AETNA BETTER HEALTH® Illinois formulary
Revised 8/2015
ILLINOIS FORMULARY REVISED August 2015
What is the Aetna Better Health Illinois Formulary? This is a drug list created by Aetna Better Health (“plan”). Aetna Better Health will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, Aetna Better Health will cover the drug. Drugs must also be filled at an Aetna Better Health network pharmacy. Can Aetna Better Health’s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website. How do I use Aetna Better Health’s formulary? • • •
Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: lists the brand name of the drug when a generic is covered Column #3: shows coverage rules for the drug
Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. How much will I pay for covered drugs? You do not have to pay for covered drugs. What are some types of coverage rules? •
Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.
•
Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.
•
Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For Page 1
ILLINOIS FORMULARY REVISED August 2015
example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on Aetna Better Health’s formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: • •
Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process.
What are generic drugs? Aetna Better Health covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan.
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ILLINOIS FORMULARY REVISED August 2015
¿Qué es el formulario de Aetna Better Health para Illinois? Es una lista de medicamentos creada por Aetna Better Health (el “plan”). Aetna Better Health ofrece cobertura para los medicamentos de esta lista. Es posible que para algunos medicamentos se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos, Aetna Better Health los cubrirá. Además, los medicamentos deben adquirirse en una farmacia de la red de Aetna Better Health. ¿Puede cambiar la lista de medicamentos de Aetna Better Health? El plan puede agregar o quitar medicamentos de la lista. Todas las eliminaciones de medicamentos del formulario se enviarán al estado, donde se revisarán antes de que se realice el cambio. Los miembros y proveedores que utilizan el formulario recibirán un aviso como mínimo 30 días antes de que se elimine un medicamento del formulario. Encontrará todos los cambios del formulario en el sitio en Internet del plan. ¿Cómo utilizo el formulario de Aetna Better Health? •
• •
Columna Nº 1: enumera los medicamentos cubiertos. Los medicamentos de marca aparecen en mayúscula (por ejemplo, MEDICAMENTO); los genéricos aparecen en minúscula (por ejemplo, medicamento). Columna Nº 2: enumera los medicamentos de marca cuando una opción genérica está cubierta. Columna Nº 3: muestra las reglas de cobertura de los medicamentos.
Los medicamentos también están agrupados según el tipo de condición que tratan. Por ejemplo, los medicamentos que se usan para tratar un dolor de oído figuran en la sección, Ear-Nose-Throat Medications. Si sabe para qué se usa el medicamento que usted toma, busque el nombre de esa sección en la lista de medicamentos y luego busque el medicamento en esa sección. ¿Cuánto pagaré por los medicamentos cubiertos? Usted no tiene que pagar por los medicamentos cubiertos. ¿Cuáles son algunos de los tipos de reglas de cobertura? • •
Aprobación previa (PA): significa que su médico primero deberá obtener la aprobación del plan antes de que se pueda adquirir el medicamento en la farmacia. Si no se aprueba, el plan no cubrirá el medicamento. Límites de cantidad (QLL): significa que el plan cubre hasta una cierta cantidad del medicamento. Por ejemplo, en el caso de algunos medicamentos, el plan cubre 60 píldoras en 30 días. Page 3
ILLINOIS FORMULARY REVISED August 2015
•
Terapia escalonada (ST): significa que posiblemente primero deba probar ciertos medicamentos para tratar su condición. Después de probar el primer medicamento, el plan cubrirá el otro medicamento para la misma condición. Por ejemplo, el Medicamento A y el Medicamento B pueden tratar su condición. Es posible que el plan no cubra el Medicamento B a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona en su caso, entonces se cubrirá el Medicamento B.
¿Qué sucede si el medicamento que tomo no está incluido en el formulario de Aetna Better Health? Primero, llame a su médico y pregúntele si su medicamento está cubierto. Si el plan no lo cubre, usted tiene dos opciones: • •
Pida a su médico un medicamento similar que esté cubierto. Su médico puede solicitar que el plan cubra el medicamento a través del proceso de aprobación previa.
¿Qué son los medicamentos genéricos? Aetna Better Health cubre tanto medicamentos de marca como genéricos. Los medicamentos genéricos cuestan menos y están aprobados por la Administración de Drogas y Alimentos (FDA). ¿Los medicamentos de venta libre están cubiertos? El plan cubrirá los medicamentos de venta libre que figuren en el formulario. Es posible que para algunos medicamentos de venta libre se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos de venta libre, el plan los cubrirá. Al igual que con otros medicamentos, se requiere una receta del médico para que el plan brinde cobertura para los medicamentos de venta libre.
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ILLINOIS FORMULARY REVISED August 2015 COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
ANESTHETICS
DRUGS USED TO RELIEVE PAIN IN SPECIFIC AREAS
ANESTÉSICOS
MEDICAMENTOS UTILIZADOS PARA ALIVIAR EL DOLOR EN ÁREAS ESPECÍFICAS TOPICAL ANESTHETICS / ANESTÉSICOS TÓPICOS lidocaine hcl Xylocaine lidocaine hcl viscous Xylocaine lidocaine-prilocaine Emla
ANTIINFECTIVES
DRUGS USED TO TREAT BACTERIAL, FUNGAL, OR VIRAL INFECTIONS
ANTIINFECCIOSOS
MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES CAUSADAS POR BACTERIAS, HONGOS O VIRUS CEPHALOSPORINS / CEFALOSPORINAS Cefaclor Ceclor cefaclor er Ceclor ER cefadroxil Duricef Cefdinir Omnicef cefpodoxime proxetil Vantin cefprozil Cefzil cefuroxime Ceftin Cephalexin 250mg, 500mg only Keflex ceftriaxone Rocephin QLL=2 grams/Rx cefuroxime axetil Ceftin SUPRAX QLL= 1 tab/Rx CLINDAMYCINS / CLINDAMICINAS CLEOCIN GRANULES clindamycin Cleocin ERYTHROMYCINS / ERITROMICINAS erythromycin Eryc erythromycin ethylsuccinate E.E.S. erythromycin w/sulfisoxazole Pediazole OTHER MACROLIDES / OTROS MACRÓLIDOS azithromycin Zithromax QLL for 250 mg=12 tabs/30 days QLL for 600 mg=8 tabs/30 days clarithromycin, er Biaxin, Biaxin XL QLL=28 tabs/30 days PENICILLINS / PENICILINAS amox tr-potassium clavulanate Augmentin QLL=28/30 days amoxicillin Amoxil ampicillin Principen dicloxacillin penicillin v potassium Veetids
ILLINOIS FORMULARY REVISED August 2015
COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
SULFONAMIDES / SULFONAMIDAS sulfamethoxazole/trimethoprim Septra sulfadiazine sulfatrim pediatric suspension TETRACYCLINES / TETRACICLINAS demeclocycline doxycycline Vibramycin minocycline hcl Dynacin tetracycline hcl Sumycin URINARY ANTIINFECTIVES / ANTIINFECCIOSOS URINARIOS FURADANTIN (25 MG/5 ML SUSPENSION) MACRODANTIN (25 MG ONLY) methenamine hippurate nitrofurantoin, Macrodantin nitrofurantoin macrocrystal Macrobid nitrofurantoin mono/macrocrystals trimethoprim
QUINOLONES / QUINOLONAS ciprofloxacin er ciprofloxacin hcl ofloxacin levofloxacin tablets, soln
Cipro XR Cipro Floxin Levaquin
QLL=3 tabs/Rx QLL=28 tabs/30 days QLL=14 tabs/90 days
TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES TÓPICOS OTC bacitracin topical ointment bacitracin/polymyxin B chlorhexidine gluconate erythromycin gentamicin sulfate mupirocin ointment, cream silver sulfadiazine sulfacetamide sodium OTC triple antibiotic cream
Polysporin Peridex Eryderm Genoptic Bactroban Silvadene Ovace Neosporin
ORAL ANTIFUNGAL DRUGS / MEDICAMENTOS ANTIFÚNGICOS ORALES clotrimazole fluconazole GRISEOFULVIN TAB MICR 500mg griseofulvin 125 mg/5 ml suspension GRISEOFULVIN TAB ULTR
Mycelex Diflucan GRIFULVIN V GRIS-PEG
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ILLINOIS FORMULARY REVISED August 2015
COVERED DRUG MEDICAMENTO CUBIERTO itraconazole capsule ketoconazole nystatin SPORANOX (ORAL SOLUTION) terbinafine Terbinafine topical
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Sporanox Nizoral Mycostatin Lamisil
STEP
QLL=84 tabs/year
VAGINAL ANTIFUNGALS / MEDICAMENTOS ANTIFÚNGICOS VAGINALES OTC clotrimazole miconazole 200 mg suppositories nystatin terconazole
Mycelex Monistat 3 Mycostatin Terazol
OTHER TOPICAL ANTIFUNGALS / OTROS MEDICAMENTOS ANTIINFECCIOSOS ciclopirox OTC clotrimazole econazole nitrate ketoconazole OTC miconazole 2% nystatin
Loprox/Penlac Lotrimin Spectazole Nizoral
TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB / CORTICOSTEROIDES Y ANTIFÚNGICOS TÓPICOS COMBINADOS clotrimazole/betamethasone nystatin w/triamcinolone
Lotrisone Mycolog II
ANTIRETROVIRALS & PROTEASE INHIBITORS /ANTIRRETROVIRALES E INHIBIDORES DE LA PROTEASA Abacavir; Lamivudine, 3TC; Zidovudine, ZDV APTIVUS ATRIPLA LAMIVUDINE/ZIDOVUDINE COMPLERA CRIXIVAN didanosine EDURANT EMTRIVA EPIVIR Lamivudine, 3TC EPZICOM
TRIZIVIR
COMBIVIR
EPIVIR HBV
FUZEON INTELENCE
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ILLINOIS FORMULARY REVISED August 2015 INVIRASE KALETRA LEXIVA Nevirapine, Nevirapine ER tabs, oral solution
COVERED DRUG MEDICAMENTO CUBIERTO NORVIR PREZISTA RESCRIPTOR REYATAZ Stavudine STRIBILD SUSTIVA Tivicay
Viramune, Viramune XR
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Zerit
Triumeq TRUVADA VIDEX SOLUTION, CHEWABLE TABS VIRACEPT VIRAMUNE XR 100mg only VIREAD Vitekta ABACAVIR Zidovudine
ZIAGEN
OTHER ANTIINFECTIVE DRUGS / OTROS MEDICAMENTOS ANTIINFECCIOSOS CLEOCIN (100 MG VAGINAL OVULE) Dapsone atovaquone suspension
MEPRON
OTHER ANTIVIRAL DRUGS / OTROS MEDICAMENTOS ANTIVIRALES Acyclovir amantadine hcl Entecavir Famciclovir Ganciclovir ISENTRESS PEGINTRON PEGINTRON REDIPEN PEGASYS
Zovirax Symmetrel
STEP; COVERED FOR ID SPECIALISTS QLL=90 caps or tabs/30 days
BARACLUDE Famvir
PA PA PA
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ILLINOIS FORMULARY REVISED August 2015 Rimantadine REBETOL (ORAL SOLUTION) RELENZA Ribavirin
Flumadine
COVERED DURING FLU SEASON (OCT 1, 2014 TO April 30, 2015); QLL=7 tabs/30 days MUST BE ON INTERFERON COVERED DURING FLU SEASON (OCT 1, 2014 TO April 30, 2015); QLL/Rx=20 inhalation diskus/Rx MUST BE ON INTERFERON
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ILLINOIS FORMULARY REVISED August 2015
COVERED DRUG MEDICAMENTO CUBIERTO Sovaldi
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES PA QLL=14 tabs/14 days
SELZENTRY TAMIFLU
TYZEKA Valacyclovir
Valtrex
ZOVIRAX (5% CREAM, OINTMENT)
COVERED DURING FLU SEASON (OCT 1, 2014 TO april 30, 2015); QLL=75mg 10 capsules/Rx; 45mg=10 capsules /Rx; 30mg=20 capsules/Rx; 12mg/ml oral suspension=3 bottles/Rx COVERED FOR GASTROENTEROLOGISTS OR ID SPECIALISTS; ALL OTHERS REQUIRE PA 500 mg tablet QLL=60 tabs/30 days 1 gram tablet QLL=30 tabs/30 days
ANTITUBERCULOSIS DRUGS / MEDICAMENTOS ANTITUBERCULOSOS Ethambutol Isoniazid Rifabutin PRIFTIN Pyrazinamide Rifampin
Myambutol Nydrazid MYCOBUTIN
Rifadin
AMEBICIDES / AMIBICIDAS YODOXIN
ANTHELMINTICS / ANTIHELMÍNTICOS ALBENZA Mebendazole Ivermectin
STROMECTOL
PLASMODICIDES / PLASMODICIDAS chloroquine phosphate DARAPRIM hydroxychloroquine sulfate Mefloquine
Plaquenil Lariam
TRICHOMONOCIDES / TRICOMONICIDAS Metronidazole
Flagyl
AMINOGLYCOSIDES / AMINOGLUCÓSIDOS Neomycin Paromomycin
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ILLINOIS FORMULARY REVISED August 2015
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
DRUGS USED FOR CANCER TREATMENT, TRANSPLANTS OR OTHER RARE CONDITIONS Medications within this class are covered for FDA-approved indications and may require prior authorization. All injectable medications within this class require prior authorization.
MEDICAMENTOS INMUNOSUPRESORES/ANTINEOPLÁSICOS
MEDICAMENTOS UTILIZADOS PARA EL TRATAMIENTO DEL CÁNCER, ENFERMEDADES RARAS O TRASPLANTES
Los medicamentos de esta clase están cubiertos para el uso según las indicaciones aprobadas por la FDA y pueden requerir autorización previa. Todos los medicamentos inyectables dentro de esta clase requieren autorización previa.
anagrelide capsules anastrozole tablets AZASAN azathioprine tablets Bicalutamide CEENU CAPSULE CELLCEPT oral susp cyclophosphamide caps cyclosporine capsule, oral soln DROXIA CAPSULE EMCYT CAPSULE ENBREL etoposide capsule Exemestane FARESTON TABLET fluorouracil cream, solution flutamide capsule GLEEVEC HEXALEN CAPSULE HUMIRA HYCAMTIN CAPSULE hydroxyurea capsule, tablet IRESSA TABLET leflunomide tablet leucovorin tablet LEUKERAN TABLET Letrozole LYSODREN TABLET MATULANE CAPSULE megestrol acetate suspension, tablet mercaptopurine tablet MESNEX TABLET methotrexate tablet
Agrylin Arimidex Imuran Casodex
Cytoxan Sandimmune
PA Vepesid Aromasin Efudex
PA PA Hydrea Arava
COVERED FOR RHEUMATOLOGISTS; ALL OTHERS REQUIRE PA
Femara
Megace Purinethol Trexall Page 11
ILLINOIS FORMULARY REVISED August 2015
mycophenolate 250 mg capsules, 500 mg tablets mycophenolate 180mg, 360mg tablet NEXAVAR TABLET NILANDRON TABLET RAPAMUNE ORAL SOLN Sirolimus tablets TABLOID TABLET tacrolimus capsule tamoxifen citrate tablet TARCEVA TABLET TARGRETIN TOPICAL GEL, Bexarotene TABLET tretinoin capsule, cream, gel, solution TYKERB TABLET
CellCept MYFORTIC TABLET
PA
Rapamune Prograf Nolvadex
PA
TARGRETIN Tablet Vesinoid
PA
AUTONOMIC AND CNS MEDICATIONS
DRUGS USED FOR PAIN MANAGEMENT AND OTHER BEHAVIORAL CONDITIONS (E.G, ANXIETY, DEPRESSION, DIFFICULTY SLEEPING, SEIZURES, ETC.)
MEDICAMENTOS PARA TRATAR AFECCIONES DEL SISTEMA NERVIOSO CENTRAL Y AUTÓNOMO
MEDICAMENTOS UTILIZADOS PARA CONTROLAR EL DOLOR Y OTRAS CONDICIONES DEL COMPORTAMIENTO (POR EJEMPLO, ANSIEDAD, DEPRESIÓN, DIFICULTADES PARA DORMIR, CONVULSIONES, ETC.)
ALCOHOL ANTAGONIST / ANTAGONISTAS DEL ALCOHOL DISULFIRAM Naltrexone
ANTABUSE
ANALGESICS / ANALGÉSICOS OTC acetaminophen tablets, capsules, suppositories, liquids, drops tramadol hcl tramadol hcl-acetaminophen Tramadol ER
Tylenol
QLL= up to 4 grams APAP/day
Ultram Ultracet
QLL=240 tabs/30 days QLL= 4 grams APAP/day QLL=30 tabs/30 days
CLASS II NARCOTICS / DROGAS CLASE II codeine sulfate fentanyl patches fentanyl lozenges hydromorphone hcl methadone hcl morphine sulfate ER Morphine sulfate IR oxycodone-acetaminophen oxycodone-aspirin
Duragesic Actiq Dilaudid Dolophine MS Contin Percocet
QLL=30 tabs/30 days PA; QLL=10 patches/30 days QLL=90 lozenges /30 days QLL for 8 mg=120 tabs/30 days PA; QLL=540 tabs/30 days
PA; QLL=90/30 days QLL=240 tabs/30 days or up to 4 grams APAP/day QLL=240 tabs/30 days Page 12
ILLINOIS FORMULARY REVISED August 2015 oxycodone hcl
Oxyir
OXYCONTIN Oxymorphone ER
QLL for 5 mg=240 tabs/30 days, 10 mg, 15 mg, 20 mg, or 30 mg=150 tabs/30 days PA/QLL=90 tabs/30 days
Opana ER
PA; QLL= 60/30 DAYS
acetaminophen-codeine Buprenorphine hydrocodone-acetaminophen (excludes combinations with 300mg acetaminophen strengths)
Tylenol #3 Subutex
QLL= 4 grams APAP/day PA; QLL=15 tabs/365 days QLL= 4 grams APAP/day
hydrocodone bit-ibuprofen SUBOXONE FILM, buprenorphine/naloxone SL tabs
Vicoprofen
QLL=240 tabs/30 days PA; 2mg/0.5mg QLL=90 /30 days 4mg/1mg QLL=180/30 days 8mg/2mg QLL=90/30 days 12mg/3mg QLL=60/days Transition of Care
CLASS III NARCOTICS / DROGAS CLASE III
DRUGS TO PREVENT AND TREAT HEADACHES / MEDICAMENTOS PARA PREVENIR Y TRATAR DOLORES DE CABEZA butalbital/acetaminophen/caffeine (50/325/40) butalbital/acetaminophen/caffeine/ codeine (50/325/40/30) butalbital/aspirin/caffeine (50/325/40) butalbital compound capsule (50/325/40/30) butorphanol nasal spray ERGOMAR ergotamine/caffeine Sumatriptan sumatriptan (inj) MIGRANAL RELPAX
Esgic/Fioricet/Triad Fioricet w/codeine Fiorinal, Fortabs Fiorinal w/codeine Stadol Cafergot Imitrex Imitrex
QLL=1 bottle/30 days
QLL=6 nasal sprays/30 days; 9 tabs/30 days QLL=4 vials/30 days; 2 kits/30 days QLL=8 units/30 days QLL=6 tabs/30 days
ANXIOLYTICS / ANSIOLÍTICOS alprazolam, -XR, intensol solution buspirone hcl chlordiazepoxide hcl clorazepate dipotassium Clonazepam diazepam 2.5 mg, 10 mg, 20 mg rectal gel Diazepam
Xanax, XR Buspar Librium Tranxene T-Tab Klonopin
QLL=90 tabs/30 days
QLL=2 pkgs/30 days Valium Page 13
ILLINOIS FORMULARY REVISED August 2015 Lorazepam, 2mg/ml injection
Ativan
Meprobamate Oxazepam
Serax
QLL=3/34 DAYS (INJECTION: QLL and no PA for LTC members)
SEDATIVE & HYPNOTIC DRUGS / MEDICAMENTOS HIPNÓTICOSY SEDANTES Estazolam flurazepam hcl temazepam 7.5 mg, 15 mg, & 30 mg ROZEREM
Dalmane Restoril
QLL=30 tabs/30 days QLL=30 caps/30 days QLL=30 caps/30 days QLL=30 tabs/30 days
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ILLINOIS FORMULARY REVISED August 2015
Zaleplon Zolpidem 5mg, 10mg
Sonata Ambien
QLL=30 caps/30 days QLL=30 tabs/30 days
ANTIMANIA DRUGS / ANTIMANÍACOS lithium carbonate
Eskalith/CR
lithium citrate
CARBAMAZEPINES / CARBAMAZEPINAS Carbamazepine carbamazepine ER CARBATROL oxcarbazepine tablets, suspension
Tegretol Tegretol XR
QLL=120/30 days
Trileptal
ANTICONVULSAN AND BENZODIAZEPINES / ANTICONVULSIVOS Y BENZODIACEPINAS Clonazepam
Klonopin
HYDANTOINS / HIDANTOÍNAS
phenytoin sodium, extended DILANTIN INFATABS, DILANTIN 30 MG EXTENDED RELEASE PHENYTEK
Dilantin, ER
VALPROIC ACID AND DERIVATIVES / ÁCIDO VALPÓRICO Y DERIVADOS DEPAKOTE ER, DELAYED RELEASE,SPRINKLE divalproex sodium ER, delayed-release valproic acid
Depakote ER, Delayed-Release Depakene
ANTICONVULSANT BARBITURATES / BARBITÚRICOS UTILIZADOS PARA EVITAR CONVULSIONES Mephobarbital Phenobarbital Primidone
Mebaral Mysoline
OTHER ANTICONVULSANTS / OTROS MEDICAMENTOS UTILIZADOS PARA EVITAR CONVULSIONES CELONTIN Ethosuximide Felbamate Gabapentin GABITRIL Lamotrigine Levetiracetam NEURONTIN SOLUTION Topiramate Zonisamide
FELBATOL Neurontin
QLL=180 units/30 days QLL=60 tabs/30 days
Lamictal Keppra Topamax Zonegran
QLL=180 units/30 days
MAO INHIBITORS / INHIBIDORES DE MAO MARPLAN NARDIL Tranylcypromine
Parnate
TERTIARY AMINES / AMINAS TERCIARIAS amitriptyline hcl
Elavil Page 15
ILLINOIS FORMULARY REVISED August 2015
Clomipramine doxepin hcl imipramine hcl, IMIPRAMINE PAMOATE
Anafranil Sinequan Tofranil,PM
Trimipramine
Surmontil
PAMOATE ONLY-COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRE PA
SECONDARY AMINES / AMINAS SECUNDARIAS Amoxapine desipramine hcl nortriptyline hcl Protriptyline
Norpramin Pamelor
SELECTIVE SEROTONIN REUPTAKE INHIBITOR / INHIBIDORES SELECTIVOS DE LA RECAPTACIÓN DE LA SEROTONINA Citalopram
Celexa
Escitalopram
Lexapr o Prozac
fluoxetine hcl fluvoxamine maleate
Luvox
paroxetine hcl
Paxil
Pexeva Pristiq sertraline hcl
Zoloft
OTHER ANTIDEPRESSANTS / OTROS ANTIDEPRESIVOS amitriptyline/ chlordiazepoxide budeprion sr bupropion, xl, sr
Maprotiline mirtazapine, ODT trazodone hcl 50 mg, 100 mg, & 150 mg venlafaxine, ER (ER capsules only) Duloxetine
Wellbutrin SR Wellbutrin
Remeron Desyrel Effexor, Effexor XR Cymbalta
QLL=30 tabs/30 days or 300 ml/30 days QLL=30 tab/30 days
QLL for 10 mg=30 caps/30 days; 20 mg, 40 mg= 60 tabs/caps/ 30 days; soln=150 ml/30 days QLL for 100 mg=90 tabs/30 days; 50 mg=60 tabs/30 days; 25 mg= 30 tabs/30 days QLL=60 tabs/30 days; soln=300 ml/30 days COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRE PA COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRE PA QLL for 25 mg=30 tabs/30 days; 50 mg or 100 mg=60 tabs/30 days; soln=75 ml/30 days
QLL=60 tabs/30 days QLL=90 tabs/30 days (IR); 60 tabs/30 days (SR 12 hr); 30 tabs/30 days (XL 24 hr) QLL=30 tabs/30 days
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ILLINOIS FORMULARY REVISED August 2015
ANTIVERTIGO AND ANTIEMETIC DRUGS / MEDICAMENTOS ANTIEMÉTICOS Y PARA TRATAR EL VÉRTIGO Granisetron
Kytril
Meclizine ondansetron hcl
COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA
Zofran
ondansetron ODT
Zofran ODT
prochlorperazine maleate promethazine hcl EMEND
Compazine Phenergan
COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA
COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA
ANTIPARKINSON ANTICHOLINERGIC DRUGS / MEDICAMENTOS ANTICOLINÉRGICOS PARA TRATAR EL MAL DE PARKINSON benztropine mesylate, injection
QLL=3/34 DAYS (INJECTION ONLY COVERED FOR LTC RESIDENTSsidents)
Trihexyphenidyl
OTHER ANTIPARKINSON DRUGS / OTROS MEDICAMENTOS PARA TRATAR EL MAL DE PARKINSON bromocriptine mesylate 2.5 mg carbidopa/levodopa
Parlodel Sinemet
Entacapone
COMTAN
Pramipexole
Mirapex
Ropinirole
Requip
Selegiline carbidopa/levodopa/entacapone
STALEVO
COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA; QLL=120 tabs/30 days COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA; QLL=90 tabs/30 days COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA; QLL=270 tabs/30 days
ANTIPSYCHOTIC DRUGS / ANTIPSICÓTICOS chlorpromazine tablets, 25mg/ml ampules clozapine 12.5 mg, 25 mg, & 100 mg fluphenazine tablets, decanoate injection, hydrochloride injection
25mg/ml ampules COVERED for LTC RESIDENTS ONLY; all others require PA; QLL=3 AMP/34 Prolixin
(HCL INJ ONLY-QLL=1/34 DAYS COVERED for LTC RESIDENTS)
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ILLINOIS FORMULARY REVISED August 2015
haloperidol tablets, decanoate injection, lactate injection
(LACTATE INJ ONLY-covered for LTC RESIDENTS; all others require PA; QLL=3/34 DAYS) COVERED FOR PSYCHIATRISTS and COVERED FOR LTC RESIDENTS; ALL OTHERS REQUIRE PA COVERED FOR PSYCHIATRISTS, ALL OTHERS REQUIRE PA
INVEGA SUSTENNA Latuda Loxapine olanzapine, olanzapine ODT
Zyprexa Zyprexa Zydis
Orally Disintegrating Tablet (ODT) ONLY- COVERED FOR PSYCHIATRISTS, ALL OTHERS REQUIRE PA
Risperdal, Risperdal M-Tab
QLL=60 tabs/30 days COVERED FOR PSYCHIATRISTS AND FOR LTC RESIDENTS, ALL OTHERS REQUIRE PA QLL=1/14 DAYS QLL=90 tabs/30 days; 300 mg=60 tabs/30 days COVERED FOR PSYCHIATRISTS, ALL OTHERS REQUIRE PA
Perphenazine risperidone, odt Risperdal Consta
Quetiapine
Seroquel
Saphris Thioridazine Thiothixene Trifluoperazine Ziprasidone
Geodon
CNS STIMULANT DRUGS / MEDICAMENTOS PARA ESTIMULAR EL SISTEMA NERVIOSO CENTRAL amphetamine/dextroamphetamine
Dextroamphetamine dexmethylphenidate IR methylin, er tabs, methylin suspension methylphenidate er, sr 10 mg , 20 mg (methylphenidate ER 18 mg, 27 mg, 35 mg, 54 mg are non-formulary and requires PA) methylphenidate hcl methylphenidate ER capsule
Adderall, Adderall XR
Focalin
Ritalin, Ritalin-SR Ritalin-SR Ritalin METADATE CD, Ritalin LA
STRATTERA
PA less than 6yrs and over 18 years; Immediate release QLL=90 tabs/30 days; Extended release QLL=30 PA less than 6yrs and over 18 years; PA less than 6yrs and over 18 years; PA less than 6yrs and over 18 years; QLL=120 tabs/30 days PA less than 6yrs and over 18 years PA less than 6yrs and over 18 years; QLL=120 tabs/30 days PA less than 6yrs and over 18 years; QLL=60 caps/30 days PA; QLL=60 caps/30 days
ANTIDEMENTIA DRUGS / MEDICAMENTOS PARA TRATAR LA DEMENCIA donepezil 5 MG, 10 MG (23 MG IS NON-FORMULARY)
Aricept
QLL=30 tabs/30 days Page 18
ILLINOIS FORMULARY REVISED August 2015 donepezil ODT
Aricept ODT
QLL=30 tabs/30 days
galantamine, -ER
Razadyne, Razadyne ER
galantamine QLL=60 tabs/30 days galantamine ER QLL=30 caps/30 days
Memantine rivastigmine capsules
NAMENDA Exelon capsules
QLL=60 caps/30 days
SMOKING CESSATION DRUGS / MEDICAMENTOS PARA DEJAR DE FUMAR Buproban
Zyban
CHANTIX OTC nicotine patch
Nicoderm
Duration for all formulary smoking cessation meds=84 days/year Duration for all formulary smoking cessation meds=84 days/year Duration for all formulary smoking cessation meds=84 days/year
OTHER CNS DRUGS / OTROS MEDICAMENTOS QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL caffeine citrate oral solution Pyridostigmine
CARDIOVASCULAR MEDICATIONS
DRUGS USEDFOR HEART CONDITIONS (HIGHBLOODPRESSURE,CHOLESTEROL,CHEST PAIN,ETC.)
MEDICAMENTOS PARA TRATAR ENFERMEDADES CARDIOVASCULARES
MEDICAMENTOS UTILIZADOS PARA TRATAR CONDICIONES DEL CORAZÓN (POR EJEMPLO, PRESIÓN SANGUÍNEA ALTA, COLESTEROL, DOLOR EN EL PECHO, ETC.)
CARDIAC GLYCOSIDES / GLUCÓSIDOS CARDÍACOS Digoxin LANOXIN
Lanoxin
CALCIUM ANTAGONISTS / SOBREDOSIS DE ANTAGONISTAS DEL CALCIO Amlodipine
cartia xt diltiazem er diltiazem hcl diltia xt dilt-CD felodipine er Isradipine nicardipine hcl nifediac cc nifedipine, er Nimodipine Nisoldipine verapamil, er
Norvasc Cardizem CD Tiazac/Taztia XT, Cardizem SR Cardizem Cardizem CD Cardizem CD Plendil DynaCirc Cardene Procardia Procardia XL Nimotop Sular Verelan/Calan/Calan SR
QLL= 30 tabs/30 days 10mg; 60tabs /30 days 5mg; 120 tabs/30 days 2.5mg QLL=60 caps or tabs/30 days QLL=120 tabs/30 days
Extended Release QLL=90 tabs/30 days
QLL=60 tabs/30 days QLL for Immediate Release=120 units/30days; QLL for Extended Release=60 units/30 days Page 19
ILLINOIS FORMULARY REVISED August 2015 CARBONIC ANHYDRASE INHIBITORS / INHIBIDORES DE LA ANHIDRASA CARBÓNICA
Page 20
ILLINOIS FORMULARY REVISED August 2015
acetazolamide, ER
Diamox
LOOP DIURETICS / DIURÉTICOS DE ASA Bumetanide Furosemide Torsemide
Bumex Lasix Demadex
THIAZIDE AND RELATED DRUGS / TIAZIDA Y MEDICAMENTOS RELACIONADOS Chlorthalidone Chlorothiazide Hydrochlorothiazide Indapamide Methyclothiazide Metolazone
Microzide Lozol Zaroxolyn
POTASSIUM SPARING DIURETICS / DIURÉTICOS QUE NO AFECTAN EL POTASIO Amiloride amiloride hcl w/hctz Spironolactone spironolactone w/hctz triamterene w/hctz
Midamor Moduretic Aldactone Aldactazide Maxzide/Diazide
BETA-ADRENERGIC ANTAGONIST DRUGS / ANTAGONISTAS BETA ADRENÉRGICOS Acebutolol Atenolol Betaxolol bisoprolol fumarate Carvedilol labetalol hcl metoprolol succinate metoprolol tartrate Nadolol Pindolol propranolol, er timolol maleate
Tenormin Kerlone Zebeta Coreg Normodyne/Trandate Toprol XL Lopressor Corgard Inderal/LA
VASODILATOR ANTIHYPERTENSIVES / ANTIHIPERTENSORES VASODILATORES doxazosin mesylate hydralazine hcl Minoxidil prazosin hcl terazosin hcl
Cardura Appresdine Minipress Hytrin
QLL=30 tabs/30 days
QLL 1mg, 2mg, 5mg=30/30 days; QLL 10 mg=60/30 days
CENTRALLY ACTING ANTIHYPERTENSIVES / ANTIHIPERTENSORES DE ACCIÓN CENTRAL clonidine patches clonidine tablets guanfacine hcl
Catapres TTS Catapres Tenex
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ILLINOIS FORMULARY REVISED August 2015
methyldopa
ANGIOTENSIN CONVERTING ENZYME INHIBITORS / ANTAGONISTAS DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA Benazepril Captopril Enalapril Fosinopril Lisinopril
Lotensin Capoten Vasotec Monopril Prinivil/Zestril
Moexipril perindopril Ramipril Quinapril trandolapril
Univasc Aceon Altace Accupril Mavik
QLL=30 tabs/30 days; 40 mg=60 tabs/30 days
ANGIOTENSIN II RECEPTOR ANTAGONISTS / ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II BENICAR, Benicar HCT
Valsartan, Valsartan HCTZ
DIOVAN, Diovan HCT
Losartan, Losartan HCTZ
Cozaar,Hyzaar
Irbesartan, Irbesartan HCTZ
Avapro, Avilide
STEP; COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA; QLL=30 tabs/30 days QLL=60 tabs/30 days;
OTHER ANTIHYPERTENSIVES / OTROS ANTIHIPERTENSIVOS amlodipine/benazepril 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20 mg, 10/40 mg atenolol w/chlorthalidone benazepril hcl w/hctz bisoprolol fumarate w/hctz captopril w/hctz enalapril maleate w/hctz fosinopril w/hctz lisinopril w/hctz methyldopa w/hctz metoprolol w/hctz moexipril w/hctz propranolol hcl w/hctz quinapril w/hctz Resperine
Lotrel 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20, 10/40 mg Tenoretic Lotensin HCT Ziac Capozide Vaseretic Monopril HCT Prinzide/Zestoretic Lopressor HCT Uniretic Inderide Quinaretic
NITRATES / NITRATOS isosorbide dinitrate, ER
Isochron/Isordil Page 22
ILLINOIS FORMULARY REVISED August 2015 isosorbide mononitrate, ER nitro-bid ointment nitroglycerin (patch, sublingual tablet, extended-release capsule) NITROSTAT
Imdur/Ismo/Monoket Nitro-Dur/Nitrostat
OTHER VASODILATING DRUGS / OTROS MEDICAMENTOS VASODILATADORES ADCIRCA
SILDENAFIL
REVATIO
CLASS 1A ANTIARRHYTHMICS / ANTIARRÍTMICOS DE CLASE 1A disopyramide, er Procainamide quinidine gluconate quinidine sulfate
COVERED FOR CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA/QLL=60 tabs/30 days COVERED FOR CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA/QLL=90 tabs/30 days
Norpace
CLASS 1B Antiarrhythmic / ANTIARRÍTMICOS DE CLASE 1B Mexiletine
Mexitil
CLASS 1C Antiarrhythmics / ANTIARRÍTMICOS DE CLASE 1C flecainide acetate propafenone hcl
Tambocor Rythmol
OTHER ANTIARRHYTHMICS / OTROS ANTIARRÍTMICOS Amiodarone
Pacerone
MULTAQ sotalol, af
Betapace
COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA
COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA
HYPOLIPOPROTEINEMICS / HIPOLIPOPROTEINÉMICOS Cholestyramine colestipol hcl Fenofibrate Gemfibrozil OTC niacin OTC SLO NIACIN
Colestid Lofibra, Tricor Lopid
QLL=60 tabs/30 days
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ILLINOIS FORMULARY REVISED August 2015
fenofibric acid ZETIA
TRILIPIX STEP
HMG-COA REDUCTASE INHIBITORS / INHIBIDORES DE LA REDUCTASA DE LA HMG-COA Atorvastatin Lovastatin
Lipitor Mevacor
Pravastatin Simvastatin Fluvastatin LESCOL XL
Pravachol Zocor LESCOL
QLL= 30 tabs/ 30 days QLL=30 tabs/30 days; 40 mg=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 caps/30 days QLL=30 tabs/30 days
OTHER CARDIOVASCULAR DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES CARDIOVASCULARES Midodrine Pentoxifylline
ProAmatine Trental
DERMATOLOGICAL MEDICATIONS
DRUGS USED TO TREAT SWELLING, REDNESS, ITCHING OR ALLERGIC SKIN REACTIONS, ACNE, HAIR LICE, ETC.
MEDICAMENTOS DERMATOLÓGICOS
MEDICAMENTOS UTILIZADOS PARA REDUCIR INFLAMACIONES, ENROJECIMIENTO DE LA PIEL, PICAZÓN O REACCIONES ALÉRGICAS DE LA PIEL, ACNÉ, PEDICULOSIS, ETC.
TOPICAL CORTICOSTEROID DRUGS / CORTICOSTEROIDES TÓPICOS alclometasone dipropionate Amcinonide betamethasone dipropionate betamethasone valerate clobetasol propionate Desonide Desoximetasone diflorasone diacetate Fluocinolone Fluocinonide fluticasone propionate Halobetasol hydrocortisone (prescription and OTC forms covered) hydrocortisone butyrate hydrocortisone valerate lidocaine-hydrocortisone mometasone furoate Prednicarbate triamcinolone acetonide
Aclovate Diprolene Beta-Val Clobevate/Temovate Desowen/Lokara Topicort Apexicon/Maxiflor/Psorcon
Cutivate Ultravate Ala-Cort/Cetacort/Hytone Locoid Westcort Elocon Dermatop Kenalog
ANTIPRURITIC DRUGS / MEDICAMENTOS ANTIPRURÍTICOS hydroxyzine hcl Page 24
ILLINOIS FORMULARY REVISED August 2015
hydroxyzine pamoate
ANTIACNE DRUGS / MEDICAMENTOS PARA TRATAR EL ACNÉ adapalene cream, gel (0.1% only) Amnesteem Benzoyl Peroxide cream lotion, wash, cream Claravis clindamycin phosphate Clindamycin/benzoyl peroxide Erythromycin Erythromycin/Benzoyl Peroxide METROGEL 1% TOPICAL GEL Metronidazole sod.sulfacetamide/sulfur10-5% only Sotret Tretinoin
Differin Accutane Accutane Cleocin T/Clindamax Benzaclin A/T/S / Emgel/Erycette
Metrocream/Metrolotion Avar/Plexion Accutane Avita/Retin-A
QLL=20 gram tube/30days
KERATOLYTIC DRUGS / MEDICAMENTOS QUERATOLÍTICOS CONDYLOX GEL podofilox solution
Condylox
ANTIPSORIASIS AND ANTIECZEMA DRUGS / MEDICAMENTOS PARA TRATAR PSORIASIS Y ECCEMAS calcipotriene ointment, scalp solution OTC DOAK TAR DISTILLATE, OIL DRITHO-SCALP POLYTAR selenium sulfide sulfacetamide sodium calcitriol ointment
Dovonex
Selseb Carmol Scalp VECTICAL OINTMENT
ORAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES OXSORALEN ULTRA
TOPICAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES ammonium lactate CARAC ELIDEL FLUOROPLEX Fluorouracil imiquimod 5% cream HYPERCARE SANTYL OTC zinc oxide ointment
Lac-Hydrin STEP/QLL=30 gm/30 days Efudex Aldara
Desitin
SCABICIDES / ESCABICIDAS Acticin Malathion OTC permethrin 1% lotion
Elimite 5% Topical Cream Ovide Nix
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ILLINOIS FORMULARY REVISED August 2015
permethrin 5% cream (prescription strength) OTC Pyrethrin 0.33% ULESFIA LOTION
Elimite
EAR-NOSE-THROAT MEDICATIONS
DRUGS USED FOR EAR INFECTIONS, NASAL ALLERGIES OR DRY MOUTH
MEDICAMENTOS PARA TRATAR AFECCIONES DE NARIZ, OÍDO Y GARGANTA
MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES NASALES, DEL OÍDO O BOCA SECA
DRUGS AFFECTING THE EAR / MEDICAMENTOS PARA AFECCIONES DE OÍDO antipyrine/benzocaine otic acetic acid otic CIPRO HC CIPRODEX OTIC neomycin/polymixin/hydrocortisone Ofloxacin
Benzotic/Otogesic
DRUGS AFFECTING THE NOSE / MEDICAMENTOS PARA AFECCIONES DE NARIZ Azelastine Flunisolide fluticasone propionate ipratropium bromide
Astelin Nasarel Flonase Atrovent
QLL= 2 bottles/30 days
STEP STEP
OTC Nasacort AQ Oxymetazoline
Afrin
DRUGS AFFECTING THE THROAT AND MOUTH / MEDICAMENTOS PARA AFECCIONES DE BOCA Y GARGANTA chlorhexidine gluconate doxycycline hyclate pilocarpine hcl triamcinolone acetonide 0.1% paste
Peridex Periostat Salagen Kenalog
ENDOCRINE MEDICATIONS
USED FOR DIABETES, LOW/HIGH THYROID LEVELS, OSTEOPOROSIS, ETC.
MEDICAMENTOS PARA TRATAR AFECCIONES ENDÓCRINAS
UTILIZADOS PARA TRATAR DIABETES, NIVELES BAJOS/ALTOS DE HORMONA TIROIDEA, OSTEOPOROSIS, ETC.
ORAL HYPOGLYCEMIC DRUGS / MEDICAMENTOS HIPOGLUCÉMICOS ORALES Acarbose Chlorpropamide Glimepiride glipizide, er glipizide-metformin Glyburide glyburide-metformin
Precose Diabinese Amaryl Glucotrol, XL Metaglip Diabeta/Micronase Glucovance
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ILLINOIS FORMULARY REVISED August 2015
metformin, ─er Nateglinide Repeglinide PRANDIMET Tolazamide Tolbutamide JANUMET, JANUMET XR JANUVIA
Glucophage, XR Starlix
Prandin
STEP STEP
INSULIN SENSITIZERS / SENSIBILIZADORES DE INSULINA AVANDAMET AVANDARYL AVANDIA DUETACT Pioglitazone pioglitazone/metformin
OTHER GLUCOSE-LOWERING DRUGS Drugs
ACTOS ACTOPLUS MET
QLL=60 tabs/30 days QLL=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=90 tabs/30 days
Byetta
STEP
INSULIN (VIALS ONLY) / INSULINA (SOLO EN FRASCOS) HUMALOG 50/50 VIAL HUMALOG 75/25 VIAL HUMALOG 100U VIAL HUMULIN 50/50 VIAL HUMULIN R (100 U/ML VIAL) HUMULIN R (500 U/ML VIAL) HUMULIN 70/30 VIAL NOVOLIN 70/30 VIAL NOVOLIN R VIAL NOVOLIN N VIAL NOVOLOG VIAL NOVOLOG MIX 70/30 VIAL LANTUS VIAL LEVEMIR VIAL
GLUCOSE ELEVATING DRUGS / MEDICAMENTOS QUE ELEVAN EL NIVEL DE GLUCOSA GLUCAGEN VIALS GLUCAGON OTC glucose chewable tablets
GLUCOCORTICOID DRUGS / GLUCOCORTICOIDES Cortisone Dexamethasone Hydrocortisone Methylprednisolone Prednisolone Prednisone
Cortef Medrol Prelone Sterapred Page 27
ILLINOIS FORMULARY REVISED August 2015 Prednisolone phosphate orally disintegrating tablet
ORAPRED ODT
GROWTH HORMONES / HORMONAS DE CRECIMIENTO NORDITROPIN
PA
Page 28
ILLINOIS FORMULARY REVISED August 2015
NORDITROPIN NORDIFLEX NUTROPIN NUTROPIN AQ
PA PA PA
MINERALOCORTICOID DRUGS / MINERALOCORTICOIDES fludrocortisone acetate
Florinef
THYROID SUPPLEMENTS / SUPLEMENTOS TIROIDEOS NP Thyroid Levothroid levothyroxine sodium Levoxyl Liothyronine thyroid, dessicated Unithroid
ARMOUR THYROID Synthroid Synthroid Cytomel Armour Thyroid Synthroid
ANTITHYROID DRUGS / MEDICAMENTOS ANTITIROIDEOS Methimazole Propylthiouracil
Tapazole
ANDROGEN DRUGS / ANDRÓGENOS Danazol testosterone cypionate (200 mg/ml only)
OTHER ENDOCRINE DRUGS / OTROS MEDICAMENTOS ENDÓCRINOS alendronate sodium
Fosamax
Cabergoline
Dostinex
calcitonin nasal spray CHEMET
Miacalcin
desmopressin acetate
DDAVP/Minirin
Etidronate fortical nasal spray SENSIPAR
QLL 35 mg or 70 mg=4 tabs/30 days; QLL 5 mg,10 mg, 40 mg=30 tabs/30 days COVERED FOR ENDO; ALL OTHERS REQUIRE PA;
QLL=1 bottle/30 days; QLL=90 tabs/30 days
Didronel
GASTROINTESTINAL MEDICATIONS
COVERED FOR NEPHROLOGIST; ALL OTHERS REQUIRE PA
DRUGS USED FOR HEART BURN, REDUCE ACID PRODUCTION IN THE STOMACH, DIARRHEA, CONSTIPATION, ETC.
MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES
MEDICAMENTOS UTILIZADOS PARA TRATAR LA ACIDEZ, REDUCIR LA PRODUCCIÓN DE ÁCIDO DEL ESTÓMAGO, DIARREA, CONSTIPACIÓN, ETC.
ANTIDIARRHEAL DRUGS / ANTIDIARRÉICOS
Page 29
ILLINOIS FORMULARY REVISED August 2015
bismuth subsalicylate diphenoxylate w/atropine OTC loperamide
Pepto Bismol Lomotil Imodium
ANTISPASMODICS – DRUGS AFFECT GI MOTILITY / ANTIESPASMÓDICOS – MEDICAMENTOS QUE AFECTAN LA MOTILIDAD GASTROINTESTINAL dicyclomine hcl glycopyrrolate tablets Hyoscyamine metoclopramide hcl
Bentyl Robinul Nulev/Levbrel Reglan
ANTIULCER DRUGS (OTC AND PRESCRIPTION FORMS COVERED) / MEDICAMENTOS PARA PREVENIR ÚLCERAS (COBERTURA PARA MEDICAMENTOS CON RECETA Y DE VENTA LIBRE) Cimetidine Famotidine Nizatidine Ranitidine
Tagamet Pepcid Axid Zantac
OTHER ANTIULCER DRUGS / OTROS MEDICAMENTOS PARA PREVENIR ÚLCERAS Misoprostol Sucralfate
Cytotec Carafate
PROTON PUMP INHIBITORS / INHIBIDORES DE LA BOMBA DE PROTONES omeprazole (rx and OTC), First Omeprazole Pantoprazole
Prilosec Protonix
QLL=120 tabs /30 days QLL=30 tabs/30 days
LAXATIVES AND CATHARTICS / LAXANTES Y PURGANTES OTC bisacodyl OTC docusate OTC docusate-senna Generlac OTC glycerin OTC MIRALAX polyethylene glycol 3350 powder for solution OTC psyllium OTC SENOKOT (brand and generic dosage forms covered) OTC SORBITOL 70% ORAL SOLN
Dulcolax Colace Peri-Colace Fleet Miralax Metamucil
QLL=527 g/30 days QLL=527 g/30 days
OTHER GI DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES OTC aluminum hydroxide gel OTC antacid liquid, suspension AMITIZA ASACOL Dezicol OTC calcium antacid tablet CANASA
Alternagel
QLL=60 caps/30 days
Tums
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ILLINOIS FORMULARY REVISED August 2015
CORTIFOAM CREON 5, 10, 15, CREON LIPASE 6,000; 12,000; 24,000 UNITS DIPENTUM OTC effervescent pain relief OTC hemorrhoidal cream OTC hydrocortisone enema suspension Hydrocortisone 2.5% rectal cream IPECAC SYRUP mesalamine enema NULYTELY WITH FLAVOR PACKS PANCREAZE PANCRELIPASE 5,000 UNITS PEG 3350 ELECTROLYTE SOLUTION PENTASA PROCTOFOAM-HC Propantheline OTC simethicone drops sulfasalazine, sulfasalazine delayed-release sulfazine, sulfazine delayed -release Ursodiol VIOKASE 8, 16 ZENPEP 5,000U; 10,000U, 15,000U, 20,000U
Alka Seltzer PreparationH Proctosol-hydrocortisone 2.5% rectal cream
Azulfidine Azulfidine Actigall
IMMUNOLOGICALS AND VACCINES
VACCINES AND DRUGS USED FOR MULTIPLE SCLEROSIS
ESTIMULADORES INMUNOLÓGICOS Y VACUNAS VACUNAS Y MEDICAMENTOS UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE FLUMIST
RHOGAM MicRhoGAM
COVERED DURING FLU SEASON (OCT 1, 2012 TO April 30, 2013); PA >49 YEARS; QLL=#1/YEAR
INTERFERONS USED FOR MULTIPLE
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ILLINOIS FORMULARY REVISED August 2015
SCLEROSIS / INTERFERONES UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE AVONEX BETASERON COPAXONE EXTAVIA REBIF
PA PA PA PA PA
MUSCULOSKELETAL MEDICATIONS
DRUGS USED TO RELEIVE PAIN, MUSCLE SPASMS, JOINT PAIN/SWELLING DUE TO GOUT
MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS
MEDICAMENTOS UTILIZADOS PARA ALIVIAR DOLOR, ESPASMOS DE LOS MÚSCULOS, DOLOR ARTICULAR/HINCHAZÓN PROVOCADOS POR LA GOTA
SALICYLATES AND RELATED DRUGS / SALICILATOS Y MEDICAMENTOS RELACIONADOS OTC aspirin 81 mg, 325 mg,
Ecotrin
choline magnesium trisalicylate Diflunisal Salsalate
Dolobid Disalcid
NON-STEROIDAL ANTIINFLAMMATORY AGENTS / AGENTES ANTIINFLAMATORIOS NO ESTEROIDES diclofenac sodium Etodolac Fenoprofen Flurbiprofen ibuprofen (prescription and OTC forms covered) Indomethacin Ketoprofen Ketorolac Meclofenamate Meloxicam Nabumetone Naproxen OTC naproxen
Lodine/Lodine XL Anasaid Motrin Indocin SR Orudis/Oruvail Toradol
QLL=20 tabs/30 days and 2 Rxs per 90 days
Mobic Relafen Naprosyn Aleve Page 32
ILLINOIS FORMULARY REVISED August 2015
Oxaprozin Piroxicam Sulindac Tolmetin
Daypro Feldene Clinoril
COX-2 Inhibitors Celecoxib
Celebrex
OTHER DRUGS FOR ARTHRITIS / OTROS MEDICAMENTOS PARA TRATAR ARTRITIS RIDAURA
DRUGS TO PREVENT AND TREAT GOUT / MEDICAMENTOS PARA PREVENIR Y TRATAR LA GOTA Allopurinol colchicine colchicine / probenecid Probenecid ULORIC
STEP
COVERED FOR RHEUMATOLOGISTS; ALL OTHERS REQUIRE PA
Zyloprim
Colcrys STEP
DIRECT MUSCLE RELAXANTS / RELAJANTES MUSCULARES DIRECTOS Baclofen dantrolene capsule tizanidine hcl
CNS MUSCLE RELAXANTS / RELAJANTES MUSCULARES QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL Carisoprodol
cyclobenzaprine hcl Methocarbamol Metaxalone
Dantrium Zanaflex
Soma
Flexeril Robaxin Skelaxin
PA (refer to HFS website: http://www.hfs.illinois.gov/pharmacy /carisoprodol.html); Cummulative QLL=240 tabs/365 days QLL=120 tabs/30 days QLL=120 tabs/30 days QLL=120 tabs/30 days
OTHER MUSCULOSKELETAL MEDICATIONS /OTROS MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS OTC capsaicin RILUTEK
COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA
Page 33
ILLINOIS FORMULARY REVISED August 2015 NUTRITION, BLOOD MODIFIERS, ELECTROLYTES VITAMINS AND DRUGS USED TO REDUCE BLEEDING NUTRICIÓN, AGENTES QUE MODIFICAN LA SANGRE, ELECTROLITOS VITAMINAS Y MEDICAMENTOS UTILIZADOS PARA REDUCIR EL SANGRADO THERAPEUTIC VITAMINS & MINERALS / MINERALES Y VITAMINAS TERAPÉUTICAS OTC calciferol, OTC ergocalciferol drops Calcitriol calcium acetate OTC calcium carbonate, OTC calcium carbonate 600 mg + D OTC calcium citrate CYANOCOBALAMIN INJ (VITAMIN B12) ergocalciferol 1.25 mg capsule, (prescription) OTC ferrous fumerate OTC ferrous gluconate OTC ferrous sulfate OTC Fish Oil folic acid (prescription-strength covered only) Levocarnitine OTC magnesium oxide OTC multivitamins (generic, adult multivitamins) NEPHROCAPS, NEPHROCAPS QT OTC pyridoxine (vitamin B6) OTC sodium bicarbonate sodium fluoride stannous fluoride rinse OTC vitamin C 500, 1000 mg OTC vitamin D OTC thiamine (vitamin B1) Paricalcitol
Drisdol Calcijex/Rocaltrol Phoslo Caltrate Citracal Vitamin D2
Iron
COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA
ZEMPLAR
POTASSIUM SUPPLEMENTS / SUPLEMENTOS DE POTASIO citric acid monohydrate, sodium citrate dihydrate oral solution klor con, klor con m, klor con effervescent potassium chloride tablets, oral solution SHOHL'S MODIFIED
COVERED FOR NEPHROLOGISTS; ALL OTHERS REQUIRE PA
Bicitra
K-Dur/Klotrix
POTASSIUM REMOVING RESINS / RESINAS PARA ELIMINAR POTASIO sodium polystyrene sulfonate, powder
Kayexalate
ORAL ANTICOAGULANTS / ANTICOAGULANTES ORALES warfarin sodium Xarelto Eliquis
HEPARINS / HEPARINAS
Coumadin
PA PA Page 34
ILLINOIS FORMULARY REVISED August 2015 heparin sodium vials [inj] (heparin lock flush solution requires PA)
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ILLINOIS FORMULARY REVISED August 2015
LOW-MOLECULAR WEIGHT HEPARINS (LMWH) / HEPARINAS DE BAJO PESO MOLECULAR enoxaparin [inj] FRAGMIN [inj]
Lovenox
ANTIPLATELET DRUGS / MEDICAMENTOS ANTIPLAQUETARIOS Cilostazol Clopidogrel Dipyridamole ticlopidine hcl
Pletal Plavix Persantine Ticlid
10 DAYS W/O PA 10 DAYS W/O PA (10 DAYS=10 SYRINGES)
QLL=30 tabs/30 days
HEMOSTATICS / HEMOSTÁTICOS aminocaproic acid MEPHYTON
Amicar
BLOOD DETOXICANTS / Enulose Generlac Lactulose RENVELA
OTHER BLOOD MODIFIERS / DESINTOXICANTES DE LA SANGRE Anagrelide SOLIRIS
Agrylin COVERED FOR HEMATOLOGISTS; ALL OTHERS REQUIRE PA
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS BIRTH CONTROL PILLS, VITAMINS FOR PREGANCY, HORMONE REPLACEMENT THERAPY FOR MENOPAUSAL WOMEN, ETC.
MEDICAMENTOS PARA TRATAR AFECCIONES OBSTÉTRICAS Y GINECOLÓGICAS PÍLDORAS ANTICONCEPTIVAS, VITAMINAS PARA EL EMBARAZO, TERAPIA DE REEMPLAZO HORMONAL PARA MUJERES MENOPÁUSICAS, ETC. CONTRACEPTIVES / ANTICONCEPTIVOS Apri Aranelle Aviane Azurette Balziva Brevicon Camila Caziant Cesia Condoms Cryselle ELLA Enpresse Errin
Desogen Tri-Norinyl Alesse-28 Mircette Ovcon-35 Modicon Nor-Q-D Cyclessa Cyclessa Lo/Ovral-28 Tri-levlen 28 Nor-Q-D Page 36
ILLINOIS FORMULARY REVISED August 2015
Gianvi gildess FE Jolessa Jolivette junel, junel FE Kariva kelnor 1/35 Leena Lessina OTC levonorgestrel levora-28 low-ogestrel Lutera Mirena mirogestin, microgestin FE Mononessa Necon
Yaz Loestrin FE Seasonale Nor-Q-D Loestrin, Loestrin FE Mircette Demulen 1/35-28 Tri-Norinyl Alesse-28 Plan B Nordette-28 Lo/Ovral-28 Alesse-28 Loestrin, Loestrin FE Ortho-Cyclen Modicon, Necon, Norinyl 1+35, Norinyl 1+50, Ortho Novum
Nexplanon nora-be Nortrel NUVARING Ocella Ogestrel Ethinyl Estradiol; Norelgestromin patch OTC NEXT CHOICE
QLL= 1 implant/3 years Nor-Q-D Modicon, Norinyl 1+35, Ortho Novum Yasmin 28, Yaz Ovral-28 ORTHO EVRA
OTC PLAN B ONE STEP Paragard Portia Previfem Quasense Reclipsen Solia Sprintec Sronyx tilia fe tri-legest Trinessa tri-previfem
QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year
Nordette-28 Ortho-Cyclen Seasonale Desogen Desogen Ortho-Cyclen Alesse-28 Estrostep Fe Estrostep Fe Ortho Tri-Cyclen Ortho Tri-Cyclen
QLL=1 ring/month
QLL=3 patches/28 days QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year QLL=1 tab (1 pkg)/1 month; QLL=3 tabs (3 pkg)/year
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ILLINOIS FORMULARY REVISED August 2015 tri-sprintec trivora-28 Velivet Zenchent zovia 1/35E zovia 1/50E
Ortho Tri-Cyclen Tri-Levlen 28 Cyclessa Ortho Novum Demulen 1/35-28 Demulen 1/50-21
PRENATAL VITAMINS; covered for females only; QLL=100 tabs/90 days for all legend prenatal vitamins VITAMINAS PRENATALES; se brinda cobertura solo para mujeres; QLL = 100 tabletas cada 90 días para todas las vitaminas prenatales con receta advanced care plus bp multinatal plus cal-nate concept dha Folbecal natalcare glosstabs natatab Rx Prenafirst prenatal advantage (prenatal AD) prenatabs FA prenatal H prenatabs rx prenatal U SELECT-OB, SELECT-OB+ DHA trimesis rx Trinate ultra-natal vinate II vinate az vinate calcium vinatal forte vinate gt vinate m vinate one vinate ultra vitafol-ob vitafol-pn Vitaspire
OB/GYN TOPICAL ANTIINFECTIVES / ANTIINFECCIOSOS TÓPICOS GINECOLÓGICOS acidic vaginal jelly clindamycin 2% vaginal cream CLEOCIN OVULE metronidazole 0.75% vaginal gel, 1% gel OTC miconazole vaginal suppositories, cream
Clindamax MetroGel
ESTROGEN DRUGS / ESTRÓGENOS Page 38
ILLINOIS FORMULARY REVISED August 2015
estradiol tablets estradiol transdermal patch estropipate ESTRACE VAGINAL CREAM ESTRING FEMRING MENEST PREMARIN VAGINAL CREAM W/APPLICATOR VAGIFEM
Estrace Climara Ogen/Ortho-Est
QLL=4 patches/30 days
ESTROGEN-PROGESTIN COMBINATIONS / COMBINACIONES DE ESTRÓGENO/PROGESTINA ACTIVELLA CLIMARA PRO COMBIPATCH estradiol/norethindrone acetate 1 mg-0.5 mg FEMHRT PREFEST PREMPHASE PREMPRO
Activella1 mg-0.5mg
SELECTIVE ESTROGEN RECEPTOR MODULATOR / MODULADOR SELECTIVO DE RECEPTORES ESTROGÉNICOS Raloxifene
EVISTA
QLL=30 tabs/30 days
PROGESTIN DRUGS / PROGESTINAS Camila Errin Jolivette medroxyprogesterone acetate (inj)
medroxyprogesterone acetate tablets nora-be norethindrone acetate PROGESTERONE CAPSULE
Micronor/Nor-Q-D Micronor/Nor-Q-D Micronor/Nor-Q-D Depo Provera Provera Micronor/Nor-Q-D Aygestin PROMETRIUM
QLL for injection=1/90 days
OTHER OB/GYN DRUGS / OTROS MEDICAMENTOS GINECOLÓGICOS METHERGINE TABLETS
OPHTHALMIC MEDICATIONS
DRUGS USED FOR EYE INFECTIONS, DRY EYES, GLAUCOMA, ETC.
MEDICAMENTOS OFTÁLMICOS
MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES EN LOS OJOS, OJOS SECOS, GLAUCOMA, ETC.
OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES OFTÁLMICOS TÓPICOS bacitracin ophth ointment bacitracin/polymixin ophth ointment
AK-Poly Bac Page 39
ILLINOIS FORMULARY REVISED August 2015
ciprofloxacin hcl (ophth drops) CILOXAN OPTHALMIC OINTMENT erythromycin gentamicin sulfate levofloxacin neomycin/polymyxin/bacitracin neomycin/polymyxin/gramicidin Ofloxacin polymyxin/trimethoprim sulfacetamide sodium tobramycin sulfate TOBREX OINTMENT VIGAMOX ZYMAXID
Ciloxan
Garamycin/Gentak Quixin Neosporin Ocuflox Polytrim Bleph-10 Tobrex
OPHTHALMIC CORTICOSTEROID DRUGS / MEDICAMENTOS CORTICOSTEROIDES OFTÁLMICOS dexamethasone fluorometholone FML FORTE PRED MILD prednisolone
Omnipred/Pred Forte
OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS / ANTIINFECCIOSOS/CORTICOSTEROIDES OFTÁLMICOS neomycin/polymixin/hydrocortisone neomycin/polymyxin/dexamethasone prednisolone/sulfacetamide TOBRADEX OINTMENT tobramycin/dexamethasone susp
Cortisporin Methadex/Maxitrol
Tobradex
ANTIGLAUCOMA DRUGS / MEDICAMENTOS ANTIGLAUCOMA acetazolamide, ER Alphagan P 0.1% AZOPT BETOPTIC S betaxolol hcl brimonidine tartrate 0.15%, 0.2% carteolol hcl COMBIGAN dorzolamide dorzolamide/timolol ISOPTO CARBACHOL Latanoprost
Alphagan P
Trusopt Cosopt Xalatan Page 40
ILLINOIS FORMULARY REVISED August 2015
levobunolol hcl LUMIGAN methazolamide metipranolol PHOSPHOLINE IODIDE pilocarpine hcl timolol maleate TRAVATAN Z Travoprost
Betagan STEP Optipranolol Isopto Carpine Timoptic/Timoptic-XE PA PA
OTHER OPHTHALMIC DRUGS / OTROS MEDICAMENTOS OFTÁLMICOS ak-con Azelastine OTC artificial tears atropine sulfate drops, ointment cromolyn sodium Cyclopentolate 1% diclofenac sodium flurbiprofen sodium ketorolac tromethamine ISOPTO HOMATROPINE ISOPTO HYOSCINE MUROCOLL-2 NEVANAC PATANOL phenylephrine OTC REFRESH TEARS, LIQUIGEL (15 ML AND 30 ML BOTTLE ONLY) OTC sodium chloride 5% drops, ointment OTC SYSTANE (15 ML AND 30 ML BOTTLE ONLY) Trifluridine Tropicamide OTC ZADITOR
Optivar Tears Again Isopto Atropine Crolom Cyclogyl Voltaren Ocufen Acular, Acular LS
Tropicacyl
RESPIRATORY MEDICATIONS DRUGS USED FOR ASTHMA, ALLERGIES, COUGH/COLD, ETC. MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS MEDICAMENTOS UTILIZADOS PARA TRATAR ASMA, ALERGIAS, TOS/RESFRÍO, ETC. BETA-2 ADRENERGIC DRUGS / MEDICAMENTOS ADRENÉRGICOS BETA-2 albuterol sulfate (inhalation soln, syrup, tablet) metaproterenol
QLL=375 ml/30 days for inhalation soln
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ILLINOIS FORMULARY REVISED August 2015
PROAIR HFA PROVENTIL HFA SEREVENT DISKUS Terbutaline VENTOLIN HFA
QLL= 2 inhalers/30 days QLL= 2 inhalers/30 days
QLL= 2 inhalers/30 days
INHALED CORTICOSTEROIDS / CORTICOSTEROIDES INHALADOS ADVAIR DISKUS
Covered for ages 4-11 years; all others require PA
ADVAIR HFA budesonide respules 0.25 mg/2 ml, 0.50 mg/2 ml FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER/INHALER PULMICORT 1 MG/2 ML RESPULES
PA Pulmicort Respules
QLL=120 ml/30 days (60 respules/30 days)
QLL=1 inhaler or flexhaler/30 days QLL=120 ml/30 days (60 respules/30 days)
SYMBICORT
LEUKOTRIENE MODIFIERS / MODIFICADORES DE LEUCOTRIENOS Montelukast Zafirlukast
SINGULAIR Accolate
METHYL XANTHINE DRUGS / METILXANTINAS
QLL=30 tabs/30 days STEP THERAPY FOR MEMBERS WITH DIAGNOSIS OF ASTHMA; QLL=60 tabs/30 days
aminophylline theophylline, er
OTHER DRUGS FOR ASTHMA / OTROS MEDICAMENTOS UTILIZADOS PARA TRATAR EL ASMA
ATROVENT (INHALER) cromolyn sodium inhalation soln EPIPEN, EPIPEN JR ipratropium bromide ipratropium bromide/albuterol inhalation soln COMBIVENT RESPIMAT
Intal
OTHER RESPIRATORY DRUGS / OTROS MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS SPIRIVA, Spiriva Respimat
STEP; QLL=30 caps/30 days
sodium chloride 0.9% nebulizer solution OTC
ANTIHISTAMINES / ANTIHISTAMÍNICOS Bromax carbinoxamine
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ILLINOIS FORMULARY REVISED August 2015 cetirizine OTC tablets, cetirizine-D OTC tablets, cetirizine OTC solution cetirizine syrup (prescription and OTC) chlorpheniramine maleate clemastine fumarate cyproheptadine hcl Dexchlorpheniramine solution only diphenhydramine (prescription and OTC forms covered) hydroxyzine hcl OTC loratadine, OTC loratadine-D Vazol solution
OTC Zyrtec, Zyrtec Syrup
cetirizine-D QLL=60 tabs/30 days cetirizine soln QLL=150 ml/30 days
Tavist Periactin Benadryl
OTC Claritin, Claritin-D
OTC loratadine-D=30 tabs/30 days
ANTIHISTAMINE-DECONGESTANT COMBINATIONS COMBINACIONES DE ANTIHISTAMÍNICOS-DESCONGESTIVOS brompheniramine/phenyephrine oral soln OTC brompheniramine-pseudoephedrine elixir ceron drops, syrup lohist-lq liquid r-tanna pediatric suspension Virdec 1mg-3.5mg/ml Drops
Rondec drops, syrup
ANTITUSSIVE AND EXPECTORANT DRUGS / ANTITUSÍGENOS Y EXPECTORANTES Benzonatate OTC CHERATUSSIN AC
Tessalon
guaifenesin-dm nr liquid guaifenesin tablets guaifenesin w/codeine MUCINEX, Mucinex D, DM OTC promethazine vc w/codeine syrup
Humibid Romilar AC/Tussi-Organidin DM NR Phenergan VC w/Codeine
promethazine vc syrup
Phenergan VC
promethazine w/dm syrup OTC tussin DM Virdec DM 3.5mg-1mg-3mg/ml Drops
Phenergan DM Robitussin DM
OTHER DRUGS FOR COUGH, COLD, ALLERGY / OTROS TRATAMIENTOS PARA TRATAR ALERGIAS, TOS Y RESFRÍO OTC nasal spray OTC pseudoephedrine (all generic dosage forms covered)
Afrin Sudafed
TOXICOLOGY MEDICATIONS
DRUGS USED TO TREAT OVERDOSE OR REDUCE HIGH LEVELS OF COPPER IN THE BODY
MEDICAMENTOS TOXICOLÓGICOS
MEDICAMENTOS PARA TRATAR LA SOBREDOSIS O REDUCIR LOS NIVELES DE COBRE EN EL CUERPO acetylcysteine
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ILLINOIS FORMULARY REVISED August 2015
CUPRIMINE
UROLOGICAL MEDICATIONS
DRUGS USED TO TREAT OVERACTIVE BLADDER, CONDITIONS FOR THE PROSTATE, ETC.
MEDICAMENTOS UROLÓGICOS
MEDICAMENTOS UTILIZADOS PARA TRATAR LA HIPERACTIVIDAD DE LA VEJIGA, CONDICIONES DE LA PRÓSTATA, ETC.
ANTICHOLINERGIC ANTISPASMODICS DRUGS / ANTIESPASMÓDICOS ANTICOLINÉRGICOS Flavoxate oxybutynin chloride oxybutynin chloride er Trospium ER Trospium
Urispas Ditropan Ditropan XL SANCTURA XR Sanctura
STEP STEP; QLL=60 tabs/30 days
CHOLINERGIC STIMULANTS / ESTIMULANTES COLINÉRGICOS Bethanecol
URINARY ANESTHETICS / ANESTÉSICOS URINARIOS phenazopyridine hcl
Pyridium/Urodol
OTHER GENITOURINARY PRODUCTS / OTROS PRODUCTOS GENITOURINARIOS Alfuzosin ELMIRON Finasteride K-PHOS CYTRA, -K Potassium citrate Tamsulosin
Uroxatral Proscar
Flomax
QLL=60 caps/30 days
MEDICAL (MISCELLANEOUS) SUPPLIES BLOOD GLUCOSE METERS, TEST STRIPS, OTHER SUPPLIES; SPACERS AND PEAK FLOW METERS FOR ASTHMA SUMINISTROS MÉDICOS (VARIOS) MEDIDORES DE LA GLUCOSA EN SANGRE, TIRAS REACTIVAS, OTROS SUMINISTROS; ESPACIADORES Y MEDIDORES DEL FLUJO MÁXIMO PARA EL ASMA
DIABETIC SUPPLIES: Combined QLL for test strips=150/month / SUMINISTROS DIABÉTICOS: QLL combinado para tiras reactivas = 150 por mes
Page 44
ILLINOIS FORMULARY REVISED August 2015
MICROLET LANCING DEVICE/LANCETS AUTOJECT 2 INJECTION DEVICE insulin syringes ONE TOUCH ULTRA2, UKTRALINK, ULTRAMINI, ULTRASMART, VERIO, VERIO IQ ONE TOUCH SELECT ONE TOUCH TEST STRIPS, CONTROL SOLUTION SOFT TOUCH SOFTCLIX CHEMSTRIP KETOSTIX
OTHER SUPPLIES / OTROS SUMINISTROS AEROCHAMBER, MICROCHAMBER ALCOHOL PREP PADS ASSESS PEAK FLOW METER MICROCHAMBER PEAK FLOW METER PERSONAL BEST PEAK FLOW METER
QLL=#1/YEAR QLL=#1/YEAR QLL=#1/YEAR QLL=#1/YEAR
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