PDL Prior Authorization Implementation Schedule /
PA Start Date / Therapeutic Class / P&T Review Date
7/1/11 / TOP$ (Single Drug Reviews) include:
Antidepressants, Other (Oleptro ER)
Antihistamines, Minimally Sedating (Claritin
Liqui-Gels)
Antipsychotics (Latuda)
Glucocorticoids, Inhaled (Dulera)
Ophthalmics, Antibiotics (Moxeza and
Zymaxid)
Ophthalmics for Allergic Conjunctivitis
(Lastacaft)
Ophthalmics, Anti-Inflammatories (Bromday)
Sedative Hypnotics (Silenor and Zolpimist)
Stimulants and Related Agents (Kapvay) / 5/24/11
10/1/10 / TOP$ (New Classes) include:
Antibiotics, Inhaled
Bile Salts
TOP$ (Single Drug Reviews) include:
Acne Agents, Topical (SE BPO)
Analgesics, Narcotics Long (Exalgo)
Analgesics, Narcotics Short (Rybix ODT)
Immunosuppressives, Oral (Zortress)
MS Agents (Ampyra)
Proton Pump Inhibitors (Zegerid OTC) / 8/19/10
4/1/10 / TOP$ (New Classes) include:
Colony Stimulating Factors
Fibromyalgia Agents
Immunosuppressives, Oral
TOP$ (Single Drug Reviews) include:
Antifungals, Oral (Terbinex)
Anti-Hyperuricemics (Colcrys)
Antiparasitics, Topical (Ulesfia)
Antipsychotics (Saphris; Invega Sustenna)
Cytokine and CAM Antagonists (Simponi;
Stelara)
Hypoglycemics, Incretins (Onglyza)
NSAIDs (Zipsor)
Ophthalmics for Allergic Conjunctivitis
(Bepreve)
Ophthalmics, Anti-Inflammatories (Acuvail;
Ozurdex)
Ophthalmics, Antibiotics (Besivance)
Pancreatic Enzymes (Zenpep)
Platelet Aggregation Inhibitors (Effient)
Stimulants and Related Agents (Intuniv;Nuvigil) / 3/2/10
10/1/09 / TOP$ (New Classes) include:
Antihyperuricemics
Antifungals, Topical
Tetracyclines
TOP$ (Single Drug Reviews) include:
Analgesics, Short-Acting Narcotics (Dilaudid
Liquid)
Anticonvulsants (Banzel; Vimpat)
Bladder Relaxants (Toviaz)
BPH Agents (Rapaflo)
Hypoglycemics, Meglitinides (Prandimet)
Lipotropics, Other (Trilipix)
Phosphate Binders (Eliphos)
Proton Pump Inhibitors (Kapidex; Prilosec
Suspension)
Ulcerative Colitis Agents (Apriso;sfRowasa) / 8/20/09
4/1/09 / TOP$ (New Class) includes:
PAH Agents, Oral
TOP$ (Single Drug Reviews) include:
Antidepressants, Other (Venlafaxine ER)
Antiemetics (Sancuso)
Antifungals, Topical (Xolegel Corepak;
Xolegel Duo)
Anti-Parkinson’s Agents (Requip XL)
Glucocorticoids, Inhaled (Alvesco)
Intranasal Rhinitis Agents (Patanase) / 2/5/09
10/1/08 / TOP$ (New Classes) include:
Analgesics/Anesthetics, Topical
Antibiotics, Vaginal
Antiparasitics, Topical
Pancreatic Enzymes
TOP$ (Single Drug Reviews) include:
Acne Agents, Topical (Atralin)
Antihistamines, Minimally Sedating
(Allegra ODT; cetirizine; cetirizine D;
cetirizine syrup)
Beta Blockers (Bystolic)
Lipotropics, Other (Fenoglide)
Lipotropics, Statins (Simcor)
Phosphate Binders (Renvela) / 8/21/08
4/1/08 / TOP$ (New Classes) include:
Antibiotics, GI
Impetigo Agents, Topical
Skeletal Muscle Relaxants
TOP$ (Single Drug Reviews) include:
Alzheimer’s Agents (Exelon Patch)
Antifungals, Topical (Extina)
Anti-Parkinson’s Agents (Neupro Patch)
Bronchodilators, Long-Acting Beta Agonists
(Brovana and Perforomist)
Glucocorticoids, Inhaled (Symbicort)
Intranasal Rhinitis Agents (Veramyst)
Leukotriene Modifiers (Zyflo CR)
Ophthalmics, Fluoroquinolones and
Macrolides (AzaSite)
Stimulants and Related Agents (Vyvanse) / 2/14/08
10/2/07 / TOP$ (New Classes) include:
Hepatitis B Agents
Ophthalmics, NSAIDs
Atypical Antipsychotics (to be implemented 1/1/08)
TOP$ (Single Drug Reviews) include:
Acne Agents, Topical (Ziana)
Analgesics, Short-Acting Narcotics (Fentora)
Antihistamines, Minimally Sedating (Allegra
Syrup and Claritin Chewable OTC)
Beta Blockers (Coreg CR)
Growth Hormones (Omnitrope)
Proton Pump Inhibitors (Nexium Suspension)
Ulcerative Colitis Agents (Lialda) / 8/9/07
4/3/07 / TOP$ (Single Drug Reviews) include:
Antifungals, Oral (Noxafil)
Antifungals, Topical (Xolegel)
Anti-Parkinson’s Agents (Azilect and Zelapar)
Hypoglycemics, Insulins and Related Agents
(Exubera)
Stimulants and Related Agents (Daytrana) / 2/8/07
10/3/06 / TOP$ (New Class) includes:
Androgenic Agents
TOP$ (Single Drug Reviews) include:
Analgesic Narcotics (Ultram ER)
Hypoglycemics, TZDs (Avandaryl)
Proton Pump Inhibitors (Zegerid- Oral
Solid Forms) / 8/17/06
4/4/06 / TOP$ (New Classes) include:
Acne Agents, Topical
Anticonvulsants
TOP$ (Single Drug Reviews) include:
Bone Resorption Suppressants (Actonel
with Calcium; Fortical)
Fluoroquinolones, Oral (Proquin XR)
Glucocorticoids, Inhaled (Asmanex) / 2/9/06
10/6/05 / TOP$ (New Classes) include:
Alzheimer’s Agents
Anti-Parkinson’s Agents
Atopic Dermatitis
Hypoglycemics, Metformins
Ophthalmics, Glaucoma Agents
Platelet Aggregation Inhibitors
TOP$ (Single Drug Reviews) include:Analgesics, Narcotics (Combunox)
Sedative Hypnotics (Lunesta) / 8/18/05
7/6/05 / TOP$ (New Classes) include:
Anticoagulants, Injectable
Growth Hormones (CLINICAL PA also)
Sedative Hypnotics
Ulcerative Colitis Agents / 3/8/05
1/23/05 / Bronchodilators, Anticholinergics / 12/2/04
11/3/04 / Antidepressants (SSRIs)- Symbyax ONLY
Antimigraine Triptans- Relpax ONLY / 9/23/04
7/21/04 / Antidepressants, SSRIs – Pexeva; Antivirals – Valtrex; Beta Blockers – Innopran XL; Disease Modifying Antirheumatic Drugs; Erectile Dysfunction Agents; Erythropoietins; Hepatitis C Agents; Multiple Sclerosis Agents; NSAIDs – Prevacid Naprapac; Ophthalmics, Allergic Conjunctivitis -- Elestat / 6/10/04
5/19/04 / Antihistamines, Minimally Sedating; Phosphate Binders / 3/18/04
5/12/04 / Antidepressants, Other; Beta Blockers – Inderal LA and Innopran XL; Bladder Relaxants; Lipotropics, Statins – Crestor; Ophthalmics, Allergic Conjunctivitis; Ophthalmics, Antibiotics; Otics, Antibiotics / 3/18/04
2/4/04 / Antidepressants, SSRIs; Antiemetics; Beta-Agonist Bronchodilators; Claudication Agents; Hypoglycemics, Meglitinides; Stimulants and Related Agents / 12/11/04
1/21/04 / Antifungals, Oral; Cephalosporins and Related Antibiotics; Antifungals, Topical; Hypoglycemics, Insulins / 10/23/03
1/7/04 / Antimigraine Agents, Triptans; Analgesics, Narcotic; Bone Resorption Suppression and Related Agents; Estrogen Agents, Combination;Estrogen Agents, Oral and Transdermal / 10/23/03
12/17/03 / Macrolides; Antivirals; Hypoglycemics, Thiazolidinediones; Fluoroquinolones / 10/23/03
12/03/03 / ACE Inhibitors; Calcium Channel Blocking Agents; Lipotropics, Statins / 9/10/03
11/19/03 / Angiotensin Receptor Blockers; Nasal Corticosteroids; NSAIDs/COX II Inhibitors / 9/10/03
11/05/03 / ACE Inhibitor/Calcium Channel Blocker Combination; Benign Prostatic Hyperplasia; Beta Blockers; Inhaled Corticosteroids; Leukotriene Receptor Antagonists; Lipotropics, Other; Proton Pump Inhibitors / 9/10/03