AETNA BETTER HEALTH® OF NEW JERSEY Formulary
2-01-2016
NJ-14-05-38
FORMULARY
What is the Aetna Better Health of New Jersey Formulary? This is a drug list created by Aetna Better Health of New Jersey (“plan”). Aetna Better Health of New Jersey will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, Aetna Better Health of New Jersey will cover the drug. Drugs must also be filled at an Aetna Better Health of New Jersey network pharmacy. Can Aetna Better Health of New Jersey’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 60 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 of New Jersey’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? Description 1-34 day 1-34 day supply supply GENERIC BRAND FamilyCare Plan A No Copay FamilyCare Plan B No Copay FamilyCare Plan C $1 FamilyCare Plan D $5 FamilyCare Plan No Copay MLTSS •
No Copay No Copay $5 $5 No Copay
35-102 day supply GENERIC (mailorder only) No Copay No Copay $2 $10 No Copay
35-102 day supply BRAND (mailorder only) No Copay No Copay $10 $10 No Copay
American Indians and Alaska Native members will NOT have a copay. Page 1
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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 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 of New Jersey’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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¿Qué es el formulario de Aetna Better Health of New Jersey? Es una lista de medicamentos creada por Aetna Better Health of New Jersey (el “plan”). Aetna Better Health of New Jersey 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 of New Jersey los cubrirá. Además, los medicamentos deben adquirirse en una farmacia de la red de Aetna Better Health of New Jersey. ¿Puede cambiar la lista de medicamentos de Aetna Better Health of New Jersey? 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 60 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 of New Jersey? •
• •
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, EarNose-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? Descripción
Suministro para 1-34 días (GENÉRICOS)
Suministro para 1-34 días (DE MARCA)
Suministro para 35-102 días (GENÉRICOS)
FamilyCare Plan A FamilyCare Plan B FamilyCare Plan C
Sin copago Sin copago $1
Sin copago Sin copago $5
Sin copago Sin copago $2
Suministro para 35-102 días (DE MARCA) Sin copago Sin copago $10 Page 3
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Descripción
Suministro para 1-34 días (GENÉRICOS)
Suministro para 1-34 días (DE MARCA)
Suministro para 35-102 días (GENÉRICOS)
FamilyCare Plan D
$5
$5
$10
Suministro para 35-102 días (DE MARCA) $10
FamilyCare Plan MLTSS
Sin copago
Sin copago
Sin copago
Sin copago
•
Los miembros que sean indígenas americanos o nativos de Alaska NO tienen copago.
¿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. 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 of New Jersey? 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 of New Jersey cubre tanto medicamentos de marca como genéricos. Los medicamentos genéricos cuestan menos y están aprobados por la Administración de Drogas y Alimentos (FDA).
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¿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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REFERENCE DRUG NAME COVERED DRUG NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO DE REFERENCIA ANESTHETICS DRUGS USED TO RELIEVE PAIN IN SPECIFIC AREAS
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
ANESTÉSICOS MEDICAMENTOS UTILIZADOS PARA ALIVIAR EL DOLOR EN ÁREAS ESPECÍFICAS TOPICAL ANESTHETICS / ANESTÉSICOS TÓPICOS lidocaine hcl Xylocaine lidocaine hcl viscous Xylocaine lidocaine-prilocaine Emla lidocaine 5% transdermal patch QLL =90 patches/30 days Lidoderm 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 cefpodoxime proxetil cefprozil cefuroxime Cephalexin 250mg, 500mg ceftriaxone cefuroxime axetil SUPRAX
Omnicef Vantin Cefzil Ceftin Keflex Rocephin Ceftin
QLL= 1 tab/Rx
CLINDAMYCINS / CLINDAMICINAS clindamycin granules powder for sln clindamycin
Cleocin Granules
ERYTHROMYCINS / ERITROMICINAS erythromycin, DR erythromycin ethylsuccinate
Eryc, Delayed Release
erythromycin w/sulfisoxazole
QLL=2 grams/Rx
Cleocin
E.E.S. Pediazole
OTHER MACROLIDES / OTROS MACRÓLIDOS azithromycin Zithromax clarithromycin, er Biaxin, Biaxin XL PENICILLINS / PENICILINAS Page 6
COVERED DRUG MEDICAMENTO CUBIERTO amox tr-potassium clavulanate amoxicillin ampicillin dicloxacillin penicillin v potassium SULFONAMIDES / SULFONAMIDAS GANTRISIN (SUSPENSION) sulfamethoxazole/trimethoprim sulfadiazine
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Augmentin Amoxil Principen
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Veetids
Septra
sulfatrim pediatric suspension TETRACYCLINES / TETRACICLINAS demeclocycline doxycycline minocycline hcl tetracycline hcl
Vibramycin Dynacin Sumycin
URINARY ANTIINFECTIVES / ANTIINFECCIOSOS URINARIOS methenamine hippurate nitrofurantoin, nitrofurantoin macrocrystal nitrofurantoin mono/macrocrystals nitrofurantoin 25 mg/5 ML suspension trimethoprim QUINOLONES / QUINOLONAS ciprofloxacin er ciprofloxacin hcl ofloxacin levofloxacin
Macrodantin Macrobid Furdantin suspension
Cipro XR Cipro Floxin
QLL=3 tabs/Rx QLL=28 tabs/30 days
QLL=14 tabs/90 days Levaquin TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES TÓPICOS OTC bacitracin topical ointment bacitracin/polymyxin B Polysporin chlorhexidine gluconate erythromycin gentamicin sulfate mupirocin 2% cream, ointment silver sulfadiazine
Peridex/Perisol Eryderm Genoptic Bactroban Silvadene Page 7
COVERED DRUG MEDICAMENTO CUBIERTO sulfacetamide sodium OTC triple antibiotic cream
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Ovace
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Neosporin
ORAL ANTIFUNGAL DRUGS / MEDICAMENTOS ANTIFÚNGICOS ORALES clotrimazole Mycelex fluconazole Diflucan griseofulvin microsize Grifulvin V griseofulvin 125 mg/5 ml suspension griseofulvin ultramicrosize itraconazole capsule ketoconazole nystatin
Gris-Peg Sporanox Nizoral Mycostatin
SPORANOX (ORAL SOLUTION) terbinafine Lamisil VAGINAL ANTIFUNGALS / MEDICAMENTOS ANTIFÚNGICOS VAGINALES OTC clotrimazole Mycelex miconazole 200 mg suppositories nystatin terconazole
QLL=84 tabs/year
Monistat 3 Mycostatin Terazol
OTHER TOPICAL ANTIFUNGALS / OTROS MEDICAMENTOS ANTIINFECCIOSOS ciclopirox Loprox/Penlac OTC clotrimazole Terbinafine econazole nitrate
Lotrimin Spectazole
ketoconazole OTC miconazole 2% nystatin
Nizoral
OTC tolnaftate
Tinactin
TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB / CORTICOSTEROIDES Y ANTIFÚNGICOS TÓPICOS COMBINADOS clotrimazole/betamethasone Lotrisone nystatin w/triamcinolone
Mycolog II
ANTIRETROVIRALS & PROTEASE INHIBITORS / ANTIRRETROVIRALES E INHIBIDORES DE LA PROTEASA abacavir Ziagen APTIVUS ATRIPLA Page 8
COVERED DRUG MEDICAMENTO CUBIERTO COMPLERA
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
CRIXIVAN didanosine EDURANT EMTRIVA EPZICOM FORTOVASE FUZEON INTELENCE INVIRASE KALETRA lamivudine, HBV lamivudine/zidovudine LEXIVA
Epivir, HBV Combivir
nevirapine tablet/XR, oral suspension NORVIR PREZISTA
Viramune/XR
RESCRIPTOR REYATAZ stavudine STRIBILD SUSTIVA abacavir/lamivudine/zidovudine
Zerit
Trizivir
TRUVADA VIDEX SOLUTION, CHEWABLE TABS VIRACEPT VIREAD zidovudine
Retrovir
OTHER ANTIINFECTIVE DRUGS / OTROS MEDICAMENTOS ANTIINFECCIOSOS CLEOCIN (100 MG VAGINAL OVULE) dapsone atovaquone
Mepron OTHER ANTIVIRAL DRUGS / OTROS MEDICAMENTOS ANTIVIRALES acyclovir, 5% ointment Zovirax
REQUIRES STEP QLL=4000mg/day Page 9
COVERED DRUG MEDICAMENTO CUBIERTO amantadine hcl entecavir famciclovir ganciclovir
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Symmetrel Baraclude Famvir
ISENTRESS PEGINTRON PEGINTRON REDIPEN PEGASYS rimantadine REBETOL (ORAL SOLUTION) RELENZA ribavirin
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
PA
Flumadine
PA PA QLL=14 tabs/RX MUST BE ON INTERFERON QLL/Rx=20 inhalation diskus/Rx MUST BE ON INTERFERON
SELZENTRY TAMIFLU
TYZEKA
valacyclovir
Valtrex
ANTITUBERCULOSIS DRUGS / MEDICAMENTOS ANTITUBERCULOSOS ethambutol Myambutol isoniazid rifabutin PRIFTIN pyrazinamide rifampin
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
Nydrazid Mycobutin
Rifadin
AMEBICIDES / AMIBICIDAS YODOXIN ANTHELMINTICS / ANTIHELMÍNTICOS ALBENZA ivermectin mebendazole
Stromectol
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COVERED DRUG MEDICAMENTO CUBIERTO PLASMODICIDES / PLASMODICIDAS chloroquine phosphate
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
DARAPRIM hydroxychloroquine sulfate
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
PA Plaquenil
mefloquine
Lariam
TRICHOMONOCIDES / TRICOMONICIDAS metronidazole
Flagyl
AMINOGLYCOSIDES / AMINOGLUCÓSIDOS neomycin paromomycin 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 service authorization. All injectable medications within this class require service 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 Agrylin anastrozole tablets Arimidex AZASAN azathioprine tablets Imuran bicalutamide CEENU CAPSULE
Casodex
cyclophosphamide capsules cyclosporine capsule, oral soln DROXIA CAPSULE EMCYT CAPSULE ENBREL etoposide capsule exemestane FARESTON TABLET fluorouracil cream, solution flutamide capsule GLEEVEC
Sandimmune
PA Vepesid Aromasin Efudex PA
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COVERED DRUG MEDICAMENTO CUBIERTO HEXALEN CAPSULE HUMIRA HYCAMTIN CAPSULE hydroxyurea capsule, tablet
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES PA
Hydrea
IRESSA TABLET leflunomide tablet letrozole tablet
Arava Femara
leucovorin tablet LEUKERAN TABLET LYSODREN TABLET MATULANE CAPSULE megestrol acetate suspension, tablet mercaptopurine tablet MESNEX TABLET methotrexate tablet mycophenolate 250 mg capsules, 500 mg tablets, suspension mycophenolic acid 180mg, 360mg delayed-release tablet NEXAVAR TABLET
Megace Purinethol Trexall CellCept Myfortic PA
NILANDRON TABLET RAPAMUNE ORAL SOLN sirolimus tablet TABLOID TABLET tacrolimus capsule
Rapamune Prograf
tamoxifen citrate tablet TARCEVA TABLET TARGRETIN TOPICAL GEL
Nolvadex
Bexarotene tablets
Targretin Vesinoid
tretinoin capsule, cream, gel, solution TYKERB TABLET
PA
PA
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REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA 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 Antabuse naltrexone ANALGESICS / ANALGÉSICOS OTC acetaminophen tablets, capsules, suppositories, liquids, drops tramadol hcl tramadol hcl-acetaminophen CLASS II NARCOTICS / DROGAS CLASE II codeine sulfate fentanyl patches fentanyl lozenges hydromorphone hcl methadone hcl morphine sulfate, ER oxycodone-acetaminophen 5325mg/5ml solution oxycodone-acetaminophen tabs 2.5325mg, 5-325mg, 7.5-325mg, 10325mg oxycodone-aspirin oxycodone hcl
OXYCONTIN Oxymorphone IR
Tylenol
QLL= up to 4 grams APAP/day
Ultram Ultracet
QLL=240 tabs/30 days QLL= 240 tabs/30 days
Duragesic Actiq Dilaudid Dolophine MS Contin, Kadian Percocet
QLL=30 tabs/30 days PA/QLL=10 patches/30 days QLL=90 lozenges /30 days QLL=2, 4mg 180 tabs/30 days; 8 mg=120 tabs/30 days PA; QLL=240 tabs/30 days PA/QLL=60 tabs or caps/30 days QLL= 4 grams APAP/day QLL=240 tabs/30 days QLL=240 tabs/30 days
Oxyir
Opana
Oxymorphone ER
Opana CLASS III NARCOTICS / DROGAS CLASE III acetaminophen-codeine buprenorphine buprenorphine-naloxone sublingual tablet
QLL for 5 mg=240 tabs or caps/30 days, 10 mg, 15 mg, 20 mg, or 30 mg=180 tabs/30 days PA/STEP QLL=90 tabs/30 days STEP QLL PA/STEP QLL 60 tabs/30 days
Tylenol #3 Subutex Suboxone
QLL= 4 grams APAP/day PA; QLL=16mg/day PA; QLL=16mg/day
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REFERENCE DRUG NAME COVERED DRUG NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO DE REFERENCIA hydrocodone-acetaminophen tablets Norco 5mg-325mg, 7.5mg-325mg, 10mg325mg, Hydrocodone-acetaminophen solution 7.5-325mg/15ml, 10325mg/15ml hydrocodone bit-ibuprofen Vicoprofen DRUGS TO PREVENT AND TREAT HEADACHES / MEDICAMENTOS PARA PREVENIR Y TRATAR DOLORES DE CABEZA butalbital/acetaminophen/caffeine Esgic/Fioricet/Triad tabs/caps 50/325/40mg butalbital/acetaminophen/caffeine/ Fioricet w/codeine codeine 50-325-40-30mg cap butalbital/aspirin/caffeine tab/cap Fiorinal, Fortabs 50-325-40mg butalbital/aspirin/caffeine/codeine Fiorinal w/codeine cap 50-325-40-30mg butorphanol nasal spray Stadol dihydroergotamine nasal spray ERGOMAR ergotamine/caffeine Cafergot/Migergot sumatriptan Imitrex sumatriptan (inj)
Imitrex
rizatriptan benzoate tablets
Maxalt
ANXIOLYTICS / ANSIOLÍTICOS alprazolam, -XR, intensol solution
QLL= 4 grams APAP/day QLL=240 tabs/30 days QLL=180 tabs or caps/30 days QLL=180 tabs or caps/30 days QLL=180 tabs or caps/30 days QLL=180 tabs or caps/30 days QLL=1 bottle/30 days QLL=8 units/30 days
QLL=6 nasal sprays/30 days; 9 tabs/30 days QLL=4 vials/30 days; 2 kits/30 days QLL=12 tabs/30 days
Xanax, XR
buspirone hcl
Buspar
chlordiazepoxide hcl
Librium
clorazepate dipotassium clonazepam diazepam 2.5 mg, 10 mg, 20 mg rectal gel diazepam
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL= 4 grams APAP/day
QLL=90 tabs/30 days; 30mg tab 60/30 days
Tranxene T-Tab Klonopin QLL=2 pkgs/30 days Valium
lorazepam meprobamate
Ativan
oxazepam
Serax
SEDATIVE & HYPNOTIC DRUGS / MEDICAMENTOS HIPNÓTICOSY SEDANTES QLL= 300 ml/ 30 days chloral hydrate syrup estazolam
QLL=30 tabs/30 days Page 14
REFERENCE DRUG NAME COVERED DRUG NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO DE REFERENCIA flurazepam hcl Dalmane temazepam Restoril ROZEREM zaleplon Sonata zolpidem IR 5 & 10 mg Ambien ANTIMANIA DRUGS / ANTIMANÍACOS lithium carbonate Eskalith/CR lithium citrate CARBAMAZEPINES / CARBAMAZEPINAS carbamazepine carbamazepine ER carbamazepine SR oxcarbazepine tablets, suspension
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL=30 caps/30 days QLL=30 caps/30 days QLL=30 tabs/30 days QLL=30 caps/30 days QLL=30 tabs/30 days
Tegretol Tegretol XR Carbatrol Trileptal
QLL=120 tabs/30 days
ANTICONVULSAN AND BENZODIAZEPINES / ANTICONVULSIVOS Y BENZODIACEPINAS clonazepam Klonopin HYDANTOINS / HIDANTOÍNAS phenytoin sodium, extended, infatabs DILANTIN 30 MG EXTENDED RELEASE
Dilantin, ER
phenytoin ER capsule
Phenytek VALPROIC ACID AND DERIVATIVES / ÁCIDO VALPÓRICO Y DERIVADOS divalproex sodium ER, Depakote ER, DR, Sprinkles Delayed- Release, Sprinkles valproic acid Depakene ANTICONVULSANT BARBITURATES / BARBITÚRICOS UTILIZADOS PARA EVITAR CONVULSIONES phenobarbital primidone
Mysoline
OTHER ANTICONVULSANTS / OTROS MEDICAMENTOS UTILIZADOS PARA EVITAR CONVULSIONES CELONTIN ethosuximide felbamate gabapentin GABITRIL 12mg, 16mg lamotrigine levetiracetam tiagabine 2mg, 4mg topiramate
Felbatol Neurontin Lamictal Keppra Gabitril Topamax
QLL=180 units/30 days QLL=60 tabs/30 days
QLL=60 tabs/30 days QLL=120 units/30 days Page 15
REFERENCE DRUG NAME COVERED DRUG NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO DE REFERENCIA zonisamide Zonegran MAO INHIBITORS / INHIBIDORES DE MAO MARPLAN NARDIL tranylcypromine Parnate TERTIARY AMINES / AMINAS TERCIARIAS perphenazine- amitriptyline
Triavil
amitriptyline hcl clomipramine
Elavil Anafranil
doxepin hcl
Sinequan Tofranil Surmontil
imipramine hcl trimipramine
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL=180 units/30 days
SECONDARY AMINES / AMINAS SECUNDARIAS amoxapine desipramine hcl Norpramin nortriptyline hcl Pamelor protriptyline SELECTIVE SEROTONIN REUPTAKE INHIBITOR / INHIBIDORES SELECTIVOS DE LA RECAPTACIÓN DE LA SEROTONINA citalopram Celexa escitalopram fluoxetine hcl 10mg, 20mg, & 40 mg
Lexapro Prozac
fluvoxamine maleate
Luvox
paroxetine hcl
Paxil
sertraline hcl
Zoloft
OTHER ANTIDEPRESSANTS / OTROS ANTIDEPRESIVOS amitriptyline/ chlordiazepoxide budeprion sr bupropion, xl, sr duloxetine
Wellbutrin SR Wellbutrin, SR, XL Cymbalta
QLL=30 tabs/30 days or 300 ml/30 days QLL=30 tabs/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 for 10, 20, 40mg=30 tabs/30 days; 30mg=60 tabs/30 days soln=300 ml/30 days 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 QLL = 60 tabs/30 day SR/ER; 30 tabs/30 days for XL QLL=60 caps/30 days Page 16
COVERED DRUG MEDICAMENTO CUBIERTO maprotiline
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Remeron Desyrel Effexor
QLL=30 tabs/30 days
Effexor XR
QLL=30 caps/30 days
mirtazapine, ODT trazodone hcl venlafaxine venlafaxine XR capsules
ANTIVERTIGO AND ANTIEMETIC DRUGS / MEDICAMENTOS ANTIEMÉTICOS Y PARA TRATAR EL VÉRTIGO granisetron Kytril meclizine ondansetron hcl, ODT prochlorperazine maleate, suppository promethazine hcl
Zofran, ODT Compazine, Compro suppository Phenergan
COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA QLL for 4mg=21 tabs/30 days; for 8mg=21 tabs/30 days; soln 50ml/30 days
EMEND
QLL=6 tabs/30 days
ANTIPARKINSON ANTICHOLINERGIC DRUGS / MEDICAMENTOS ANTICOLINÉRGICOS PARA TRATAR EL MAL DE PARKINSON benztropine mesylate trihexyphenidyl OTHER ANTIPARKINSON DRUGS / OTROS MEDICAMENTOS PARA TRATAR EL MAL DE PARKINSON Parlodel bromocriptine mesylate carbidopa/levodopa Sinemet carbidopa/levodopa/entacapone Stalevo entacapone
Comtan
pramipexole
Mirapex
ropinirole
Requip
selegiline ANTIPSYCHOTIC DRUGS / ANTIPSICÓTICOS
COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA; QLL=270 tabs/30 days 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
Page 17
COVERED DRUG MEDICAMENTO CUBIERTO chlorpromazine tablets clozapine fluphenazine decanoate fluphenazine hclhaloperidol haloperidol decanoate injection loxapine olanzapine, odt perphenazine risperidone, odt
quetiapine
thioridazine thiothixene ziprasidone
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; Zyprexa ALL OTHERS REQUIRES PA if < 18 years QLL=30 tabs/30 days COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS IF Risperdal, Risperdal M-Tab MEMBER is 6 YEARS OR OLDER; ALL OTHERS REQUIRES PA if < 18 years QLL=60 tabs/30 days Seroquel COVERED FOR PSYCHIATRISTS IF MEMBER is 6 YEARS OR OLDER; ALL OTHERS REQUIRES PA if < 18 years; QLL=90 tabs/30 days; 300 mg, 400mg=60 tabs/30 days COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years COVERED FOR PSYCHIATRISTS; ALL OTHERS REQUIRES PA if < 18 years Geodon COVERED FOR PSYCHIATRISTS IF MEMBER is 6 YEARS OR OLDER; ALL OTHERS REQUIRES PA if < 18 years; QLL = 60 caps/30 days Page 18
REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA CNS STIMULANT DRUGS / MEDICAMENTOS PARA ESTIMULAR EL SISTEMA NERVIOSO CENTRAL PA REQUIRED FOR MEMBERS < 6 YEARS OF AGE AND >18 YEARS OF AGE amphetamine/dextroamphetamine Adderall, Immediate release QLL=90 tabs/30 Adderall XR days; Extended release QLL=30 caps/30 days dextroamphetamine dexmethylphenidate Focalin QLL = 60 tabs/ 30 days guanfacine ER tablets STEP; Intuniv PA if < 6 years; QLL = 30 tablets/ 30 days METHYLIN CHEWABLE QLL=120 tabs/30 days methylphenidate, er tabs, solution Ritalin, Methylin QLL=120 tabs/30 days methylphenidate er, sr methylphenidate er 18 mg, 27 mg, 36 mg, & 54 mg methylphenidate hcl methylphenidate CD STRATTERA
Ritalin LA, SR QLL = 30 tabs/30 days Ritalin METADATE CD
QLL=120 tabs/30 days QLL=60 caps/30 days STEP; 10 mg, 18 mg, 25 mg, 40 mg: QLL = 60 caps/30 days 60 mg, 80 mg, 100 mg: QLL=30 caps/30 days ANTIDEMENTIA DRUGS / MEDICAMENTOS PARA TRATAR LA DEMENCIA donepezil 5 MG, 10 MG Aricept QLL=30 tabs/30 days (23 MG IS NON-FORMULARY) donepezil ODT Aricept ODT QLL=30 tabs/30 days galantamine, -ER Razadyne, galantamine Razadyne ER QLL=60 tabs/30 days galantamine ER QLL=30 caps/30 days rivastigmine capsules Exelon capsules QLL=60 caps/30 days SMOKING CESSATION DRUGS / MEDICAMENTOS PARA DEJAR DE FUMAR buproban Zyban Duration for all formulary smoking cessation meds=6 months/year Duration for all formulary smoking CHANTIX cessation meds=6 months/year OTC nicotine lozenges Duration for all formulary smoking cessation meds=6 months/year OTC nicotine patch Nicoderm Duration for all formulary smoking cessation meds=6 months/year Nicotrol 10 mg Inhaler Duration for all formulary smoking cessation meds=6 months/year OTHER CNS DRUGS / OTROS MEDICAMENTOS QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL caffeine citrate oral solution pyridostigmine Page 19
REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA CARDIOVASCULAR MEDICATIONS DRUGS USED FOR HEART CONDITIONS (HIGH BLOOD PRESSURE, 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 Norvasc QLL= 30 tabs/30 days cartia xt Cardizem CD QLL 60/30 days diltiazem er Tiazac/Taztia XT QLL=60 caps or tabs/30 days diltiazem hcl Cardizem QLL=120 tabs/30 days diltia xt Cardizem CD QLL 60/30 days dilt-CD Cardizem CD QLL 60/30 days felodipine er Plendil isradipine DynaCirc nicardipine hcl Cardene nifediac cc Extended Release nifedipine, er Procardia QLL=30 tabs/30 days Procardia XL nimodipine Nimotop nisoldipine 20mg, 30mg, 40mg Sular QLL=30 tabs/30 days verapamil, er Verelan/Calan/Calan SR QLL for IR=120 units/30days; for CR=60 units/30 days; for SR 24hr 30 units/30 days CARBONIC ANHYDRASE INHIBITORS / INHIBIDORES DE LA ANHIDRASA CARBÓNICA 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 Page 20
REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA POTASSIUM SPARING DIURETICS / DIURÉTICOS QUE NO AFECTAN EL POTASIO amiloride Midamor amiloride hcl w/hctz Moduretic spironolactone spironolactone w/hctz triamterene w/hctz
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
Tenormin Kerlone Zebeta Coreg Normodyne/Trandate Toprol XL Lopressor
QLL=60 tabs/30 days QLL=60 tabs/30 days
Corgard Inderal/LA
timolol maleate VASODILATOR ANTIHYPERTENSIVES / ANTIHIPERTENSORES VASODILATORES doxazosin mesylate Cardura QLL=30 tabs/30 days hydralazine hcl Appresdine minoxidil prazosin hcl Minipress terazosin hcl Hytrin QLL=30 caps/30 days CENTRALLY ACTING ANTIHYPERTENSIVES / ANTIHIPERTENSORES DE ACCIÓN CENTRAL clonidine patches Catapres TTS clonidine tablets guanfacine hcl methyldopa
Catapres Tenex
ANGIOTENSIN CONVERTING ENZYME INHIBITORS / ANTAGONISTAS DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA benazepril Lotensin captopril Capoten enalapril fosinopril
Vasotec Monopril Page 21
COVERED DRUG MEDICAMENTO CUBIERTO lisinopril
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Prinivil/Zestril
moexipril perindopril ramipril
Univasc Aceon Altace
quinapril trandolapril
Accupril Mavik
ANGIOTENSIN II RECEPTOR ANTAGONISTS / ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II BENICAR
valsartan irbesartan
Diovan Avapro
losartan
Cozaar
OTHER ANTIHYPERTENSIVES / OTROS ANTIHIPERTENSIVOS amlodipine/benazepril 2.5/10 mg, Lotrel 2.5/10 mg, 5/10 mg, 5/10 5/20 mg, 10/20, 10/40 mg mg, 5/20 mg, 10/20 mg, 10/40 mg amlodipine/valsartan Exforge amlodipine/valsartan/hctz Exforge HCT atenolol w/chlorthalidone Tenoretic benazepril hcl w/hctz Lotensin HCT bisoprolol fumarate w/hctz Ziac captopril w/hctz Capozide enalapril maleate w/hctz fosinopril w/hctz hydra-zide lisinopril w/hctz methyldopa w/hctz metoprolol w/hctz moexipril w/hctz propranolol hcl w/hctz quinapril w/hctz resperine
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL=30 tabs/30 days; 40 mg=60 tabs/30 days
STEP; COVERED FOR CARDIOLOGISTS, ALL OTHERS REQUIRE PA; QLL=30 tabs/30 days QLL=60 tabs/30 days
QL=30/30 days QL=30/30 days
Vaseretic Monopril HCT Prinzide/Zestoretic Lopressor HCT Uniretic Inderide Quinaretic
Page 22
COVERED DRUG MEDICAMENTO CUBIERTO BENICAR HCT
losartan HCT valsartan hydrochlorothiazide NITRATES / NITRATOS isosorbide dinitrate, ER isosorbide mononitrate, ER nitro-bid ointment nitroglycerin (patch, sublingual tablet, extended-release capsule) NITROSTAT
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
Hyzaar DIOVAN HCT
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES STEP; COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA; QLL=30 tabs/30 days QLL=30 tabs/30 days
Isochron/Isordil Imdur/Ismo/Monoket Nitro-Dur/Nitrostat
OTHER VASODILATING DRUGS / OTROS MEDICAMENTOS VASODILATADORES ADCIRCA COVERED FOR CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA/QLL=60 tabs/30 days sildenafil Revatio COVERED FOR CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA/QLL=90 tabs/30 days CLASS 1A ANTIARRHYTHMICS / ANTIARRÍTMICOS DE CLASE 1A disopyramide, er Norpace procainamide quinidine gluconate quinidine sulfate CLASS 1B ANTIARRHYTHMIC / ANTIARRÍTMICOS DE CLASE 1B mexiletine Mexitil CLASS 1C ANTIARRHYTHMICS / ANTIARRÍTMICOS DE CLASE 1C flecainide acetate Tambocor propafenone hcl, ER Rythmol, SR OTHER ANTIARRHYTHMICS / OTROS ANTIARRÍTMICOS amiodarone Pacerone MULTAQ sotalol, af
Betapace
COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA
HYPOLIPOPROTEINEMICS / HIPOLIPOPROTEINÉMICOS Page 23
COVERED DRUG MEDICAMENTO CUBIERTO cholestyramine colestipol hcl fenofibrate 54mg, 67mg, 134mg, 160mg, 200mg fenofibrate 48mg, 145mg OTC fish oil gemfibrozil OTC niacin OTC SLO NIACIN fenofibric acid DR
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Colestid Lofibra Tricor Lopid
QLL=60 tabs/30 days
Trilipix
ZETIA
STEP
HMG-COA REDUCTASE INHIBITORS / INHIBIDORES DE LA REDUCTASA DE LA HMG-COA atorvastatin QLL=30 tabs/30 days Crestor lovastatin fluvastatin pravastatin simvastatin LESCOL XL
Mevacor Lescol Pravachol Zocor
QLL=30 tabs/30 days; 40 mg=60 tabs/30 days QLL=30 caps/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days
OTHER CARDIOVASCULAR DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES CARDIOVASCULARES midodrine ProAmatine pentoxifylline 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 Aclovate amcinonide betamethasone dipropionate betamethasone valerate clobetasol propionate desonide desoximetasone diflorasone diacetate
Diprolene Beta-Val Clobevate/Temovate Desowen/Lokara Topicort Apexicon/Maxiflor/Psorcon Page 24
COVERED DRUG MEDICAMENTO CUBIERTO Fluocinolone cream, ointment, scalp/body oil Fluocinonide cream 0.05% fluticasone propionate halobetasol hydrocortisone (prescription and OTC forms covered) hydrocortisone butyrate
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Synalar, Derma-Smoothe/FS
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Cutivate Ultravate Ala-Cort/Cetacort/Hytone Locoid
hydrocortisone valerate lidocaine-hydrocortisone mometasone furoate
Westcort
prednicarbate triamcinolone acetonide
Dermatop Kenalog/Triderm
Elocon
ANTIPRURITIC DRUGS / MEDICAMENTOS ANTIPRURÍTICOS hydroxyzine hcl hydroxyzine pamoate ANTIACNE DRUGS / MEDICAMENTOS PARA TRATAR EL ACNÉ adapalene 0.1% cream, gel Differin amnesteem Accutane benzoyl peroxide acne wash 2.5%, 5%, BPO 5.25%, 7%, 10% claravis Accutane clindamycin phosphate Cleocin T/Clindamax erythromycin A/T/S / Emgel/Erycette Metronidazole cream, gel, lotion Metrocream, Metrogel, Metrolotion sod.sulfacetamide/sulfur tf Avar/Plexion sotret Accutane tretinoin Avita/Retin-A KERATOLYTIC DRUGS / MEDICAMENTOS QUERATOLÍTICOS CONDYLOX GEL podofilox solution
QLL=20 gram tube/30days
Condylox
ANTIPSORIASIS AND ANTIECZEMA DRUGS / MEDICAMENTOS PARA TRATAR PSORIASIS Y ECCEMAS calcipotriene ointment, scalp solution Dovonex OTC DOAK TAR DISTILLATE, OIL DRITHO-SCALP
Page 25
COVERED DRUG MEDICAMENTO CUBIERTO POLYTAR selenium sulfide sulfacetamide sodium Topical Tacrolimus
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Selseb Carmol Scalp STEP
VECTICAL OINTMENT ORAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES methoxsalen Oxsoralen Ultra TOPICAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES ammonium lactate Lac-Hydrin CARAC ELIDEL FLUOROPLEX fluorouracil imiquimod 5% cream HYPERCARE SANTYL OTC zinc oxide ointment
STEP/QLL=30 gm/30 days Efudex Aldara
Desitin
SCABICIDES / ESCABICIDAS cumulative QLL=454 grams/180 days acticin Elimite 5% Topical Cream malathion OTC permethrin 1% lotion
Ovide Nix
QLL=2 packages/180 days QLL=1 packages/180 days QLL=2 packages/180 days
permethrin 5% cream (prescription strength) OTC Pyrethrin 0.33%
Elimite
QLL=2 packages/180 days
ULESFIA LOTION
QLL=1 packages/180 days QLL=2 packages/180 days
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 Benzotic/Otogesic acetic acid otic Acetasol/Borofair CIPRO HC CIPRODEX OTIC neomycin/polymixin/hydrocortisone ofloxacin Page 26
REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA DRUGS AFFECTING THE NOSE / MEDICAMENTOS PARA AFECCIONES DE NARIZ azelastine Astelin QLL= 2 bottles/30 days flunisolide Nasarel STEP fluticasone propionate Flonase STEP ipratropium bromide Atrovent Nasacort OTC Allergy 24 HR oxymetazoline
QLL=2 bottles/30 days Afrin
DRUGS AFFECTING THE THROAT AND MOUTH / MEDICAMENTOS PARA AFECCIONES DE BOCA Y GARGANTA chlorhexidine gluconate Peridex doxycycline hyclate Periostat pilocarpine hcl Salagen triamcinolone acetonide 0.1% paste 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 Precose chlorpropamide Diabinese glimepiride glipizide, er glipizide-metformin glyburide glyburide-metformin
Amaryl Glucotrol, XL Metaglip Diabeta/Micronase Glucovance
JANUMET, JANUMET XR
STEP
JANUVIA metformin, ─er nateglinide PRANDIMET repaglinide
STEP Glucophage, XR Starlix Prandin
tolazamide tolbutamide DPP-IV Dipeptidyl Peptidase-4 Inhibitors Tradjenta Jentadueto
STEP-Metformin STEP-Metformin Page 27
COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
SGLT2 Sodium-Glucose Co-transporter 2 inhibitors Invokana Invokamet Farxiga GLP-1 Glucagon-like peptide-1 receptor Trulicity INSULIN SENSITIZERS / SENSIBILIZADORES DE INSULINA AVANDAMET AVANDARYL AVANDIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES STEP-Metformin STEP-Metformin STEP-Metformin STEP-Metformin QLL=60 tabs/30 days QLL=60 tabs/30 days QLL=30 tabs/30 days
pioglitazone ACTOS QLL=30 tabs/30 days pioglitazone HCL and glimepiride DUETACT QLL=30 tabs/30 days pioglitazone HCL and metformin ACTOPLUS MET QLL=90 tabs/30 days 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 N (100 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 OTHER GLUCOSE-LOWERING DRUGS BYETTA
STEP
GLUCOSE ELEVATING DRUGS / MEDICAMENTOS QUE ELEVAN EL NIVEL DE GLUCOSA GLUCAGEN VIALS GLUCAGON OTC glucose chewable tablets GLUCOCORTICOID DRUGS / GLUCOCORTICOIDES cortisone Page 28
COVERED DRUG MEDICAMENTO CUBIERTO dexamethasone hydrocortisone methylprednisolone prednisolone prednisone prednisolone sodium phosphate ODT
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Baycadron Cortef Medrol Prelone
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Sterapred
Orapred ODT GROWTH HORMONES / HORMONAS DE CRECIMIENTO NORDITROPIN NORDITROPIN NORDIFLEX
PA PA
MINERALOCORTICOID DRUGS / MINERALOCORTICOIDES fludrocortisone acetate Florinef THYROID SUPPLEMENTS / SUPLEMENTOS TIROIDEOS ARMOUR THYROID levothroid levothyroxine sodium levoxyl liothyronine thyroid, dessicated unithroid
Synthroid Synthroid Cytomel Armour Thyroid Synthroid
ANTITHYROID DRUGS / MEDICAMENTOS ANTITIROIDEOS methimazole Tapazole/Northyx propylthiouracil 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
QLL 35 mg or 70 mg=4 tabs/30 days; QLL 5 mg,10 mg, 40 mg=30 tabs/30 days COVERED FOR ENDOCRINLOGISTS; ALL OTHERS REQUIRE PA;
Page 29
COVERED DRUG MEDICAMENTO CUBIERTO desmopressin acetate etidronate fortical nasal spray SENSIPAR
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA DDAVP/Minirin
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL=1 bottle/30 days; QLL=90 tabs/30 days
Didronel
COVERED FOR NEPHROLOGIST; ALL OTHERS REQUIRE PA
GASTROINTESTINAL MEDICATIONS 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 bismuth subsalicylate Pepto Bismol diphenoxylate w/atropine Lomotil OTC loperamide
Imodium
ANTISPASMODICS – DRUGS AFFECT GI MOTILITY / ANTIESPASMÓDICOS – MEDICAMENTOS QUE AFECTAN LA MOTILIDAD GASTROINTESTINAL dicyclomine hcl Bentyl glycopyrrolate tablets Robinul hyoscyamine Nulev/Levbrel metoclopramide hcl
Reglan
ANTIULCER DRUGS (OTC AND PRESCRIPTION FORMS COVERED) / MEDICAMENTOS PARA PREVENIR ÚLCERAS (COBERTURA PARA MEDICAMENTOS CON RECETA Y DE VENTA LIBRE) cimetidine Tagamet famotidine Pepcid nizatidine Axid ranitidine Zantac OTHER ANTIULCER DRUGS / OTROS MEDICAMENTOS PARA PREVENIR ÚLCERAS misoprostol Cytotec sucralfate Carafate PROTON PUMP INHIBITORS / INHIBIDORES DE LA BOMBA DE PROTONES
OTC omeprazole OTC esomeprazole OTC lansoprazole
OTC Prilosec OTC Nexium OTC Prevacid
QLL=60tabs /30 days QLL=60/30 days QLL= 60/30 days Page 30
COVERED DRUG MEDICAMENTO CUBIERTO OTC H2 Blockers pantoprazole
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Protonix
LAXATIVES AND CATHARTICS / LAXANTES Y PURGANTES OTC bisacodyl Dulcolax OTC docusate generlac OTC glycerin
Colace Fleet
OTC MIRALAX polyethylene glycol 3350 powder for solution OTC psyllium
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL= 60/30 days QLL=30 tabs/30 days STEP through 2 of the 3 OTC PPI’s
QLL=510 g/30 days Miralax Metamucil
OTC SENOKOT (brand and generic dosage forms covered) OTC SORBITOL 70% ORAL SOLN OTHER GI DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES AMITIZA QLL=60 caps/30 days OTC calcium antacid tablet
Tums
CANASA CORTIFOAM CREON 5, 10, 15, CREON LIPASE 6,000; 12,000; 24,000 UNITS DELZICOL DIPENTUM hydrocortisone Colocort, enema suspension Hydrocort Proctosol-hydrocortisone 2.5% rectal Proctozone HC 2.5%, cream Proctocream HC 2.5%, Anusol HC 2.5% IPECAC SYRUP LIPRAM 4,500; LIPRAM CR5; LIPRAM PN10, LIPRAM PN16, LIPRAM PN 20, LIPRAM UL20 mesalamine enema NULYTELY WITH FLAVOR PACKS OTC acidophilus Page 31
COVERED DRUG MEDICAMENTO CUBIERTO OTC aluminum hydroxide gel
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Alternagel
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
OTC antacid liquid, suspension OTC effervescent pain relief OTC hemorrhoidal cream
Alka Seltzer PreparationH
OTC simethicone drops PANCREAZE PANCRELIPASE 5,000 UNITS PEG 3350 ELECTROLYTE SOLUTION PENTASA PROCTOFOAM-HC propantheline sulfasalazine, sulfasalazine delayed-release sulfazine, sulfazine delayed -release ULTRASE, ULTRASE MT12, MT18, MT20 ursodiol
Azulfidine Azulfidine Actigall
ZENPEP 5,000U; 10,000U, 15,000U, 20,000U IMMUNOLOGICALS AND VACCINES VACCINES AND DRUGS USED FOR MULTIPLE SCLEROSIS ESTIMULADORES INMUNOLÓGICOS Y VACUNAS VACUNAS Y MEDICAMENTOS UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE RHOGAM INTERFERONS USED FOR MULTIPLE SCLEROSIS / INTERFERONES UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE Glatiramer Acetate Glatropa Aubagio
PA PA
Copaxone
PA
EXTAVIA
PA PA
REBIF
Page 32
REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA 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 OTC aspirin 325 mg choline magnesium trisalicylate diflunisal Dolobid salsalate Disalcid NON-STEROIDAL ANTIINFLAMMATORY AGENTS / AGENTES ANTIINFLAMATORIOS NO ESTEROIDES diclofenac sodium etodolac Lodine/Lodine XL fenoprofen flurbiprofen ibuprofen (prescription and OTC forms covered) indomethacin ketoprofen ketorolac
Anasaid Motrin Indocin SR Orudis/Oruvail Toradol
meclofenamate meloxicam nabumetone naproxen
QLL=20 tabs/30 days and 2 Rxs per 90 days
Mobic Relafen Naprosyn
OTC naproxen oxaprozin
Aleve Daypro
piroxicam sulindac tolmetin
Feldene Clinoril
OTHER DRUGS FOR ARTHRITIS / OTROS MEDICAMENTOS PARA TRATAR ARTRITIS RIDAURA COVERED FOR RHEUMATOLOGISTS; ALL OTHERS REQUIRE PA DRUGS TO PREVENT AND TREAT GOUT / MEDICAMENTOS PARA PREVENIR Y TRATAR LA GOTA allopurinol Zyloprim Page 33
COVERED DRUG MEDICAMENTO CUBIERTO colchicine
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Colcrys
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
colchicine / probenecid probenecid ULORIC
STEP
DIRECT MUSCLE RELAXANTS / RELAJANTES MUSCULARES DIRECTOS baclofen dantrolene capsule tizanidine hcl tablets, capsules
Dantrium Zanaflex
CNS MUSCLE RELAXANTS / RELAJANTES MUSCULARES QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL carisoprodol Soma QLL=120 tabs/30 days cyclobenzaprine hcl Flexeril QLL=120 tabs/30 days methocarbamol Robaxin QLL=120 tabs/30 days metaxalone Skelaxin QLL=120 tabs/30 days OTHER MUSCULOSKELETAL MEDICATIONS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS OTC capsaicin riluzole
Rilutek
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES VITAMINS AND DRUGS USED TO REDUCE BLEEDING
COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA
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 Drisdol drops calcitriol Calcijex/Rocaltrol calcium acetate Phoslo OTC calcium carbonate, Caltrate OTC calcium carbonate 600 mg + D OTC calcium citrate Citracal ergocalciferol 1.25 mg Vitamin D2 capsule, (prescription) OTC ferrous fumerate OTC ferrous gluconate OTC ferrous sulfate folic acid (prescription-strength covered only)
Iron
Page 34
COVERED DRUG MEDICAMENTO CUBIERTO levocarnitine
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA
Zemplar
COVERED FOR NEPHROLOGISTS; ALL OTHERS REQUIRE PA
OTC magnesium oxide OTC multivitamins (generic, adult multivitamins) NEPHROCAPS 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
POTASSIUM SUPPLEMENTS / SUPLEMENTOS DE POTASIO citric acid monohydrate, sodium Bicitra citrate dihydrate oral solution klor con, klor con m, klor con effervescent potassium chloride tablets, oral K-Dur/Klotrix solution SHOHL'S MODIFIED POTASSIUM REMOVING RESINS / RESINAS PARA ELIMINAR POTASIO sodium polystyrene sulfonate Kayexalate
ORAL ANTICOAGULANTS, VITAMIN K / ANTICOAGULANTES ORALES, VITAMINA K Amicar warfarin sodium Coumadin/Jantoven XARELTO THE FIRST 45 DAYS OF THERAPY ELIQUIS WILL PROCESS WITHOUT A PA PRADAXA HEPARINS / HEPARINAS heparin sodium vials [inj] (heparin lock flush solution requires SA) LOW-MOLECULAR WEIGHT HEPARINS (LMWH) / HEPARINAS DE BAJO PESO MOLECULAR enoxaparin [inj] Lovenox 10 DAYS W/O PA (10 DAYS=20 SYRINGES) FRAGMIN [inj] 10 DAYS W/O PA (10 DAYS=10 SYRINGES) Page 35
REFERENCE DRUG NAME COVERED DRUG NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO DE REFERENCIA ANTIPLATELET DRUGS / MEDICAMENTOS ANTIPLAQUETARIOS cilostazol Pletal clopidogrel Plavix dipyridamole Persantine ticlopidine hcl Ticlid
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
QLL=30 tabs/30 days
HEMOSTATICS / HEMOSTÁTICOS MEPHYTON BLOOD DETOXICANTS / enulose generlac lactulose RENVELA tablet, powder OTHER BLOOD MODIFIERS / DESINTOXICANTES DE LA SANGRE anagrelide Agrylin SOLIRIS
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 altavera Nordette-28 alyacen Necon amethia lo LoSeasonique apri aranelle aubra aviane azurette balziva brevicon briellyn camila
Desogen Tri-Norinyl Alesse-28 Alesse-28 Mircette Ovcon-35 Modicon Ovcon-35 Nor-Q-D Page 36
COVERED DRUG MEDICAMENTO CUBIERTO camrese lo
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA LoSeasonique
caziant cesia chateal
Cyclessa Cyclessa Nordette-28
cryselle cyclafem
Lo/Ovral-28
dasetta desogestrel/ethinyl estradiol 0.15mg30mcg drospirenone/ethinyl estradiol 30.02mg elinest ELLA emoquette enpresse enskyce errin estarylla falmina generess FE chewable
Desogen Yasmin 28 Lo/Ovral-28 Desogen Tri-levlen 28 Desogen Nor-Q-D Ortho-Cyclen Alesse-28
gianvi gildagia gildess FE
Yaz Ovcon-35 Loestrin FE
heather
Nor-Q-D Seasonale Seasonale
introvale jolessa jolivette junel, junel FE kariva kelnor 1/35 kurvelo
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Nor-Q-D Loestrin, Loestrin FE Mircette Demulen 1/35-28 Nordette-28
larin FE leena
Loestrin FE Tri-Norinyl
lessina levonest
Levlite Tri-levlen 28 Page 37
COVERED DRUG MEDICAMENTO CUBIERTO levonorgestrel 0.75mg levonorgestrel 1.5mg (Next Choice, My Way) levonorgestrel/ethinyl estradiol 0.1mg-20mcg levonorgestrel/ethinyl estradiol 0.15mg-30mcg levora-28 loryna low-ogestrel
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Plan B Plan B, Plan B One Step
Nordette-28 Nordette-28 Yaz Lo/Ovral-28 Alesse-28
lyza
Nor-Q-D
mirogestin, microgestin FE mono-linyah mononessa my way myzilra necon NEXPLANON nora-be norethindrone 0.35mg norgestimate/ethinyl estradiol 0.25mg-35mcg norgestimate/ethinyl estradiol 0.1835/0.215-35/0.25-35 MG-MCG nortrel NUVARING
QLL=3 PKG/YEAR
Alesse-28
lutera marlissa medroxyprogesterone acetate (inj) MIRENA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL=3 PKG/YEAR
Nordette-28 Provera
QLL for injection=1/90 days QLL=1 device per 5 years
Loestrin, Loestrin FE Ortho-Cyclen Ortho-Cyclen Plan B, Plan B One-Step Tri-levlen 28 Modicon, Necon, Norinyl 1+35, Norinyl 1+50, Ortho Novum
QLL=3 PKG/YEAR
QLL=1 implant per 3 years Nor-Q-D Nor-Q-D Ortho-Cyclen Ortho Tri-Cyclen Modicon, Norinyl 1+35, Ortho Novum
ocella ogestrel
Yasmin 28 Ovral-28
orsythia philith pimtrea
Alesse-28 Ovcon-35 Mircette
QLL=1 ring/month
pirmella Page 38
COVERED DRUG MEDICAMENTO CUBIERTO PLAN B ONE STEP portia previfem quasense reclipsen SKYLA
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA Nordette-28 Ortho-Cyclen Seasonale Desogen
QLL=1 device per 3 years
solia sprintec sronyx
Desogen Ortho-Cyclen Levlite
syeda tilia fe
Yasmin 28 Estrostep Fe
tri-legest fe trinessa tri-estaryll
Estrostep Fe Ortho Tri-Cyclen Ortho Tri-Cyclen
tri-linyah tri-previfem tri-sprintec
Ortho Tri-Cyclen Ortho Tri-Cyclen Ortho Tri-Cyclen
trivora-28 velivet vestura viorelle wera
Tri-Levlen 28 Cyclessa Yaz Mircette
wymzya FE
Ovcon-35, Ovcon-35 FE
xulane zarah
Ortho Evra Yasmin 28 Ovcon-35, Ovcon-35 FE Demulen 1/35-28
zenchent, zenchent FE zovia 1/35E zovia 1/50E
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES QLL=3 PKG/YEAR
QLL=3 patches/28 days
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 Page 39
COVERED DRUG MEDICAMENTO CUBIERTO folbecal
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
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 OTC miconazole vaginal suppositories, cream ESTROGEN DRUGS / ESTRÓGENOS estradiol tablets estradiol transdermal patch estropipate
Clindamax MetroGel
Estrace Climara Ogen/Ortho-Est
QLL=4 patches/30 days
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COVERED DRUG MEDICAMENTO CUBIERTO ESTRACE VAGINAL CREAM
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
ESTRING FEMRING MENEST PREMARIN VAGINAL CREAM W/APPLICATOR VAGIFEM ESTROGEN-PROGESTIN COMBINATIONS / COMBINACIONES DE ESTRÓGENO/PROGESTINA CLIMARA PRO COMBIPATCH estradiol/norethindrone acetate 0.5mg-0.1mg, 1mg-0.5mg mg Ethinyl estradiol,Norethindrone acetate 0.5/2.5 PREFEST PREMPHASE
Activella
FEMHRT
PREMPRO SELECTIVE ESTROGEN RECEPTOR MODULATOR / MODULADOR SELECTIVO DE RECEPTORES ESTROGÉNICOS raloxifene Evista PROGESTIN DRUGS / PROGESTINAS medroxyprogesterone acetate tablets norethindrone acetate progesterone capsule
QLL=30 tabs/30 days
Aygestin Prometrium
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 ciprofloxacin hcl (ophth drops)
Ciloxan Page 41
COVERED DRUG MEDICAMENTO CUBIERTO CILOXAN OPTHALMIC OINTMENT erythromycin gentamicin sulfate levofloxacin neomycin/polymyxin/bacitracin neomycin/polymyxin/gramicidin ofloxacin polymyxin/trimethoprim sulfacetamide sodium tobramycin sulfate TOBREX OINTMENT
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Garamycin/Gentak Quixin/Levaquin Neosporin Ocuflox Polytrim Bleph-10 Tobrex/tobrasol
VIGAMOX gatifloxacin 0.5% ophthalmic Zymaxid solution0 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 Cortisporin neomycin/polymyxin/dexamethasone Methadex/Maxitrol prednisolone/sulfacetamide TOBRADEX OINTMENT tobramycin/dexamethasone susp
Tobradex
ANTIGLAUCOMA DRUGS / MEDICAMENTOS ANTIGLAUCOMA acetazolamide, ER AZOPT BETOPTIC S betaxolol hcl brimonidine tartrate carteolol hcl
Alphagan, Alphagan P
COMBIGAN Page 42
COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
dorzolamide dorzolamide/timolol ISOPTO CARBACHOL
Trusopt Cosopt
latanoprost 0.005% ophthalmic sln levobunolol hcl
Xalatan Betagan
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
methazolamide metipranolol PHOSPHOLINE IODIDE pilocarpine hcl timolol maleate
Optipranolol Isopto Carpine Timoptic/Timoptic-XE
travoprost OTHER OPHTHALMIC DRUGS / OTROS MEDICAMENTOS OFTÁLMICOS naphazoline AK-Con OTC ALAWAY azelastine
Optivar
OTC artificial tears atropine sulfate drops, ointment cromolyn sodium
Tears Again Isopto Atropine Crolom
cyclopentolate
Cyclogyl/Cylate Voltaren
diclofenac sodium Epinastine flurbiprofen sodium ketorolac tromethamine ketotifen fumarate 0.025% RX and OTC ISOPTO HOMATROPINE
STEP Ocufen Acular, Acular LS Zaditor
ISOPTO HYOSCINE MUROCOLL-2 NEVANAC PATANOL Polycin-b ophthalmic phenylephrine OTC REFRESH TEARS, LIQUIGEL (15 ML AND 30 ML BOTTLE ONLY)
Neofrin
Page 43
COVERED DRUG MEDICAMENTO CUBIERTO OTC sodium chloride 5% drops, ointment OTC SYSTANE (15 ML AND 30 ML BOTTLE ONLY) trifluridine tropicamide
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
Tropicacyl/Mydral
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 Arcapta Neohaler albuterol sulfate (inhalation soln, QLL=375 ml/30 days for inhalation syrup, tablet) soln ALUPENT (650 MCG INHALER) MAXAIR AUTOHALER metaproterenol SEREVENT DISKUS Striverdi Respimat terbutaline VENTOLIN HFA
QLL= 2 inhalers/30 days
INHALED CORTICOSTEROIDS / CORTICOSTEROIDES INHALADOS ADVAIR DISKUS ADVAIR HFA budesonide respules 0.25 mg/2 ml, 0.5mg/2 ml
Pulmicort Respules
DULERA PULMICORT FLEXHALER/INHALER PULMICORT 1 MG/2 ML RESPULES Flovent Diskus
PA; covered for children < 12 years old PA QLL=120 ml/30 days (60 respules/30 days) PA required > 5 yrs QLL=1 inhaler or flexhaler/30 days QLL=120 ml/30 days (60 respules/30 days)
QVAR SYMBICORT LEUKOTRIENE MODIFIERS / MODIFICADORES DE LEUCOTRIENOS montelukast Singulair zafirlukast Accolate
QLL=30 tabs/30 days QLL=60 tabs/30 days Page 44
REFERENCE DRUG NAME COVERED DRUG NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO DE REFERENCIA METHYL XANTHINE DRUGS / METILXANTINAS aminophylline theophylline, er
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
OTHER DRUGS FOR ASTHMA / OTROS MEDICAMENTOS UTILIZADOS PARA TRATAR EL ASMA ATROVENT (INHALER) COMBIVENT RESPIMAT cromolyn sodium inhalation soln
Intal
EPIPEN, EPIPEN JR Epinephrine Pen 0.3mg/0.3ml, 0.15mg/0.15ml ipratropium bromide ipratropium bromide/albuterol inhalation soln OTHER RESPIRATORY DRUGS / OTROS MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS Incruse SPIRIVA CAPS, RESPIMAT
STEP; QLL=30 caps/30 days, 1 box/30 days
sodium chloride 0.9% nebulizer solution OTC TUDORZA PRESSAIR ANTIHISTAMINES / ANTIHISTAMÍNICOS carbinoxamine tablet, liquid cetirizine OTC tablets, cetirizine-D OTC tablets, cetirizine OTC solution cetirizine syrup (prescription and OTC) chlorpheniramine maleate tablet clemastine fumarate tablet, syrup cyproheptadine hcl tablet, syrup diphenhydramine (prescription and OTC forms covered) fexofenadine tablets hydroxyzine hcl OTC loratadine, OTC loratadine-D Vazol solution
STEP TX through Epinephrine Pen
OTC Zyrtec, Zyrtec Syrup
cetirizine-D QLL=60 tabs/30 days cetirizine soln children less than 6 years old QLL=150 ml/30 days cetirizine soln children ≥ 6years old QLL=300 ml/30 days
Tavist Periactin Benadryl Allegra OTC Claritin, Claritin-D
OTC loratadine-D=30 tabs/30 days
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REFERENCE DRUG NAME COVERED DRUG NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO DE REFERENCIA ANTIHISTAMINE-DECONGESTANT COMBINATIONS COMBINACIONES DE ANTIHISTAMÍNICOS-DESCONGESTIVOS OTC brompheniramine-phenylephrine OTC brompheniraminepseudoephedrine elixir lohist-d liquid
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
nohist pdx drops r-tanna pediatric suspension rynex pse liquid Sildec Syrup OTC sudagest sinus and allergy tablet Virdec 1mg-3.5mg/ml Drops ANTITUSSIVE AND EXPECTORANT DRUGS / ANTITUSÍGENOS Y EXPECTORANTES benzonatate Tessalon OTC CHERATUSSIN AC OTC guaifenesin tablets, syrup, liquid guaifenesin w/codeine MUCINEX, MUCINEX D, DM OTC promethazine vc w/codeine syrup promethazine vc syrup promethazine w/dm syrup OTC tussin DM Virdec DM 3.5mg-1mg-3mg/ml Drops
Romilar AC/TussiOrganidin DM NR Phenergan VC w/Codeine Phenergan VC Phenergan DM Robitussin DM
OTHER DRUGS FOR COUGH, COLD, ALLERGY / OTROS TRATAMIENTOS PARA TRATAR ALERGIAS, TOS Y RESFRÍO OTC nasal spray Afrin OTC pseudoephedrine (all generic Sudafed dosage forms covered) 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 CUPRIMINE Page 46
REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA 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 Urispas oxybutynin chloride oxybutynin chloride er
Ditropan Ditropan XL trospium XR Sanctura XR trospium Sanctura Tolterodine IR Detrol IR CHOLINERGIC STIMULANTS / ESTIMULANTES COLINÉRGICOS bethanecol
STEP; QLL=30 tabs/30 days STEP; QLL=60 tabs/30 days STEP
URINARY ANESTHETICS / ANESTÉSICOS URINARIOS HYOPHEN PHENAZOFORTE phenazopyridine hcl
Pyridium/Urodol
OTHER GENITOURINARY PRODUCTS / OTROS PRODUCTOS GENITOURINARIOS ELMIRON alfuzosin finasteride
Uroxatral Proscar
K-PHOS CYTRA, -K potassium citrate tamsulosin 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 ASTHMA SUPPLIES AEROCHAMBER, MICROCHAMBER QLL=#1/YEAR ASSESS PEAK FLOW METER QLL=#1/YEAR MICROCHAMBER PEAK FLOW METER QLL=#1/YEAR PERSONAL BEST PEAK FLOW METER QLL=#1/YEAR
Page 47
REFERENCE DRUG NAME COVERED DRUG REQUIREMENTS/LIMITS NOMBRE DE MEDICAMENTO MEDICAMENTO CUBIERTO REQUERIMIENTOS/LÍMITES DE REFERENCIA DIABETIC SUPPLIES: Combined QLL for test strips=150/month SUMINISTROS DIABÉTICOS: QLL combinado para tiras reactivas = 150 por mes ALCOHOL PREP PADS MICROLET LANCING DEVICE/LANCETS AUTOJECT 2 INJECTION DEVICE Insulin needles insulin syringes ONE TOUCH ULTRA2, UKTRALINK, ULTRAMINI, ULTRASMART ONE TOUCH SELECT ONE TOUCH TEST STRIPS, CONTROL SOLUTION SOFT TOUCH SOFTCLIX CHEMSTRIP
QLL = 100/ 30 DAYS QLL = 100/ 30 DAYS
KETOSTIX Rectiv
PA QLL 30GM/30 days
Tasgina Octreotide Fondaparainux
Modafanil
PA Sandostatin Arixtra
PA PA 21 Day Supply available without a PA PA QLL of 30/30days
VISCOSUPPLEMENTS Hyalgan
PA
Gel-One
PA
Page 48
