2015 New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) WellCare Health Plans, Inc. 00
Please read: This document has information about drugs we cover in this plan. Please note that we update this drug list quarterly. Providers: Please go to https://newyork.wellcare.com/provider/pharmacy to view updates to this drug list. Members: Please go to https://newyork.wellcare.com/member/default to view updates to this drug list. Last updated (1/01/2015)
Proudly serving New York Medicaid and Child Health Plus® members.
NY028730_CAD_CVR_ENG Internal Approved 02032015 ©WellCare 2015 NY_01_15
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New York Medicaid Cough & Cold Drug List Non-Preferred Drugs
Preferred Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate
TESSALON 200 MG CAPSULE
BENZONATATE 100 MG CAPSULE
BENZONATATE 200 MG CAPSULE
Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION
Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP
Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF PLUS LOZENGE
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl ALLANHIST PDX DROPS BROMFED DM SYRUP
BROMHIST PDX DROPS ENDACOF-PD DROPS
BROTAPP DM LIQUID
Q-TAPP DM ELIXIR
Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM
DIMAPHEN DM ELIXIR
Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl C-PHEN DM PD-COF SYRUP
RONDEX-DM SYRUP SILDEC PE-DM SYRUP
DE-CHLOR DM LIQUID CORFEN DM
NOHIST-DM TRI-DEX PE
Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl PEDIATRIC COUGH-COLD LIQUID KIDKARE COUGH/COLD
MESEHIST DM
Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID
Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ
ROBITUSSIN LONG ACTING LIQUID
Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP
NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMPTOM
EXPECTORANTS DECONGESTANT-EXPECTORANT COMBINATIONS Guaifenesin/Phenylephrine HCl DONATUSSIN DROPS
PE-GUAI DROPS
DESPEC LIQUID
Last updated 07/31/14
RESCON-GG LIQUID
Page 1 of 2
New York Medicaid Cough & Cold Drug List Non-Preferred Drugs Preferred Drugs NON-NARCOTIC DECONGESTANT-EXPECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/Phenylephreine ROBAFEN CF SYRUP
NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SIMUC-DM ELIXIR
SU-TUSS DM ELIXIR
MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRUP REFENESEN DM SILTUSSIN DM DAS COUGH SYRUP MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone Polistirex TUSSIONEX PENNKINETIC SUSP
TUSSICAPS (min. age 6 years old)
HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old)
Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP (min. age 6 years old)
NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP
HC/PE/DBROM SYRUP
Codeine/Phenylephrine HCl/Promethazine PROMETH VC W/COD SYRUP
PROMETHAZINE VC/COD SYRUP
Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROPINE
HYDROMET SYRUP
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin/Hydrocodone Bit HYDROCODONE-GUAIFENESIN SYRUP NARCOF SYRUP
TUSSICLEAR DH SYRUP
Codeine Phosphate/Guaifenesin CHERATUSSIN AC SYRUP GUAIFENESIN-CODEINE SYRUP
IOPHEN C-NR
NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP
Last updated 07/31/14
Page 2 of 2
Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age.
Coverage beyond the age of 18 is evaluated through the PA process.
This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit.
Drug Name
Preference Details Coverage Details
*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines**-*Amphetamine Mixtures*** ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG
P
amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg
P
amphetamine-dextroamphetamine oral tablet 20 mg
P
QL (93 EA per 31 days)
P
QL (62 EA per 31 days)
amphetamine-dextroamphetamine oral tablet 30 mg *Amphetamines**-*Amphetamines*** dextroamphetamine sulfate oral tablet 10 mg, 5 mg
QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years)
P
P
ST; Notes (Must fail preferred Vyvanse or Adderall XR within the past 100 days.); QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years)
P
QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years)
dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg
P
QL (62 EA per 31 days); AL (Min 6 Years)
METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG
P
AL (Min 6 Years)
methylphenidate hcl oral tablet 10 mg, 5 mg
P
AL (Min 6 Years)
methylphenidate hcl oral tablet 20 mg
P
QL (93 EA per 31 days); AL (Min 6 Years)
dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Stimulants - Misc.**-*Stimulants - Misc.***
methylphenidate hcl er oral tablet AL (Min 6 Years and Max 20 P extendedrelease* 10 mg Years) P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 1
Drug Name
Preference Details Coverage Details
methylphenidate hcl er oral tablet extendedrelease* 18 mg, 27 mg, 36 mg
P
QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years)
methylphenidate hcl er oral tablet extendedrelease* 20 mg
P
QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years)
P
QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years)
P
OTC
P
PA
HUMIRA SUBCUTANEOUS* 10 MG/0.2ML
P
PA
HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML
P
PA
HUMIRA PEN SUBCUTANEOUS* KIT 40 MG/0.8ML
P
PA
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML
P
PA
simponi subcutaneous* 100 mg/ml, 50 mg/0.5ml *Gold Compounds**-*Gold Compounds***
P
PA
RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors***
P
methylphenidate hcl er oral tablet extendedrelease* 54 mg *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg *Aminoglycosides* *Aminoglycosides**-*Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies***
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
P
ST; Notes (Must fail preferred meloxicam and one other generic PDL NSAID within the past 100 days); QL (31 EA per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 2
Drug Name
Preference Details Coverage Details
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 40 mg/ml
P
diclofenac potassium oral tablet 50 mg
P
diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg
P
diclofenac sodium er oral tablet extended release 24 hr* 100 mg
P
etodolac oral capsule 200 mg, 300 mg
P
etodolac oral tablet 400 mg, 500 mg
P
fenoprofen calcium oral tablet 600 mg
P
flurbiprofen oral tablet 100 mg, 50 mg
P
ibuprofen oral suspension 100 mg/5ml
P
OTC
ibuprofen oral tablet 200 mg
P
OTC
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
P
indomethacin oral capsule 25 mg, 50 mg
P
ketoprofen oral capsule 50 mg, 75 mg
P
ketorolac tromethamine oral tablet 10 mg
P
meloxicam oral tablet 15 mg, 7.5 mg
P
nabumetone oral tablet 500 mg, 750 mg
P
naproxen oral suspension 125 mg/5ml
P
naproxen oral tablet 250 mg, 375 mg, 500 mg
P
naproxen dr oral tablet delayed release 500 mg
P
naproxen sodium oral tablet 275 mg, 550 mg
P
oxaprozin oral tablet 600 mg
P
piroxicam oral capsule 10 mg, 20 mg
P
sulindac oral tablet 150 mg, 200 mg
P
tolmetin sodium oral capsule 400 mg *Pyrimidine Synthesis Inhibitors**-*Pyrimidine Synthesis Inhibitors***
P
leflunomide oral tablet 10 mg, 20 mg
P
OTC
Notes (Maximum of a 5 day supply per Rx per month); QL (20 EA per 31 days)
QL (2000 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 3
Drug Name
Preference Details Coverage Details
*Analgesics - Nonnarcotic* *Analgesic Combinations**-*Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 mg
P
QL (186 EA per 31 days)
butalbital-apap-caffeine oral capsule 50-325-40 mg
P
QL (186 EA per 31 days)
butalbital-apap-caffeine oral tablet 50-325-40 mg
P
QL (186 EA per 31 days)
butalbital-asa-caffeine oral capsule 50-325-40 mg
P
marten-tab oral tablet 50-325 mg *Analgesics Other**-*Analgesics Other***
P
QL (186 EA per 31 days)
acetaminophen oral solution 160 mg/5ml
P
OTC
acetaminophen oral tablet 325 mg
P
OTC; QL (279 EA per 31 days)
acetaminophen oral tablet 500 mg
P
OTC; QL (186 EA per 31 days)
infants silapap oral solution 100 mg/ml
P
OTC
mapap oral liquid† 160 mg/5ml
P
OTC
MAPAP CHILDRENS ORAL SUSPENSION 160 MG/5ML
P
OTC
pain & fever childrens oral solution 160 mg/5ml *Salicylates**-*Salicylates***
P
OTC
aspir-trin oral tablet delayed release 325 mg
P
OTC
aspirin oral tablet 325 mg
P
OTC
aspirin oral tablet chewable 81 mg
P
OTC
aspirin suppository 600 mg
P
OTC
aspirin adult low strength oral tablet delayed release 81 mg
P
OTC
aspirin ec oral tablet delayed release 325 mg
P
OTC
diflunisal oral tablet 500 mg
P
eq aspirin low dose oral tablet delayed release 81 mg
P
salsalate oral tablet 500 mg, 750 mg *Analgesics - Opioid*
OTC
P
*Opioid Agonists**-*Opioid Agonists*** codeine sulfate oral tablet 15 mg, 30 mg, 60 mg
P
QL (248 EA per 31 days)
fentanyl transdermal patch 72 hr 100 mcg/hr, 12 P PA; QL (10 EA per 30 days) mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 4
Drug Name
Preference Details Coverage Details
hydromorphone hcl oral liquid† 1 mg/ml
P
hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg
P
hydromorphone hcl suppository 3 mg
P
methadone hcl oral solution 10 mg/5ml, 5 mg/5ml
P
methadone hcl oral tablet 10 mg, 5 mg
P
QL (248 EA per 31 days)
METHADOSE ORAL TABLET 10 MG
P
QL (248 EA per 31 days)
morphine sulfate injection solution 10 mg/ml, 15 mg/ml, 5 mg/ml, 8 mg/ml
P
morphine sulfate intravenous* solution 1 mg/ml, 25 mg/ml, 50 mg/ml
P
morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml
P
morphine sulfate oral tablet 15 mg, 30 mg
P
morphine sulfate suppository 10 mg, 20 mg, 30 mg, 5 mg
P
morphine sulfate (concentrate) oral solution 20 mg/ml
P
morphine sulfate (pf) injection solution 0.5 mg/ml
P
morphine sulfate (pf) intravenous* solution 2 mg/ml, 4 mg/ml, 8 mg/ml
P
morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 200 mg, 30 mg, 60 mg
P
QL (248 EA per 31 days)
oxycodone hcl oral capsule 5 mg
P
QL (248 EA per 31 days)
oxycodone hcl oral solution 5 mg/5ml
P
oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg
P
QL (248 EA per 31 days)
P
QL (248 EA per 31 days)
tramadol hcl oral tablet 50 mg *Opioid Combinations**-*Codeine Combinations***
QL (248 EA per 31 days)
QL (248 EA per 31 days)
acetaminophen-codeine oral solution 120-12 mg/5ml
P
acetaminophen-codeine #2 oral tablet 300-15 mg
P
QL (248 EA per 31 days)
acetaminophen-codeine #3 oral tablet 300-30 mg
P
QL (248 EA per 31 days)
acetaminophen-codeine #4 oral tablet 300-60 mg
P
QL (248 EA per 31 days)
ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG
P
QL (186 EA per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 5
Drug Name butalbital-apap-caff-cod oral capsule 50-325-40-30 mg
Preference Details Coverage Details P
QL (186 EA per 31 days)
P
QL (186 EA per 31 days)
hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml
P
QL (3720 ML per 31 days)
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
P
QL (248 EA per 31 days)
P
QL (155 EA per 31 days)
ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG
P
QL (248 EA per 31 days)
oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
P
QL (248 EA per 31 days)
oxycodone-aspirin oral tablet 4.8355-325 mg
P
QL (186 EA per 31 days)
ROXICET ORAL TABLET 5-325 MG *Opioid Partial Agonists**-*Opioid Partial Agonists***
P
QL (248 EA per 31 days)
buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg
P
PA
butorphanol tartrate nasal solution 10 mg/ml
P
QL (2.5 ML per 31 days)
pentazocine-naloxone hcl oral tablet 50-0.5 mg
P
butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg *Opioid Combinations**-*Hydrocodone Combinations***
hydrocodone-ibuprofen oral tablet 7.5-200 mg *Opioid Combinations**-*Opioid Combinations***
zubsolv sublingual tablet sublingual 1.4-0.36 mg, 5.7-1.4 mg *Androgens-Anabolic*
P
PA
oxandrolone oral tablet 10 mg, 2.5 mg *Androgens**-*Androgens***
P
PA
danazol oral capsule 100 mg, 200 mg, 50 mg
P
methitest oral tablet 10 mg
P
TESTIM TRANSDERMAL 50 MG/5GM
P
PA
testosterone transdermal 12.5 mg/act (1%), 50 mg/5gm
P
PA
testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml
P
*Anabolic Steroids**-*Anabolic Steroids***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 6
Drug Name testosterone enanthate intramuscular* solution 200 mg/ml *Anorectal Agents*
Preference Details Coverage Details P
*Intrarectal Steroids**-*Intrarectal Steroids*** hydrocortisone enema 100 mg/60ml *Rectal Steroids**-*Rectal Steroids***
P
PROCTOSOL HC CREAM 2.5 %
P
PROCTOZONE-HC CREAM 2.5 % *Antacids*
P
*Antacid Combinations**-*Antacid & Simethicone*** aluminum-magnesium-simethicone oral suspension 200-200-20 mg/5ml
P
OTC
P
OTC
P
OTC
P
OTC
P
OTC
P
OTC
ALBENZA ORAL TABLET 200 MG
P
PA
BILTRICIDE ORAL TABLET 600 MG
P
PA
ivermectin oral tablet 3 mg
P
QL (10 EA per 31 days)
pin-x oral suspension 50 mg/ml
P
OTC
MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML *Antacids - Aluminum Salts**-*Antacids Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml *Antacids - Bicarbonate**-*Antacids Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids Calcium Salts*** calcium carbonate antacid oral tablet chewable 500 mg *Antacids - Magnesium Salts**-*Antacids Magnesium Salts*** magnesium oxide oral tablet 250 mg, 400 mg, 420 mg *Anthelmintics* *Anthelmintics**-*Anthelmintics***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 7
Drug Name reeses pinworm medicine oral suspension 144 mg/ml *Antianginal Agents*
Preference Details Coverage Details P
OTC
*Nitrates**-*Nitrates*** isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg
P
isosorbide dinitrate er oral tablet extendedrelease* 40 mg
P
isosorbide mononitrate oral tablet 10 mg, 20 mg
P
isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg
P
NITRO-BID TRANSDERMAL OINTMENT 2 %
P
nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
P
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG *Antianxiety Agents*
P
*Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg
P
hydroxyzine hcl oral solution 10 mg/5ml
P
QL (450 ML per 31 days)
hydroxyzine hcl oral syrup 10 mg/5ml
P
QL (450 ML per 31 days)
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg
P
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg
P
meprobamate oral tablet 200 mg, 400 mg *Benzodiazepines**-*Benzodiazepines***
P
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg
P
chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg
P
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg
P
diazepam injection solution 5 mg/ml
P
diazepam oral solution 1 mg/ml
P
diazepam oral tablet 10 mg, 2 mg, 5 mg
P
AL (Min 9 Years)
QL (1240 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 8
Drug Name
Preference Details Coverage Details
lorazepam injection solution 2 mg/ml, 4 mg/ml
P
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
P
oxazepam oral capsule 10 mg, 15 mg, 30 mg *Antiarrhythmics*
P
*Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg
P
procainamide hcl injection solution 100 mg/ml, 500 mg/ml
P
quinidine gluconate injection solution 80 mg/ml
P
quinidine gluconate er oral tablet extendedrelease* 324 mg
P
quinidine sulfate oral tablet 300 mg *Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous* solution 20 mg/ml mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg *Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg *Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii***
P
P P
P P
amiodarone hcl intravenous* solution 150 mg/3ml
P
amiodarone hcl oral tablet 200 mg, 400 mg
P
PACERONE ORAL TABLET 200 MG, 400 MG
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 9
Drug Name
Preference Details Coverage Details
*Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies**-*Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents**-*Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 mg/2ml *Bronchodilators Anticholinergics**-*Bronchodilators Anticholinergics***
P
PA
P
ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT
P
QL (25.8 GM per 31 days)
ipratropium bromide inhalation solution 0.02 %
P
QL (480 ML per 31 days)
P
QL (1 EA per 30 days)
montelukast sodium oral packet 4 mg
P
AL (Min 1 Months and Max 2 Years)
montelukast sodium oral tablet 10 mg
P
montelukast sodium oral tablet chewable 4 mg, 5 mg
P
TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators**-*Leukotriene Receptor Antagonists***
zafirlukast oral tablet 10 mg, 20 mg *Steroid Inhalants**-*Steroid Inhalants***
P
ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
P
QL (1 EA per 30 days)
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH
P
QL (1 EA per 30 days)
ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
P
QL (1 EA per 30 days)
ASMANEX HFA INHALATION P AEROSOL† 100 MCG/ACT, 200 MCG/ACT P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 10
Drug Name
Preference Details Coverage Details
budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml
P
QL (120 ML per 31 days); AL (Max 8 Years)
FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST
P
QL (60 EA per 30 days)
FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT
P
QL (12 GM per 30 days)
FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT
P
QL (10.6 GM per 30 days)
P
QL (120 ML per 31 days); AL (Max 8 Years)
ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE
P
QL (60 EA per 30 days)
ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT
P
QL (12 GM per 30 days)
COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT
P
QL (4 GM per 20 days)
DULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT
P
QL (13 GM per 30 days)
ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml
P
QL (720 ML per 31 days)
P
QL (10.2 GM per 30 days)
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%
P
QL (720 ML per 31 days)
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%
P
QL (60 EA per 30 days)
albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml
P
QL (300 ML per 31 days)
albuterol sulfate oral syrup 2 mg/5ml
P
QL (2480 ML per 31 days)
albuterol sulfate oral tablet 2 mg, 4 mg
P
PULMICORT INHALATION SUSPENSION 1 MG/2ML *Sympathomimetics**-*Adrenergic Combinations***
SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Sympathomimetics**-*Beta Adrenergics***
FORADIL AEROLIZER INHALATION P QL (60 EA per 30 days) CAPSULE 12 MCG P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 11
Drug Name
Preference Details Coverage Details
metaproterenol sulfate oral syrup 10 mg/5ml
P
SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE
P
terbutaline sulfate injection solution 1 mg/ml
P
terbutaline sulfate oral tablet 2.5 mg, 5 mg
P
VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines**-*Xanthines***
P
aminophylline intravenous* solution 25 mg/ml
P
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML
P
theophylline oral solution 80 mg/15ml
P
theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg
P
theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg *Anticoagulants*
QL (60 EA per 30 days)
QL (36 GM per 31 days)
P
*Coumarin Anticoagulants**-*Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors**-*Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG *Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins***
P P
P
QL (35 EA per 365 days)
enoxaparin sodium injection solution 300 mg/3ml
P
QL (24 ML per 31 days)
enoxaparin sodium subcutaneous* solution 100 mg/ml, 150 mg/ml
P
QL (28 ML per 31 days)
enoxaparin sodium subcutaneous* solution 120 mg/0.8ml, 80 mg/0.8ml
P
QL (22.4 ML per 31 days)
enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml
P
QL (8.4 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 12
Drug Name enoxaparin sodium subcutaneous* solution 60 mg/0.6ml *Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents***
Preference Details Coverage Details P
QL (16.8 ML per 31 days)
fondaparinux sodium subcutaneous* solution 10 mg/0.8ml
P
QL (11.2 ML per 31 days)
fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml
P
QL (16 ML per 31 days)
fondaparinux sodium subcutaneous* solution 5 mg/0.4ml
P
QL (5.6 ML per 31 days)
P
QL (8.4 ML per 31 days)
fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml *Anticonvulsants* *Anticonvulsants Benzodiazepines**-*Anticonvulsants Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg
P
diazepam 10 mg, 2.5 mg, 20 mg *Anticonvulsants - Misc.**-*Anticonvulsants Misc.***
P
QL (3 EA per 31 days)
carbamazepine oral suspension 100 mg/5ml
P
QL (2480 ML per 31 days)
carbamazepine oral tablet 200 mg
P
QL (248 EA per 31 days)
carbamazepine oral tablet chewable 100 mg
P
QL (310 EA per 31 days)
EPITOL ORAL TABLET 200 MG
P
QL (248 EA per 31 days)
gabapentin oral capsule 100 mg
P
QL (310 EA per 31 days)
gabapentin oral capsule 300 mg
P
QL (372 EA per 31 days)
gabapentin oral capsule 400 mg
P
QL (279 EA per 31 days)
gabapentin oral solution 250 mg/5ml
P
QL (2230 ML per 31 days)
gabapentin oral tablet 600 mg, 800 mg
P
lamotrigine oral tablet 100 mg, 150 mg, 200 mg
P
lamotrigine oral tablet 25 mg
P
QL (310 EA per 31 days)
lamotrigine oral tablet chewable 25 mg, 5 mg
P
QL (310 EA per 31 days)
levetiracetam intravenous* solution 500 mg/5ml
P
levetiracetam oral solution 100 mg/ml
P
levetiracetam oral tablet 1000 mg, 500 mg, 750 mg
P
QL (1000 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 13
Drug Name
Preference Details Coverage Details
levetiracetam oral tablet 250 mg
P
QL (372 EA per 31 days)
oxcarbazepine oral suspension 300 mg/5ml
P
QL (1240 ML per 31 days)
oxcarbazepine oral tablet 150 mg
P
QL (310 EA per 31 days)
oxcarbazepine oral tablet 300 mg
P
QL (248 EA per 31 days)
oxcarbazepine oral tablet 600 mg
P
primidone oral tablet 250 mg
P
QL (248 EA per 31 days)
primidone oral tablet 50 mg
P
QL (310 EA per 31 days)
topiramate oral capsule sprinkle 15 mg, 25 mg
P
QL (310 EA per 31 days)
topiramate oral tablet 100 mg, 25 mg, 50 mg
P
QL (310 EA per 31 days)
topiramate oral tablet 200 mg
P
QL (248 EA per 31 days)
zonisamide oral capsule 100 mg
P
QL (186 EA per 31 days)
zonisamide oral capsule 25 mg
P
QL (310 EA per 31 days)
zonisamide oral capsule 50 mg *Gaba Modulators**-*Gaba Modulators***
P
QL (372 EA per 31 days)
GABITRIL ORAL TABLET 12 MG, 16 MG
P
tiagabine hcl oral tablet 2 mg, 4 mg *Hydantoins**-*Hydantoins***
P
DILANTIN ORAL CAPSULE 30 MG
P
fosphenytoin sodium injection solution 100 mg pe/2ml
P
PEGANONE ORAL TABLET 250 MG
P
QL (372 EA per 31 days)
phenytoin oral suspension 125 mg/5ml
P
QL (930 ML per 31 days)
phenytoin oral tablet chewable 50 mg
P
QL (372 EA per 31 days)
phenytoin sodium injection solution 50 mg/ml
P
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg *Succinimides**-*Succinimides***
QL (310 EA per 31 days)
P
ethosuximide oral capsule 250 mg
P
ethosuximide oral solution 250 mg/5ml *Valproic Acid**-*Valproic Acid***
P
QL (930 ML per 31 days)
divalproex sodium oral capsule sprinkle 125 mg
P
QL (310 EA per 31 days)
divalproex sodium oral tablet delayed release 125 mg, 250 mg
P
QL (310 EA per 31 days)
divalproex sodium oral tablet delayed release 500 mg
P
QL (279 EA per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 14
Drug Name
Preference Details Coverage Details
divalproex sodium er oral tablet extended release 24 hr* 250 mg
P
QL (310 EA per 31 days)
divalproex sodium er oral tablet extended release 24 hr* 500 mg
P
QL (279 EA per 31 days)
valproic acid oral capsule 250 mg
P
QL (310 EA per 31 days)
valproic acid oral solution 250 mg/5ml
P
QL (2790 ML per 31 days)
valproic acid oral syrup 250 mg/5ml *Antidepressants*
P
QL (2790 ML per 31 days)
*Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg *Antidepressants - Misc.**-*Antidepressants Misc.***
P P
bupropion hcl oral tablet 100 mg, 75 mg
P
bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg
P
bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg
P
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg *Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)***
P
phenelzine sulfate oral tablet 15 mg
P
tranylcypromine sulfate oral tablet 10 mg *Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)***
P
citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg
P
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg
P
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
P
fluoxetine hcl oral solution 20 mg/5ml
P
fluoxetine hcl oral tablet 10 mg, 20 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 15
Drug Name
Preference Details Coverage Details
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg
P
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
P
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg *Serotonin Modulators**-*Serotonin Modulators*** nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 50 mg *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg *Tricyclic Agents**-*Tricyclic Agents***
P
P P
P P
amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
P
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg
P
clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg
P
desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
P
doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg
P
doxepin hcl oral concentrate 10 mg/ml
P
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
P
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg
P
nortriptyline hcl oral solution 10 mg/5ml
P
protriptyline hcl oral tablet 10 mg, 5 mg *Antidiabetics*
P
QL (31 EA per 31 days)
QL (2325 ML per 31 days)
*Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 16
Drug Name
Preference Details Coverage Details
*Antidiabetic Combinations**-*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 50-500 MG
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (62 EA per 31 days)
P
ST
JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG *Antidiabetic Combinations**-*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG *Antidiabetic Combinations**-*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg *Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedion e Combinations***
P P
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
AVANDAMET ORAL TABLET 2-1000 MG, 4-500 MG
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 8-4 MG *Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 17
Drug Name
Preference Details Coverage Details
*Biguanides**-*Biguanides*** metformin hcl oral tablet 1000 mg, 500 mg, 850 mg
P
metformin hcl er oral tablet extended release 24 hr* 500 mg, 750 mg
P
metformin hcl er (osm) oral tablet extended release 24 hr* 500 mg
P
RIOMET ORAL SOLUTION 500 MG/5ML *Diabetic Other**-*Diabetic Other***
P
QL (900 ML per 31 days)
GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG
P
QL (2 EA per 31 days)
GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG
P
QL (2 EA per 31 days)
GLUCAGON EMERGENCY INJECTION KIT 1 MG
P
QL (2 EA per 31 days)
P
OTC
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (31 EA per 31 Days)
BYDUREON SUBCUTANEOUS* 2 MG
P
ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days)
BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG
P
ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days)
P
ST; Notes (Must fail preferred METFORMIN TABS, METFORMIN ER TABS, and RIOMET SOLN within the past 100 days)
glucose oral tablet chewable 4 gm *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG
TRADJENTA ORAL TABLET 5 MG *Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***
BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 18
Drug Name
Preference Details Coverage Details
P
ST; Notes (Must fail preferred METFORMIN TABS, METFORMIN ER TABS, and RIOMET SOLN within the past 100 days)
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
P
ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.)
APIDRA INJECTION SOLUTION 100 UNIT/ML
P
QL (60 ML per 31 days)
APIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML
P
QL (60 ML per 31 days)
HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML
P
QL (60 ML per 31 days)
HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML
P
QL (60 ML per 31 days)
HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML
P
QL (60 ML per 31 days)
HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML
P
QL (60 ML per 31 days)
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* (75-25) 100 UNIT/ML
P
QL (60 ML per 31 days)
HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML
P
OTC; QL (60 ML per 31 days)
HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML
P
OTC; QL (60 ML per 31 days)
HUMULIN N KWIKPEN SUBCUTANEOUS* 100 UNIT/ML
P
QL (60 ML per 31 days)
HUMULIN R INJECTION SOLUTION 100 UNIT/ML
P
OTC; QL (60 ML per 31 days)
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML
P
QL (60 ML per 31 days)
BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML *Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg *Insulin**-*Human Insulin***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 19
Drug Name LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors**-*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylureas**-*Sulfonylureas***
Preference Details Coverage Details P
QL (60 ML per 31 days)
P
QL (60 ML per 31 days)
P
ST
P
ST
chlorpropamide oral tablet 100 mg, 250 mg
P
glimepiride oral tablet 1 mg, 2 mg, 4 mg
P
glipizide oral tablet 10 mg, 5 mg
P
glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg
P
GLIPIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG
P
glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg
P
glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg *Antidiarrheals*
P
*Antiperistaltic Agents**-*Antiperistaltic Agents*** diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml
P
diphenoxylate-atropine oral tablet 2.5-0.025 mg
P
loperamide a-d oral tablet 2 mg
P
loperamide hcl oral capsule 2 mg *Antidotes*
P
OTC
*Antidotes - Chelating Agents**-*Antidotes Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG
P
PA
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 20
Drug Name
Preference Details Coverage Details
*Antidotes**-*Antidotes*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg *Opioid Antagonists**-*Opioid Antagonists*** naltrexone hcl oral tablet 50 mg *Antiemetics*
P
P
*5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists*** ondansetron oral tablet dispersible 4 mg, 8 mg
P
ondansetron hcl oral solution 4 mg/5ml
P
ondansetron hcl oral tablet 4 mg, 8 mg *Antiemetics - Anticholinergic**-*Antiemetics Anticholinergic***
P
meclizine hcl oral tablet 12.5 mg, 25 mg
P
OTC
meclizine hcl oral tablet chewable 25 mg
P
OTC
travel sickness oral tablet chewable 25 mg *Antifungals*
P
OTC
griseofulvin microsize oral suspension 125 mg/5ml
P
QL (450 ML per 31 days)
griseofulvin microsize oral tablet 500 mg
P
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg
P
nystatin oral tablet 500000 unit
P
terbinafine hcl oral tablet 250 mg *Imidazole-Related Antifungals**-*Imidazoles***
P
ketoconazole oral tablet 200 mg *Imidazole-Related Antifungals**-*Triazoles***
P
*Antifungals**-*Antifungals***
fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml
P
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 21
Drug Name
Preference Details Coverage Details
*Antihistamines* *Antihistamines Alkylamines**-*Antihistamines Alkylamines*** allergy oral tablet 4 mg *Antihistamines Ethanolamines**-*Antihistamines Ethanolamines***
P
OTC
aler-dryl oral tablet 50 mg
P
OTC
BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML
P
OTC
diphenhydramine hcl oral capsule 25 mg, 50 mg
P
OTC
diphenhydramine hcl oral tablet 25 mg *Antihistamines Non-Sedating**-*Antihistamines Non-Sedating***
P
OTC
ALLEGRA ALLERGY CHILDRENS ORAL SUSPENSION 30 MG/5ML
P
OTC
allergy oral tablet dispersible 10 mg
P
OTC
cetirizine hcl oral syrup 1 mg/ml, 5 mg/5ml
P
OTC; QL (300 ML per 31 days)
cetirizine hcl oral tablet 10 mg, 5 mg
P
OTC
cetirizine hcl childrens oral solution 1 mg/ml
P
OTC; QL (300 ML per 31 days)
childrens loratadine oral syrup 5 mg/5ml
P
OTC; QL (310 ML per 31 days)
fexofenadine hcl oral tablet 180 mg, 60 mg
P
OTC
fexofenadine hcl childrens oral suspension 30 mg/5ml
P
OTC
levocetirizine dihydrochloride oral solution 2.5 mg/5ml
P
ST; Notes (Must fail preferred loratadine solution and cetirizine syrup within the past 100 days)
levocetirizine dihydrochloride oral tablet 5 mg
P
loratadine oral tablet 10 mg
P
OTC
loratadine hives relief oral solution 5 mg/5ml *Antihistamines Phenothiazines**-*Antihistamines Phenothiazines***
P
OTC
promethazine hcl oral syrup 6.25 mg/5ml
P
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 22
Drug Name
Preference Details Coverage Details
promethazine hcl suppository 25 mg, 50 mg
P
PROMETHEGAN SUPPOSITORY 25 MG *Antihistamines - Piperidines**-*Antihistamines - Piperidines***
P
cyproheptadine hcl oral syrup 2 mg/5ml
P
cyproheptadine hcl oral tablet 4 mg *Antihyperlipidemics*
P
QL (300 ML per 31 days)
*Bile Acid Sequestrants**-*Bile Acid Sequestrants*** cholestyramine oral packet 4 gm
P
cholestyramine oral powder 4 gm/dose
P
cholestyramine light oral packet 4 gm
P
cholestyramine light oral powder 4 gm/dose *Fibric Acid Derivatives**-*Fibric Acid Derivatives***
P
fenofibrate oral tablet 160 mg, 54 mg
P
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
P
gemfibrozil oral tablet 600 mg *Hmg Coa Reductase Inhibitors**-*Hmg Coa Reductase Inhibitors***
P
atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg
P
lovastatin oral tablet 10 mg, 20 mg, 40 mg
P
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg
P
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg *Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors***
P
ZETIA ORAL TABLET 10 MG *Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives***
P
NIACOR ORAL TABLET 500 MG
P
PA
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 23
Drug Name
Preference Details Coverage Details
*Antihypertensives* *Ace Inhibitors**-*Ace Inhibitors*** benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
P
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
P
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
P
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg
P
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg
P
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
P
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg *Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** losartan potassium oral tablet 100 mg, 25 mg, 50 mg *Antiadrenergic Antihypertensives**-*Antiadrenergics Centrally Acting***
P
P
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
P
guanfacine hcl oral tablet 1 mg, 2 mg
P
methyldopa oral tablet 250 mg, 500 mg *Antiadrenergic Antihypertensives**-*Antiadrenergics Peripherally Acting***
P
doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg
P
prazosin hcl oral capsule 1 mg, 2 mg, 5 mg
P
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg *Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
QL (31 EA per 31 days)
P
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 24
Drug Name
Preference Details Coverage Details
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
P
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg
P
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg *Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg *Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations***
P
P
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg
P
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
P
propranolol-hctz oral tablet 40-25 mg, 80-25 mg *Vasodilators**-*Vasodilators***
P
hydralazine hcl injection solution 20 mg/ml
P
hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg
P
minoxidil oral tablet 10 mg, 2.5 mg *Anti-Infective Agents - Misc.*
QL (31 EA per 31 days)
P
*Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.*** metronidazole oral tablet 250 mg, 500 mg
P
trimethoprim oral tablet 100 mg
P
vancomycin hcl intravenous* solution reconstituted 1000 mg, 500 mg, 750 mg
P
vancomycin hcl oral capsule 125 mg, 250 mg *Anti-Infective Misc. Combinations**-*Anti-Infective Misc. Combinations***
P
sulfamethoxazole-tmp ds oral tablet 800-160 mg
P
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
P
PA
QL (1200 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 25
Drug Name sulfamethoxazole-trimethoprim oral tablet 400-80 mg *Antiprotozoal Agents**-*Antiprotozoal Agents***
Preference Details Coverage Details P
atovaquone oral suspension 750 mg/5ml *Leprostatics**-*Leprostatics***
P
dapsone oral tablet 100 mg, 25 mg *Lincosamides**-*Lincosamides***
P
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg
P
clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml
P
clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml
P
clindamycin phosphate intravenous* solution 300 mg/2ml *Oxazolidinones**-*Oxazolidinones*** sivextro oral tablet 200 mg *Antimalarials*
QL (2400 ML per 31 days)
P
P
PA
*Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg *Antimalarials**-*Antimalarials***
P
DARAPRIM ORAL TABLET 25 MG
P
hydroxychloroquine sulfate oral tablet 200 mg
P
mefloquine hcl oral tablet 250 mg
P
primaquine phosphate oral tablet 26.3 mg *Antimyasthenic/Cholinergic Agents*
P
*Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRUP 60 MG/5ML
P
MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG
P
pyridostigmine bromide oral tablet 60 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 26
Drug Name
Preference Details Coverage Details
*Antimycobacterial Agents* *Antimycobacterial Agents**-*Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg
P
isoniazid injection solution 100 mg/ml
P
isoniazid oral tablet 100 mg, 300 mg
P
pyrazinamide oral tablet 500 mg
P
rifabutin oral capsule 150 mg
P
rifampin intravenous* solution reconstituted 600 mg
P
rifampin oral capsule 150 mg, 300 mg *Antineoplastics And Adjunctive Therapies*
P
*Alkylating Agents**-*Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG
P
PA
MYLERAN ORAL TABLET 2 MG *Alkylating Agents**-*Imidazotetrazines***
P
PA
P
PA
ALKERAN ORAL TABLET 2 MG
P
PA
cyclophosphamide oral capsule 25 mg, 50 mg
P
PA
LEUKERAN ORAL TABLET 2 MG *Alkylating Agents**-*Nitrosoureas***
P
PA
lomustine oral capsule 10 mg, 100 mg, 40 mg *Antimetabolites**-*Antimetabolites***
P
PA
ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML
P
PA
capecitabine oral tablet 150 mg, 500 mg
P
PA
fluorouracil intravenous* solution 500 mg/10ml
P
PA
gemcitabine hcl intravenous* solution 1 gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml
P
PA
gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, 200 mg
P
PA
mercaptopurine oral tablet 50 mg
P
methotrexate oral tablet 2.5 mg
P
temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg *Alkylating Agents**-*Nitrogen Mustards***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 27
Drug Name
Preference Details Coverage Details
methotrexate sodium injection solution reconstituted 1 gm
P
methotrexate sodium (pf) injection solution 1 gm/40ml, 25 mg/ml, 250 mg/10ml, 50 mg/2ml
P
TABLOID ORAL TABLET 40 MG *Antineoplastic - Angiogenesis Inhibitors**-*Vascular Endothelial Growth Factor (Vegf) Inhibitors***
P
PA
P
PA
ERIVEDGE ORAL CAPSULE 150 MG *Antineoplastic - Hormonal And Related Agents**-*Antiadrenals***
P
PA
LYSODREN ORAL TABLET 500 MG *Antineoplastic - Hormonal And Related Agents**-*Antiandrogens***
P
PA
XTANDI ORAL CAPSULE 40 MG *Antineoplastic - Hormonal And Related Agents**-*Antiestrogens***
P
PA
tamoxifen citrate oral tablet 10 mg, 20 mg *Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors***
P
anastrozole oral tablet 1 mg
P
letrozole oral tablet 2.5 mg *Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic***
P
EMCYT ORAL CAPSULE 140 MG *Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs***
P
PA
TRELSTAR DEPOT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG
P
PA
TRELSTAR DEPOT MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG
P
PA
AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML *Antineoplastic - Hedgehog Pathway Inhibitors**-*Antineoplastic - Hedgehog Pathway Inhibitors***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 28
Drug Name
Preference Details Coverage Details
TRELSTAR LA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG
P
PA
TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG
P
PA
P
PA
megestrol acetate oral suspension 40 mg/ml
P
QL (600 ML per 31 days)
megestrol acetate oral tablet 20 mg, 40 mg *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Braf Kinase Inhibitors***
P
ZELBORAF ORAL TABLET 240 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors***
P
PA
ZOLINZA ORAL CAPSULE 100 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors***
P
PA
P
PA
P
PA
P
PA
BOSULIF ORAL TABLET 100 MG, 500 MG
P
PA
CAPRELSA ORAL TABLET 100 MG, 300 MG
P
PA
TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 22.5 MG *Antineoplastic - Hormonal And Related Agents**-*Progestins-Antineoplastic***
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors***
GILOTRIF ORAL TABLET 20 MG, 30 MG, P PA; QL (31 EA per 31 days) 40 MG P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 29
Drug Name
Preference Details Coverage Details
GLEEVEC ORAL TABLET 100 MG, 400 MG
P
PA
ICLUSIG ORAL TABLET 15 MG, 45 MG
P
PA
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
P
PA
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
P
PA
TASIGNA ORAL CAPSULE 150 MG, 200 MG
P
PA
TYKERB ORAL TABLET 250 MG
P
PA
XALKORI ORAL CAPSULE 200 MG, 250 MG
P
PA
P
PA; QL (155 EA per 31 days)
P
PA
P
PA
ZYKADIA ORAL CAPSULE 150 MG *Antineoplastic Enzyme Inhibitors**-*Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Antineoplastic Enzymes**-*Antineoplastic Enzymes*** ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT *Antineoplastics Misc.**-*Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg *Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg *Mitotic Inhibitors**-*Mitotic Inhibitors*** etoposide oral capsule 50 mg
P
P P
P
PA
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 30
Drug Name
Preference Details Coverage Details
*Antiparkinson Agents* *Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg
P
trihexyphenidyl hcl oral elixir 0.4 mg/ml
P
trihexyphenidyl hcl oral tablet 2 mg, 5 mg *Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics***
P
amantadine hcl oral capsule 100 mg
P
amantadine hcl oral syrup 50 mg/5ml
P
amantadine hcl oral tablet 100 mg
P
bromocriptine mesylate oral capsule 5 mg
P
bromocriptine mesylate oral tablet 2.5 mg *Antiparkinson Dopaminergics**-*Levodopa Combinations***
P
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa er oral tablet extendedrelease* 50-200 mg *Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg *Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors***
P P
P
ST; Notes (Must fail preferred ropinirole within the past 100 days.)
P
selegiline hcl oral capsule 5 mg
P
selegiline hcl oral tablet 5 mg *Antipsychotics/Antimanic Agents*
P
*Antimanic Agents**-*Antimanic Agents*** lithium oral solution 8 meq/5ml
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 31
Drug Name
Preference Details Coverage Details
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg
P
lithium carbonate oral tablet 300 mg
P
lithium carbonate er oral tablet extendedrelease* 300 mg, 450 mg *Benzisoxazoles**-*Benzisoxazoles***
P
risperidone oral solution 1 mg/ml
P
QL (496 ML per 31 days); AL (Min 5 Years)
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
P
QL (62 EA per 31 days); AL (Min 5 Years)
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
P
QL (62 EA per 31 days); AL (Min 5 Years)
P
QL (62 EA per 31 days); AL (Min 5 Years)
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 5 mg
P
AL (Min 3 Years)
haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml
P
AL (Min 18 Years)
haloperidol lactate injection solution 5 mg/ml
P
AL (Min 3 Years)
haloperidol lactate oral concentrate 2 mg/ml *Dibenzapines**-*Dibenzodiazepines***
P
AL (Min 3 Years)
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
P
AL (Min 18 Years)
clozapine oral tablet dispersible 12.5 mg
P
QL (31 EA per 31 days); AL (Min 18 Years)
P
ST; Notes (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.); AL (Min 18 Years)
P
AL (Min 10 Years)
P
AL (Min 18 Years)
RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG *Butyrophenones**-*Butyrophenones***
*Dibenzapines**-*Dibenzo-Oxepino Pyrroles*** SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG *Dibenzapines**-*Dibenzothiazepines*** quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg *Dibenzapines**-*Dibenzoxazepines*** loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 32
Drug Name
Preference Details Coverage Details
*Dibenzapines**-*Thienbenzodiazepines*** P
QL (31 EA per 31 days); AL (Min 13 Years)
chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg
P
AL (Min 6 Months)
fluphenazine decanoate injection solution 25 mg/ml
P
AL (Min 12 Years)
fluphenazine hcl oral concentrate 5 mg/ml
P
QL (248 ML per 31 days); AL (Min 18 Years)
fluphenazine hcl oral elixir 2.5 mg/5ml
P
QL (2480 ML per 31 days); AL (Min 18 Years)
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg
P
AL (Min 18 Years)
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
P
AL (Min 12 Years)
prochlorperazine suppository 25 mg
P
AL (Min 2 Years)
prochlorperazine maleate oral tablet 10 mg, 5 mg
P
AL (Min 2 Years)
thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg
P
AL (Min 2 Years)
P
AL (Min 6 Years)
P
ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.)
P
ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.)
P
AL (Min 12 Years)
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg *Phenothiazines**-*Phenothiazines***
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg *Quinolinone Derivatives**-*Quinolinone Derivatives*** ABILIFY ORAL SOLUTION 1 MG/ML
ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG *Thioxanthenes**-*Thioxanthenes*** thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 33
Drug Name
Preference Details Coverage Details
*Antiseptics & Disinfectants* *Chlorine Antiseptics**-*Chlorine Antiseptics*** P
OTC; QL (480 ML per 31 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
P
QL (62 EA per 31 days)
ATRIPLA ORAL TABLET 600-200-300 MG
P
COMPLERA ORAL TABLET 200-25-300 MG
P
EPZICOM ORAL TABLET 600-300 MG
P
KALETRA ORAL SOLUTION 400-100 MG/5ML
P
KALETRA ORAL TABLET 100-25 MG, 200-50 MG
P
lamivudine-zidovudine oral tablet 150-300 mg
P
STRIBILD ORAL TABLET 150-150-200-300 MG
P
QL (31 EA per 31 days)
P
QL (31 EA per 31 days)
chlorhexidine gluconate external liquid† 4 % *Antivirals* *Antiretrovirals**-*Antiretroviral Combinations***
TRUVADA ORAL TABLET 200-300 MG *Antiretrovirals**-*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 300 MG *Antiretrovirals**-*Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG *Antiretrovirals**-*Antiretrovirals - Integrase Inhibitors***
QL (31 EA per 31 days)
P
P
ISENTRESS ORAL PACKET 100 MG
P
ISENTRESS ORAL TABLET 400 MG
P
ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG
P
TIVICAY ORAL TABLET 50 MG
P
QL (62 EA per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 34
Drug Name
Preference Details Coverage Details
*Antiretrovirals**-*Antiretrovirals - Protease Inhibitors*** APTIVUS ORAL CAPSULE 250 MG
P
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
P
INVIRASE ORAL CAPSULE 200 MG
P
INVIRASE ORAL TABLET 500 MG
P
LEXIVA ORAL SUSPENSION 50 MG/ML
P
LEXIVA ORAL TABLET 700 MG
P
NORVIR ORAL CAPSULE 100 MG
P
NORVIR ORAL SOLUTION 80 MG/ML
P
NORVIR ORAL TABLET 100 MG
P
PREZISTA ORAL SUSPENSION 100 MG/ML
P
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
P
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
P
QL (62 EA per 31 days)
P
QL (310 EA per 31 days)
EDURANT ORAL TABLET 25 MG
P
QL (31 EA per 31 days)
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG
P
nevirapine oral suspension 50 mg/5ml
P
nevirapine oral tablet 200 mg
P
RESCRIPTOR ORAL TABLET 100 MG, 200 MG
P
SUSTIVA ORAL CAPSULE 200 MG, 50 MG
P
SUSTIVA ORAL TABLET 600 MG *Antiretrovirals**-*Antiretrovirals Rti-Nucleoside Analogues-Purines***
P
abacavir sulfate oral tablet 300 mg
P
didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg
P
VIRACEPT ORAL TABLET 250 MG, 625 MG *Antiretrovirals**-*Antiretrovirals Rti-Non-Nucleoside Analogues***
QL (124 EA per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 35
Drug Name VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM
Preference Details Coverage Details P
ZIAGEN ORAL SOLUTION 20 MG/ML *Antiretrovirals**-*Antiretrovirals Rti-Nucleoside Analogues-Pyrimidines***
P
EMTRIVA ORAL CAPSULE 200 MG
P
QL (31 EA per 31 days)
EMTRIVA ORAL SOLUTION 10 MG/ML
P
QL (170 ML per 31 days)
EPIVIR ORAL SOLUTION 10 MG/ML
P
EPIVIR HBV ORAL SOLUTION 5 MG/ML
P
lamivudine oral tablet 100 mg, 150 mg, 300 mg *Antiretrovirals**-*Antiretrovirals Rti-Nucleoside Analogues-Thymidines***
P
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg
P
stavudine oral solution reconstituted 1 mg/ml
P
zidovudine oral capsule 100 mg
P
zidovudine oral syrup 50 mg/5ml
P
zidovudine oral tablet 300 mg *Antiretrovirals**-*Antiretrovirals Rti-Nucleotide Analogues***
P
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG *Antiretrovirals**-*Antiretrovirals Adjuvants***
QL (1860 ML per 31 days)
P
tybost oral tablet 150 mg *Hepatitis Agents**-*Hepatitis B Agents***
P
QL (31 EA per 31 days)
entecavir oral tablet 0.5 mg, 1 mg *Hepatitis Agents**-*Hepatitis C Agents***
P
PA
OLYSIO ORAL CAPSULE 150 MG
P
PA; QL (28 EA per 28 days)
PEGASYS SUBCUTANEOUS* KIT 180 MCG/0.5ML
P
PA
PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML
P
PA
PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML
P
PA
RIBASPHERE ORAL TABLET 200 MG
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 36
Drug Name
Preference Details Coverage Details
ribavirin oral tablet 200 mg
P
SOVALDI ORAL TABLET 400 MG *Herpes Agents**-*Herpes Agents - Purine Analogues***
P
acyclovir oral capsule 200 mg
P
acyclovir oral suspension 200 mg/5ml
P
acyclovir oral tablet 400 mg, 800 mg
P
valacyclovir hcl oral tablet 1 gm, 500 mg *Influenza Agents**-*Influenza Agents***
P
rimantadine hcl oral tablet 100 mg *Influenza Agents**-*Neuraminidase Inhibitors***
P
PA; QL (28 EA per 28 days)
QL (3500 ML per 31 days) QL (62 EA per 31 days)
RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER
P
QL (40 EA per 365 days); AL (Min 7 Years)
TAMIFLU ORAL CAPSULE 30 MG
P
QL (40 EA per 365 days)
TAMIFLU ORAL CAPSULE 45 MG, 75 MG
P
QL (20 EA per 365 days)
P
QL (360 ML per 365 days); AL (Max 18 Years)
P
PA
P
PA
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML *Assorted Classes* *Immunomodulators**-*Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG *Immunomodulators**-*Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG *Immunosuppressive Agents**-*Cyclosporine Analogs*** cyclosporine oral capsule 100 mg, 25 mg
P
cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg
P
cyclosporine modified oral solution 100 mg/ml
P
GENGRAF ORAL CAPSULE 100 MG, 25 MG
P
GENGRAF ORAL SOLUTION 100 MG/ML
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 37
Drug Name SANDIMMUNE ORAL SOLUTION 100 MG/ML *Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors***
Preference Details Coverage Details P
mycophenolate mofetil oral capsule 250 mg
P
mycophenolate mofetil oral suspension reconstituted 200 mg/ml
P
mycophenolate mofetil oral tablet 500 mg *Immunosuppressive Agents**-*Macrolide Immunosuppressants*** HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5 MG
P
P
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg *Immunosuppressive Agents**-*Purine Analogs***
P
azathioprine oral tablet 50 mg *Potassium Removing Resins**-*Potassium Removing Resins***
P
sodium polystyrene sulfonate oral powder
P
SPS ORAL SUSPENSION 15 GM/60ML *Beta Blockers*
P
QL (454 GM per 31 days)
*Alpha-Beta Blockers**-*Alpha-Beta Blockers*** carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg
P
labetalol hcl intravenous* solution 5 mg/ml
P
labetalol hcl oral tablet 100 mg, 200 mg, 300 mg *Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective***
P
atenolol oral tablet 100 mg, 25 mg, 50 mg
P
bisoprolol fumarate oral tablet 10 mg, 5 mg
P
metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 50 mg
P
metoprolol tartrate intravenous* solution 1 mg/ml
P
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 38
Drug Name
Preference Details Coverage Details
*Beta Blockers Non-Selective**-*Beta Blockers Non-Selective*** nadolol oral tablet 20 mg, 40 mg, 80 mg
P
pindolol oral tablet 10 mg, 5 mg
P
propranolol hcl intravenous* solution 1 mg/ml
P
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
P
propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg
P
SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG
P
sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg
P
sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg
P
timolol maleate oral tablet 10 mg, 20 mg, 5 mg *Calcium Channel Blockers*
P
*Calcium Channel Blockers**-*Calcium Channel Blockers*** amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg
P
CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG
P
dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
P
diltiazem hcl intravenous* solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml
P
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
P
diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg
P
diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
P
diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 39
Drug Name
Preference Details Coverage Details
MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
P
NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
P
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
P
nifedipine oral capsule 10 mg
P
nifedipine er oral tablet extended release 24 hr* 90 mg
P
nifedipine er osmotic oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg
P
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg
P
verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg
P
verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg *Cardiotonics*
P
*Cardiac Glycosides**-*Cardiac Glycosides*** digoxin injection solution 0.25 mg/ml
P
digoxin oral solution 0.05 mg/ml
P
digoxin oral tablet 0.125 mg, 250 mcg *Cardiovascular Agents - Misc.*
P
*Peripheral Vasodilators**-*Peripheral Vasodilators*** no flush niacin oral tablet 500 mg *Pulmonary Hypertension - Endothelin Receptor Antagonists**-*Pulmonary Hypertension - Endothelin Receptor Antagonists***
P
OTC
LETAIRIS ORAL TABLET 10 MG, 5 MG *Pulmonary Hypertension - Phosphodiesterase Inhibitors**-*Pulmonary Hypertension Phosphodiesterase Inhibitors***
P
PA
sildenafil citrate oral tablet 20 mg
P
PA
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 40
Drug Name
Preference Details Coverage Details
*Cephalosporins* *Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 mg
P
cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml
P
cefadroxil oral tablet 1 gm
P
cephalexin oral capsule 250 mg, 500 mg, 750 mg
P
cephalexin oral suspension reconstituted 125 mg/5ml
P
cephalexin oral suspension reconstituted 250 mg/5ml *Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation***
P
cefaclor oral capsule 250 mg, 500 mg
P
cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
P
cefprozil oral tablet 250 mg, 500 mg
P
cefuroxime axetil oral suspension reconstituted 125 mg/5ml
P
cefuroxime axetil oral tablet 250 mg, 500 mg *Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation***
P
cefdinir oral capsule 300 mg
P
cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
P
cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml
P
cefpodoxime proxetil oral tablet 100 mg, 200 mg *Contraceptives*
QL (300 ML per 31 days)
P
*Combination Contraceptives Oral**-*Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 41
Drug Name
Preference Details Coverage Details
*Combination Contraceptives Oral**-*Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET 0.15-30 MG-MCG
P
APRI ORAL TABLET 0.15-30 MG-MCG
P
AVIANE ORAL TABLET 0.1-20 MG-MCG
P
BALZIVA ORAL TABLET 0.4-35 MG-MCG
P
CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG
P
ESTARYLLA ORAL TABLET 0.25-35 MG-MCG
P
GIANVI ORAL TABLET 3-0.02 MG
P
JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
JUNEL 1/20 ORAL TABLET 1-20 MG-MCG
P
JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG
P
KELNOR 1/35 ORAL TABLET 1-35 MG-MCG
P
LESSINA ORAL TABLET 0.1-20 MG-MCG
P
LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG
P
LORYNA ORAL TABLET 3-0.02 MG
P
LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG
P
LUTERA ORAL TABLET 0.1-20 MG-MCG
P
MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG
P
MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG
P
MONONESSA ORAL TABLET 0.25-35 MG-MCG
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 42
Drug Name
Preference Details Coverage Details
NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG
P
NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG
P
NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG
P
NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG
P
NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG
P
OCELLA ORAL TABLET 3-0.03 MG
P
PORTIA-28 ORAL TABLET 0.15-30 MG-MCG
P
PREVIFEM ORAL TABLET 0.25-35 MG-MCG
P
RECLIPSEN ORAL TABLET 0.15-30 MG-MCG
P
SOLIA ORAL TABLET 0.15-30 MG-MCG
P
SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG
P
SRONYX ORAL TABLET 0.1-20 MG-MCG
P
SYEDA ORAL TABLET 3-0.03 MG
P
VESTURA ORAL TABLET 3-0.02 MG
P
ZARAH ORAL TABLET 3-0.03 MG
P
ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG
P
ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG *Combination Contraceptives Oral**-*Extended-Cycle Contraceptives Oral*** QUASENSE ORAL TABLET 0.15-0.03 MG *Combination Contraceptives Oral**-*Triphasic Contraceptives - Oral***
P
P
CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG
P
ENPRESSE-28 ORAL TABLET
P
QL (91 EA per 91 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 43
Drug Name
Preference Details Coverage Details
NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
P
NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
P
ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG
P
TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRIVORA (28) ORAL TABLET
P
VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG *Combination Contraceptives Transdermal**-*Combination Contraceptives Transdermal*** XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR *Combination Contraceptives Vaginal**-*Combination Contraceptives Vaginal*** NUVARING VAGINAL RING 0.12-0.015 MG/24HR *Emergency Contraceptives**-*Emergency Contraceptives***
P
P
P
levonorgestrel oral tablet 0.75 mg
P
QL (4 EA per 31 days)
NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG
P
OTC
P
OTC
P
QL (1 ML per 93 days)
PLAN B ONE-STEP ORAL TABLET 1.5 MG *Progestin Contraceptives Injectable**-*Progestin Contraceptives Injectable*** medroxyprogesterone acetate intramuscular* suspension 150 mg/ml
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 44
Drug Name
Preference Details Coverage Details
*Corticosteroids* *Glucocorticosteroids**-*Glucocorticosteroids* ** A-METHAPRED INJECTION SOLUTION RECONSTITUTED 125 MG, 40 MG
P
cortisone acetate oral tablet 25 mg
P
dexamethasone oral elixir 0.5 mg/5ml
P
dexamethasone oral solution 0.5 mg/5ml
P
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
P
dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml
P
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg
P
methylprednisolone oral tablet 16 mg, 32 mg, 8 mg
P
methylprednisolone (pak) oral tablet 4 mg
P
methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml
P
methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg
P
prednisolone oral solution 15 mg/5ml
P
prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml
P
prednisone oral solution 5 mg/5ml
P
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg *Mineralocorticoids**-*Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 mg *Cough/Cold/Allergy*
P
P
*Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG
P
OTC
ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG
P
OTC
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 45
Drug Name
Preference Details Coverage Details
allergy relief/nasal decongest oral tablet extended release 24 hr* 10-240 mg
P
OTC
cetirizine-pseudoephedrine er oral tablet extended release 12 hr* 5-120 mg
P
OTC
DELSYM NGHT TIME CGH/CLD CHILD ORAL LIQUID† 12.5-5 MG/5ML
P
OTC
DELSYM NIGHT TIME COUGH/COLD ORAL LIQUID† 6.25-2.5 MG/5ML
P
OTC
fexofenadine-pseudoephed er oral tablet extended release 24 hr* 180-240 mg
P
OTC
triprolidine-pse oral tablet 2.5-60 mg *Expectorants**-*Expectorants***
P
OTC
mucus relief oral tablet 400 mg
P
OTC
refenesen oral tablet 200 mg
P
OTC
refenesen 400 oral tablet 400 mg
P
OTC
robafen oral syrup 100 mg/5ml *Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants***
P
OTC
P
OTC
P
OTC
BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 % sodium chloride inhalation nebulization solution 0.9 % *Mucolytics**-*Mucolytics*** acetylcysteine inhalation solution 10 %, 20 % *Dermatologicals*
P
*Acne Products**-*Acne Antibiotics*** clindamycin phosphate external 1 %
P
clindamycin phosphate external lotion 1 %
P
clindamycin phosphate external solution 1 %
P
ery external pad 2 %
P
erythromycin external 2 %
P
erythromycin external solution 2 %
P
sulfacetamide sodium external suspension 10 % *Acne Products**-*Acne Combinations***
P
benzoyl peroxide-erythromycin external 5-3 % *Acne Products**-*Acne Products***
P
acne medication external lotion 10 % P OTC P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 46
Drug Name
Preference Details Coverage Details P
OTC
AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG
P
ST; Notes (Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks); QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years)
AVITA EXTERNAL 0.025 %
P
QL (45 GM per 31 days); AL (Max 20 Years)
AVITA EXTERNAL CREAM 0.025 %
P
QL (45 GM per 31 days); AL (Max 20 Years)
benzoyl peroxide external 10 %, 5 %
P
OTC
CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG
P
ST; Notes (Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks); QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years)
LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID† 4 %
P
LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID† 8 %
P
tretinoin external 0.01 %, 0.025 %
P
QL (45 GM per 31 days); AL (Max 20 Years)
tretinoin external cream 0.025 %, 0.05 %, 0.1 %
P
QL (45 GM per 31 days); AL (Max 20 Years)
bacitracin-neomycin-polymyxin external ointment 400-5-5000
P
OTC
cvs triple antibiotic external ointment 3.5-400-5000
P
OTC
P
OTC
acne medication 5 external lotion 5 %
*Antibiotics - Topical**-*Antibiotic Mixtures Topical***
double antibiotic external ointment 500-10000 unit/gm *Antibiotics - Topical**-*Antibiotic Steroid Combinations - Topical*** CORTISPORIN EXTERNAL OINTMENT 1 %
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 47
Drug Name
Preference Details Coverage Details
*Antibiotics - Topical**-*Antibiotics Topical*** bacitracin zinc external ointment 500 unit/gm
P
OTC
gentamicin sulfate external cream 0.1 %
P
gentamicin sulfate external ointment 0.1 %
P
mupirocin external ointment 2 % *Antifungals - Topical**-*Antifungals Topical***
P
ciclopirox external solution 8 %
P
ciclopirox olamine external cream 0.77 %
P
ciclopirox olamine external suspension 0.77 %
P
nystatin external cream 100000 unit/gm
P
nystatin external ointment 100000 unit/gm
P
nystatin external powder 100000 unit/gm
P
terbinafine hcl external cream 1 % *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical***
P
OTC
baza antifungal external cream 2 %
P
OTC
clotrimazole external cream 1 %
P
OTC
clotrimazole external solution 1 %
P
OTC
econazole nitrate external cream 1 %
P
ketoconazole external cream 2 %
P
ketoconazole external shampoo 2 %
P
miconazole nitrate external cream 2 % *Anti-Inflammatory Agents Topical**-*Anti-Inflammatory Agents Topical***
P
OTC
VOLTAREN TRANSDERMAL 1 % *Antineoplastic Or Premalignant Lesion Agents - Topical**-*Antineoplastic Antimetabolites Topical***
P
QL (300 GM per 31 days)
fluorouracil external cream 5 %
P
PA
fluorouracil external solution 2 %, 5 % *Antipsoriatics**-*Antipsoriatics***
P
PA
calcipotriene external cream 0.005 %
P
calcipotriene external ointment 0.005 %
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 48
Drug Name
Preference Details Coverage Details
calcipotriene external solution 0.005 %
P
DRITHO-CREME HP EXTERNAL CREAM 1 %
P
TAZORAC EXTERNAL 0.05 %, 0.1 %
P
QL (30 GM per 31 days); AL (Max 20 Years)
P
QL (30 GM per 31 days); AL (Max 20 Years)
TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % *Antiseborrheic Products**-*Antiseborrheic Products*** selenium sulfide external lotion 2.5 % *Antivirals - Topical**-*Antivirals - Topical***
P
P
ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.)
P
ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.)
silver sulfadiazine external cream 1 %
P
QL (400 GM per 31 days)
SSD EXTERNAL CREAM 1 % *Corticosteroids - Topical**-*Corticosteroids Topical***
P
QL (400 GM per 31 days)
DENAVIR EXTERNAL CREAM 1 %
ZOVIRAX EXTERNAL CREAM 5 % *Burn Products**-*Burn Products***
alclometasone dipropionate external cream 0.05 %
P
alclometasone dipropionate external ointment 0.05 %
P
betamethasone dipropionate external cream 0.05 %
P
betamethasone dipropionate external lotion 0.05 %
P
betamethasone dipropionate external ointment 0.05 %
P
betamethasone dipropionate aug external cream 0.05 %
P
betamethasone valerate external cream 0.1 %
P
betamethasone valerate external lotion 0.1 %
P
betamethasone valerate external ointment 0.1 %
P
clobetasol propionate external 0.05 %
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 49
Drug Name
Preference Details Coverage Details
clobetasol propionate external cream 0.05 %
P
clobetasol propionate external ointment 0.05 %
P
desonide external cream 0.05 %
P
fluocinolone acetonide external cream 0.01 %, 0.025 %
P
fluocinolone acetonide external ointment 0.025 %
P
fluocinolone acetonide external solution 0.01 %
P
fluocinolone acetonide body external oil 0.01 %
P
fluocinolone acetonide scalp external oil 0.01 %
P
fluocinonide external 0.05 %
P
fluocinonide external cream 0.05 %
P
fluocinonide external ointment 0.05 %
P
fluocinonide external solution 0.05 %
P
fluocinonide-e external cream 0.05 %
P
fluticasone propionate external cream 0.05 %
P
fluticasone propionate external ointment 0.005 %
P
halobetasol propionate external cream 0.05 %
P
halobetasol propionate external ointment 0.05 %
P
hydrocortisone external cream 1 %
P
OTC
hydrocortisone external lotion 1 %
P
OTC
hydrocortisone external lotion 2.5 %
P
hydrocortisone external ointment 1 %
P
hydrocortisone external ointment 2.5 %
P
hydrocortisone valerate external cream 0.2 %
P
hydrocortisone valerate external ointment 0.2 %
P
mometasone furoate external cream 0.1 %
P
mometasone furoate external ointment 0.1 %
P
triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %
P
triamcinolone acetonide external ointment 0.1 % *Emollient/Keratolytic Agents**-*Emollient/Keratolytic Agents***
P
REMEVEN EXTERNAL CREAM 50 %
P
urea external cream 40 %
P
OTC
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 50
Drug Name
Preference Details Coverage Details
X-VIATE EXTERNAL CREAM 40 % *Emollients**-*Emollients***
P
AMLACTIN EXTERNAL LOTION 12 %
P
OTC; QL (400 GM per 31 days)
ammonium lactate external cream 12 %
P
OTC; QL (400 GM per 31 days)
ammonium lactate external lotion 12 % *Enzymes - Topical**-*Enzymes - Topical***
P
OTC; QL (400 GM per 31 days)
P
PA
P
ST; Notes (Must fail preferred topical corticosteroid with use for at least 4 weeks or with 90 days of history.); QL (30 GM per 31 days); AL (Min 2 Years)
CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 %
P
OTC
COMPOUND W EXTERNAL LIQUID† 17 %
P
OTC
COMPOUND W MAXIMUM STRENGTH EXTERNAL 17 %
P
OTC
CONDYLOX EXTERNAL 0.5 %
P
PA
podofilox external solution 0.5 %
P
SANTYL EXTERNAL OINTMENT 250 UNIT/GM *Immunosuppressive Agents Topical**-*Macrolide Immunosuppressants Topical***
ELIDEL EXTERNAL CREAM 1 %
*Keratolytic/Antimitotic Agents**-*Keratolytic/Antimitotic Agents***
SALACTIC FILM EXTERNAL SOLUTION 17 % *Local Anesthetics - Topical**-*Local Anesthetics - Topical***
P
OTC
capsaicin external cream 0.025 %
P
OTC
lidocaine external ointment 5 %
P
lidocaine external patch 5 %
P
lidocaine hcl external 2 %
P
lidocaine hcl external solution 4 % *Local Anesthetics - Topical**-*Topical Anesthetic Combinations***
P
lidocaine-prilocaine external cream 2.5-2.5 %
P
PA
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 51
Drug Name lidocaine-prilocaine external kit 2.5-2.5 % *Misc. Topical**-*Misc. Topical*** HYPERCARE EXTERNAL SOLUTION 20 % *Rosacea Agents**-*Rosacea Agents***
Preference Details Coverage Details P
P
metronidazole external 1 %
P
metronidazole external cream 0.75 % *Scabicides & Pediculicides**-*Scabicides & Pediculicides***
P
ACTICIN EXTERNAL CREAM 5 %
P
QL (60 GM per 31 days)
malathion external lotion 0.5 %
P
QL (118 ML per 31 days); AL (Min 6 Years)
permethrin external cream 5 %
P
QL (60 GM per 31 days)
permethrin external lotion 1 %
P
OTC; QL (60 ML per 31 days)
spinosad external suspension 0.9 % *Diagnostic Products*
P
AL (Min 4 Years)
*Diagnostic Drugs**-*Diagnostic Drugs*** dipyridamole intravenous* solution 5 mg/ml *Diagnostic Tests**-*Diagnostic Tests***
ACCU-CHEK ACTIVE IN VITRO STRIP
ACCU-CHEK AVIVA PLUS IN VITRO STRIP
ACCU-CHEK COMFORT CURVE IN VITRO STRIP
ACCU-CHEK COMPACT TEST DRUM IN VITRO STRIP
P
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
P
Notes (QL: 204/31 DS for Members 21 years old and younger; QL: 102/31 DS for Members over 21 years old); OTC
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 52
Drug Name
Preference Details Coverage Details
ACCU-CHEK SMARTVIEW IN VITRO STRIP
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
CLINISTIX IN VITRO STRIP
P
OTC; QL (100 EA per 31 days)
DIASTIX IN VITRO STRIP
P
OTC; QL (100 EA per 31 days)
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
FREESTYLE TEST IN VITRO STRIP
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
KETOSTIX IN VITRO STRIP
P
OTC; QL (100 EA per 31 days)
P
Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC
P
OTC
FREESTYLE INSULINX TEST IN VITRO STRIP
FREESTYLE LITE TEST IN VITRO STRIP
PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP PRECISION XTRA KETONE IN VITRO STRIP *Digestive Aids* *Digestive Enzymes**-*Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT
P
PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 8000 UNIT
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 53
Drug Name
Preference Details Coverage Details
*Diuretics* *Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors*** acetazolamide oral tablet 125 mg, 250 mg
P
methazolamide oral tablet 25 mg, 50 mg *Diuretic Combinations**-*Diuretic Combinations***
P
amiloride-hydrochlorothiazide oral tablet 5-50 mg
P
spironolactone-hctz oral tablet 25-25 mg
P
triamterene-hctz oral capsule 37.5-25 mg
P
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg *Loop Diuretics**-*Loop Diuretics***
P
bumetanide injection solution 0.25 mg/ml
P
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
P
furosemide oral solution 10 mg/ml, 8 mg/ml
P
furosemide oral tablet 20 mg, 40 mg, 80 mg
P
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg *Potassium Sparing Diuretics**-*Potassium Sparing Diuretics***
P
spironolactone oral tablet 100 mg, 25 mg, 50 mg *Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics***
P
chlorothiazide oral tablet 250 mg, 500 mg
P
chlorthalidone oral tablet 25 mg, 50 mg
P
hydrochlorothiazide oral capsule 12.5 mg
P
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg
P
indapamide oral tablet 1.25 mg, 2.5 mg
P
metolazone oral tablet 10 mg, 2.5 mg, 5 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 54
Drug Name
Preference Details Coverage Details
*Endocrine And Metabolic Agents - Misc.* *Bone Density Regulators**-*Bisphosphonates*** alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg *Bone Density Regulators**-*Calcitonins*** calcitonin (salmon) nasal solution 200 unit/act FORTICAL NASAL SOLUTION 200 UNIT/ACT *Bone Density Regulators**-*Rank Ligand (Rankl) Inhibitors*** PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML *Growth Hormones**-*Growth Hormones*** TEV-TROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG *Hormone Receptor Modulators**-*Selective Estrogen Receptor Modulators (Serms)***
P
P P
P
PA
P
PA
raloxifene hcl oral tablet 60 mg *Metabolic Modifiers**-*Carnitine Replenisher - Agents***
P
levocarnitine intravenous* solution 200 mg/ml
P
levocarnitine oral solution 1 gm/10ml
P
levocarnitine oral tablet 330 mg *Metabolic Modifiers**-*Gaa Deficiency Treatment - Agents***
P
LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG *Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs***
P
calcitriol oral capsule 0.25 mcg, 0.5 mcg
P
calcitriol oral solution 1 mcg/ml *Posterior Pituitary Hormones**-*Vasopressin***
P
desmopressin ace rhinal tube nasal solution 0.01 %
P
desmopressin ace spray refrig nasal solution 0.01 %
P
QL (900 ML per 31 days)
PA
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 55
Drug Name desmopressin acetate oral tablet 0.1 mg, 0.2 mg desmopressin acetate spray nasal solution 0.01 % *Estrogens*
Preference Details Coverage Details P P
*Estrogen Combinations**-*Estrogen & Progestin*** estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg
P
PREMPHASE ORAL TABLET 0.625-5 MG
P
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG *Estrogens**-*Estrogens***
P
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
P
estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
P
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg
P
PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG
P
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG *Fluoroquinolones*
P
*Fluoroquinolones**-*Fluoroquinolones*** ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg levofloxacin oral tablet 250 mg, 500 mg, 750 mg *Gastrointestinal Agents - Misc.*
P P
*Antiflatulents**-*Antiflatulents*** gas relief oral suspension 20 mg/0.3ml
P
OTC
simethicone oral suspension 40 mg/0.6ml
P
OTC
simethicone oral tablet chewable 80 mg *Gallstone Solubilizing Agents**-*Gallstone Solubilizing Agents***
P
OTC
ursodiol oral capsule 300 mg *Gastrointestinal Stimulants**-*Gastrointestinal Stimulants***
P
metoclopramide hcl oral solution 5 mg/5ml
P
QL (1500 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 56
Drug Name metoclopramide hcl oral tablet 10 mg, 5 mg *Inflammatory Bowel Agents**-*Inflammatory Bowel Agents***
Preference Details Coverage Details P
APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM
P
balsalazide disodium oral capsule 750 mg
P
mesalamine enema 4 gm
P
sulfasalazine oral tablet 500 mg
P
sulfasalazine oral tablet delayed release 500 mg *Intestinal Acidifiers**-*Intestinal Acidifiers***
P
generlac oral solution 10 gm/15ml *Phosphate Binder Agents**-*Phosphate Binder Agents***
P
QL (4185 ML per 31 days)
calcium acetate oral capsule 667 mg
P
QL (372 EA per 31 days)
ELIPHOS ORAL TABLET 667 MG
P
QL (372 EA per 31 days)
RENVELA ORAL PACKET 0.8 GM, 2.4 GM
P
RENVELA ORAL TABLET 800 MG *Genitourinary Agents - Miscellaneous*
QL (1800 ML per 31 days)
P
*Alkalinizers**-*Citrates*** P
QL (3600 ML per 31 days)
P
QL (3600 ML per 31 days)
P
QL (1000 ML per 31 days)
sodium chloride irrigation solution 0.9 % *Interstitial Cystitis Agents**-*Interstitial Cystitis Agents***
P
QL (1000 ML per 31 days)
elmiron oral capsule 100 mg *Prostatic Hypertrophy Agents**-*5-Alpha Reductase Inhibitors***
P
PA
AVODART ORAL CAPSULE 0.5 MG
P
finasteride oral tablet 5 mg
P
cytra-2 oral solution 500-334 mg/5ml CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML *Genitourinary Irrigants**-*Genitourinary Irrigants*** ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 %
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 57
Drug Name
Preference Details Coverage Details
*Prostatic Hypertrophy Agents**-*Alpha 1-Adrenoceptor Antagonists*** tamsulosin hcl oral capsule 0.4 mg *Urinary Analgesics**-*Urinary Analgesics***
P
phenazopyridine hcl oral tablet 100 mg, 200 mg *Gout Agents*
P
*Gout Agent Combinations**-*Gout Agent Combinations*** colchicine-probenecid oral tablet 0.5-500 mg *Gout Agents**-*Gout Agents***
P
allopurinol oral tablet 100 mg, 300 mg
P
COLCRYS ORAL TABLET 0.6 MG *Uricosurics**-*Uricosurics***
P
probenecid oral tablet 500 mg *Hematological Agents - Misc.*
P
*Bradykinin B2 Receptor Antagonists**-*Bradykinin B2 Receptor Antagonists*** FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML *Hematorheologic Agents**-*Hematorheologic Agents*** pentoxifylline er oral tablet extendedrelease* 400 mg *Platelet Aggregation Inhibitors**-*Phosphodiesterase Iii Inhibitors***
P
PA
P
cilostazol oral tablet 100 mg, 50 mg *Platelet Aggregation Inhibitors**-*Platelet Aggregation Inhibitors***
P
dipyridamole oral tablet 25 mg, 50 mg, 75 mg *Platelet Aggregation Inhibitors**-*Quinazoline Agents***
P
anagrelide hcl oral capsule 0.5 mg, 1 mg *Platelet Aggregation Inhibitors**-*Thienopyridine Derivatives***
P
clopidogrel bisulfate oral tablet 75 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 58
Drug Name
Preference Details Coverage Details
*Hematopoietic Agents* *Cobalamins**-*Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml
P
vitamin b-12 oral tablet 1000 mcg *Folic Acid/Folates**-*Folic Acid/Folates***
P
OTC
folic acid oral tablet 1 mg, 400 mcg, 800 mcg *Hematopoietic Growth Factors**-*Erythropoiesis-Stimulating Agents (Esas)***
P
OTC
P
PA
P
PA
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML *Hematopoietic Growth Factors**-*Granulocyte Colony-Stimulating Factors (G-Csf)*** NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML *Hematopoietic Mixtures**-*Iron Combinations*** CENTRATEX ORAL CAPSULE 106-1 MG poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg *Iron**-*Iron***
P P
ferrous sulfate oral elixir 220 (44 fe) mg/5ml
P
OTC
ferrous sulfate oral solution 75 (15 fe) mg/ml
P
OTC
ferrous sulfate oral tablet 325 (65 fe) mg
P
OTC
ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg
P
OTC
POLY-IRON 150 ORAL CAPSULE 150 MG
P
OTC
P
OTC
diphenhydramine hcl (sleep) oral tablet 50 mg
P
OTC
gnp nighttime sleep aid oral tablet 25 mg
P
OTC
slow release iron oral tablet extendedrelease* 160 (50 fe) mg *Hypnotics* *Antihistamine Hypnotics**-*Antihistamine Hypnotics***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 59
Drug Name
Preference Details Coverage Details
ra nighttime sleep aid oral tablet 25 mg
P
OTC
sleep tabs oral tablet 25 mg *Barbiturate Hypnotics**-*Barbiturate Hypnotics***
P
OTC
phenobarbital oral elixir 20 mg/5ml
P
QL (2000 ML per 31 days)
phenobarbital oral tablet 100 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
P
phenobarbital oral tablet 15 mg
P
QL (310 EA per 31 days)
phenobarbital oral tablet 16.2 mg
P
QL (383 EA per 31 days)
phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml *Non-Barbiturate Hypnotics**-*Benzodiazepine Hypnotics***
P
estazolam oral tablet 1 mg, 2 mg
P
temazepam oral capsule 15 mg, 30 mg
P
triazolam oral tablet 0.125 mg, 0.25 mg *Non-Barbiturate Hypnotics**-*Non-Benzodiazepine Gaba-Receptor Modulators***
P
AL (Min 18 Years)
zolpidem tartrate oral tablet 10 mg, 5 mg
P
QL (31 EA per 31 days); AL (Min 18 Years)
fiber oral tablet 625 mg
P
OTC
METAMUCIL ORAL CAPSULE 0.52 GM
P
OTC
metamucil oral powder 48.57 %
P
OTC
METAMUCIL ORAL WAFER
P
OTC
P
OTC
GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM
P
QL (4000 ML per 31 days)
GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM
P
QL (4000 ML per 31 days)
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM
P
QL (1 EA per 31 days)
*Laxatives* *Bulk Laxatives**-*Bulk Laxatives***
METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 % *Laxative Combinations**-*Bowel Evacuant Combinations***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 60
Drug Name
Preference Details Coverage Details
peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm
P
QL (4000 ML per 31 days)
peg 3350/electrolytes oral solution reconstituted 240 gm
P
QL (4000 ML per 31 days)
peg-3350/electrolytes oral solution reconstituted 236 gm
P
QL (4000 ML per 31 days)
P
QL (4000 ML per 31 days)
P
OTC
lactulose oral solution 10 gm/15ml
P
QL (4185 ML per 31 days)
polyethylene glycol 3350 oral powder
P
OTC; QL (527 GM per 31 days)
sorbitol oral solution 70 % *Saline Laxatives**-*Saline Laxative Mixtures***
P
OTC
enema disposable enema *Saline Laxatives**-*Saline Laxatives***
P
OTC
milk of magnesia oral suspension 1200 mg/15ml *Stimulant Laxatives**-*Stimulant Laxatives***
P
OTC
bisacodyl suppository 10 mg
P
OTC
bisacodyl ec oral tablet delayed release 5 mg
P
OTC
senna oral syrup 8.8 mg/5ml
P
OTC
senna oral tablet 8.6 mg
P
OTC
senna laxative oral tablet 8.6 mg *Surfactant Laxatives**-*Surfactant Laxatives***
P
OTC
docusate sodium oral liquid† 50 mg/5ml
P
OTC
docusate sodium oral tablet 100 mg
P
OTC
stool softener oral capsule 100 mg, 250 mg
P
OTC
stool softener laxative dc oral capsule 240 mg
P
OTC
TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM *Laxative Combinations**-*Laxatives & Dss*** sennosides-docusate sodium oral tablet 8.6-50 mg *Laxatives - Miscellaneous**-*Laxatives Miscellaneous***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 61
Drug Name
Preference Details Coverage Details
*Local Anesthetics-Parenteral* *Local Anesthetics - Amides**-*Local Anesthetics - Amides*** lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %
P
lidocaine hcl (pf) injection solution 2 % *Macrolides*
P
*Azithromycin**-*Azithromycin*** azithromycin intravenous* solution reconstituted 500 mg
P
azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml
P
azithromycin oral tablet 250 mg
P
azithromycin oral tablet 500 mg, 600 mg
P
azithromycin hydrogencitrate intravenous* solution reconstituted 2.5 gm *Clarithromycin**-*Clarithromycin*** clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg *Erythromycins**-*Erythromycins***
QL (6 EA per 31 days)
P
P P
E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML
P
ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG
P
ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML
P
ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML
P
ERYTHROCIN STEARATE ORAL TABLET 250 MG
P
erythromycin base oral capsule delayed release particles 250 mg
P
erythromycin base oral tablet 250 mg, 500 mg
P
erythromycin ethylsuccinate oral tablet 400 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 62
Drug Name
Preference Details Coverage Details
*Medical Devices* *Auditory Supplies**-*Hearing Aid Supplies-Batteries*** P
OTC
ACCU-CHEK AVIVA PLUS KIT W/DEVICE
P
OTC; QL (1 EA per 365 days)
ACCU-CHEK COMPACT PLUS CARE KIT
P
OTC; QL (1 EA per 365 days)
ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE
P
OTC; QL (1 EA per 365 days)
FREESTYLE FREEDOM LITE KIT W/DEVICE
P
OTC; QL (1 EA per 365 days)
FREESTYLE INSULINX SYSTEM KIT W/DEVICE
P
OTC; QL (1 EA per 365 days)
FREESTYLE LITE DEVICE
P
OTC; QL (1 EA per 365 days)
glucose control in vitro solution
P
OTC
lancet device
P
OTC
lancets
P
Notes (Accu-Chek Multiclix lancets: QL (204.00 per 31 days); All other lancets: QL (200.00 per 31 days)); OTC
PRECISION XTRA DEVICE *Misc. Devices**-*Applicators,Cotton Balls,Etc***
P
OTC; QL (1 EA per 365 days)
alcohol pads pad 70 % *Parenteral Therapy Supplies**-*Needles & Syringes***
P
OTC
BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 1 ML
P
Notes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)
EXEL PEN NEEDLES 1/3" 31G X 8 MM
P
Notes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)
insulin syringe 29g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml
P
Notes (All Syringes Are Covered); OTC; QL (100 EA per 31 days)
hearing aid battery *Diabetic Supplies**-*Glucose Monitoring Test Supplies***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 63
Drug Name
Preference Details Coverage Details
*Respiratory Therapy Supplies**-*Peak Flow Meters*** P
OTC; QL (2 EA per 365 days)
P
QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU
P
QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU LARGE
P
QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU SMALL
P
QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU W/MASK
P
QL (2 EA per 365 days)
E-Z SPACER DEVICE
P
QL (2 EA per 365 days)
MICROCHAMBER
P
QL (2 EA per 365 days)
MICROSPACER
P
QL (2 EA per 365 days)
OPTICHAMBER ADVANTAGE
P
QL (2 EA per 365 days)
OPTICHAMBER ADVANTAGE-LG MASK
P
QL (2 EA per 365 days)
OPTICHAMBER ADVANTAGE-MED MASK
P
QL (2 EA per 365 days)
OPTICHAMBER ADVANTAGE-SM MASK
P
QL (2 EA per 365 days)
OPTICHAMBER FACE MASK-LARGE
P
OTC; QL (2 EA per 365 days)
OPTICHAMBER FACE MASK-MEDIUM
P
OTC; QL (2 EA per 365 days)
OPTICHAMBER FACE MASK-SMALL
P
OTC; QL (2 EA per 365 days)
OPTIHALER *Migraine Products*
P
QL (2 EA per 365 days)
naratriptan hcl oral tablet 1 mg, 2.5 mg
P
ST; Notes (Must fail preferred sumatriptan tablets within the past 100 days.); QL (9 EA per 31 days)
sumatriptan nasal solution 20 mg/act, 5 mg/act
P
QL (12 EA per 31 days)
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg
P
QL (9 EA per 31 days)
peak flow meter device *Respiratory Therapy Supplies**-*Respiratory Therapy Supplies*** IN-CHECK DIAL FLOW TRAINER DEVICE *Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies***
*Serotonin Agonists**-*Selective Serotonin Agonists 5-Ht(1)***
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 64
Drug Name sumatriptan succinate subcutaneous* solution 4 mg/0.5ml, 6 mg/0.5ml *Minerals & Electrolytes*
Preference Details Coverage Details P
QL (4 ML per 31 days)
P
OTC
cal-lac oral capsule 500 mg
P
OTC
calcium acetate (phos binder) oral tablet 667 mg
P
QL (372 EA per 31 days)
calcium carbonate oral suspension 1250 mg/5ml
P
OTC
calcium carbonate oral tablet 1250 mg, 600 mg
P
OTC
calcium lactate oral tablet 648 mg *Electrolyte Mixtures**-*Electrolytes Oral***
P
OTC
ORALYTE ORAL SOLUTION
P
OTC; QL (4000 ML per 31 days)
P
OTC; QL (4000 ML per 31 days)
*Calcium**-*Calcium Combinations*** calcium carbonate-vitamin d oral tablet 600-400 mg-unit *Calcium**-*Calcium***
ORALYTE FREEZER POPS ORAL SOLUTION *Fluoride**-*Fluoride Combinations*** FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 0.5 (F)-236.79 MG, 1 (F)-236.79 MG *Fluoride**-*Fluoride*** sodium fluoride oral solution 1.1 (0.5 f) mg/ml sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg *Iodine Products**-*Iodine Products*** SSKI ORAL SOLUTION 1 GM/ML *Magnesium**-*Magnesium*** magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 mg) mg, 500 mg sm magnesium oxide oral tablet 250 mg *Phosphate**-*Phosphate*** K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG *Potassium**-*Potassium*** KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ
P
P P
P
P
OTC
P
OTC
N/A
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 65
Drug Name
Preference Details Coverage Details
KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ
P
KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ
P
KLOR-CON M20 ORAL TABLET EXTENDEDRELEASE* 20 MEQ
P
potassium chloride intravenous* solution 0.4 meq/ml, 10 meq/100ml, 2 meq/ml, 40 meq/100ml
P
potassium chloride oral liquid† 20 meq/15ml (10%), 40 meq/15ml (20%)
P
potassium chloride oral solution 20 meq/15ml (10%)
P
potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq
P
potassium chloride er oral tablet extendedrelease* 10 meq, 8 meq *Sodium**-*Sodium***
P
normal saline flush intravenous* solution 0.9 %
P
QL (310 ML per 31 days)
saline flush intravenous* solution 0.9 %
P
QL (310 ML per 31 days)
sodium chloride injection solution 0.9 %
P
QL (310 ML per 31 days)
sodium chloride intravenous* solution 0.9 % *Zinc**-*Zinc***
P
zinc sulfate oral tablet 220 (50 zn) mg *Mouth/Throat/Dental Agents*
P
OTC
*Anesthetics Topical Oral**-*Anesthetics Topical Oral*** lidocaine viscous mouth/throat solution 2 % *Anti-Infectives - Throat**-*Anti-Infectives Throat***
P
clotrimazole mouth/throat lozenge 10 mg
P
clotrimazole mouth/throat troche 10 mg
P
nystatin mouth/throat suspension 100000 unit/ml *Antiseptics - Mouth/Throat**-*Antiseptics Mouth/Throat***
P
QL (300 ML per 31 days)
chlorhexidine gluconate mouth/throat solution 0.12 %
P
QL (480 ML per 31 days)
PERIOGARD MOUTH/THROAT SOLUTION 0.12 %
P
QL (480 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 66
Drug Name
Preference Details Coverage Details
*Dental Products**-*Fluoride Dental Products*** CAVAREST DENTAL 1.1 %
P
DENTAGEL DENTAL 1.1 %
P
FLUORIDEX DAILY DEFENSE DENTAL 1.1 %
P
KARIGEL DENTAL 1.1 %
P
KARIGEL-N DENTAL 1.1 %
P
NEUTRAGARD ADVANCED DENTAL 1.1 %
P
PHOS-FLUR DENTAL 1.1 %
P
sf dental 1.1 % *Steroids - Mouth/Throat**-*Steroids Mouth/Throat***
P
triamcinolone acetonide mouth/throat paste 0.1 % *Throat Products - Misc.**-*Saliva Stimulants*** pilocarpine hcl oral tablet 5 mg, 7.5 mg *Multivitamins*
P
P
*B-Complex W/ C**-*B-Complex W/ C*** vitamin b complex-c oral capsule *B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid***
P
OTC
rena-vite oral tablet *Multivitamins**-*Multivitamins***
P
OTC
multi-vitamins oral tablet *Ped Multi Vitamins W/Fl & Fe**-*Ped Multi Vitamins W/Fl & Fe***
P
OTC
P
AL (Max 17 Years)
P
AL (Max 17 Years)
P
AL (Max 17 Years)
multi-vit/fluoride/iron oral solution 0.25-10 mg/ml multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml *Ped Multi Vitamins W/Fl & Fe**-*Ped Vitamins Acd Fluoride & Iron*** tri-vit/fluoride/iron oral solution 0.25-10 mg/ml
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 67
Drug Name
Preference Details Coverage Details
*Ped Mv W/ Fluoride**-*Ped Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml
P
AL (Max 17 Years)
multi-vitamin/fluoride oral tablet chewable 0.5 mg
P
AL (Max 17 Years)
P
AL (Max 17 Years)
tri-vit/fluoride oral solution 0.25 mg/ml
P
AL (Max 17 Years)
tri-vitamin/fluoride oral solution 0.5 mg/ml
P
AL (Max 17 Years)
vitamins acd-fluoride oral solution 0.25 mg/ml *Ped Mv W/ Iron**-*Ped Mv W/ Iron***
P
AL (Max 17 Years)
polyvitamin/iron oral solution 10 mg/ml *Pediatric Multiple Vitamins**-*Pediatric Multiple Vitamins W/ C***
P
OTC
poly-vitamin oral solution 35 mg/ml *Pediatric Vitamins**-*Pediatric Vitamins A & D W/ C***
P
OTC
tri-vitamin oral solution 1500-400-35 *Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa***
P
OTC
ELITE-OB ORAL TABLET 50-1.25 MG
P
MYNATAL ADVANCE ORAL TABLET
P
mynatal-z oral tablet
P
mynate 90 plus oral tablet extendedrelease*
P
PRENATABS RX ORAL TABLET 29-1 MG
P
prenatal oral tablet 28-0.8 mg
P
prenatal 19 oral tablet chewable
P
prenatal low iron oral tablet 27-0.8 mg
P
prenatal plus oral tablet 27-1 mg
P
prenatal plus iron oral tablet 29-1 mg
P
PRENATAL-U ORAL CAPSULE 106.5-1 MG
P
trinatal rx 1 oral tablet 60-1 mg
P
TRINATE ORAL TABLET
P
multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg *Ped Mv W/ Fluoride**-*Ped Vitamins Acd W/ Fluoride***
OTC OTC
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 68
Drug Name
Preference Details Coverage Details
VINATE AZ EXTRA ORAL TABLET 29-1 MG
P
VINATE II ORAL TABLET 29-1 MG
P
VINATE M ORAL TABLET 27-1 MG *Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil***
P
PR NATAL 400 EC ORAL 29-1-200 & 400 MG (DR) *Musculoskeletal Therapy Agents*
P
*Central Muscle Relaxants**-*Central Muscle Relaxants*** baclofen oral tablet 10 mg, 20 mg
P
carisoprodol oral tablet 350 mg
P
chlorzoxazone oral tablet 500 mg
P
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
P
methocarbamol oral tablet 500 mg, 750 mg
P
tizanidine hcl oral tablet 2 mg, 4 mg
P
QL (124 EA per 31 days) QL (93 EA per 31 days) ST; Notes (Must fail preferred baclofen and cyclobenzaprine within the past 100 days)
*Direct Muscle Relaxants**-*Direct Muscle Relaxants*** dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg *Viscosupplements**-*Viscosupplements***
P
P
PA
saline nasal spray nasal solution 0.65 % *Nasal Antiallergy**-*Nasal Antihistamines***
P
OTC
azelastine hcl nasal solution 137 mcg/spray *Nasal Antiallergy**-*Nasal Mast Cell Stabilizers***
P
supartz intra-articular* 25 mg/2.5ml *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.**-*Nasal Agents Misc.***
cromolyn sodium nasal aerosol, solution 5.2 mg/act
P
OTC
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 69
Drug Name
Preference Details Coverage Details
*Nasal Anticholinergics**-*Nasal Anticholinergics*** ipratropium bromide nasal solution 0.03 %, 0.06 % *Nasal Steroids**-*Nasal Steroids*** flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act *Sympathomimetic Decongestants**-*Systemic Decongestants*** pseudoephedrine hcl oral tablet 30 mg, 60 mg *Ophthalmic Agents*
P
P P
P
OTC
P
OTC; QL (15 ML per 31 days)
*Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % *Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic Combinations*** dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml *Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic***
P
betaxolol hcl ophthalmic solution 0.5 %
P
BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %
P
carteolol hcl ophthalmic solution 1 %
P
levobunolol hcl ophthalmic solution 0.25 %, 0.5 %
P
metipranolol ophthalmic solution 0.3 %
P
timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %
P
timolol maleate ophthalmic solution 0.25 %, 0.5 % *Cycloplegic Mydriatics**-*Cycloplegic Mydriatics***
P
atropine sulfate ophthalmic ointment 1 %
P
atropine sulfate ophthalmic solution 1 %
P
atropine-care ophthalmic solution 1 %
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 70
Drug Name
Preference Details Coverage Details
*Miotics**-*Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 2 % *Ophthalmic Adrenergic Agents**-*Ophthalmic Selective Alpha Adrenergic Agonists***
P
brimonidine tartrate ophthalmic solution 0.2 % *Ophthalmic Anti-Infectives**-*Ophthalmic Antibiotics***
P
ciprofloxacin hcl ophthalmic solution 0.3 %
P
erythromycin ophthalmic ointment 5 mg/gm
P
gentamicin sulfate ophthalmic ointment 0.3 %
P
gentamicin sulfate ophthalmic solution 0.3 %
P
ofloxacin ophthalmic solution 0.3 %
P
tobramycin ophthalmic solution 0.3 % *Ophthalmic Anti-Infectives**-*Ophthalmic Anti-Infective Combinations***
P
ak-poly-bac ophthalmic ointment 500-10000 unit/gm
P
bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm
P
neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000
P
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-0.25
P
polycin b ophthalmic ointment 500-10000 unit/gm
P
polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% *Ophthalmic Anti-Infectives**-*Ophthalmic Antivirals***
P
trifluridine ophthalmic solution 1 % *Ophthalmic Anti-Infectives**-*Ophthalmic Sulfonamides***
P
sulfacetamide sodium ophthalmic solution 10 % *Ophthalmic Immunomodulators**-*Ophthalmic Immunomodulators***
P
RESTASIS OPHTHALMIC EMULSION 0.05 %
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 71
Drug Name
Preference Details Coverage Details
*Ophthalmic Steroids**-*Ophthalmic Steroid Combinations*** neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1
P
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
P
neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1
P
poly-dex ophthalmic ointment 3.5-10000-0.1
P
PRED-G OPHTHALMIC SUSPENSION 0.3-1 %
P
sulfacetamide-prednisolone ophthalmic solution 10-0.23 %
P
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % *Ophthalmic Steroids**-*Ophthalmic Steroids***
P
dexamethasone sodium phosphate ophthalmic solution 0.1 %
P
fluorometholone ophthalmic suspension 0.1 %
P
FML FORTE OPHTHALMIC SUSPENSION 0.25 %
P
LOTEMAX OPHTHALMIC SUSPENSION 0.5 %
P
MAXIDEX OPHTHALMIC SUSPENSION 0.1 %
P
prednisolone acetate ophthalmic suspension 1 %
P
VEXOL OPHTHALMIC SUSPENSION 1 % *Ophthalmics - Misc.**-*Ophthalmic Antiallergic***
P
cromolyn sodium ophthalmic solution 4 %
P
ketotifen fumarate ophthalmic solution 0.025 % *Ophthalmics - Misc.**-*Ophthalmic Carbonic Anhydrase Inhibitors***
P
AZOPT OPHTHALMIC SUSPENSION 1 %
P
dorzolamide hcl ophthalmic solution 2 %
P
OTC
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 72
Drug Name
Preference Details Coverage Details
*Ophthalmics - Misc.**-*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** diclofenac sodium ophthalmic solution 0.1 %
P
flurbiprofen sodium ophthalmic solution 0.03 % *Prostaglandins Ophthalmic**-*Prostaglandins Ophthalmic***
P
latanoprost ophthalmic solution 0.005 % *Otic Agents*
P
QL (5 ML per 31 days)
*Otic Agents - Miscellaneous**-*Otic Agents Miscellaneous*** acetic acid-aluminum acetate otic solution 2 % *Otic Anti-Infectives**-*Otic Anti-Infectives***
P
ofloxacin otic solution 0.3 % *Otic Combinations**-*Otic Analgesic Combinations***
P
antipyrine-benzocaine otic solution 5.4-1.4 %, 5.5-1.4 %, 54-14 mg/ml oticin otic liquid† 1-0.1 % *Otic Combinations**-*Otic Steroid-Anti-Infective Combinations***
P P
CIPRODEX OTIC SUSPENSION 0.3-0.1 %
P
neomycin-polymyxin-hc otic solution 3.5-10000-1
P
neomycin-polymyxin-hc otic suspension 3.5-10000-1 *Oxytocics*
ST; Notes (Preferred for members 6 years old and younger; Members 7 years old and older: Covered w/step edit: Must fail ofloxacin 0.3% ear drops within the past 100 days.); AL (Max 6 Years)
P
*Oxytocics**-*Oxytocics*** methylergonovine maleate injection solution 0.2 mg/ml
P
methylergonovine maleate oral tablet 0.2 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 73
Drug Name
Preference Details Coverage Details
*Passive Immunizing Agents* *Monoclonal Antibodies**-*Antiviral Monoclonal Antibodies*** SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML *Penicillins*
P
PA
*Aminopenicillins**-*Aminopenicillins*** amoxicillin oral capsule 250 mg, 500 mg
P
amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
P
amoxicillin oral tablet 500 mg, 875 mg
P
amoxicillin oral tablet chewable 125 mg, 250 mg
P
ampicillin oral capsule 250 mg, 500 mg
P
ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml *Natural Penicillins**-*Natural Penicillins***
P
BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML
P
penicillin g procaine intramuscular* suspension 600000 unit/ml
P
penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml
P
penicillin v potassium oral tablet 250 mg, 500 mg
P
PFIZERPEN-G INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT *Penicillin Combinations**-*Penicillin Combinations***
QL (300 ML per 31 days)
QL (300 ML per 31 days)
P
amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml
P
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg
P
amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg
P
BICILLIN C-R INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML
P
QL (300 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 74
Drug Name BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML *Penicillinase-Resistant Penicillins**-*Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule 250 mg, 500 mg oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm *Progestins*
Preference Details Coverage Details P
P P
*Progestins**-*Progestins*** MAKENA INTRAMUSCULAR* OIL 250 MG/ML
P
medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg
P
norethindrone acetate oral tablet 5 mg *Psychotherapeutic And Neurological Agents Misc.*
PA
P
*Agents For Chemical Dependency**-*Alcohol Deterrents*** acamprosate calcium oral tablet delayed release 333 mg
P
disulfiram oral tablet 250 mg, 500 mg *Antidementia Agents**-*Cholinomimetics Ache Inhibitors***
P
donepezil hcl oral tablet 10 mg, 5 mg
P
EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR
P
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg *Antidementia Agents**-*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists***
QL (186 EA per 31 days)
P
NAMENDA ORAL SOLUTION 10 MG/5ML
P
NAMENDA ORAL TABLET 10 MG, 5 MG
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 75
Drug Name
Preference Details Coverage Details
NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG
P
NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG
P
NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 *Combination Psychotherapeutics**-*Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg *Combination Psychotherapeutics**-*Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg *Fibromyalgia Agents**-*Fibromyalgia Agent Snris*** SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG *Multiple Sclerosis Agents**-*Ms Agents Pyrimidine Synthesis Inhibitors***
P
P
P
P P
AUBAGIO ORAL TABLET 14 MG, 7 MG *Multiple Sclerosis Agents**-*Multiple Sclerosis Agents - Interferons***
P
PA
EXTAVIA SUBCUTANEOUS* KIT 0.3 MG
P
PA
REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML
P
PA
REBIF REBIDOSE SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML
P
PA
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG
P
PA
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 76
Drug Name REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG *Multiple Sclerosis Agents**-*Multiple Sclerosis Agents*** COPAXONE SUBCUTANEOUS* KIT 20 MG/ML *Psychotherapeutic And Neurological Agents Misc.**-*Psychotherapeutic And Neurological Agents - Misc.*** ORAP ORAL TABLET 1 MG, 2 MG *Smoking Deterrents**-*Smoking Deterrents***
Preference Details Coverage Details P
PA
P
PA
P
AL (Min 12 Years)
buproban oral tablet extended release 12 hr* 150 mg
P
CHANTIX ORAL TABLET 0.5 MG, 1 MG
P
PA
CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG
P
PA
CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42
P
PA
nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr
P
OTC; QL (140 EA per 365 days)
nicotine polacrilex mouth/throat gum 2 mg, 4 mg
P
OTC; QL (4032 EA per 365 Days)
P
PA
P
PA
P
ST; Notes (Members must have trial of doxycycline monohydrate 50 mg or 100 mg capsules within the last 100 days.)
*Respiratory Agents - Misc.* *Cystic Fibrosis Agents**-*Cftr Potentiators*** KALYDECO ORAL TABLET 150 MG *Cystic Fibrosis Agents**-*Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 1 MG/ML *Tetracyclines* *Tetracyclines**-*Tetracyclines*** doxycycline hyclate oral capsule 100 mg, 50 mg
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 77
Drug Name
Preference Details Coverage Details
doxycycline hyclate oral tablet 100 mg
P
doxycycline hyclate oral tablet 20 mg
P
doxycycline monohydrate oral capsule 100 mg, 50 mg
P
minocycline hcl oral capsule 100 mg, 50 mg, 75 mg
P
tetracycline hcl oral capsule 250 mg, 500 mg *Thyroid Agents*
ST; Notes (Members must have trial of doxycycline monohydrate 50 mg Gor 100 mg capsules within the last 100 days.)
P
*Antithyroid Agents**-*Antithyroid Agents*** methimazole oral tablet 10 mg, 5 mg
P
propylthiouracil oral tablet 50 mg *Thyroid Hormones**-*Thyroid Hormones***
P
ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG
P
levothyroxine sodium intravenous* solution reconstituted 100 mcg, 500 mcg
P
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
P
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg
P
NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG
P
np thyroid oral tablet 30 mg, 60 mg, 90 mg
P
THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)
P
THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)
P
THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)
P
THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)
P
QL (558 EA per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 78
Drug Name THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG) UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG *Ulcer Drugs*
Preference Details Coverage Details P
P
*Antispasmodics**-*Antispasmodics*** dicyclomine hcl oral capsule 10 mg
P
dicyclomine hcl oral solution 10 mg/5ml
P
dicyclomine hcl oral tablet 20 mg *Antispasmodics**-*Quaternary Anticholinergics***
P
glycopyrrolate oral tablet 1 mg, 2 mg
P
propantheline bromide oral tablet 15 mg *H-2 Antagonists**-*H-2 Antagonists***
P
acid reducer oral tablet 75 mg
P
OTC
cimetidine oral tablet 200 mg
P
OTC
cimetidine oral tablet 300 mg, 400 mg, 800 mg
P
cimetidine hcl oral solution 300 mg/5ml
P
famotidine oral tablet 10 mg
P
famotidine oral tablet 20 mg, 40 mg
P
famotidine premixed intravenous* solution 20-0.9 mg/50ml-%
P
ranitidine acid reducer oral tablet 75 mg
P
ranitidine hcl injection solution 1000 mg/40ml, 150 mg/6ml, 50 mg/2ml
P
ranitidine hcl oral capsule 150 mg, 300 mg
P
ranitidine hcl oral syrup 15 mg/ml
P
QL (620 ML per 31 days)
ranitidine hcl oral tablet 150 mg
P
OTC
ranitidine hcl oral tablet 300 mg *Misc. Anti-Ulcer**-*Misc. Anti-Ulcer***
P
CARAFATE ORAL SUSPENSION 1 GM/10ML
P
sucralfate oral tablet 1 gm
P
OTC
OTC
QL (1240 ML per 31 days)
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 79
Drug Name
Preference Details Coverage Details
*Proton Pump Inhibitors**-*Proton Pump Inhibitors*** P
ST; Notes (Must fail preferred omeprazole or pantoprazole within the past 100 days.); OTC
lansoprazole oral capsule delayed release 30 mg
P
ST; Notes (Must fail preferred omeprazole or pantoprazole within the past 100 days.)
omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg
P
lansoprazole oral capsule delayed release 15 mg
pantoprazole sodium oral tablet delayed release 20 mg, 40 mg *Ulcer Drugs - Prostaglandins**-*Ulcer Drugs Prostaglandins*** misoprostol oral tablet 100 mcg, 200 mcg *Urinary Anti-Infectives*
P
P
*Urinary Anti-Infective Combinations**-*Urinary Antiseptic-Antispasmodic &/Or Analgesics*** URETRON D/S ORAL TABLET
P
uticap oral capsule 120 mg *Urinary Anti-Infectives**-*Urinary Anti-Infectives***
P
MACRODANTIN ORAL CAPSULE 25 MG
P
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
P
nitrofurantoin monohyd macro oral capsule 100 mg *Urinary Antispasmodics*
AL (Max 8 Years)
P
*Urinary Antispasmodics**-*Urinary Antispasmodics*** bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg
P
oxybutynin chloride oral syrup 5 mg/5ml
P
oxybutynin chloride oral tablet 5 mg
P
oxybutynin chloride er oral tablet extended release 24 hr* 10 mg, 15 mg, 5 mg
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 80
Drug Name
Preference Details Coverage Details P
ST; Notes (Must fail preferred oxybutinin er tablets within the past 100 days)
3 day vaginal vaginal cream 2 %
P
OTC
clotrimazole vaginal cream 1 %
P
OTC
GYNE-LOTRIMIN 3 VAGINAL CREAM 2 %
P
OTC
miconazole 3 vaginal suppository 200 mg
P
miconazole 3 combo pack vaginal kit 200-2 mg-% (9gm)
P
OTC
miconazole nitrate vaginal cream 2 %
P
OTC
miconazole nitrate vaginal suppository 100 mg
P
OTC
MONISTAT 3 VAGINAL CREAM 4 %
P
OTC
terconazole vaginal cream 0.4 %, 0.8 %
P
terconazole vaginal suppository 80 mg *Vaginal Anti-Infectives**-*Vaginal Anti-Infectives***
P
clindamycin phosphate vaginal cream 2 %
P
metronidazole vaginal 0.75 %
P
VANDAZOLE VAGINAL 0.75 % *Vaginal Estrogens**-*Vaginal Estrogens***
P
trospium chloride oral tablet 20 mg *Vaginal Products* *Vaginal Anti-Infectives**-*Imidazole-Related Antifungals***
PREMARIN VAGINAL CREAM 0.625 MG/GM *Vaginal Progestins**-*Vaginal Progestins*** ENDOMETRIN VAGINAL INSERT 100 MG *Vasopressors*
P
P
*Anaphylaxis Therapy Agents**-*Anaphylaxis Therapy Agents*** EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML *Vasopressors**-*Vasopressors*** midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg
P
QL (6 EA per 180 days)
P
QL (6 EA per 180 days)
P
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 81
Drug Name
Preference Details Coverage Details
*Vitamins* *Oil Soluble Vitamins**-*Vitamin A*** vitamin a oral capsule 10000 unit, 8000 unit *Oil Soluble Vitamins**-*Vitamin D*** vitamin d (ergocalciferol) oral capsule 50000 unit *Oil Soluble Vitamins**-*Vitamin K***
P
OTC
P
QL (4 EA per 28 Days)
MEPHYTON ORAL TABLET 5 MG
P
vitamin k (phytonadione) oral tablet 100 mcg *Water Soluble Vitamins**-*Biotin***
P
OTC
biotin 5000 oral capsule 5 mg *Water Soluble Vitamins**-*Vitamin B-1***
P
OTC
thiamine hcl injection solution 100 mg/ml
P
vitamin b-1 oral tablet 100 mg, 250 mg, 50 mg *Water Soluble Vitamins**-*Vitamin B-3***
P
OTC
niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg
P
OTC
niacin er oral capsule extended release* 500 mg
P
OTC
niacin er oral tablet extendedrelease* 500 mg
P
OTC
NIACOR ORAL TABLET 500 MG *Water Soluble Vitamins**-*Vitamin B-6***
P
vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50 mg, 500 mg
P
OTC
vitamin b-6 er oral tablet extendedrelease* 200 mg
P
OTC
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 82
Index
3 day vaginal ...............................................................................................
abacavir sulfate ...............................................................................................
abacavir-lamivudine-zidovudine
81 35
............................................................................................... 34 ABILIFY .............................................................. 33 acamprosate calcium ............................................................................................... 75 acarbose ................................................................... 16 ACCU-CHEK ACTIVE ............................................................................................... 52 ACCU-CHEK AVIVA PLUS ............................................................................................... 52 ACCU-CHEK COMFORT CURVE ................................................................... 52 ACCU-CHEK COMPACT PLUS CARE ............................................................................................... 63 ACCU-CHEK COMPACT TEST DRUM ............................................................................................... 52 ACCU-CHEK NANO SMARTVIEW ............................................................................................... 63 ACCU-CHEK SMARTVIEW ............................................................................................... 53 acetaminophen ................................................................................................... 4 acetaminophen-codeine ................................................................................................... 5 acetaminophen-codeine #2 ................................................................................................... 5 acetaminophen-codeine #3 ................................................................................................... 5 acetaminophen-codeine #4 ................................................................................................... 5 acetazolamide ............................................................................................... 54 acetic acid-aluminum acetate ............................................................................................... 73 acetylcysteine ............................................................................................... 46 acid reducer ......................................................... 79 acne medication ............................................................................................... 46 acne medication 5 ............................................................................................... 47 ACTICIN ............................................................. 52 acyclovir ................................................................... 37
ADDERALL XR
1 ADRUCIL .......................................................... 27 ADVAIR DISKUS ............................................................................................... 11 ADVAIR HFA ............................................................................................... 11 AEROCHAMBER PLUS FLO-VU ................................................................. 64 AEROCHAMBER PLUS FLO-VU LARGE ............................................................................................... 64 AEROCHAMBER PLUS FLO-VU SMALL ............................................................................................... 64 AEROCHAMBER PLUS FLO-VU W/MASK ............................................................................................... 64 AFINITOR ............................................................................................... 29 ak-poly-bac .......................................................... 71 ALAVERT ALLERGY/SINUS ............................................................................................... 45 ALBENZA ............................................................. 7 albuterol sulfate ............................................................................................... 11 alclometasone dipropionate ............................................................................................... 49 alcohol pads ......................................................... 63 alendronate sodium ............................................................................................... 55 aler-dryl .................................................................... 22 ALKERAN ............................................................................................... 27 ALLEGRA ALLERGY CHILDRENS ............................................................................................... 22 ALLEGRA-D ALLERGY & CONGESTION ............................................................................................... 45 allergy ......................................................................... 22 allergy relief/nasal decongest ............................................................................................... 46 allopurinol ............................................................. 58 alprazolam ................................................................ 8 ALTAVERA ............................................................................................... 42 aluminum hydroxide gel ................................................................................................... 7 ...................................................................................................
aluminum-magnesium-simethicon e ............................................................................................... 7 amantadine hcl ............................................................................................... 31 A-METHAPRED ............................................................................................... 45 amiloride-hydrochlorothiazide ............................................................................................... 54 aminophylline ............................................................................................... 12 amiodarone hcl ................................................................................................... 9 amitriptyline hcl ............................................................................................... 16 AMLACTIN ............................................................................................... 51 amlodipine besylate ............................................................................................... 39 ammonium lactate ............................................................................................... 51 AMNESTEEM ............................................................................................... 47 amoxapine ............................................................. 16 amoxicillin ............................................................ 74 amoxicillin-pot clavulanate ............................................................................................... 74 amphetamine-dextroamphetamine ................................................................................................... 1 ampicillin ................................................................ 74 anagrelide hcl ............................................................................................... 58 anastrozole ........................................................... 28 antipyrine-benzocaine ............................................................................................... 73 APIDRA ................................................................ 19 APIDRA SOLOSTAR ............................................................................................... 19 APRI ............................................................................ 42 APRISO .................................................................. 57 APTIVUS ............................................................. 35 ARGYLE STERILE SALINE ............................................................................................... 57 ARMOUR THYROID ............................................................................................... 78 artificial tears ............................................................................................... 70 ASCOMP-CODEINE ................................................................................................... 5 ASMANEX 120 METERED DOSES ..................................................................... 10
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 83
ASMANEX 30 METERED DOSES ..................................................................... 10 ASMANEX 60 METERED DOSES ..................................................................... 10 ASMANEX HFA ............................................................................................... 10 aspirin ............................................................................. 4 aspirin adult low strength ................................................................................................... 4 aspirin ec ..................................................................... 4 aspir-trin ..................................................................... 4 atenolol ...................................................................... 38 atenolol-chlorthalidone ............................................................................................... 25 atorvastatin calcium ............................................................................................... 23 atovaquone ............................................................ 26 atovaquone-proguanil hcl ............................................................................................... 26 ATRIPLA ............................................................ 34 atropine sulfate ............................................................................................... 70 atropine-care .................................................................................... 70, 71 ATROVENT HFA ............................................................................................... 10 AUBAGIO ......................................................... 76 AVANDAMET ............................................................................................... 17 AVANDARYL ............................................................................................... 17 AVANDIA ......................................................... 19 AVASTIN ............................................................ 28 AVIANE ................................................................ 42 AVITA ...................................................................... 47 AVODART ............................................................................................... 57 azathioprine ........................................................ 38 azelastine hcl .................................................................................... 69, 70 azithromycin ............................................................................................... 62 azithromycin hydrogencitrate ............................................................................................... 62 AZOPT ..................................................................... 72 bacitracin zinc ............................................................................................... 48 bacitracin-neomycin-polymyxin ............................................................................................... 47 bacitracin-polymyxin b ............................................................................................... 71 baclofen ..................................................................... 69
balsalazide disodium
............................................................................................... 57 BALZIVA ............................................................ 42 baza antifungal ............................................................................................... 48 BD INSULIN SYRINGE ULTRAFINE ............................................................................................... 63 BENADRYL ALLERGY CHILDRENS ............................................................................................... 22 benazepril hcl ............................................................................................... 24 benazepril-hydrochlorothiazide ............................................................................................... 24 benzoyl peroxide ............................................................................................... 47 benzoyl peroxide-erythromycin ............................................................................................... 46 benztropine mesylate ............................................................................................... 31 betamethasone dipropionate ............................................................................................... 49 betamethasone dipropionate aug ............................................................................................... 49 betamethasone valerate ............................................................................................... 49 betaxolol hcl ............................................................................................... 70 bethanechol chloride ............................................................................................... 80 BETHKIS ................................................................ 2 BETOPTIC-S ............................................................................................... 70 BICILLIN C-R ............................................................................................... 74 BICILLIN C-R 900/300 ............................................................................................... 75 BICILLIN L-A ............................................................................................... 74 BILTRICIDE ................................................................................................... 7 biotin 5000 ............................................................ 82 bisacodyl .................................................................. 61 bisacodyl ec ......................................................... 61 bisoprolol fumarate ............................................................................................... 38 bisoprolol-hydrochlorothiazide ............................................................................................... 25 BOSULIF ............................................................. 29 brimonidine tartrate ............................................................................................... 71
bromocriptine mesylate ...............................................................................................
BRONCHO SALINE
31
............................................................................................... 46 budesonide ............................................................. 11 bumetanide ........................................................... 54 buprenorphine hcl ................................................................................................... 6 buproban .................................................................. 77 bupropion hcl ............................................................................................... 15 bupropion hcl er (sr) ............................................................................................... 15 bupropion hcl er (xl) ............................................................................................... 15 buspirone hcl ................................................................................................... 8 butalbital-acetaminophen ................................................................................................... 4 butalbital-apap-caff-cod ................................................................................................... 6 butalbital-apap-caffeine ................................................................................................... 4 butalbital-asa-caff-codeine ................................................................................................... 6 butalbital-asa-caffeine ................................................................................................... 4 butorphanol tartrate ................................................................................................... 6 BYDUREON ............................................................................................... 18 BYETTA 10 MCG PEN ............................................................................................... 18 BYETTA 5 MCG PEN ............................................................................................... 19 calcipotriene .................................................................................... 48, 49 calcitonin (salmon) ............................................................................................... 55 calcitriol ................................................................... 55 calcium acetate ............................................................................................... 57 calcium acetate (phos binder) ............................................................................................... 65 calcium carbonate ............................................................................................... 65 calcium carbonate antacid ................................................................................................... 7 calcium carbonate-vitamin d ............................................................................................... 65 calcium lactate ............................................................................................... 65
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 84
cal-lac .......................................................................... 65 capecitabine ........................................................ 27 CAPRELSA ............................................................................................... 29 capsaicin .................................................................. 51 captopril ................................................................... 24 captopril-hydrochlorothiazide ............................................................................................... 25 CARAFATE ............................................................................................... 79 carbamazepine ............................................................................................... 13 carbidopa-levodopa ............................................................................................... 31 carbidopa-levodopa er ............................................................................................... 31 carisoprodol ........................................................ 69 carteolol hcl ......................................................... 70 CARTIA XT ............................................................................................... 39 carvedilol ................................................................. 38 CAVAREST ............................................................................................... 67 CAZIANT ........................................................... 43 cefaclor ...................................................................... 41 cefadroxil ............................................................... 41 cefdinir ....................................................................... 41 cefpodoxime proxetil ............................................................................................... 41 cefprozil .................................................................... 41 cefuroxime axetil ............................................................................................... 41 celecoxib ...................................................................... 2 CENTRATEX ............................................................................................... 59 cephalexin .............................................................. 41 cetirizine hcl ............................................................................................... 22 cetirizine hcl childrens ............................................................................................... 22 cetirizine-pseudoephedrine er ............................................................................................... 46 CHANTIX .......................................................... 77 CHANTIX CONTINUING MONTH PAK ............................................................................................... 77 CHANTIX STARTING MONTH PAK ............................................................................................... 77 childrens ibuprofen ................................................................................................... 3
childrens loratadine ...............................................................................................
chlordiazepoxide hcl
22
...................................................................................................
chlordiazepoxide-amitriptyline ...............................................................................................
chlorhexidine gluconate ...............................................................................................
chlorothiazide ...............................................................................................
chlorpromazine hcl ...............................................................................................
chlorpropamide ...............................................................................................
chlorthalidone ...............................................................................................
chlorzoxazone ...............................................................................................
cholestyramine ...............................................................................................
cholestyramine light
8
76 34 54 33 20 54 69 23
............................................................................................... 23 ciclopirox ................................................................ 48 ciclopirox olamine ............................................................................................... 48 cilostazol ................................................................. 58 cimetidine ............................................................... 79 cimetidine hcl ............................................................................................... 79 CIPRODEX ............................................................................................... 73 ciprofloxacin hcl ............................................................................................... 56 citalopram hydrobromide ............................................................................................... 15 CLARAVIS ............................................................................................... 47 clarithromycin ............................................................................................... 62 CLEAR AWAY 1-STEP WART REMOVER ............................................................................................... 51 clindamycin hcl ............................................................................................... 26 clindamycin palmitate hcl ............................................................................................... 26 clindamycin phosphate ............................................................................................... 26 CLINISTIX ............................................................................................... 53 clobetasol propionate .................................................................................... 49, 50
clomipramine hcl
............................................................................................... 16 clonazepam .......................................................... 13 clonidine hcl ........................................................ 24 clopidogrel bisulfate ............................................................................................... 58 clorazepate dipotassium ................................................................................................... 8 clotrimazole ......................................................... 48 clozapine .................................................................. 32 codeine sulfate ................................................................................................... 4 colchicine-probenecid ............................................................................................... 58 COLCRYS .......................................................... 58 COMBIVENT RESPIMAT ............................................................................................... 11 COMPLERA ............................................................................................... 34 COMPOUND W ............................................................................................... 51 COMPOUND W MAXIMUM STRENGTH ............................................................................................... 51 CONDYLOX ............................................................................................... 51 COPAXONE ............................................................................................... 77 cortisone acetate ............................................................................................... 45 CORTISPORIN ............................................................................................... 47 CREON ................................................................... 53 CRIXIVAN ............................................................................................... 35 cromolyn sodium ............................................................................................... 10 CRYSELLE-28 ............................................................................................... 42 cvs triple antibiotic ............................................................................................... 47 cyanocobalamin ............................................................................................... 59 cyclobenzaprine hcl ............................................................................................... 69 cyclophosphamide ............................................................................................... 27 cyclosporine ........................................................ 37 cyclosporine modified ............................................................................................... 37 cyproheptadine hcl ............................................................................................... 23
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 85
cytra-2 ........................................................................ 57 CYTRA-3 ............................................................. 57 danazol .......................................................................... 6 dantrolene sodium ............................................................................................... 69 dapsone ...................................................................... 26 DARAPRIM ............................................................................................... 26 deferoxamine mesylate ............................................................................................... 21 DELSYM NGHT TIME CGH/CLD CHILD ............................................................................................... 46 DELSYM NIGHT TIME COUGH/COLD ............................................................................................... 46 DENAVIR .......................................................... 49 DENTAGEL ............................................................................................... 67 desipramine hcl ............................................................................................... 16 desmopressin ace rhinal tube ............................................................................................... 55 desmopressin ace spray refrig ............................................................................................... 55 desmopressin acetate ............................................................................................... 56 desmopressin acetate spray ............................................................................................... 56 desonide .................................................................... 50 dexamethasone ............................................................................................... 45 dexamethasone sodium phosphate ............................................................................................... 45 dexmethylphenidate hcl ................................................................................................... 1 dextroamphetamine sulfate ................................................................................................... 1 dextroamphetamine sulfate er ................................................................................................... 1 DIASTIX .............................................................. 53 diazepam ..................................................................... 8 diclofenac potassium ................................................................................................... 3 diclofenac sodium ................................................................................................... 3 diclofenac sodium er ................................................................................................... 3 dicloxacillin sodium ............................................................................................... 75 dicyclomine hcl ............................................................................................... 79
didanosine .............................................................. 35 diflunisal ...................................................................... 4 digoxin ....................................................................... 40 DILANTIN ............................................................................................... 14 diltiazem hcl ............................................................................................... 39 diltiazem hcl er ............................................................................................... 39 diltiazem hcl er beads ............................................................................................... 39 diltiazem hcl er coated beads ............................................................................................... 39 dilt-xr ........................................................................... 39 diphenhydramine hcl ............................................................................................... 22 diphenhydramine hcl (sleep) ............................................................................................... 59 diphenoxylate-atropine ............................................................................................... 20 dipyridamole ............................................................................................... 52 disopyramide phosphate ................................................................................................... 9 disulfiram ............................................................... 75 divalproex sodium ............................................................................................... 14 divalproex sodium er ............................................................................................... 15 docusate sodium ............................................................................................... 61 donepezil hcl ............................................................................................... 75 dorzolamide hcl .................................................................................... 72, 73 dorzolamide hcl-timolol mal ............................................................................................... 70 double antibiotic ............................................................................................... 47 doxazosin mesylate ............................................................................................... 24 doxepin hcl ........................................................... 16 doxycycline hyclate .................................................................................... 77, 78 doxycycline monohydrate ............................................................................................... 78 DRITHO-CREME HP ............................................................................................... 49 DULERA ............................................................. 11 E.E.S. GRANULES ............................................................................................... 62
econazole nitrate ...............................................................................................
EDURANT
48
............................................................................................... 35 ELIDEL .................................................................. 51 ELIPHOS ............................................................. 57 ELITE-OB ........................................................... 68 ELIXOPHYLLIN ............................................................................................... 12 elmiron ....................................................................... 57 EMCYT .................................................................. 28 EMTRIVA .......................................................... 36 enalapril maleate ............................................................................................... 24 enalapril-hydrochlorothiazide ............................................................................................... 25 ENDOCET ............................................................ 6 ENDOMETRIN ............................................................................................... 81 enema disposable ............................................................................................... 61 enoxaparin sodium .................................................................................... 12, 13 ENPRESSE-28 ............................................................................................... 43 entecavir ................................................................... 36 EPIPEN 2-PAK ............................................................................................... 81 EPIPEN JR 2-PAK ............................................................................................... 81 EPITOL ................................................................... 13 EPIVIR .................................................................... 36 EPIVIR HBV ............................................................................................... 36 EPZICOM ........................................................... 34 eq aspirin low dose ................................................................................................... 4 ERIVEDGE ............................................................................................... 28 ERWINAZE ............................................................................................... 30 ery ..................................................................................... 46 ERYPED 200 ............................................................................................... 62 ERYPED 400 ............................................................................................... 62 ERY-TAB ............................................................ 62 ERYTHROCIN STEARATE ............................................................................................... 62 erythromycin ............................................................................................... 46
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 86
erythromycin base ...............................................................................................
erythromycin ethylsuccinate ...............................................................................................
escitalopram oxalate ...............................................................................................
ESTARYLLA
62 62 15
............................................................................................... 42 estazolam ................................................................ 60 estradiol .................................................................... 56 estradiol-norethindrone acet ............................................................................................... 56 estropipate ............................................................ 56 ethambutol hcl ............................................................................................... 27 ethosuximide ............................................................................................... 14 etodolac ........................................................................ 3 etoposide .................................................................. 30 EXEL PEN NEEDLES 1/3" ............................................................................................... 63 EXELON .............................................................. 75 EXJADE ................................................................ 20 EXTAVIA ........................................................... 76 E-Z SPACER ............................................................................................... 64 famotidine .............................................................. 79 famotidine premixed ............................................................................................... 79 fenofibrate ............................................................. 23 fenofibrate micronized ............................................................................................... 23 fenoprofen calcium ................................................................................................... 3 fentanyl ......................................................................... 4 ferrous sulfate ............................................................................................... 59 fexofenadine hcl ............................................................................................... 22 fexofenadine hcl childrens ............................................................................................... 22 fexofenadine-pseudoephed er ............................................................................................... 46 fiber ................................................................................ 60 finasteride .............................................................. 57 FIRAZYR ........................................................... 58 flecainide acetate ................................................................................................... 9 FLOVENT DISKUS ............................................................................................... 11 FLOVENT HFA ............................................................................................... 11
fluconazole ............................................................ 21 fludrocortisone acetate ............................................................................................... 45 flunisolide ............................................................... 70 fluocinolone acetonide ............................................................................................... 50 fluocinolone acetonide body ............................................................................................... 50 fluocinolone acetonide scalp ............................................................................................... 50 fluocinonide ......................................................... 50 fluocinonide-e ............................................................................................... 50 FLUOR-A-DAY ............................................................................................... 65 FLUORIDEX DAILY DEFENSE .......................................................... 67 fluorometholone ............................................................................................... 72 fluorouracil .......................................................... 27 fluoxetine hcl ............................................................................................... 15 fluphenazine decanoate ............................................................................................... 33 fluphenazine hcl ............................................................................................... 33 flurbiprofen .............................................................. 3 flurbiprofen sodium ............................................................................................... 73 fluticasone propionate ............................................................................................... 50 fluvoxamine maleate ............................................................................................... 16 FML FORTE ............................................................................................... 72 folic acid .................................................................. 59 fondaparinux sodium ............................................................................................... 13 FORADIL AEROLIZER ............................................................................................... 11 FORTICAL ............................................................................................... 55 fosinopril sodium ............................................................................................... 24 fosphenytoin sodium ............................................................................................... 14 FREESTYLE FREEDOM LITE ............................................................................. 63 FREESTYLE INSULINX SYSTEM ............................................................... 63 FREESTYLE INSULINX TEST ........................................................................... 53
FREESTYLE LITE ...............................................................................................
FREESTYLE LITE TEST ...............................................................................................
FREESTYLE TEST
63 53
............................................................................................... 53 furosemide ............................................................. 54 FUZEON .............................................................. 34 gabapentin ............................................................. 13 GABITRIL ........................................................ 14 gas relief .................................................................. 56 GAVILYTE-G ............................................................................................... 60 GAVILYTE-N WITH FLAVOR PACK ............................................................................................... 60 gemcitabine hcl ............................................................................................... 27 gemfibrozil ............................................................ 23 generlac ..................................................................... 57 GENGRAF ............................................................................................... 37 gentamicin sulfate ............................................................................................... 48 GIANVI ................................................................. 42 GILOTRIF ........................................................ 29 GLEEVEC .......................................................... 30 glimepiride ............................................................ 20 glipizide ..................................................................... 20 glipizide er ............................................................. 20 GLIPIZIDE XL ............................................................................................... 20 glipizide-metformin hcl ............................................................................................... 17 GLUCAGEN ............................................................................................... 18 GLUCAGEN HYPOKIT ............................................................................................... 18 GLUCAGON EMERGENCY ............................................................................................... 18 glucose ........................................................................ 18 glucose control ............................................................................................... 63 glyburide .................................................................. 20 glyburide micronized ............................................................................................... 20 glyburide-metformin ............................................................................................... 17 glycopyrrolate ............................................................................................... 79 gnp nighttime sleep aid ............................................................................................... 59
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 87
GOLYTELY ...............................................................................................
griseofulvin microsize ...............................................................................................
griseofulvin ultramicrosize ...............................................................................................
guanfacine hcl ...............................................................................................
GYNE-LOTRIMIN 3 ...............................................................................................
halobetasol propionate
60 21 21 24 81
............................................................................................... 50 haloperidol ............................................................ 32 haloperidol decanoate ............................................................................................... 32 haloperidol lactate ............................................................................................... 32 hearing aid battery ............................................................................................... 63 HECORIA .......................................................... 38 HEXALEN ........................................................ 27 HUMALOG ............................................................................................... 19 HUMALOG KWIKPEN ............................................................................................... 19 HUMALOG MIX 50/50 ............................................................................................... 19 HUMALOG MIX 75/25 ............................................................................................... 19 HUMALOG MIX 75/25 KWIKPEN ......................................................... 19 HUMIRA ................................................................ 2 HUMIRA PEN ................................................................................................... 2 HUMIRA PEN-CROHNS STARTER .............................................................. 2 HUMULIN 70/30 ............................................................................................... 19 HUMULIN N ............................................................................................... 19 HUMULIN N KWIKPEN ............................................................................................... 19 HUMULIN R ............................................................................................... 19 HUMULIN R U-500 (CONCENTRATED) ............................................................................................... 19 hydralazine hcl ............................................................................................... 25 hydrochlorothiazide ............................................................................................... 54
hydrocodone-acetaminophen ...................................................................................................
hydrocodone-ibuprofen ...................................................................................................
hydrocortisone ...................................................................................................
hydrocortisone valerate ...............................................................................................
hydromorphone hcl
...............................................................................................
hydroxyurea ...............................................................................................
hydroxyzine hcl
7
5
26 30
...................................................................................................
hydroxyzine pamoate ...................................................................................................
HYPERCARE
6
50
...................................................................................................
hydroxychloroquine sulfate
6
8 8
............................................................................................... 52 ibuprofen ..................................................................... 3 ICLUSIG .............................................................. 30 imipramine hcl ............................................................................................... 16 IN-CHECK DIAL FLOW TRAINER .......................................................... 64 indapamide ........................................................... 54 indomethacin ................................................................................................... 3 infants silapap ................................................................................................... 4 insulin syringe ............................................................................................... 63 INTELENCE ............................................................................................... 35 INVIRASE ......................................................... 35 INVOKAMET ............................................................................................... 17 INVOKANA ............................................................................................... 20 ipratropium bromide ............................................................................................... 10 ipratropium-albuterol ............................................................................................... 11 ISENTRESS ............................................................................................... 34 isoniazid ................................................................... 27 isosorbide dinitrate ................................................................................................... 8 isosorbide dinitrate er ................................................................................................... 8
isosorbide mononitrate ...................................................................................................
isosorbide mononitrate er
8
................................................................................................... 8 ivermectin .................................................................. 7 JAKAFI .................................................................. 30 JANTOVEN ............................................................................................... 12 JANUMET ........................................................ 17 JANUMET XR ............................................................................................... 17 JANUVIA ........................................................... 18 JARDIANCE ............................................................................................... 20 JENTADUETO ............................................................................................... 17 JUNEL 1.5/30 ............................................................................................... 42 JUNEL 1/20 ............................................................................................... 42 JUNEL FE 1.5/30 ............................................................................................... 42 JUNEL FE 1/20 ............................................................................................... 42 KALETRA ........................................................ 34 KALYDECO ............................................................................................... 77 KARIGEL .......................................................... 67 KARIGEL-N ............................................................................................... 67 KARIVA ............................................................... 41 KELNOR 1/35 ............................................................................................... 42 ketoconazole ............................................................................................... 21 ketoprofen ................................................................. 3 ketorolac tromethamine ................................................................................................... 3 KETOSTIX ............................................................................................... 53 ketotifen fumarate ............................................................................................... 72 KLOR-CON ............................................................................................... 65 KLOR-CON 10 ............................................................................................... 66 KLOR-CON M10 ............................................................................................... 66 KLOR-CON M20 ............................................................................................... 66 K-PHOS-NEUTRAL ............................................................................................... 65
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 88
labetalol hcl ......................................................... 38 lactulose ................................................................... 61 lamivudine ............................................................. 36 lamivudine-zidovudine ............................................................................................... 34 lamotrigine ........................................................... 13 lancet device ............................................................................................... 63 lancets ......................................................................... 63 lansoprazole ........................................................ 80 LANTUS ............................................................... 20 LANTUS SOLOSTAR ............................................................................................... 20 latanoprost ............................................................ 73 LAVOCLEN-4 CREAMY WASH ....................................................................... 47 LAVOCLEN-8 CREAMY WASH ....................................................................... 47 leflunomide ............................................................... 3 LESSINA .............................................................. 42 LETAIRIS .......................................................... 40 letrozole .................................................................... 28 leucovorin calcium ............................................................................................... 30 LEUKERAN ............................................................................................... 27 levetiracetam .................................................................................... 13, 14 levobunolol hcl ............................................................................................... 70 levocarnitine ............................................................................................... 55 levocetirizine dihydrochloride ............................................................................................... 22 levofloxacin ......................................................... 56 levonorgestrel ............................................................................................... 44 LEVORA 0.15/30 (28) ............................................................................................... 42 levothyroxine sodium ............................................................................................... 78 LEXIVA ................................................................. 35 lidocaine ................................................................... 51 lidocaine hcl ........................................................ 51 lidocaine hcl (cardiac) ................................................................................................... 9 lidocaine hcl (pf) ............................................................................................... 62 lidocaine viscous ............................................................................................... 66 lidocaine-prilocaine .................................................................................... 51, 52
liothyronine sodium
............................................................................................... 78 lisinopril .................................................................... 24 lisinopril-hydrochlorothiazide ............................................................................................... 25 lithium ......................................................................... 31 lithium carbonate ............................................................................................... 32 lithium carbonate er ............................................................................................... 32 lomustine ................................................................. 27 loperamide a-d ............................................................................................... 20 loperamide hcl ............................................................................................... 20 loratadine ............................................................... 22 loratadine hives relief ............................................................................................... 22 lorazepam .................................................................. 9 LORYNA ............................................................. 42 losartan potassium ............................................................................................... 24 losartan potassium-hctz ............................................................................................... 25 LOTEMAX ............................................................................................... 72 lovastatin ................................................................. 23 LOW-OGESTREL ............................................................................................... 42 loxapine succinate ............................................................................................... 32 LUMIZYME ............................................................................................... 55 LUTERA .............................................................. 42 LYSODREN ............................................................................................... 28 MAALOX MULTI SYMPTOM MAX ST .................................................................... 7 MACRODANTIN ............................................................................................... 80 magnesium oxide ................................................................................................... 7 MAKENA ........................................................... 75 malathion ................................................................ 52 mapap .............................................................................. 4 MAPAP CHILDRENS ................................................................................................... 4 maprotiline hcl ............................................................................................... 15 marten-tab ................................................................ 4 MATZIM LA ............................................................................................... 40
MAXIDEX ........................................................ 72 meclizine hcl ............................................................................................... 21 medroxyprogesterone acetate ............................................................................................... 44 mefloquine hcl ............................................................................................... 26 megestrol acetate ............................................................................................... 29 melatonin maximum strength ................................................................................................... 2 meloxicam ................................................................. 3 MEPHYTON ............................................................................................... 82 meprobamate ................................................................................................... 8 mercaptopurine ............................................................................................... 27 mesalamine ........................................................... 57 MESTINON ............................................................................................... 26 METAMUCIL ............................................................................................... 60 metamucil ............................................................... 60 METAMUCIL SMOOTH TEXTURE ......................................................... 60 metaproterenol sulfate ............................................................................................... 12 metformin hcl ............................................................................................... 18 metformin hcl er ............................................................................................... 18 metformin hcl er (osm) ............................................................................................... 18 methadone hcl ................................................................................................... 5 METHADOSE ................................................................................................... 5 methazolamide ............................................................................................... 54 methimazole ........................................................ 78 methitest ...................................................................... 6 methocarbamol ............................................................................................... 69 methotrexate ............................................................................................... 27 methotrexate sodium ............................................................................................... 28 methotrexate sodium (pf) ............................................................................................... 28 methyldopa ........................................................... 24
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 89
methylergonovine maleate ...............................................................................................
METHYLIN
73
...................................................................................................
methylphenidate hcl ...................................................................................................
methylphenidate hcl er ...........................................................................................
methylprednisolone
1
1, 2
...............................................................................................
methylprednisolone (pak) ...............................................................................................
methylprednisolone acetate
1
45 45
............................................................................................... 45 methylprednisolone sodium succ ............................................................................................... 45 metipranolol ............................................................................................... 70 metoclopramide hcl .................................................................................... 56, 57 metolazone ............................................................ 54 metoprolol succinate er ............................................................................................... 38 metoprolol tartrate ............................................................................................... 38 metronidazole ............................................................................................... 25 mexiletine hcl ................................................................................................... 9 miconazole 3 ............................................................................................... 81 miconazole 3 combo pack ............................................................................................... 81 miconazole nitrate ............................................................................................... 48 MICROCHAMBER ............................................................................................... 64 MICROGESTIN 1.5/30 ............................................................................................... 42 MICROGESTIN 1/20 ............................................................................................... 42 MICROGESTIN FE 1.5/30 ............................................................................................... 42 MICROGESTIN FE 1/20 ............................................................................................... 42 MICROSPACER ............................................................................................... 64 midodrine hcl ............................................................................................... 81 milk of magnesia ............................................................................................... 61
minocycline hcl
............................................................................................... 78 minoxidil ................................................................. 25 mirtazapine .......................................................... 15 misoprostol ........................................................... 80 mometasone furoate ............................................................................................... 50 MONISTAT 3 ............................................................................................... 81 MONONESSA ............................................................................................... 42 montelukast sodium ............................................................................................... 10 morphine sulfate ................................................................................................... 5 morphine sulfate (concentrate) ................................................................................................... 5 morphine sulfate (pf) ................................................................................................... 5 morphine sulfate er ................................................................................................... 5 mucus relief .......................................................... 46 multi-vit/fluoride ............................................................................................... 68 multi-vit/fluoride/iron ............................................................................................... 67 multivitamin/fluoride ............................................................................................... 68 multi-vitamin/fluoride ............................................................................................... 68 multi-vitamin/fluoride/iron ............................................................................................... 67 multi-vitamins ............................................................................................... 67 mupirocin ................................................................ 48 mycophenolate mofetil ............................................................................................... 38 MYLERAN ............................................................................................... 27 MYNATAL ADVANCE ............................................................................................... 68 mynatal-z ................................................................ 68 mynate 90 plus ............................................................................................... 68 nabumetone ............................................................. 3 nadolol ........................................................................ 39 naltrexone hcl ............................................................................................... 21 NAMENDA ............................................................................................... 75 NAMENDA TITRATION PAK .............................................................................. 76
NAMENDA XR
............................................................................................... 76 NAMENDA XR TITRATION PACK ......................................................................... 76 naproxen ..................................................................... 3 naproxen dr ............................................................. 3 naproxen sodium ................................................................................................... 3 naratriptan hcl ............................................................................................... 64 NATURE-THROID ............................................................................................... 78 NECON 0.5/35 (28) ............................................................................................... 43 NECON 1/35 (28) ............................................................................................... 43 NECON 7/7/7 ............................................................................................... 44 nefazodone hcl ............................................................................................... 16 neomycin-bacitracin zn-polymyx ............................................................................................... 71 neomycin-polymyxin-dexameth ............................................................................................... 72 neomycin-polymyxin-gramicidin ............................................................................................... 71 neomycin-polymyxin-hc ............................................................................................... 72 NEUPOGEN ............................................................................................... 59 NEUTRAGARD ADVANCED ............................................................................................... 67 nevirapine ............................................................... 35 NEXT CHOICE ONE DOSE ............................................................................................... 44 niacin ............................................................................ 82 niacin er .................................................................... 82 NIACOR ............................................................... 23 nicotine ...................................................................... 77 nicotine polacrilex ............................................................................................... 77 NIFEDIAC CC ............................................................................................... 40 NIFEDICAL XL ............................................................................................... 40 nifedipine ................................................................. 40 nifedipine er ......................................................... 40 nifedipine er osmotic ............................................................................................... 40 NITRO-BID ................................................................................................... 8
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 90
nitrofurantoin macrocrystal ...............................................................................................
nitrofurantoin monohyd macro ...............................................................................................
nitroglycerin
80
...............................................................................................
80
...................................................................................................
NITROSTAT ...................................................................................................
no flush niacin ...............................................................................................
norethindrone acetate ...............................................................................................
normal saline flush ...............................................................................................
NORTREL 0.5/35 (28) ...............................................................................................
NORTREL 1/35 (21) ...............................................................................................
NORTREL 1/35 (28) ...............................................................................................
NORTREL 7/7/7 ...............................................................................................
nortriptyline hcl
OPTICHAMBER FACE MASK-MEDIUM
8 8
40 75 66 43 43 43 44
............................................................................................... 16 NORVIR ............................................................... 35 np thyroid ............................................................... 78 NUVARING ............................................................................................... 44 nystatin ...................................................................... 21 OCELLA ............................................................... 43 ofloxacin .................................................................. 71 olanzapine .............................................................. 33 OLYSIO ................................................................. 36 omeprazole ........................................................... 80 ondansetron ......................................................... 21 ondansetron hcl ............................................................................................... 21 OPTICHAMBER ADVANTAGE ............................................................................................... 64 OPTICHAMBER ADVANTAGE-LG MASK ............................................................................................... 64 OPTICHAMBER ADVANTAGE-MED MASK ............................................................................................... 64 OPTICHAMBER ADVANTAGE-SM MASK ............................................................................................... 64 OPTICHAMBER FACE MASK-LARGE ............................................................................................... 64
OPTICHAMBER FACE MASK-SMALL ...............................................................................................
OPTIHALER
PEGASYS PROCLICK ...............................................................................................
64
penicillin g procaine ...............................................................................................
64
............................................................................................... 64 ORALYTE ......................................................... 65 ORALYTE FREEZER POPS ............................................................................................... 65 ORAP ......................................................................... 77 ORTHO TRI-CYCLEN LO ............................................................................................... 44 oticin ............................................................................. 73 oxacillin sodium ............................................................................................... 75 oxandrolone ............................................................ 6 oxaprozin ................................................................... 3 oxazepam ................................................................... 9 oxcarbazepine
............................................................................................... 14 oxybutynin chloride ............................................................................................... 80 oxybutynin chloride er ............................................................................................... 80 oxycodone hcl ................................................................................................... 5 oxycodone-acetaminophen ................................................................................................... 6 oxycodone-aspirin ................................................................................................... 6 PACERONE ................................................................................................... 9 pain & fever childrens ................................................................................................... 4 pantoprazole sodium ............................................................................................... 80 paroxetine hcl ............................................................................................... 16 peak flow meter ............................................................................................... 64 peg 3350/electrolytes ............................................................................................... 61 peg 3350-kcl-na bicarb-nacl ............................................................................................... 61 peg-3350/electrolytes ............................................................................................... 61 PEGANONE ............................................................................................... 14 PEGASYS ........................................................... 36
penicillin v potassium ...............................................................................................
pentazocine-naloxone hcl
36 74 74
...................................................................................................
pentoxifylline er ...............................................................................................
PERIOGARD
6
58
............................................................................................... 66 permethrin ............................................................. 52 perphenazine ............................................................................................... 33 perphenazine-amitriptyline ............................................................................................... 76 PERTZYE ........................................................... 53 PFIZERPEN-G ............................................................................................... 74 phenazopyridine hcl ............................................................................................... 58 phenelzine sulfate ............................................................................................... 15 phenobarbital ............................................................................................... 60 phenobarbital sodium ............................................................................................... 60 phenytoin ................................................................ 14 phenytoin sodium ............................................................................................... 14 phenytoin sodium extended ............................................................................................... 14 PHOS-FLUR ............................................................................................... 67 pilocarpine hcl ............................................................................................... 67 pindolol ...................................................................... 39 pin-x .................................................................................. 7 pioglitazone hcl ............................................................................................... 19 pioglitazone hcl-metformin hcl ............................................................................................... 17 piroxicam ................................................................... 3 PLAN B ONE-STEP ............................................................................................... 44 podofilox ................................................................. 51
polycin b ................................................................... 71 poly-dex .................................................................... 72 polyethylene glycol 3350 ............................................................................................... 61
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 91
POLY-IRON 150 ...............................................................................................
poly-iron 150 forte ...............................................................................................
polymyxin b-trimethoprim
59 59
............................................................................................... 71 poly-vitamin ........................................................ 68 polyvitamin/iron ............................................................................................... 68 PORTIA-28 ............................................................................................... 43 potassium chloride ............................................................................................... 66 potassium chloride crys er ............................................................................................... 66 potassium chloride er ............................................................................................... 66 PR NATAL 400 EC ............................................................................................... 69 pramipexole dihydrochloride ............................................................................................... 31 pravastatin sodium ............................................................................................... 23 prazosin hcl .......................................................... 24 PRECISION XTRA ............................................................................................... 63 PRECISION XTRA BLOOD GLUCOSE ......................................................... 53 PRECISION XTRA KETONE ............................................................................................... 53 PRED-G ................................................................. 72 prednisolone ........................................................ 45 prednisolone acetate ............................................................................................... 72 prednisolone sodium phosphate ............................................................................................... 45 prednisone .............................................................. 45 PREMARIN ............................................................................................... 56 PREMPHASE ............................................................................................... 56 PREMPRO ........................................................ 56 PRENATABS RX ............................................................................................... 68 prenatal ..................................................................... 68 prenatal 19 ............................................................ 68 prenatal low iron ............................................................................................... 68 prenatal plus ............................................................................................... 68 prenatal plus iron ............................................................................................... 68
PRENATAL-U ...............................................................................................
PREVIFEM
68
............................................................................................... 43 PREZISTA ......................................................... 35 primaquine phosphate ............................................................................................... 26 primidone ................................................................ 14 probenecid ............................................................. 58 procainamide hcl ................................................................................................... 9 prochlorperazine ............................................................................................... 33 prochlorperazine maleate ............................................................................................... 33 PROCRIT ............................................................ 59 PROCTOSOL HC ................................................................................................... 7 PROCTOZONE-HC ................................................................................................... 7 PROLIA ................................................................. 55 promethazine hcl .................................................................................... 22, 23 PROMETHEGAN ............................................................................................... 23 propafenone hcl ................................................................................................... 9 propantheline bromide ............................................................................................... 79 propranolol hcl ............................................................................................... 39 propranolol hcl er ............................................................................................... 39 propranolol-hctz ............................................................................................... 25 propylthiouracil ............................................................................................... 78 protriptyline hcl ............................................................................................... 16 pseudoephedrine hcl ............................................................................................... 70 PULMICORT ............................................................................................... 11 PULMOZYME ............................................................................................... 77 pyrazinamide ............................................................................................... 27 pyridostigmine bromide ............................................................................................... 26 QUASENSE ............................................................................................... 43
quetiapine fumarate
............................................................................................... 32 quinapril hcl ........................................................ 24 quinidine gluconate ................................................................................................... 9 quinidine gluconate er ................................................................................................... 9 quinidine sulfate ................................................................................................... 9 ra nighttime sleep aid ............................................................................................... 60 raloxifene hcl ............................................................................................... 55 ramipril ...................................................................... 24 ranitidine acid reducer ............................................................................................... 79 ranitidine hcl ............................................................................................... 79 REBIF ....................................................................... 76 REBIF REBIDOSE ............................................................................................... 76 REBIF REBIDOSE TITRATION PACK ............................................................................................... 76 REBIF TITRATION PACK ............................................................................................... 77 RECLIPSEN ............................................................................................... 43 reeses pinworm medicine ................................................................................................... 8 refenesen .................................................................. 46 refenesen 400 ............................................................................................... 46 RELENZA DISKHALER ............................................................................................... 37 REMEVEN ............................................................................................... 50 rena-vite ................................................................... 67 RENVELA ......................................................... 57 RESCRIPTOR ............................................................................................... 35 RESTASIS .......................................................... 71 REVLIMID ............................................................................................... 37 REYATAZ ......................................................... 35 RIBASPHERE ............................................................................................... 36 ribavirin .................................................................... 37 RIDAURA ............................................................ 2 rifabutin .................................................................... 27 rifampin .................................................................... 27
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 92
rimantadine hcl
............................................................................................... 37 RIOMET ............................................................... 18 risperidone ............................................................. 32 RISPERIDONE M-TAB ............................................................................................... 32 rivastigmine tartrate ............................................................................................... 75 robafen ....................................................................... 46 ropinirole hcl ............................................................................................... 31 ROXICET ............................................................... 6 SALACTIC FILM ............................................................................................... 51 saline flush ............................................................ 66 saline nasal spray ............................................................................................... 69 salsalate ........................................................................ 4 SANDIMMUNE ............................................................................................... 38 SANTYL ............................................................... 51 SAPHRIS ............................................................. 32 SAVELLA ........................................................... 76 SAVELLA TITRATION PACK ............................................................................................... 76 selegiline hcl ............................................................................................... 31 selenium sulfide ............................................................................................... 49 SELZENTRY ............................................................................................... 34 senna ............................................................................. 61 senna laxative ............................................................................................... 61 sennosides-docusate sodium ............................................................................................... 61 SEREVENT DISKUS ............................................................................................... 12 sertraline hcl ............................................................................................... 16 sf ......................................................................................... 67 sildenafil citrate ............................................................................................... 40 silver sulfadiazine ............................................................................................... 49 simethicone ........................................................... 56 simponi .......................................................................... 2 simvastatin ............................................................ 23 sivextro ...................................................................... 26 sleep tabs ................................................................. 60 slow release iron ............................................................................................... 59
sm magnesium oxide ...............................................................................................
sodium bicarbonate
65
...................................................................................................
sodium chloride ...............................................................................................
sodium fluoride ...............................................................................................
sodium polystyrene sulfonate
7
46 65
............................................................................................... 38 SOLIA ....................................................................... 43 sorbitol ....................................................................... 61 SORINE ................................................................. 39 sotalol hcl ............................................................... 39 sotalol hcl (af) ............................................................................................... 39 SOVALDI ............................................................ 37 spinosad .................................................................... 52 spironolactone ............................................................................................... 54 spironolactone-hctz ............................................................................................... 54 SPRINTEC 28 ............................................................................................... 43 SPRYCEL ........................................................... 30 SPS .................................................................................. 38 SRONYX ............................................................. 43 SSD ................................................................................ 49 SSKI ............................................................................. 65 stavudine .................................................................. 36 STIVARGA ............................................................................................... 29 stool softener ............................................................................................... 61 stool softener laxative dc .................................................................................... 61, 62 STRIBILD .......................................................... 34 sucralfate ................................................................ 79 sulfacetamide sodium ............................................................................................... 46 sulfacetamide-prednisolone ............................................................................................... 72 sulfamethoxazole-tmp ds ............................................................................................... 25 sulfamethoxazole-trimethoprim .................................................................................... 25, 26 sulfasalazine ............................................................................................... 57 sulindac ......................................................................... 3 sumatriptan .......................................................... 64 sumatriptan succinate .................................................................................... 64, 65
supartz ........................................................................ 69 SUSTIVA ............................................................. 35 SUTENT ............................................................... 29 SYEDA .................................................................... 43 SYMBICORT ............................................................................................... 11 SYNAGIS ............................................................ 74 TABLOID ........................................................... 28 tacrolimus .............................................................. 38 TAMIFLU .......................................................... 37 tamoxifen citrate ............................................................................................... 28 tamsulosin hcl ............................................................................................... 58 TARCEVA ......................................................... 30 TASIGNA ........................................................... 30 TAZORAC ........................................................ 49 temazepam ............................................................ 60 temozolomide ............................................................................................... 27 terazosin hcl ........................................................ 24 terbinafine hcl ............................................................................................... 21 terbutaline sulfate ............................................................................................... 12 terconazole ........................................................... 81 TESTIM ..................................................................... 6 testosterone ............................................................. 6 testosterone cypionate ................................................................................................... 6 testosterone enanthate ................................................................................................... 7 tetracycline hcl ............................................................................................... 78 TEV-TROPIN ............................................................................................... 55 THALOMID ............................................................................................... 37 theophylline ......................................................... 12 theophylline er ............................................................................................... 12 thiamine hcl ......................................................... 82 thioridazine hcl ............................................................................................... 33 thiothixene ............................................................ 33 THYROLAR-1 ............................................................................................... 78 THYROLAR-1/2 ............................................................................................... 78 THYROLAR-1/4 ............................................................................................... 78
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 93
THYROLAR-2 ...............................................................................................
THYROLAR-3 ...............................................................................................
tiagabine hcl ...............................................................................................
timolol maleate
78 79 14
............................................................................................... 39 TIVICAY .............................................................. 34 tizanidine hcl ............................................................................................... 69 TOBRADEX ............................................................................................... 72 tobramycin ............................................................ 71 tolmetin sodium ................................................................................................... 3 topiramate ............................................................. 14 torsemide ................................................................. 54 TRADJENTA ............................................................................................... 18 tramadol hcl ........................................................... 5 tranylcypromine sulfate ............................................................................................... 15 travel sickness ............................................................................................... 21 trazodone hcl ............................................................................................... 16 TRELSTAR DEPOT ............................................................................................... 28 TRELSTAR DEPOT MIXJECT ............................................................................................... 28 TRELSTAR LA ............................................................................................... 29 TRELSTAR LA MIXJECT ............................................................................................... 29 TRELSTAR MIXJECT ............................................................................................... 29 tretinoin .................................................................... 47 triamcinolone acetonide ............................................................................................... 50 triamterene-hctz ............................................................................................... 54 triazolam ................................................................. 60 TRI-ESTARYLLA ............................................................................................... 44 trifluoperazine hcl ............................................................................................... 33 trifluridine ............................................................. 71 trihexyphenidyl hcl ............................................................................................... 31 TRILYTE ............................................................ 61
trimethoprim
............................................................................................... 25 trinatal rx 1 ......................................................... 68 TRINATE ........................................................... 68 TRINESSA (28) ............................................................................................... 44 TRI-PREVIFEM ............................................................................................... 44 triprolidine-pse ............................................................................................... 46 TRI-SPRINTEC ............................................................................................... 44 tri-vit/fluoride ............................................................................................... 68 tri-vit/fluoride/iron ............................................................................................... 67 tri-vitamin .............................................................. 68 tri-vitamin/fluoride ............................................................................................... 68 TRIVORA (28) ............................................................................................... 44 trospium chloride ............................................................................................... 81 TRUVADA ............................................................................................... 34 TUDORZA PRESSAIR ............................................................................................... 10 tybost ........................................................................... 36 TYKERB .............................................................. 30 UNITHROID ............................................................................................... 79 urea ................................................................................. 50 URETRON D/S ............................................................................................... 80 ursodiol ...................................................................... 56 uticap ............................................................................ 80 valacyclovir hcl ............................................................................................... 37 valproic acid ............................................................................................... 15 vancomycin hcl ............................................................................................... 25 VANDAZOLE ............................................................................................... 81 VELIVET ............................................................. 44 venlafaxine hcl ............................................................................................... 16 venlafaxine hcl er ............................................................................................... 16 VENTOLIN HFA ............................................................................................... 12
verapamil hcl ...............................................................................................
verapamil hcl er
40
............................................................................................... 40 VESTURA .......................................................... 43 VEXOL .................................................................... 72 VIDEX ..................................................................... 36 VINATE AZ EXTRA ............................................................................................... 69 VINATE II ......................................................... 69 VINATE M ............................................................................................... 69 VIRACEPT ............................................................................................... 35 VIREAD ................................................................ 36 vitamin a .................................................................. 82 vitamin b complex-c ............................................................................................... 67 vitamin b-1 ............................................................ 82 vitamin b-12 ........................................................ 59 vitamin b-6 ............................................................ 82 vitamin b-6 er ............................................................................................... 82 vitamin d (ergocalciferol) ............................................................................................... 82 vitamin k (phytonadione) ............................................................................................... 82 vitamins acd-fluoride ............................................................................................... 68 VOLTAREN ............................................................................................... 48 VYVANSE ............................................................. 1 warfarin sodium ............................................................................................... 12 XALKORI .......................................................... 30 XARELTO ......................................................... 12 XOLAIR ................................................................ 10 XTANDI ............................................................... 28 XULANE ............................................................. 44 X-VIATE .............................................................. 51 zafirlukast ............................................................. 10 ZARAH .................................................................. 43 ZELBORAF ............................................................................................... 29 ZENCHENT FE ............................................................................................... 43 ZETIA ....................................................................... 23 ZIAGEN ................................................................ 36 zidovudine .............................................................. 36 zinc sulfate ............................................................ 66 ZOLINZA ........................................................... 29
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 94
zolpidem tartrate
............................................................................................... 60 zonisamide ............................................................. 14 ZOVIA 1/35E (28) ............................................................................................... 43 ZOVIRAX .......................................................... 49 zubsolv ............................................................................ 6 ZYKADIA ......................................................... 30
P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 95
