin
HMG-CoA Reductase Inhibitors
atorvastatin
lovastatin
pravastatin
Niacor
simvastatin
none
Miscellaneous Antilipemic Agents
Antara
Fenoglide
Fibricor*
Lipofen
Lofibra*
Lopid*
Tricor
Triglide
Trilipix
Advicor
Altoprev
Caduet*
Crestor
Lescol
Lescol XL
Lipitor*
Livalo**
Mevacor*
Pravachol*
Simcor
Vytorin
Zocor*
Lovaza
Niaspan
13
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Diabetic Agents
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
Alpha-Glucosidase Inhibitors
Amylinomimetics
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or
OTC
PA REQUIRED for NAME
Non-Preferred Brand
Glyset
none
acarbose
none
none
metformin
metformin ER
Biguanides
none
none
none
none
Dipeptidyl Peptidase-4 (DPP-4)
Inhibitors
Incretin Mimetics
Precose*
Symlin
Fortamet
Glucophage*
Glucophage XR*
Glumetza
Riomet
Januvia
Janumet
Janumet XR**
Jentadueto**
Kombiglyze**
Onglyza
Tradjenta**
Bydureon**
Byetta
Victoza
Humalog
Lantus
Humulin N
Humulin R
Humulin 50/50
Humulin 70/30
Novolin N
Novolin R
Novolin 70/30
Insulins
Apidra
Humalog Mix 50/50
Humalog Mix 75/25
Humulin R (U-500)
Levemir
Novolog
Novolog Mix 70/30
Prandin
Meglitinides
none
Sulfonylureas
nateglinide
glimepiride
glyburide
glipizide
glipizide ER
glyburide and metformin
glyburide
glipizide and metformin
chlorpropamide
tolazamide
tolbutamide
PrandiMet
Starlix*
Amaryl*
DiaBeta*
Glucotrol*
Glucotrol XL*
Glucovance*
Glynase*
Metaglip*
14
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
Actos
Thiazolidinediones
NO PA REQUIRED
Preferred Generic or
OTC
PA REQUIRED for NAME
Non-Preferred Brand
none
Avandamet
Avandaryl
Avandia
Actoplus Met
Actoplus Met XR
Duetact
15
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Eye, Ear, Nose, and Throat (EENT) Preparations
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
Astepro
Refresh*
Zaditor*
azelastine
Antiallergic Agents
epinastine
azelastine
Alamast
Alocril
Alomide
Astelin*
Bepreve
Elestat *
Emadine
Lastacaft**
Optivar*
Pataday
Patanase
Patanol
cromolyn
ketotifen
Bactroban Nasal
Blephamide
Blephamide S.O.P.
Bleph-10*
Tobrex*
sulfacetamide
tobramycin
ciprofloxacin
neomycin, polymyxin B and hydrocortisone
gentamicin
erythromycin base
Antibacterials
neomycin, polymyxin B and dexamethasone
neomycin, polymyxin B and gramicidin
ofloxacin
doxycycline
polymyxin B and trimethoprim
levofloxacin
tobramycin and dexamethasone
AzaSite
Besivance
Cetraxal
Ciloxan*
Cipro HC
Ciprodex
Coly-Mycin S
Cortisporin*
Cortisporin-TC
Garamycin*
Ilotycin*
Iquix
Maxitrol*
Neosporin*
Ocuflox*
Periostat*
Poly-Pred
Polytrim*
Pred-G
Quixin*
TobraDex*
TobraDex ST
Vigamox
Zylet
Zymar
Zymaxid
bacitracin
bacitracin and polymyxin B
neomycin, bacitracin and polymyxin B
neomycin, bacitracin, polymyxin B and
hydrocortisone
sulfacetamide and prednisolone
16
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
Beconase AQ
Nasonex
fluticasone propionate
triamcinolone
Intranasal Corticosteroids
Flonase*
Nasacort AQ*
Omnaris
Rhinocort Aqua
Veramyst
flunisolide
Tyzine
Vasoconstrictors
phenylephrine
naphazoline
Adrenalin Chloride
Mydfrin*
17
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Gastrointestinal Agents
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or
OTC
none
granisetron
5-HT3 Receptor Antagonists
ondansetron
ondansetron
none
trimethobenzamide
dimenhydrinate
meclizine
prochlorperazine
Antihistamine Antiemetics
none
Miscellaneous Antiemetics
dronabinol
none
PA REQUIRED for NAME
Non-Preferred Brand
or PA Generic
Aloxi
Anzemet
Granisol
Kytril*
Sancuso
Zofran*
Zofran ODT*
Zuplenz
Antivert
Tigan*
Cesamet
Emend
Marinol*
Scopace
Transderm-Scop
Prilosec OTC
Zegerid OTC
Proton-Pump Inhibitors
omeprazole
pantoprazole
Aciphex
Dexilant
lansoprazole (generic)
Nexium
omeprazole/sodium
bicarbonate (generic)
Prevacid*
Prevpac
Prilosec*
Protonix*
18
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Genitourinary Agents
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or
OTC
PA REQUIRED for NAME
Non-Preferred Brand
or PA Generic
Oxytrol
oxybutynin
Genitourinary Smooth Muscle
Relaxants
trospium
Detrol
Detrol LA
Ditropan XL*
Enablex
Gelnique
Sanctura*
Sanctura XR
Toviaz
Vesicare
flavoxate
19
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Pain Management & Autonomic Agents
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
none
Centrally Acting
Skeletal Muscle
Relaxants
Direct-Acting
Skeletal Muscle
Relaxants
GABA-derivative
Skeletal Muscle
Relaxants
Miscellaneous
Skeletal Muscle
Relaxants
NO PA REQUIRED
Preferred Generic
cyclobenzaprine
chlorzoxazone
methocarbamol
metaxalone
none
tizanidine
cyclobenzaprine
dantrolene
none
Dantrium*
Gablofen**
Lioresal Intrathecal
baclofen
none
orphenadrine
orphenadrine/aspirin/caffeine
none
fentanyl
alfentanil
morphine
meperidine
hydromorphone
methadone
fentanyl
morphine
Opiate Agonists
PA REQUIRED for NAME
Non-Preferred Brand or PA Generic
Amrix*
carisoprodol (generic)
carisoprodol/aspirin (generic)
codeine/carisoprodol/aspirin (generic)
Fexmid
Lorzone
Parafon Forte DSC*
Robaxin*
Skelaxin*
Soma*
Zanaflex*
codeine/butalbital/acetaminophen/caffeine
codeine/butalbital/aspirin/caffeine
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
methadone
hydrocodone/acetaminophen
oxymorphone
dihydrocodeine/acetaminophen/caffeine
Norflex*
Abstral**
Actiq*
Alfenta*
Astramorph-PF*
Capital w/codeine
Conzip ER
Demerol*
Depodur
Dilaudid*
Dolophine*
Duragesic*
Duramorph*
Fentora
Fioricet w/codeine*
Fiorinal w/codeine*
Hycet
Ibudone
Infumorph
Lorcet*
Lortab*
Magnacet
Maxidone*
Methadose*
Norco*
Nucynta
Numorphan
Onsolis
Opana*
Panlor SS*
Opiate Agonists continued on next page
20
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic
PA REQUIRED for NAME
Non-Preferred Brand or PA Generic
Opiate Agonists continued from previous page
oxycodone/acetaminophen
Percocet*
oxycodone/aspirin
Percodan*
Primlev
Reprexain
Roxicodone*
Rybix ODT
Ryzolt
Sublimaze*
Sufenta*
Synalgos-DC
Trezix
Tylenol w/codeine*
Tylox*
Ultiva
Ultracet*
Ultram*
Ultram ER*
Vicodin*
Vicoprofen*
Xodol*
Xolox
Zamicet
ZerLor*
Zolvit**
Zydone
none
oxycodone
fentanyl
sufentanil
acetaminophen/codeine
oxycodone/acetaminophen
tramadol/acetaminophen
tramadol
tramadol
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydrocodone/acetaminophen
Opiate Agonists
(continued)
dihydrocodeine/acetaminophen/caffeine
codeine
ibuprofen/oxycodone
levorphanol
opium/belladonna
none
Buprenex
buprenorphine (generic)
Butrans**
Suboxone
Subutex*
Talwin
Opiate Partial
Agonists
butorphanol
nalbuphine
pentazocine/acetaminophen
pentazocine/naloxone
Maxalt MLT
naratriptan
Selective Serotonin
Agonists
sumatriptan
Amerge*
Axert
Frova
Imitrex*
Maxalt
Relpax
Sumavel DosePro
Treximet
Zomig
Zomig ZMT
21
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Allergy and Respiratory Agents
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
Inhaled Antimuscarinics
Inhaled Mast-Cell Stabilizers
Leukotriene Modifiers
Orally Inhaled Corticosteroids
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic
Atrovent HFA
Spiriva
none
Accolate*
Singulair
none
ipratropium bromide
cromolyn sodium
none
zafirlukast
Zyflo
Zyflo CR
Advair Diskus
Advair HFA
Asmanex
Dulera
Flovent Diskus
Flovent HFA
QVAR
budesonide
Respiratory Beta-Adrenergic Agonists
PA REQUIRED for NAME
Non-Preferred Brand
Alvesco
Pulmicort*
Symbicort
Combivent
Foradil
Maxair Autohaler
ProAir HFA
Proventil HFA
Serevent Diskus
Ventolin HFA
Xopenex HFA
albuterol
albuterol/ipratropium
levalbuterol
metaproterenol
terbutaline
none
guaifenesin/dyphylline
Respiratory Smooth Muscle Relaxants
guaifenesin/dyphylline
Arcapta**
Accuneb*
Brovana
Duoneb*
Perforomist
Xopenex*
Broncomar-1
Difil-G
Difil-G Forte*
Dilex-G
Elixophyllin
Lufyllin
Lufyllin-GG*
Theo-24
aminophylline
dyphylline
theophylline
22
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Skin & Mucous Membrane Agents
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
none
mupirocin
mupirocin
clindamycin
metronidazole
neomycin and polymyxin B
metronidazole
bacitracin and polymyxin B
gentamicin
neomycin, bacitracin and polymyxin B
neomycin, bacitracin, polymyxin B, and
pramoxine
Antibacterials
none
ciclopirox
ciclopirox
clotrimazole and betamethasone
ketoconazole
miconazole
Antifungals
ciclopirox
terconazole
terconazole
terconazole
butenafine
clotrimazole
econazole
nystatin
nystatin and triamcinolone
terbinafine
tioconazole
tolnaftate
Capex Shampoo
Derma-Smooth/FS*
Anti-inflammatory
Agents
PA REQUIRED for NAME
Non-Preferred Brand
or PA Generic
Altabax
Bactroban*
Centany*
Centany AT
Cleocin*
Clindesse
Cortisporin
MetroGel-Vaginal*
Neosporin G.U. Irrigant*
Vandazole*
Bensal HP
Ciclodan*
Ertaczo
Exelderm
Gynazole-1
Ketocon
Lamisil
Loprox*
Lotrisone*
Mentax
Naftin
Nizoral*
Nuzole*
Oravig
Oxistat
Penlac*
Terazol 3*
Terazol 7*
Vusion
Xolegel
Zazole*
fluocinolone
alclometasone
hydrocortisone
diflorasone
Aclovate*
Anusol-HC*
Apexicon*
Apexicon E
hydrocortisone acetate and urea
Carmol HC*
Clobeta Kit
Clobex
Anti-inflammatory Agents continued on next page
23
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
or PA Generic
Anti-inflammatory Agents continued from previous page
clobetasol
hydrocortisone
fluticasone
prednicarbate
betamethasone dipropionate and propylene
glycol
betamethasone dipropionate and propylene
glycol
mometasone
halobetasol and ammonium lactate
hydrocortisone acetate and aloe vera
clobetasol
triamcinolone
Anti-inflammatory
Agents
(continued)
hydrocortisone
hydrocortisone
clobetasol
clobetasol and emollient
desoximetasone
desoximetasone
triamcinolone
halobetasol
halobetasol and ammonium lactate
hydrocortisone valerate
amcinonide
betamethasone dipropionate
betamethasone valerate
desonide
fluocinolone
fluocinonide
hydrocortisone and aloe vera
hydrocortisone, mineral oil and white petrolatum
hydrocortisone acetate
hydrocortisone butyrate
none
Antipruritics and
Local Anesthetics
Cloderm
Cordran
Cormax*
Cortenema*
Cortifoam
Cutivate*
Dermatop*
Desonate
Diprolene*
Diprolene AF*
Elocon*
Halog
Halonate
Halonate PAC*
Kenalog
Luxiq
Momexin
Nuzon*
Olux*
Olux-E
Oralone*
Pandel
PramCort
ProCort
Proctocort*
Proctocream-HC*
Proctofoam-HC
Temovate*
Temovate Emollient*
Texacort
Topicort*
Topicort LP*
Trianex*
Ultravate*
Ultravate PAC*
Vanos
Verdeso
Westcort*
Americaine
Anamantle HC*
Anamantle HC Forte*
EMLA*
Lidamantle*
Lidamantle HC*
Lidoderm
Antipruritics and Local Anesthetics continued on next page
hydrocortisone and lidocaine
hydrocortisone and lidocaine
lidocaine and prilocaine
lidocaine
hydrocortisone and lidocaine
24
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
or PA Generic
Antipruritics and Local Anesthetics continued from previous page
hydrocortisone, lidocaine and aloe vera
Antipruritics and
Local Anesthetics
(continued)
none
Zovirax
ethyl chloride
none
Antivirals
Astringents
none
aluminum chloride
none
urea
urea
urea
urea, lactic acid, and zinc undecylenate
urea, lactic acid, and zinc undecylenate
Keratolytic Agents
Peranex HC*
Pontocaine
Prudoxin
Synera
Zonalon
salicylic acid
urea
urea
Denavir
Xerese
Drysol*
Xerac AC
Aluvea*
Carmol 40*
Kerafoam
Keralac*
Kerol*
Kerol AD*
Kerol ZX*
Remeven
Salex*
Salkera
Umecta*
Umecta PD
Uramaxin*
Uramaxin GT*
urea and hyaluronate sodium
urea, lactic acid and salicylic acid
none
Keratoplastic Agents
Doak Tar Distillate
coal tar
coal tar and lanolin
pHisoHex
silver sulfadiazine
silver sulfadiazine
silver sulfadiazine
Miscellaneous Local
Anti-infectives
none
Miscellaneous
Skin and Mucous
Membrane Agents
AVC
Silvadene*
SSD*
SSD AF*
Sulfamylon
acetic acid and oxyquinoline
silver nitrate
imiquimod
Aldara*
Artiss
Artiss Duploject
Carac
podofilox
Condylox*
Constant-Clens
calcipotriene
Dovonex*
fluorouracil
Efudex*
Elidel
Fluoroplex
Lazerformalyde*
Panretin
Picato**
Podocon-25
Protopic
Qutenza
Rectiv**
Miscellaneous Skin and Mucous Membrane Agents continued on next page
25
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A “substitution allowed” physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
or PA Generic
Miscellaneous Skin and Mucous Membrane Agents continued from previous page
Regranex
Santyl
Solaraze
Soriatane
Taclonex
Targretin
Tazorac
Vectical
Veregen
Zyclara
none
Miscellaneous
Skin and Mucous
Membrane Agents
(continued)
none
Scabicides and
Pediculicides
phenylephrine, shark liver oil, glycerin and white
petrolatum
phenylephrine, shark liver oil, mineral oil and
white petrolatum
trichloroacetic acid
permethrin
malathion
Acticin*
Eurax
lindane (generic)
Natroba
Ovide*
Ulesfia
piperonyl butoxide and pyrethrins
piperonyl butoxide, pyrethrins, and permethrin
26
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
ALABAMA MEDICAID AGENCY
PDL REFERENCE TOOL – Women’s Health
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
Cenestin
Menest
Premarin (tablets only)
estradiol and norethindrone
estradiol
estradiol valerate
estradiol
Estrogens
norethindrone and ethinyl estradiol
estropipate
none
Prenatal Vitamins
prenatal vitamins, iron, folic acid, DHA, docusate
prenatal vitamins, iron, folic acid, DHA, docusate
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, DHA, docusate
prenatal vitamins, iron, folic acid, docusate
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, omega-3 fatty acids
prenatal vitamins, iron, folic acid, DHA
folic acid, calcium, b vitamins
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, DHA
iron, ascorbic acid, cyanocobalamin, folic acid
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, DHA
Prenatal Vitamins continued on next page
Activella*
Alora
Angeliq
Climara*
Climara Pro
Combipatch
Delestrogen*
Depo-Estradiol
Divigel
Elestrin
Enjuvia
Estrace*
Estraderm
Estrasorb
Estring
Evamist
FemHRT*
Femring
Femtrace
Menostar
Ogen*
Prefest
Premarin (Cream)
Premphase
Prempro
Vagifem
Vivelle-Dot
Citranatal 90 DHA*
Citranatal Assure*
Citranatal B-Calm*
Citranatal DHA*
Citranatal Harmony
Citranatal Rx*
Concept DHA*
Concept OB*
Duet DHA Balanced*
Duet DHA Complete*
Folbecal*
Gesticare*
Gesticare DHA*
Icar-C Plus*
Icar-C Plus SR
Maxinate
Natalvit
Natelle C
Natelle One*
Natelle Plus*
Natelle-ez*
Navatab+DHA*
27
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012
This PDL reference tool is to aid a prescribing physician with generic availability and preferred product status.
A "substitution allowed" physician signature on a prescription should not require a PA to be obtained if a generic agent is available.
DRUG CLASS
NO PA REQUIRED
Preferred Brand
NO PA REQUIRED
Preferred Generic or OTC
PA REQUIRED for NAME
Non-Preferred Brand
Prenatal Vitamins continued from previous page
none
prenatal vitamins, iron, folic acid, l-methylfolate
prenatal vitamins, iron, folic acid, l-methylfolate, DHA
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, DHA, omega-3 fatty
acids
prenatal vitamins, iron, folic acid, omega-3 fatty acids
prenatal vitamins, iron, folic acid, omega-3 fatty acids
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid, docusate, DHA
prenatal vitamins, iron, folic acid, DHA
prenatal vitamins, iron, folic acid, omega-3 fatty acids
prenatal vitamins, iron, folic acid, omega-3 fatty acids
prenatal vitamins, iron, folic acid, omega-3 fatty acids
prenatal vitamins, iron, folic acid, omega-3 fatty acids,
DHA
prenatal vitamins, iron, folic acid, omega-3 fatty acids
Prenatal Vitamins
(continued)
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, omega-3 fatty acids
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, docusate
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, selenium
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, docusate
prenatal vitamins, iron, folic acid, docusate
prenatal vitamins, iron, folic acid
prenatal vitamins, iron, folic acid, DHA
Neevo*
Neevo DHA*
Nexa Select
OB Complete*
OB Complete 400*
OB Complete Premier
OB-Natal One*
OB-Natal One*
Paire OB Plus DHA*
Prefera-OB*
Prefera-OB One
Prefera-OB Plus DHA*
Prenate DHA*
Prenate Elite*
Prenate Essential*
Prenexa*
Prenexa Premier
Preque 10*
PR Natal 400*
PR Natal 400 EC
PR Natal 430*
PR Natal 430 EC*
PR Natal 440EC*
Pruet DHA*
Pruet DHA EC
Select-OB*
Select-OB+DHA
Tandem DHA*
Tandem OB*
Tricare*
Tricare DHA
Tricare Prenatal DHA One
Vinacal*
Vinate AZ
Vinate AZ Extra
Vinate C*
Vinate Calcium
Vinate Care*
Vinate GT
Vinate IC*
Vinate II
Vinate M*
Vinate One*
Vinate PN Care*
Vinate Ultra*
Vitafol-OB*
Vitafol-OB+DHA*
Vitafol-One
Vitafol-PN
Viva DHA
iron, docusate, folic acid
prenatal vitamins, iron, folic acid, DHA, EPA, omega-3
fatty acids
28
*Denotes a generic available in at least one dosage form or strength
**Will be reviewed at a future time when eligible
Effective 04/02/2012