MCD-IL CAID 2 - Harmony Health Plan

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MCD-IL CAID 2 - Harmony Health Plan
2015
Harmony Medicaid
Comprehensive Preferred Drug
List (List of Covered Drugs)
Harmony Health Plan
00
9
Please read: This document contains information about the drugs we cover in this
plan.
Please note that the Illinois Harmony Medicaid Preferred Drug List is updated
quarterly.
Providers, please visit our website at
https://www.harmonyhpi.com/provider/pharmacyservices
to view updates to the preferred drug list.
Members, please visit our website at
https://www.harmonyhpi.com/member/preferreddruglist
to view updates to the preferred drug list.
Last updated (1/01/2015)
Harmony Health Plan 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
Harmony Health Plan 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)
childrens non-aspirin oral tablet chewable 80 mg
P
OTC
infants silapap oral solution 100 mg/ml
P
OTC
mapap oral liquid† 160 mg/5ml
P
OTC
nortemp infants oral suspension 80 mg/0.8ml
P
OTC
pain & fever childrens oral solution 160 mg/5ml
P
OTC
pain & fever childrens oral suspension 160
mg/5ml
P
OTC
q-pap infants oral solution 80 mg/0.8ml
*Salicylates**-*Salicylates***
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
OTC
px enteric aspirin oral tablet delayed release 81
mg
P
OTC
salsalate oral tablet 500 mg, 750 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
4
Drug Name
Preference Details Coverage Details
*Analgesics - Opioid*
*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
mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
P
PA; QL (10 EA per 30 days)
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***
acetaminophen-codeine oral solution 120-12
mg/5ml
QL (248 EA per 31 days)
QL (248 EA per 31 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
5
Drug Name
Preference Details Coverage Details
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)
butalbital-apap-caff-cod oral capsule
50-325-40-30 mg
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
*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
Preference Details Coverage Details
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
testosterone enanthate intramuscular* solution
200 mg/ml
*Anorectal Agents*
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***
antacid oral suspension 200-200-20 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 antacid extra strength oral tablet
chewable 750 mg
calcium carbonate antacid oral tablet chewable
500 mg
*Antacids - Magnesium Salts**-*Antacids Magnesium Salts***
magnesium oxide oral tablet 250 mg, 400 mg,
420 mg
P
OTC
P
OTC
P
OTC
P
OTC
P
OTC
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
7
Drug Name
Preference Details Coverage Details
*Anthelmintics*
*Anthelmintics**-*Anthelmintics***
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
P
OTC
reeses pinworm medicine oral suspension 144
mg/ml
*Antianginal Agents*
*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***
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg
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
8
Drug Name
Preference Details Coverage Details
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
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
AL (Min 9 Years)
QL (1240 ML per 31 days)
*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
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
PACERONE ORAL TABLET 200 MG, 400
MG
*Antiasthmatic And Bronchodilator Agents*
Preference Details Coverage Details
P
*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,
P
QL (1 EA per 30 days)
BREATH ACTIVATED 220 MCG/INH
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
ASMANEX HFA INHALATION
AEROSOL† 100 MCG/ACT, 200 MCG/ACT
P
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
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)
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***
albuterol sulfate oral tablet 2 mg, 4 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
11
Drug Name
Preference Details Coverage Details
FORADIL AEROLIZER INHALATION
CAPSULE 12 MCG
P
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 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 (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)
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
Preference Details Coverage Details
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
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)
enoxaparin sodium subcutaneous* solution 60
mg/0.6ml
*Heparins And Heparinoid-Like
Agents**-*Synthetic Heparinoid-Like
Agents***
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)
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 intravenous* solution 500 mg/5ml
P
levetiracetam oral solution 100 mg/ml
P
levetiracetam oral tablet 1000 mg, 500 mg, 750
mg
P
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 (1000 ML per 31 days)
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)
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 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)
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
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
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
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
P
QL (31 EA per 31 days)
QL (2325 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
16
Drug Name
Preference Details Coverage Details
*Antidiabetics*
*Alpha-Glucosidase
Inhibitors**-*Alpha-Glucosidase Inhibitors***
acarbose oral tablet 100 mg, 25 mg, 50 mg
*Antidiabetic Combinations**-*Dipeptidyl
Peptidase-4 Inhibitor-Biguanide
Combinations***
JANUMET ORAL TABLET 50-1000 MG,
50-500 MG
JANUMET XR ORAL TABLET
EXTENDED RELEASE 24 HR* 100-1000
MG, 50-1000 MG, 50-500 MG
JENTADUETO ORAL TABLET 2.5-1000
MG, 2.5-500 MG, 2.5-850 MG
P
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.)
P
ST; Notes (Must fail preferred
metformin, metformin er, or
riomet within the past 100 days.);
QL (62 EA per 31 days)
P
ST
*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***
AVANDARYL ORAL TABLET 4-1 MG, 4-2
MG, 8-4 MG
P
P
P
ST; Notes (Must fail preferred
metformin, metformin er, or
riomet within the past 100 days.)
*Antidiabetic
Combinations**-*Thiazolidinedione-Biguanide
Combinations***
ST; Notes (Must fail preferred
P
metformin, metformin er, or
riomet within the past 100 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
AVANDAMET ORAL TABLET 2-1000 MG,
4-500 MG
17
Drug Name
pioglitazone hcl-metformin hcl oral tablet
15-500 mg, 15-850 mg
Preference Details Coverage Details
P
ST; Notes (Must fail preferred
metformin, metformin er, or
riomet within the past 100 days.)
*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)
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)***
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
*Insulin Sensitizing
Agents**-*Thiazolidinediones***
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)
LANTUS SUBCUTANEOUS* SOLUTION
100 UNIT/ML
P
QL (60 ML per 31 days)
LANTUS SOLOSTAR SUBCUTANEOUS*
100 UNIT/ML
P
QL (60 ML per 31 days)
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
Preference Details Coverage Details
*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***
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
*Antidiarrheal Agents - Misc.**-*Antidiarrheal
Agents - Misc.***
bismatrol oral suspension 262 mg/15ml
*Antiperistaltic Agents**-*Antiperistaltic
Agents***
P
OTC
anti-diarrheal oral tablet 2 mg
P
OTC
diphenoxylate-atropine oral liquid† 2.5-0.025
mg/5ml
P
diphenoxylate-atropine oral tablet 2.5-0.025 mg
P
loperamide hcl oral capsule 2 mg
*Antidotes*
P
*Antidotes - Chelating Agents**-*Antidotes Chelating Agents***
EXJADE ORAL TABLET SOLUBLE 125
MG, 250 MG, 500 MG
*Antidotes**-*Antidotes***
deferoxamine mesylate injection solution
reconstituted 2 gm, 500 mg
P
PA
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
20
Drug Name
Preference Details Coverage Details
*Opioid Antagonists**-*Opioid Antagonists***
naltrexone hcl oral tablet 50 mg
*Antiemetics*
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
*Antiemetics - Miscellaneous**-*Antiemetic
Combinations***
P
OTC
formula em oral solution 1.87-1.87-21.5
*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
methotrexate sodium injection solution 25 mg/ml
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***
AVASTIN INTRAVENOUS* SOLUTION
100 MG/4ML, 400 MG/16ML
*Antineoplastic - Hedgehog Pathway
Inhibitors**-*Antineoplastic - Hedgehog
Pathway Inhibitors***
P
PA
P
PA
ERIVEDGE ORAL CAPSULE 150 MG
*Antineoplastic - Hormonal And Related
Agents**-*Antiadrenals***
P
LYSODREN ORAL TABLET 500 MG
*Antineoplastic - Hormonal And Related
Agents**-*Antiandrogens***
P
bicalutamide oral tablet 50 mg
P
XTANDI ORAL CAPSULE 40 MG
*Antineoplastic - Hormonal And Related
Agents**-*Antiestrogens***
P
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
TRELSTAR DEPOT INTRAMUSCULAR*
SUSPENSION RECONSTITUTED 3.75 MG
P
TRELSTAR DEPOT MIXJECT
INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 3.75 MG
P
PA
PA
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
28
Drug Name
Preference Details Coverage Details
TRELSTAR LA INTRAMUSCULAR*
SUSPENSION RECONSTITUTED 11.25
MG
P
TRELSTAR LA MIXJECT
INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 11.25 MG
P
TRELSTAR MIXJECT
INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 22.5 MG
*Antineoplastic - Hormonal And Related
Agents**-*Progestins-Antineoplastic***
P
megestrol acetate oral suspension 40 mg/ml
P
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
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***
QL (600 ML per 31 days)
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)
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***
P
P
P
leucovorin calcium injection solution
reconstituted 100 mg, 200 mg, 350 mg
P
leucovorin calcium intravenous* solution 10
mg/ml
P
leucovorin calcium oral tablet 10 mg, 15 mg, 25
mg, 5 mg
*Mitotic Inhibitors**-*Mitotic Inhibitors***
etoposide oral capsule 50 mg
PA
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
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
INVEGA SUSTENNA
INTRAMUSCULAR* SUSPENSION 117
MG/0.75ML
P
PA; QL (0.75 ML per 28 days);
AL (Min 18 Years)
INVEGA SUSTENNA
INTRAMUSCULAR* SUSPENSION 156
MG/ML
P
PA; QL (1 ML per 28 days); AL
(Min 18 Years)
INVEGA SUSTENNA
INTRAMUSCULAR* SUSPENSION 234
MG/1.5ML
P
PA; QL (1.5 ML per 28 days);
AL (Min 18 Years)
INVEGA SUSTENNA
INTRAMUSCULAR* SUSPENSION 39
MG/0.25ML
P
PA; QL (0.25 ML per 28 days);
AL (Min 18 Years)
INVEGA SUSTENNA
INTRAMUSCULAR* SUSPENSION 78
MG/0.5ML
P
PA; QL (0.5 ML per 28 days);
AL (Min 18 Years)
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
P
AL (Min 3 Years)
RISPERIDONE M-TAB ORAL TABLET
DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG,
4 MG
*Butyrophenones**-*Butyrophenones***
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**-*Dibenzodiazepines***
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)
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)
*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
*Dibenzapines**-*Thienbenzodiazepines***
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
mg, 5 mg, 7.5 mg
*Phenothiazines**-*Phenothiazines***
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
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2
mg, 5 mg
*Quinolinone Derivatives**-*Quinolinone
Derivatives***
Preference Details Coverage Details
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
PA
P
AL (Min 12 Years)
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)
TRUVADA ORAL TABLET 200-300 MG
P
QL (31 EA per 31 days)
ABILIFY ORAL SOLUTION 1 MG/ML
ABILIFY ORAL TABLET 10 MG, 15 MG, 2
MG, 20 MG, 30 MG, 5 MG
ABILIFY MAINTENA
INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 300 MG, 400 MG
*Thioxanthenes**-*Thioxanthenes***
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5
mg
*Antiseptics & Disinfectants*
*Chlorine Antiseptics**-*Chlorine
Antiseptics***
chlorhexidine gluconate external liquid† 4 %
*Antivirals*
*Antiretrovirals**-*Antiretroviral
Combinations***
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
34
Drug Name
Preference Details Coverage Details
*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***
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
*Antiretrovirals**-*Antiretrovirals - Protease
Inhibitors***
P
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)
P
QL (31 EA per 31 days)
VIRACEPT ORAL TABLET 250 MG, 625
MG
*Antiretrovirals**-*Antiretrovirals Rti-Non-Nucleoside Analogues***
EDURANT ORAL TABLET 25 MG
QL (62 EA per 31 days)
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
Preference Details Coverage Details
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
VIDEX ORAL SOLUTION
RECONSTITUTED 2 GM, 4 GM
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
QL (1860 ML per 31 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
36
Drug Name
Preference Details Coverage Details
*Antiretrovirals**-*Antiretrovirals
Adjuvants***
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
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)
TAMIFLU ORAL SUSPENSION
RECONSTITUTED 6 MG/ML
P
QL (360 ML per 365 days); AL
(Max 18 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
37
Drug Name
Preference Details Coverage Details
*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***
P
PA
P
PA
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
SANDIMMUNE ORAL SOLUTION 100
MG/ML
*Immunosuppressive Agents**-*Inosine
Monophosphate Dehydrogenase Inhibitors***
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
P
QL (454 GM 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
38
Drug Name
Preference Details Coverage Details
*Beta Blockers*
*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
*Beta Blockers Non-Selective**-*Beta Blockers
Non-Selective***
P
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
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
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
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
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
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
*Cephalosporins*
P
PA
*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
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
41
Drug Name
Preference Details Coverage Details
*Cephalosporins - 3Rd
Generation**-*Cephalosporins - 3Rd
Generation***
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*
P
*Combination Contraceptives Oral**-*Biphasic Contraceptives - Oral***
AZURETTE ORAL TABLET 0.15-0.02/0.01
MG (21/5)
P
KARIVA ORAL TABLET 0.15-0.02/0.01 MG
(21/5)
P
lo loestrin fe oral tablet 1 mg-10 mcg / 10 mcg
P
NECON 10/11 (28) ORAL TABLET 35 MCG
P
PIMTREA ORAL TABLET 0.15-0.02/0.01
MG (21/5)
P
viorele oral tablet 0.15-0.02/0.01 mg (21/5)
*Combination Contraceptives Oral**-*Combination Contraceptives - Oral***
P
ALTAVERA ORAL TABLET 0.15-30
MG-MCG
P
alyacen 1/35 oral tablet 1-35 mg-mcg
P
APRI ORAL TABLET 0.15-30 MG-MCG
P
AUBRA ORAL TABLET 0.1-20 MG-MCG
P
AVIANE ORAL TABLET 0.1-20 MG-MCG
P
BALZIVA ORAL TABLET 0.4-35 MG-MCG
P
briellyn oral tablet 0.4-35 mg-mcg
P
CHATEAL ORAL TABLET 0.15-30
MG-MCG
P
CRYSELLE-28 ORAL TABLET 0.3-30
MG-MCG
P
CYCLAFEM 1/35 ORAL TABLET 1-35
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
DASETTA 1/35 ORAL TABLET 1-35
MG-MCG
P
desogestrel-ethinyl estradiol oral tablet 0.15-30
mg-mcg
P
drospirenone-ethinyl estradiol oral tablet 3-0.03
mg
P
ELINEST ORAL TABLET 0.3-30 MG-MCG
P
EMOQUETTE ORAL TABLET 0.15-30
MG-MCG
P
ENSKYCE ORAL TABLET 0.15-30
MG-MCG
P
ESTARYLLA ORAL TABLET 0.25-35
MG-MCG
P
FALMINA ORAL TABLET 0.1-20
MG-MCG
P
GIANVI ORAL TABLET 3-0.02 MG
P
GILDAGIA ORAL TABLET 0.4-35
MG-MCG
P
GILDESS 1.5/30 ORAL TABLET 1.5-30
MG-MCG
P
GILDESS 1/20 ORAL TABLET 1-20
MG-MCG
P
GILDESS FE 1.5/30 ORAL TABLET 1.5-30
MG-MCG
P
GILDESS FE 1/20 ORAL TABLET 1-20
MG-MCG
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
KURVELO ORAL TABLET 0.15-30
MG-MCG
P
LARIN 1/20 ORAL TABLET 1-20 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
43
Drug Name
Preference Details Coverage Details
LARIN FE 1.5/30 ORAL TABLET 1.5-30
MG-MCG
P
LARIN FE 1/20 ORAL TABLET 1-20
MG-MCG
P
LESSINA ORAL TABLET 0.1-20 MG-MCG
P
levonorgestrel-ethinyl estrad 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
marlissa oral tablet 0.15-30 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
MONO-LINYAH ORAL TABLET 0.25-35
MG-MCG
P
MONONESSA ORAL TABLET 0.25-35
MG-MCG
P
NECON 0.5/35 (28) ORAL TABLET 0.5-35
MG-MCG
P
NECON 1/35 (28) ORAL TABLET 1-35
MG-MCG
P
norgestimate-eth estradiol oral tablet 0.25-35
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
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
OGESTREL ORAL TABLET 0.5-50
MG-MCG
P
ORSYTHIA ORAL TABLET 0.1-20
MG-MCG
P
PHILITH ORAL TABLET 0.4-35 MG-MCG
P
PIRMELLA 1/35 ORAL TABLET 1-35
MG-MCG
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
VYFEMLA ORAL TABLET 0.4-35
MG-MCG
P
WERA ORAL TABLET 0.5-35 MG-MCG
P
WYMZYA FE ORAL TABLET
CHEWABLE 0.4-35 MG-MCG
P
ZARAH ORAL TABLET 3-0.03 MG
P
ZENCHENT ORAL TABLET 0.4-35
MG-MCG
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**-*Continuous Contraceptives - Oral***
AMETHYST ORAL TABLET 90-20 MCG
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
45
Drug Name
Preference Details Coverage Details
*Combination Contraceptives Oral**-*Extended-Cycle Contraceptives Oral***
AMETHIA ORAL TABLET 0.15-0.03 &0.01
MG
P
AMETHIA LO ORAL TABLET 0.1-0.02 &
0.01 MG
P
CAMRESE ORAL TABLET 0.15-0.03 &0.01
MG
P
CAMRESE LO ORAL TABLET 0.1-0.02 &
0.01 MG
P
DAYSEE ORAL TABLET 0.15-0.03 &0.01
MG
P
INTROVALE ORAL TABLET 0.15-0.03 MG
P
JOLESSA ORAL TABLET 0.15-0.03 MG
P
levonorgest-eth estrad 91-day oral tablet
0.15-0.03 mg
P
QUASENSE ORAL TABLET 0.15-0.03 MG
*Combination Contraceptives Oral**-*Triphasic Contraceptives - Oral***
P
alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg
P
ARANELLE ORAL TABLET 0.5/1/0.5-35
MG-MCG
P
CAZIANT ORAL TABLET 0.1/0.125/0.15
-0.025 MG
P
CESIA ORAL TABLET 0.1/0.125/0.15 -0.025
MG
P
CYCLAFEM 7/7/7 ORAL TABLET
0.5/0.75/1-35 MG-MCG
P
DASETTA 7/7/7 ORAL TABLET
0.5/0.75/1-35 MG-MCG
P
ENPRESSE-28 ORAL TABLET
P
LEENA ORAL TABLET 0.5/1/0.5-35
MG-MCG
P
LEVONEST ORAL TABLET
P
MYZILRA ORAL TABLET
P
NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35
MG-MCG
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
46
Drug Name
Preference Details Coverage Details
norgestim-eth estrad triphasic oral tablet
0.18/0.215/0.25 mg-35 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
PIRMELLA 7/7/7 ORAL TABLET
0.5/0.75/1-35 MG-MCG
P
TILIA FE ORAL TABLET 1-20/1-30/1-35
MG-MCG
P
TRI-ESTARYLLA ORAL TABLET
0.18/0.215/0.25 MG-35 MCG
P
TRI-LEGEST FE ORAL TABLET
1-20/1-30/1-35 MG-MCG
P
TRI-LINYAH 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***
levonorgestrel oral tablet 0.75 mg
P
P
P
P
QL (4 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
47
Drug Name
NEXT CHOICE ONE DOSE ORAL
TABLET 1.5 MG
PLAN B ONE-STEP ORAL TABLET 1.5
MG
*Progestin Contraceptives Injectable**-*Progestin Contraceptives Injectable***
DEPO-PROVERA INTRAMUSCULAR*
SUSPENSION 150 MG/ML
medroxyprogesterone acetate intramuscular*
suspension 150 mg/ml
*Progestin Contraceptives - Oral**-*Progestin
Contraceptives - Oral***
Preference Details Coverage Details
P
OTC
P
OTC
P
QL (1 ML per 93 days)
P
QL (1 ML per 93 days)
CAMILA ORAL TABLET 0.35 MG
P
ERRIN ORAL TABLET 0.35 MG
P
HEATHER ORAL TABLET 0.35 MG
P
JENCYCLA ORAL TABLET 0.35 MG
P
JOLIVETTE ORAL TABLET 0.35 MG
P
LYZA ORAL TABLET 0.35 MG
P
NOR-QD ORAL TABLET 0.35 MG
P
NORA-BE ORAL TABLET 0.35 MG
P
norethindrone oral tablet 0.35 mg
*Corticosteroids*
P
*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
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
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
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
guaifenesin oral solution 100 mg/5ml
P
OTC
mucus relief oral tablet 400 mg
P
OTC
refenesen oral tablet 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
49
Drug Name
Preference Details Coverage Details
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
acne medication 5 external lotion 5 %
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
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
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)
CLARAVIS ORAL CAPSULE 10 MG, 20
MG, 30 MG, 40 MG
P
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)
P
OTC
P
OTC
*Antibiotics - Topical**-*Antibiotic Mixtures
Topical***
double antibiotic external ointment 500-10000
unit/gm
triple antibiotic external ointment 5-400-5000
*Antibiotics - Topical**-*Antibiotic Steroid
Combinations - Topical***
CORTISPORIN EXTERNAL OINTMENT 1
%
*Antibiotics - Topical**-*Antibiotics Topical***
P
bacitracin zinc external ointment 500 unit/gm
P
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 %
P
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
51
Drug Name
Preference Details Coverage Details
*Antifungals - Topical**-*Imidazole-Related
Antifungals - Topical***
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
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
DENAVIR EXTERNAL CREAM 1 %
P
ST; Notes (Must fail preferred
oral acyclovir or valacyclovir
within the past 100 days.)
ZOVIRAX EXTERNAL CREAM 5 %
P
ST; Notes (Must fail preferred
oral acyclovir or valacyclovir
within the past 100 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
52
Drug Name
Preference Details Coverage Details
*Burn Products**-*Burn Products***
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)
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
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
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
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
OTC
triamcinolone acetonide external ointment 0.1 %
*Emollient/Keratolytic
Agents**-*Emollient/Keratolytic Agents***
P
REMEVEN EXTERNAL CREAM 50 %
P
urea external cream 40 %
P
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)
SANTYL EXTERNAL OINTMENT 250
UNIT/GM
*Immunosuppressive Agents Topical**-*Macrolide Immunosuppressants Topical***
ELIDEL EXTERNAL CREAM 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
54
Drug Name
Preference Details Coverage Details
*Keratolytic/Antimitotic
Agents**-*Keratolytic/Antimitotic Agents***
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
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 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
lidocaine-prilocaine external kit 2.5-2.5 %
*Misc. Topical**-*Misc. Topical***
P
HYPERCARE EXTERNAL SOLUTION 20
%
*Misc. Topical**-*Skin Protectants***
P
4-N-1 EXTERNAL CREAM 1 %
P
OTC
BAZA PROTECT EXTERNAL CREAM
*Rosacea Agents**-*Rosacea Agents***
P
OTC
metronidazole external 1 %
P
metronidazole external cream 0.75 %
*Scabicides & Pediculicides**-*Scabicide
Combinations***
P
complete lice treatment combination kit
0.33-4-0.5 %
P
OTC
lice killing maximum strength external shampoo
0.33-4 %
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
55
Drug Name
Preference Details Coverage Details
*Scabicides & Pediculicides**-*Scabicides &
Pediculicides***
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***
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
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)
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=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
Preference Details Coverage Details
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
lactase enzyme oral tablet 3000 unit
P
PERTZYE ORAL CAPSULE DELAYED
RELEASE PARTICLES 16000 UNIT, 8000
UNIT
*Diuretics*
OTC
P
*Carbonic Anhydrase Inhibitors**-*Carbonic
Anhydrase Inhibitors***
acetazolamide oral tablet 125 mg, 250 mg
P
methazolamide oral tablet 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
57
Drug Name
Preference Details Coverage Details
*Diuretic Combinations**-*Diuretic
Combinations***
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
*Endocrine And Metabolic Agents - Misc.*
P
*Bone Density
Regulators**-*Bisphosphonates***
alendronate sodium oral tablet 10 mg, 35 mg, 40
mg, 5 mg, 70 mg
*Bone Density Regulators**-*Calcitonins***
P
calcitonin (salmon) nasal solution 200 unit/act
P
FORTICAL NASAL SOLUTION 200
UNIT/ACT
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
*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
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
desmopressin acetate oral tablet 0.1 mg, 0.2 mg
P
desmopressin acetate spray nasal solution 0.01
%
*Estrogens*
QL (900 ML per 31 days)
PA
P
*Estrogen Combinations**-*Estrogen &
Progestin***
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
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
59
Drug Name
Preference Details Coverage Details
*Estrogens**-*Estrogens***
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
metoclopramide hcl oral tablet 10 mg, 5 mg
*Inflammatory Bowel Agents**-*Inflammatory
Bowel Agents***
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
P
QL (1500 ML per 31 days)
QL (1800 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
60
Drug Name
Preference Details Coverage Details
*Intestinal Acidifiers**-*Intestinal
Acidifiers***
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*
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
*Prostatic Hypertrophy Agents**-*Alpha
1-Adrenoceptor Antagonists***
P
tamsulosin hcl oral capsule 0.4 mg
*Urinary Analgesics**-*Urinary Analgesics***
P
phenazopyridine hcl oral tablet 100 mg, 200 mg
*Gout Agents*
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 %
*Gout Agent Combinations**-*Gout Agent
Combinations***
colchicine-probenecid oral tablet 0.5-500 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
61
Drug Name
Preference Details Coverage Details
*Gout Agents**-*Gout Agents***
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
*Hematopoietic Agents*
P
*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
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
62
Drug Name
Preference Details Coverage Details
*Hematopoietic Growth
Factors**-*Erythropoiesis-Stimulating Agents
(Esas)***
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
PA
P
PA
P
P
ferrous gluconate oral tablet 324 (38 fe) mg
P
OTC
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 syrup 300 (60 fe) mg/5ml
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
ra nighttime sleep aid oral tablet 25 mg
P
OTC
sleep tabs 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
63
Drug Name
Preference Details Coverage Details
*Barbiturate Hypnotics**-*Barbiturate
Hypnotics***
phenobarbital oral elixir 20 mg/5ml
P
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***
QL (2000 ML per 31 days)
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 laxative 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)
peg 3350-kcl-na bicarb-nacl oral solution
reconstituted 420 gm
P
QL (4000 ML 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
64
Drug Name
Preference Details Coverage Details
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)
senna s oral tablet 8.6-50 mg
*Laxatives - Miscellaneous**-*Laxatives Miscellaneous***
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)
SANI-SUPP PEDIATRIC SUPPOSITORY
1.2 GM
P
OTC
P
OTC
P
OTC
bisacodyl ec oral tablet delayed release 5 mg
P
OTC
laxative suppository 10 mg
P
OTC
senna oral syrup 176 mg/5ml, 8.8 mg/5ml
P
OTC
senna laxative oral tablet 8.6 mg
P
OTC
P
OTC
docusate sodium oral tablet 100 mg
P
OTC
ra col-rite oral capsule 50 mg
P
OTC
silace oral liquid† 150 mg/15ml
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***
sorbitol oral solution 70 %
*Saline Laxatives**-*Saline Laxatives***
milk of magnesia oral suspension 1200 mg/15ml,
400 mg/5ml
*Stimulant Laxatives**-*Stimulant
Laxatives***
stimulant laxative oral tablet delayed release 5
mg
*Surfactant Laxatives**-*Surfactant
Laxatives***
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
*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
66
Drug Name
Preference Details Coverage Details
*Medical Devices*
*Contraceptives**-*Cervical Caps***
FEMCAP VAGINAL DEVICE 26 MM, 30
MM
P
PRENTIF CAVITY-RIM CERV CAP
VAGINAL DEVICE 22 MM, 25 MM, 28
MM, 31 MM
P
PRENTIF FITTING SET VAGINAL
*Contraceptives**-*Condoms - Female***
P
FC FEMALE CONDOM
*Contraceptives**-*Condoms - Male***
P
OTC
condoms
P
OTC
premium condoms lubricated
P
OTC
TROJAN
P
OTC
TROJAN NATURALAMB
*Contraceptives**-*Contraceptive Sponge***
P
OTC
TODAY SPONGE VAGINAL 1000 MG
*Contraceptives**-*Diaphragms***
P
OTC
OMNIFLEX DIAPHRAGM VAGINAL
DIAPHRAGM
P
ORTHO DIAPHRAGM COIL VAGINAL
KIT 100 MM, 105 MM, 50 MM
P
ORTHO DIAPHRAGM FLAT VAGINAL
KIT 55 MM, 60 MM, 65 MM, 70 MM, 75
MM, 80 MM, 85 MM, 90 MM, 95 MM
P
WIDE-SEAL DIAPHRAGM 60 VAGINAL
DIAPHRAGM 2 %
P
WIDE-SEAL DIAPHRAGM 65 VAGINAL
DIAPHRAGM 2 %
P
WIDE-SEAL DIAPHRAGM 70 VAGINAL
DIAPHRAGM 2 %
P
WIDE-SEAL DIAPHRAGM 75 VAGINAL
DIAPHRAGM 2 %
P
WIDE-SEAL DIAPHRAGM 80 VAGINAL
DIAPHRAGM 2 %
P
WIDE-SEAL DIAPHRAGM 85 VAGINAL
DIAPHRAGM 2 %
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
67
Drug Name
WIDE-SEAL DIAPHRAGM 90 VAGINAL
DIAPHRAGM 2 %
WIDE-SEAL DIAPHRAGM 95 VAGINAL
DIAPHRAGM 2 %
*Diabetic Supplies**-*Glucose Monitoring Test
Supplies***
Preference Details Coverage Details
P
P
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)
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=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
*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
69
Drug Name
Preference Details Coverage Details
P
QL (4 ML per 31 days)
P
QL (4 ML per 31 days)
P
OTC
calcium-vitamin d oral tablet 500-200 mg-unit
*Calcium**-*Calcium***
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)
sumatriptan succinate subcutaneous* 6 mg/0.5ml
sumatriptan succinate subcutaneous* solution 4
mg/0.5ml, 6 mg/0.5ml
*Minerals & Electrolytes*
*Calcium**-*Calcium Combinations***
calcium carbonate-vitamin d oral tablet 600-400
mg-unit
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
P
P
P
P
P
OTC
P
OTC
N/A
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
*Potassium**-*Potassium***
KLOR-CON ORAL TABLET
EXTENDEDRELEASE* 8 MEQ
P
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 %
P
sodium chloride oral tablet 1 gm
*Zinc**-*Zinc***
P
OTC
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
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
71
Drug Name
Preference Details Coverage Details
*Antiseptics - Mouth/Throat**-*Antiseptics Mouth/Throat***
chlorhexidine gluconate mouth/throat solution
0.12 %
PERIOGARD MOUTH/THROAT
SOLUTION 0.12 %
*Dental Products**-*Fluoride Dental
Products***
P
QL (480 ML per 31 days)
P
QL (480 ML per 31 days)
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
*Multiple Vitamins W/ Iron**-*Multiple
Vitamins W/ Iron***
P
OTC
multi-vitamin/iron oral tablet
*Multiple Vitamins W/ Minerals**-*Multiple
Vitamins W/ Minerals***
P
OTC
multi-vitamin/minerals oral tablet
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
thera-m oral tablet
P
OTC
vitatrum oral tablet chewable
*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 16 Years)
P
AL (Max 16 Years)
P
AL (Max 16 Years)
multi-vit/fluoride oral solution 0.25 mg/ml, 0.5
mg/ml
P
AL (Max 16 Years)
multi-vitamin/fluoride oral tablet chewable 0.5
mg
P
AL (Max 16 Years)
P
AL (Max 16 Years)
tri-vit/fluoride oral solution 0.25 mg/ml
P
AL (Max 16 Years)
tri-vitamin/fluoride oral solution 0.5 mg/ml
P
AL (Max 16 Years)
vitamins acd-fluoride oral solution 0.25 mg/ml
*Ped Mv W/ Iron**-*Ped Mv W/ Iron***
P
AL (Max 16 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
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
*Ped Mv W/ Fluoride**-*Ped Mv W/
Fluoride***
multivitamin/fluoride oral tablet chewable 0.25
mg, 0.5 mg, 1 mg
*Ped Mv W/ Fluoride**-*Ped Vitamins Acd W/
Fluoride***
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
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
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*
OTC
OTC
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
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
74
Drug Name
Preference Details Coverage Details
*Viscosupplements**-*Viscosupplements***
P
PA
P
OTC
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.***
BABY AYR SALINE NASAL SOLUTION
0.65 %
cromolyn sodium nasal aerosol, solution 5.2
mg/act
*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
OTC
P
P
P
P
OTC
P
OTC
P
OTC
P
OTC; QL (15 ML per 31 days)
*Artificial Tears And Lubricants**-*Artificial
Tear And Lubricant Combinations***
artificial tears ophthalmic ointment 83-15 %
*Artificial Tears And Lubricants**-*Artificial
Tear Ointments***
ALTALUBE OPHTHALMIC OINTMENT
85-15 %
*Artificial Tears And Lubricants**-*Artificial
Tears And Lubricants***
artificial tears ophthalmic solution 1.4 %
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
*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 %
*Miotics**-*Miotics - Direct Acting***
P
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 %
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
76
Drug Name
Preference Details Coverage Details
*Ophthalmic Anti-Infectives**-*Ophthalmic
Anti-Infective Combinations***
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 %
*Ophthalmic Steroids**-*Ophthalmic Steroid
Combinations***
P
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
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
TOBRADEX OPHTHALMIC OINTMENT
0.3-0.1 %
*Ophthalmic Steroids**-*Ophthalmic
Steroids***
Preference Details Coverage Details
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 %
*Ophthalmics - Misc.**-*Ophthalmic
Hyperosmolar Products***
P
MURO 128 OPHTHALMIC SOLUTION 2 %
P
OTC
sodium chloride (hypertonic) ophthalmic
ointment 5 %
P
OTC
P
OTC
sodium chloride (hypertonic) ophthalmic
solution 5 %
*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 %
P
OTC
QL (5 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
78
Drug Name
Preference Details Coverage Details
*Otic Agents*
*Otic Agents - Miscellaneous**-*Otic Agents Miscellaneous***
acetic acid-aluminum acetate otic solution 2 %
P
earwax treatment drops otic solution 6.5 %
*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*
OTC
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
methylergonovine maleate oral tablet 0.2 mg
*Passive Immunizing Agents*
P
P
*Monoclonal Antibodies**-*Antiviral
Monoclonal Antibodies***
SYNAGIS INTRAMUSCULAR*
SOLUTION 100 MG/ML, 50 MG/0.5ML
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
79
Drug Name
Preference Details Coverage Details
*Penicillins*
*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
BICILLIN C-R 900/300
INTRAMUSCULAR* SUSPENSION
900000-300000 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
80
Drug Name
Preference Details Coverage Details
*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*
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
NAMENDA TITRATION PAK ORAL
TABLET 5 (28)-10 (21) 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
81
Drug Name
NAMENDA XR ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 14 MG,
21 MG, 28 MG, 7 MG
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***
Preference Details Coverage Details
P
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
REBIF REBIDOSE SUBCUTANEOUS*
SOLUTION 22 MCG/0.5ML, 44
MCG/0.5ML
P
REBIF REBIDOSE TITRATION PACK
SUBCUTANEOUS* SOLUTION 6X8.8 &
6X22 MCG
P
REBIF TITRATION PACK
SUBCUTANEOUS* SOLUTION 6X8.8 &
6X22 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
82
Drug Name
Preference Details Coverage Details
*Multiple Sclerosis Agents**-*Multiple
Sclerosis Agents***
COPAXONE SUBCUTANEOUS* 40
MG/ML
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***
P
PA; QL (12 ML per 28 days)
P
P
AL (Min 12 Years)
buproban oral tablet extended release 12 hr* 150
mg
P
nicotine transdermal patch 24 hr 14 mg/24hr, 21
mg/24hr, 7 mg/24hr
P
OTC; QL (70 EA per 365 days)
nicotine polacrilex mouth/throat gum 2 mg, 4 mg
P
OTC; QL (2016 EA per 365
days)
P
OTC; QL (1680 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.)
doxycycline hyclate oral tablet 100 mg
P
ST; Notes (Members must have
trial of doxycycline monohydrate
50 mg or 100 mg capsules within
the last 100 days.)
doxycycline hyclate oral tablet 20 mg
P
nicotine polacrilex mouth/throat lozenge 2 mg, 4
mg
*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
83
Drug Name
Preference Details Coverage Details
doxycycline monohydrate oral capsule 100 mg,
50 mg
P
doxycycline monohydrate oral tablet 100 mg
P
minocycline hcl oral capsule 100 mg, 50 mg, 75
mg
P
tetracycline hcl oral capsule 250 mg, 500 mg
*Thyroid Agents*
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
THYROLAR-3 ORAL TABLET 180
(37.5-150) 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
84
Drug Name
UNITHROID ORAL TABLET 100 MCG,
112 MCG, 125 MCG, 175 MCG, 200 MCG,
25 MCG, 300 MCG, 50 MCG, 75 MCG, 88
MCG
WESTHROID 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
*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
85
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
omeprazole magnesium oral capsule delayed
release 20.6 (20 base) 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*
OTC
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
86
Drug Name
Preference Details Coverage Details
P
ST; Notes (Must fail preferred
oxybutinin er tablets within the
past 100 days)
ENCARE VAGINAL SUPPOSITORY 100
MG
P
OTC
OPTIONS CONCEPTROL VAGINAL 4 %
P
OTC
OPTIONS GYNOL II CONTRACEPTIVE
VAGINAL 3 %
P
OTC
SHUR-SEAL CONTRACEPTIVE
VAGINAL 2 %
P
OTC
VCF VAGINAL CONTRACEPTIVE
VAGINAL FILM 28 %
P
OTC
P
OTC
3 day vaginal vaginal cream 2 %
P
OTC
clotrimazole vaginal cream 1 %
P
OTC
clotrimazole 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*
*Spermicides**-*Spermicides***
VCF VAGINAL CONTRACEPTIVE
VAGINAL FOAM 12.5 %
*Vaginal Anti-Infectives**-*Imidazole-Related
Antifungals***
PREMARIN VAGINAL CREAM 0.625
MG/GM
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
87
Drug Name
Preference Details Coverage Details
*Vaginal Progestins**-*Vaginal Progestins***
ENDOMETRIN VAGINAL INSERT 100
MG
*Vasopressors*
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
*Vitamins*
P
QL (6 EA per 180 days)
P
QL (6 EA per 180 days)
P
*Oil Soluble Vitamins**-*Vitamin A***
vitamin a oral capsule 10000 unit, 8000 unit
*Oil Soluble Vitamins**-*Vitamin D***
P
OTC
ergocalciferol oral solution 8000 unit/ml
P
OTC
vitamin d (ergocalciferol) oral capsule 50000
unit
P
QL (4 EA per 28 days)
vitamin d3 oral tablet 400 unit
*Oil Soluble Vitamins**-*Vitamin K***
P
OTC
MEPHYTON ORAL TABLET 5 MG
P
vitamin k (phytonadione) oral tablet 100 mcg
*Water Soluble Vitamins**-*Biotin***
P
OTC
biotin oral capsule 5 mg, 5000 mcg
P
OTC
biotin 5000 oral capsule 5 mg
P
OTC
biotin maximum strength oral capsule 5000 mcg
*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
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
88
Drug Name
Preference Details Coverage Details
*Water Soluble Vitamins**-*Vitamin B-6***
vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg,
50 mg, 500 mg
vitamin b-6 er oral tablet extendedrelease* 200
mg
*Water Soluble Vitamins**-*Vitamin C***
vitamin c oral tablet 250 mg
P
OTC
P
OTC
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
89
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
Index
3 day vaginal
87
4-N-1 ............................................................................ 55
abacavir sulfate
............................................................................................... 36
abacavir-lamivudine-zidovudine
............................................................................................... 34
ABILIFY .............................................................. 34
ABILIFY MAINTENA
............................................................................................... 34
acamprosate calcium
............................................................................................... 81
acarbose ................................................................... 17
ACCU-CHEK ACTIVE
............................................................................................... 56
ACCU-CHEK AVIVA PLUS
............................................................................................... 56
ACCU-CHEK COMFORT
CURVE ................................................................... 56
ACCU-CHEK COMPACT
PLUS CARE
............................................................................................... 68
ACCU-CHEK COMPACT
TEST DRUM
............................................................................................... 56
ACCU-CHEK NANO
SMARTVIEW
............................................................................................... 68
ACCU-CHEK SMARTVIEW
............................................................................................... 56
acetaminophen
................................................................................................... 4
acetaminophen-codeine
................................................................................................... 5
acetaminophen-codeine #2
................................................................................................... 6
acetaminophen-codeine #3
................................................................................................... 6
acetaminophen-codeine #4
................................................................................................... 6
acetazolamide
............................................................................................... 57
acetic acid-aluminum acetate
............................................................................................... 79
acetylcysteine
............................................................................................... 50
acid reducer ......................................................... 85
acne medication
............................................................................................... 50
...............................................................................................
acne medication 5
50
ACTICIN ............................................................. 56
acyclovir ................................................................... 37
ADDERALL XR
................................................................................................... 1
ADRUCIL .......................................................... 27
ADVAIR DISKUS
............................................................................................... 11
ADVAIR HFA
............................................................................................... 11
AEROCHAMBER PLUS
FLO-VU ................................................................. 69
AEROCHAMBER PLUS
FLO-VU LARGE
............................................................................................... 69
AEROCHAMBER PLUS
FLO-VU SMALL
............................................................................................... 69
AEROCHAMBER PLUS
FLO-VU W/MASK
............................................................................................... 69
AFINITOR
............................................................................................... 29
ak-poly-bac .......................................................... 77
ALAVERT ALLERGY/SINUS
............................................................................................... 49
ALBENZA ............................................................. 8
albuterol sulfate
............................................................................................... 11
alclometasone dipropionate
............................................................................................... 53
alcohol pads ......................................................... 68
alendronate sodium
­
............................................................................................... 58
aler-dryl .................................................................... 22
ALKERAN
............................................................................................... 27
ALLEGRA ALLERGY
CHILDRENS
............................................................................................... 22
ALLEGRA-D ALLERGY &
CONGESTION
............................................................................................... 49
allergy ......................................................................... 22
allergy relief/nasal decongest
­
............................................................................................... 49
allopurinol ............................................................. 62
alprazolam ................................................................ 8
...............................................................................................
ALTALUBE
...............................................................................................
ALTAVERA
...............................................................................................
aluminum hydroxide gel
75
42
................................................................................................... 7
alyacen 1/35 ........................................................ 42
alyacen 7/7/7
............................................................................................... 46
amantadine hcl
............................................................................................... 31
A-METHAPRED
............................................................................................... 48
AMETHIA ......................................................... 46
AMETHIA LO
............................................................................................... 46
AMETHYST
............................................................................................... 45
amiloride-hydrochlorothiazide
............................................................................................... 58
aminophylline
............................................................................................... 12
amiodarone hcl
................................................................................................... 9
amitriptyline hcl
............................................................................................... 16
AMLACTIN
............................................................................................... 54
amlodipine besylate
............................................................................................... 39
ammonium lactate
............................................................................................... 54
AMNESTEEM
............................................................................................... 50
amoxapine ............................................................. 16
amoxicillin ............................................................ 80
amoxicillin-pot clavulanate
............................................................................................... 80
amphetamine-dextroamphetamine
................................................................................................... 1
ampicillin ................................................................ 80
anagrelide hcl
............................................................................................... 62
anastrozole ........................................................... 28
antacid ............................................................................ 7
anti-diarrheal
............................................................................................... 20
antipyrine-benzocaine
............................................................................................... 79
APIDRA ................................................................ 19
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
APIDRA SOLOSTAR
............................................................................................... 19
APRI ............................................................................ 42
APRISO .................................................................. 60
APTIVUS ............................................................. 35
ARANELLE
............................................................................................... 46
ARGYLE STERILE SALINE
............................................................................................... 61
ARMOUR THYROID
............................................................................................... 84
artificial tears
............................................................................................... 75
ASCOMP-CODEINE
................................................................................................... 6
ASMANEX 120 METERED
DOSES ..................................................................... 10
ASMANEX 30 METERED
DOSES ..................................................................... 10
ASMANEX 60 METERED
DOSES ..................................................................... 10
ASMANEX HFA
............................................................................................... 11
aspirin ............................................................................. 4
aspirin adult low strength
................................................................................................... 4
aspirin ec ..................................................................... 4
atenolol ...................................................................... 39
atenolol-chlorthalidone
............................................................................................... 25
atorvastatin calcium
............................................................................................... 23
atovaquone ............................................................ 26
atovaquone-proguanil hcl
............................................................................................... 26
ATRIPLA ............................................................ 34
atropine sulfate
............................................................................................... 76
atropine-care
............................................................................................... 76
ATROVENT HFA
............................................................................................... 10
AUBAGIO ......................................................... 82
AUBRA .................................................................. 42
AVANDAMET
............................................................................................... 17
AVANDARYL
............................................................................................... 17
AVANDIA ......................................................... 19
AVASTIN ............................................................ 28
AVIANE ................................................................ 42
AVITA ...................................................................... 50
AVODART
............................................................................................... 61
azathioprine ........................................................ 38
azelastine hcl
............................................................................................... 75
azithromycin
............................................................................................... 66
azithromycin hydrogencitrate
............................................................................................... 66
AZOPT ..................................................................... 78
AZURETTE
............................................................................................... 42
BABY AYR SALINE
............................................................................................... 75
bacitracin zinc
............................................................................................... 51
bacitracin-polymyxin b
............................................................................................... 77
baclofen ..................................................................... 74
balsalazide disodium
............................................................................................... 60
BALZIVA ............................................................ 42
baza antifungal
............................................................................................... 52
BAZA PROTECT
............................................................................................... 55
BD INSULIN SYRINGE
ULTRAFINE
............................................................................................... 68
BENADRYL ALLERGY
CHILDRENS
............................................................................................... 22
benazepril hcl
............................................................................................... 24
benazepril-hydrochlorothiazide
............................................................................................... 24
benzoyl peroxide
............................................................................................... 50
benzoyl peroxide-erythromycin
............................................................................................... 50
benztropine mesylate
............................................................................................... 31
betamethasone dipropionate
............................................................................................... 53
betamethasone dipropionate aug
............................................................................................... 53
betamethasone valerate
............................................................................................... 53
betaxolol hcl
............................................................................................... 76
bethanechol chloride
............................................................................................... 86
BETHKIS ................................................................ 2
BETOPTIC-S
............................................................................................... 76
bicalutamide
............................................................................................... 28
BICILLIN C-R
............................................................................................... 80
BICILLIN C-R 900/300
............................................................................................... 80
BICILLIN L-A
............................................................................................... 80
BILTRICIDE
................................................................................................... 8
biotin ............................................................................. 88
biotin 5000 ............................................................ 88
biotin maximum strength
............................................................................................... 88
bisacodyl ec ......................................................... 65
bismatrol ................................................................. 20
bisoprolol fumarate
............................................................................................... 39
bisoprolol-hydrochlorothiazide
............................................................................................... 25
BOSULIF ............................................................. 29
briellyn ....................................................................... 42
brimonidine tartrate
............................................................................................... 76
bromocriptine mesylate
............................................................................................... 31
BRONCHO SALINE
............................................................................................... 50
budesonide ............................................................. 11
bumetanide ........................................................... 58
buprenorphine hcl
................................................................................................... 6
buproban .................................................................. 83
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
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
butalbital-asa-caffeine
...................................................................................................
butorphanol tartrate
...................................................................................................
BYDUREON
...............................................................................................
calcipotriene
...............................................................................................
calcitonin (salmon)
4
6
18
52
............................................................................................... 58
calcitriol ................................................................... 59
calcium acetate
............................................................................................... 61
calcium acetate (phos binder)
............................................................................................... 70
calcium antacid extra strength
................................................................................................... 7
calcium carbonate
............................................................................................... 70
calcium carbonate antacid
................................................................................................... 7
calcium carbonate-vitamin d
............................................................................................... 70
calcium lactate
............................................................................................... 70
calcium-vitamin d
............................................................................................... 70
cal-lac .......................................................................... 70
CAMILA ............................................................... 48
CAMRESE ........................................................ 46
CAMRESE LO
............................................................................................... 46
capecitabine ........................................................ 27
CAPRELSA
............................................................................................... 29
capsaicin .................................................................. 55
captopril ................................................................... 24
captopril-hydrochlorothiazide
............................................................................................... 25
CARAFATE
............................................................................................... 85
carbamazepine
............................................................................................... 13
carbidopa-levodopa
............................................................................................... 31
carbidopa-levodopa er
............................................................................................... 31
carisoprodol ........................................................ 74
carteolol hcl ......................................................... 76
CARTIA XT
............................................................................................... 40
carvedilol ................................................................. 39
CAVAREST
............................................................................................... 72
CAZIANT ........................................................... 46
cefaclor ...................................................................... 41
cefadroxil ............................................................... 41
cefdinir ....................................................................... 42
cefpodoxime proxetil
............................................................................................... 42
cefprozil .................................................................... 41
cefuroxime axetil
............................................................................................... 41
celecoxib ...................................................................... 2
CENTRATEX
............................................................................................... 63
cephalexin .............................................................. 41
CESIA ....................................................................... 46
cetirizine hcl
............................................................................................... 22
cetirizine hcl childrens
............................................................................................... 22
cetirizine-pseudoephedrine er
............................................................................................... 49
CHATEAL ......................................................... 42
childrens ibuprofen
................................................................................................... 3
childrens loratadine
............................................................................................... 22
childrens non-aspirin
................................................................................................... 4
chlordiazepoxide hcl
................................................................................................... 9
chlordiazepoxide-amitriptyline
............................................................................................... 82
chlorhexidine gluconate
............................................................................................... 34
chlorothiazide
............................................................................................... 58
chlorpromazine hcl
............................................................................................... 33
chlorpropamide
............................................................................................... 20
chlorthalidone
............................................................................................... 58
chlorzoxazone
............................................................................................... 74
cholestyramine
............................................................................................... 23
cholestyramine light
............................................................................................... 23
ciclopirox ................................................................ 51
ciclopirox olamine
............................................................................................... 51
cilostazol ................................................................. 62
cimetidine ............................................................... 85
cimetidine hcl
............................................................................................... 85
CIPRODEX
............................................................................................... 79
ciprofloxacin hcl
............................................................................................... 60
citalopram hydrobromide
............................................................................................... 15
CLARAVIS
............................................................................................... 51
clarithromycin
............................................................................................... 66
CLEAR AWAY 1-STEP WART
REMOVER
............................................................................................... 55
clindamycin hcl
............................................................................................... 26
clindamycin palmitate hcl
............................................................................................... 26
clindamycin phosphate
............................................................................................... 26
CLINISTIX
............................................................................................... 56
clobetasol propionate
............................................................................................... 53
clomipramine hcl
............................................................................................... 16
clonazepam .......................................................... 13
clonidine hcl ........................................................ 24
clopidogrel bisulfate
............................................................................................... 62
clorazepate dipotassium
................................................................................................... 9
clotrimazole ......................................................... 52
clotrimazole 3
............................................................................................... 87
clozapine .................................................................. 33
codeine sulfate
................................................................................................... 5
colchicine-probenecid
............................................................................................... 61
COLCRYS .......................................................... 62
COMBIVENT RESPIMAT
............................................................................................... 11
COMPLERA
............................................................................................... 34
complete lice treatment
............................................................................................... 55
COMPOUND W
............................................................................................... 55
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
COMPOUND W MAXIMUM
STRENGTH
............................................................................................... 55
condoms .................................................................... 67
CONDYLOX
............................................................................................... 55
COPAXONE
............................................................................................... 83
cortisone acetate
............................................................................................... 48
CORTISPORIN
............................................................................................... 51
CREON ................................................................... 57
CRIXIVAN
............................................................................................... 35
cromolyn sodium
............................................................................................... 10
CRYSELLE-28
............................................................................................... 42
cyanocobalamin
............................................................................................... 62
CYCLAFEM 1/35
............................................................................................... 42
CYCLAFEM 7/7/7
............................................................................................... 46
cyclobenzaprine hcl
............................................................................................... 74
cyclophosphamide
............................................................................................... 27
cyclosporine ........................................................ 38
cyclosporine modified
............................................................................................... 38
cyproheptadine hcl
............................................................................................... 23
cytra-2 ........................................................................ 61
CYTRA-3 ............................................................. 61
danazol .......................................................................... 6
dantrolene sodium
............................................................................................... 74
dapsone ...................................................................... 26
DARAPRIM
............................................................................................... 26
DASETTA 1/35
............................................................................................... 43
DASETTA 7/7/7
............................................................................................... 46
DAYSEE ............................................................... 46
deferoxamine mesylate
............................................................................................... 20
DELSYM NGHT TIME
CGH/CLD CHILD
............................................................................................... 49
DELSYM NIGHT TIME
COUGH/COLD
49
DENAVIR .......................................................... 52
DENTAGEL
............................................................................................... 72
DEPO-PROVERA
............................................................................................... 48
desipramine hcl
............................................................................................... 16
desmopressin ace rhinal tube
............................................................................................... 59
desmopressin ace spray refrig
............................................................................................... 59
desmopressin acetate
............................................................................................... 59
desmopressin acetate spray
............................................................................................... 59
desogestrel-ethinyl estradiol
............................................................................................... 43
desonide .................................................................... 53
dexamethasone
............................................................................................... 48
dexamethasone sodium phosphate
............................................................................................... 48
dexmethylphenidate hcl
................................................................................................... 1
dextroamphetamine sulfate
................................................................................................... 1
dextroamphetamine sulfate er
................................................................................................... 1
DIASTIX .............................................................. 56
diazepam ..................................................................... 9
diclofenac potassium
................................................................................................... 3
diclofenac sodium
................................................................................................... 3
diclofenac sodium er
................................................................................................... 3
dicloxacillin sodium
............................................................................................... 81
dicyclomine hcl
............................................................................................... 85
didanosine .............................................................. 36
diflunisal ...................................................................... 4
digoxin ............................................................ 40, 41
DILANTIN
............................................................................................... 14
diltiazem hcl
............................................................................................... 40
diltiazem hcl er
............................................................................................... 40
...............................................................................................
diltiazem hcl er beads
...............................................................................................
diltiazem hcl er coated beads
40
............................................................................................... 40
dilt-xr ........................................................................... 40
diphenhydramine hcl
............................................................................................... 22
diphenhydramine hcl (sleep)
............................................................................................... 63
diphenoxylate-atropine
............................................................................................... 20
dipyridamole
............................................................................................... 56
disopyramide phosphate
................................................................................................... 9
disulfiram ............................................................... 81
divalproex sodium
.................................................................................... 14, 15
divalproex sodium er
............................................................................................... 15
docusate sodium
............................................................................................... 65
donepezil hcl
............................................................................................... 81
dorzolamide hcl
............................................................................................... 78
dorzolamide hcl-timolol mal
............................................................................................... 76
double antibiotic
............................................................................................... 51
doxazosin mesylate
............................................................................................... 24
doxepin hcl ........................................................... 16
doxycycline hyclate
............................................................................................... 83
doxycycline monohydrate
............................................................................................... 84
DRITHO-CREME HP
............................................................................................... 52
drospirenone-ethinyl estradiol
............................................................................................... 43
DULERA ............................................................. 11
E.E.S. GRANULES
............................................................................................... 66
earwax treatment drops
............................................................................................... 79
econazole nitrate
............................................................................................... 52
EDURANT
............................................................................................... 35
ELIDEL .................................................................. 54
ELINEST .............................................................. 43
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
ELIPHOS ............................................................. 61
ELITE-OB ........................................................... 73
elixophyllin ........................................................... 12
ELMIRON ......................................................... 61
EMCYT .................................................................. 28
EMOQUETTE
............................................................................................... 43
EMTRIVA .......................................................... 36
enalapril maleate
............................................................................................... 24
enalapril-hydrochlorothiazide
............................................................................................... 25
ENCARE .............................................................. 87
ENDOCET ............................................................ 6
ENDOMETRIN
............................................................................................... 88
enoxaparin sodium
.................................................................................... 12, 13
ENPRESSE-28
............................................................................................... 46
ENSKYCE ......................................................... 43
entecavir ................................................................... 37
EPIPEN 2-PAK
............................................................................................... 88
EPIPEN JR 2-PAK
............................................................................................... 88
EPITOL ................................................................... 13
EPIVIR .................................................................... 36
EPIVIR HBV
............................................................................................... 36
EPZICOM ........................................................... 34
eq aspirin low dose
................................................................................................... 4
ergocalciferol
............................................................................................... 88
ERIVEDGE
............................................................................................... 28
ERRIN ..................................................................... 48
ERWINAZE
............................................................................................... 30
ery ..................................................................................... 50
ERYPED 200
............................................................................................... 66
ERYPED 400
............................................................................................... 66
ERY-TAB ............................................................ 66
ERYTHROCIN STEARATE
............................................................................................... 66
erythromycin
............................................................................................... 50
erythromycin base
............................................................................................... 66
erythromycin ethylsuccinate
...............................................................................................
escitalopram oxalate
...............................................................................................
ESTARYLLA
66
15
............................................................................................... 43
estazolam ................................................................ 64
estradiol .................................................................... 60
estropipate ............................................................ 60
ethambutol hcl
............................................................................................... 27
ethosuximide
............................................................................................... 14
etodolac ........................................................................ 3
etoposide .................................................................. 30
EXEL PEN NEEDLES 1/3"
............................................................................................... 68
EXELON .............................................................. 81
EXJADE ................................................................ 20
EXTAVIA ........................................................... 82
E-Z SPACER
............................................................................................... 69
FALMINA ......................................................... 43
famotidine .............................................................. 85
famotidine premixed
............................................................................................... 85
FC FEMALE CONDOM
............................................................................................... 67
FEMCAP .............................................................. 67
fenofibrate ............................................................. 23
fenofibrate micronized
............................................................................................... 23
fenoprofen calcium
................................................................................................... 3
fentanyl ......................................................................... 5
ferrous gluconate
............................................................................................... 63
ferrous sulfate
............................................................................................... 63
fexofenadine hcl
............................................................................................... 22
fexofenadine hcl childrens
............................................................................................... 22
fexofenadine-pseudoephed er
............................................................................................... 49
fiber laxative
............................................................................................... 64
finasteride .............................................................. 61
FIRAZYR ........................................................... 62
flecainide acetate
................................................................................................... 9
FLOVENT DISKUS
...............................................................................................
FLOVENT HFA
11
............................................................................................... 11
fluconazole ............................................................ 21
fludrocortisone acetate
............................................................................................... 49
flunisolide ............................................................... 75
fluocinolone acetonide
............................................................................................... 53
fluocinolone acetonide body
............................................................................................... 53
fluocinolone acetonide scalp
............................................................................................... 53
fluocinonide ......................................................... 53
fluocinonide-e
............................................................................................... 53
FLUOR-A-DAY
............................................................................................... 70
FLUORIDEX DAILY
DEFENSE .......................................................... 72
fluorometholone
............................................................................................... 78
fluorouracil .......................................................... 27
fluoxetine hcl
............................................................................................... 16
fluphenazine decanoate
............................................................................................... 33
fluphenazine hcl
............................................................................................... 33
flurbiprofen .............................................................. 3
flurbiprofen sodium
............................................................................................... 78
fluticasone propionate
.................................................................................... 53, 54
fluvoxamine maleate
............................................................................................... 16
FML FORTE
............................................................................................... 78
folic acid .................................................................. 62
fondaparinux sodium
............................................................................................... 13
FORADIL AEROLIZER
............................................................................................... 12
formula em ........................................................... 21
FORTICAL
............................................................................................... 58
fosinopril sodium
............................................................................................... 24
fosphenytoin sodium
............................................................................................... 14
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
FREESTYLE FREEDOM
LITE ............................................................................. 68
FREESTYLE INSULINX
SYSTEM ............................................................... 68
FREESTYLE INSULINX
TEST ........................................................................... 57
FREESTYLE LITE
............................................................................................... 68
FREESTYLE LITE TEST
............................................................................................... 57
FREESTYLE TEST
............................................................................................... 57
furosemide ............................................................. 58
FUZEON .............................................................. 35
gabapentin ............................................................. 13
GABITRIL ........................................................ 14
gas relief .................................................................. 60
GAVILYTE-G
............................................................................................... 64
GAVILYTE-N WITH
FLAVOR PACK
............................................................................................... 64
gemcitabine hcl
............................................................................................... 27
gemfibrozil ............................................................ 23
generlac ..................................................................... 61
GENGRAF
............................................................................................... 38
gentamicin sulfate
............................................................................................... 51
GIANVI ................................................................. 43
GILDAGIA
............................................................................................... 43
GILDESS 1.5/30
............................................................................................... 43
GILDESS 1/20
............................................................................................... 43
GILDESS FE 1.5/30
............................................................................................... 43
GILDESS FE 1/20
............................................................................................... 43
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
............................................................................................... 68
glyburide .................................................................. 20
glyburide micronized
............................................................................................... 20
glyburide-metformin
............................................................................................... 17
glycopyrrolate
............................................................................................... 85
gnp nighttime sleep aid
............................................................................................... 63
GOLYTELY
............................................................................................... 64
griseofulvin microsize
............................................................................................... 21
griseofulvin ultramicrosize
............................................................................................... 21
guaifenesin ............................................................ 49
guanfacine hcl
............................................................................................... 24
halobetasol propionate
............................................................................................... 54
haloperidol ............................................................ 32
haloperidol decanoate
............................................................................................... 32
haloperidol lactate
............................................................................................... 32
HEATHER ........................................................ 48
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
...............................................................................................
HUMULIN N KWIKPEN
...............................................................................................
HUMULIN R
...............................................................................................
HUMULIN R U-500 (CONCENTRATED)
­
...............................................................................................
hydralazine hcl
...............................................................................................
hydrochlorothiazide
...............................................................................................
hydrocodone-acetaminophen
19
19
19
19
25
58
...................................................................................................
hydrocodone-ibuprofen
...................................................................................................
hydrocortisone
...................................................................................................
hydrocortisone valerate
...............................................................................................
hydromorphone hcl
...............................................................................................
hydroxyurea
...............................................................................................
hydroxyzine hcl
7
5
26
30
...................................................................................................
hydroxyzine pamoate
...................................................................................................
HYPERCARE
6
54
...................................................................................................
hydroxychloroquine sulfate
6
8
8
55
ibuprofen ..................................................................... 3
ICLUSIG .............................................................. 30
imipramine hcl
............................................................................................... 16
IN-CHECK DIAL FLOW
TRAINER .......................................................... 69
indapamide ........................................................... 58
indomethacin
................................................................................................... 3
infants silapap
................................................................................................... 4
insulin syringe
............................................................................................... 68
INTELENCE
............................................................................................... 36
INTROVALE
............................................................................................... 46
INVEGA SUSTENNA
............................................................................................... 32
...............................................................................................
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
96
INVIRASE ......................................................... 35
INVOKAMET
............................................................................................... 17
INVOKANA
............................................................................................... 20
ipratropium bromide
............................................................................................... 10
ipratropium-albuterol
............................................................................................... 11
ISENTRESS
............................................................................................... 35
isoniazid ................................................................... 27
isosorbide dinitrate
................................................................................................... 8
isosorbide dinitrate er
................................................................................................... 8
isosorbide mononitrate
................................................................................................... 8
isosorbide mononitrate er
................................................................................................... 8
ivermectin .................................................................. 8
JAKAFI .................................................................. 30
JANTOVEN
............................................................................................... 12
JANUMET ........................................................ 17
JANUMET XR
............................................................................................... 17
JANUVIA ........................................................... 18
JARDIANCE
............................................................................................... 20
JENCYCLA
............................................................................................... 48
JENTADUETO
............................................................................................... 17
JOLESSA .............................................................. 46
JOLIVETTE
............................................................................................... 48
JUNEL 1.5/30
............................................................................................... 43
JUNEL 1/20
............................................................................................... 43
JUNEL FE 1.5/30
............................................................................................... 43
JUNEL FE 1/20
............................................................................................... 43
KALETRA ........................................................ 34
KALYDECO
............................................................................................... 83
KARIGEL .......................................................... 72
KARIGEL-N
............................................................................................... 72
KARIVA ............................................................... 42
KELNOR 1/35
...............................................................................................
ketoconazole
43
............................................................................................... 21
ketoprofen ................................................................. 3
ketorolac tromethamine
................................................................................................... 3
KETOSTIX
............................................................................................... 57
ketotifen fumarate
............................................................................................... 78
KLOR-CON
............................................................................................... 71
KLOR-CON 10
............................................................................................... 71
KLOR-CON M10
............................................................................................... 71
KLOR-CON M20
............................................................................................... 71
K-PHOS-NEUTRAL
............................................................................................... 70
KURVELO
............................................................................................... 43
labetalol hcl ......................................................... 39
lactase enzyme
............................................................................................... 57
lactulose ................................................................... 65
lamivudine ............................................................. 36
lamivudine-zidovudine
............................................................................................... 34
lamotrigine ........................................................... 13
lancet device
............................................................................................... 68
lancets ......................................................................... 68
lansoprazole ........................................................ 86
LANTUS ............................................................... 19
LANTUS SOLOSTAR
............................................................................................... 19
LARIN 1/20
............................................................................................... 43
LARIN FE 1.5/30
............................................................................................... 44
LARIN FE 1/20
............................................................................................... 44
latanoprost ............................................................ 78
LAVOCLEN-4 CREAMY
WASH ....................................................................... 51
LAVOCLEN-8 CREAMY
WASH ....................................................................... 51
laxative ...................................................................... 65
LEENA .................................................................... 46
leflunomide ............................................................... 3
LESSINA .............................................................. 44
LETAIRIS .......................................................... 41
letrozole .................................................................... 28
leucovorin calcium
............................................................................................... 30
LEUKERAN
............................................................................................... 27
levetiracetam
............................................................................................... 14
levobunolol hcl
............................................................................................... 76
levocarnitine
............................................................................................... 59
levocetirizine dihydrochloride
............................................................................................... 22
levofloxacin ......................................................... 60
LEVONEST
............................................................................................... 46
levonorgest-eth estrad 91-day
............................................................................................... 46
levonorgestrel
............................................................................................... 47
levonorgestrel-ethinyl estrad
............................................................................................... 44
LEVORA 0.15/30 (28)
............................................................................................... 44
levothyroxine sodium
............................................................................................... 84
LEXIVA ................................................................. 35
lice killing maximum strength
............................................................................................... 55
lidocaine ................................................................... 55
lidocaine hcl ........................................................ 55
lidocaine hcl (cardiac)
................................................................................................... 9
lidocaine hcl (pf)
............................................................................................... 66
lidocaine viscous
.................................................................................... 71, 72
lidocaine-prilocaine
............................................................................................... 55
liothyronine sodium
............................................................................................... 84
lisinopril .................................................................... 24
lisinopril-hydrochlorothiazide
............................................................................................... 25
lithium ......................................................................... 31
lithium carbonate
............................................................................................... 32
lithium carbonate er
............................................................................................... 32
lo loestrin fe ........................................................ 42
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
97
lomustine ................................................................. 27
loperamide hcl
............................................................................................... 20
loratadine ............................................................... 22
loratadine hives relief
............................................................................................... 22
lorazepam .................................................................. 9
LORYNA ............................................................. 44
losartan potassium
............................................................................................... 24
losartan potassium-hctz
............................................................................................... 25
LOTEMAX
............................................................................................... 78
lovastatin ................................................................. 23
LOW-OGESTREL
............................................................................................... 44
loxapine succinate
............................................................................................... 33
LUMIZYME
............................................................................................... 59
LUTERA .............................................................. 44
LYSODREN
............................................................................................... 28
LYZA ......................................................................... 48
MACRODANTIN
............................................................................................... 86
magnesium oxide
................................................................................................... 7
MAKENA ........................................................... 81
malathion ................................................................ 56
mapap .............................................................................. 4
maprotiline hcl
............................................................................................... 15
marlissa ..................................................................... 44
marten-tab ................................................................ 4
MATZIM LA
............................................................................................... 40
MAXIDEX ........................................................ 78
meclizine hcl
............................................................................................... 21
medroxyprogesterone acetate
............................................................................................... 48
mefloquine hcl
............................................................................................... 26
megestrol acetate
............................................................................................... 29
melatonin maximum strength
................................................................................................... 2
meloxicam ................................................................. 3
MEPHYTON
............................................................................................... 88
meprobamate
...................................................................................................
mercaptopurine
8
............................................................................................... 27
mesalamine ........................................................... 60
MESTINON
............................................................................................... 26
METAMUCIL
............................................................................................... 64
METAMUCIL SMOOTH
TEXTURE ......................................................... 64
metaproterenol sulfate
............................................................................................... 12
metformin hcl
............................................................................................... 18
metformin hcl er
............................................................................................... 18
metformin hcl er (osm)
............................................................................................... 18
methadone hcl
................................................................................................... 5
METHADOSE
................................................................................................... 5
methazolamide
............................................................................................... 57
methimazole ........................................................ 84
methitest ...................................................................... 7
methocarbamol
............................................................................................... 74
methotrexate
............................................................................................... 27
methotrexate sodium
.................................................................................... 27, 28
methotrexate sodium (pf)
............................................................................................... 28
methyldopa ........................................................... 24
methylergonovine maleate
............................................................................................... 79
METHYLIN
................................................................................................... 1
methylphenidate hcl
................................................................................................... 1
methylphenidate hcl er
........................................................................................... 1, 2
methylprednisolone
............................................................................................... 48
methylprednisolone (pak)
............................................................................................... 49
methylprednisolone acetate
............................................................................................... 49
methylprednisolone sodium succ
............................................................................................... 49
metipranolol
...............................................................................................
metoclopramide hcl
76
............................................................................................... 60
metolazone ............................................................ 58
metoprolol succinate er
............................................................................................... 39
metoprolol tartrate
............................................................................................... 39
metronidazole
............................................................................................... 25
mexiletine hcl
................................................................................................... 9
miconazole 3
............................................................................................... 87
miconazole 3 combo pack
............................................................................................... 87
miconazole nitrate
............................................................................................... 52
MICROCHAMBER
............................................................................................... 69
MICROGESTIN 1.5/30
............................................................................................... 44
MICROGESTIN 1/20
............................................................................................... 44
MICROGESTIN FE 1.5/30
............................................................................................... 44
MICROGESTIN FE 1/20
............................................................................................... 44
MICROSPACER
............................................................................................... 69
midodrine hcl
............................................................................................... 88
milk of magnesia
............................................................................................... 65
minocycline hcl
............................................................................................... 84
minoxidil ................................................................. 25
mirtazapine .......................................................... 15
misoprostol ........................................................... 86
mometasone furoate
............................................................................................... 54
MONISTAT 3
............................................................................................... 87
MONO-LINYAH
............................................................................................... 44
MONONESSA
............................................................................................... 44
montelukast sodium
............................................................................................... 10
morphine sulfate
................................................................................................... 5
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
98
morphine sulfate (concentrate)
...................................................................................................
morphine sulfate (pf)
...................................................................................................
morphine sulfate er
5
5
5
mucus relief .......................................................... 49
multi-vit/fluoride
............................................................................................... 73
multi-vit/fluoride/iron
............................................................................................... 73
multivitamin/fluoride
............................................................................................... 73
multi-vitamin/fluoride
............................................................................................... 73
multi-vitamin/fluoride/iron
............................................................................................... 73
multi-vitamin/iron
............................................................................................... 72
multi-vitamin/minerals
............................................................................................... 72
multi-vitamins
............................................................................................... 73
mupirocin ................................................................ 51
MURO 128 ......................................................... 78
mycophenolate mofetil
............................................................................................... 38
MYLERAN
............................................................................................... 27
MYNATAL ADVANCE
............................................................................................... 74
mynatal-z ................................................................ 74
mynate 90 plus
............................................................................................... 74
MYZILRA ......................................................... 46
nabumetone ............................................................. 3
nadolol ........................................................................ 39
naltrexone hcl
............................................................................................... 21
NAMENDA
............................................................................................... 81
NAMENDA TITRATION
PAK .............................................................................. 81
NAMENDA XR
............................................................................................... 82
NAMENDA XR TITRATION
PACK ......................................................................... 82
naproxen ..................................................................... 3
naproxen dr ............................................................. 3
naproxen sodium
................................................................................................... 3
...................................................................................................
naratriptan hcl
...............................................................................................
NATURE-THROID
...............................................................................................
NECON 0.5/35 (28)
...............................................................................................
NECON 1/35 (28)
...............................................................................................
NECON 10/11 (28)
...............................................................................................
NECON 7/7/7
...............................................................................................
nefazodone hcl
69
84
44
44
42
46
16
neomycin-bacitracin zn-polymyx
............................................................................................... 77
neomycin-polymyxin-dexameth
............................................................................................... 77
neomycin-polymyxin-gramicidin
............................................................................................... 77
neomycin-polymyxin-hc
............................................................................................... 77
NEUPOGEN
............................................................................................... 63
NEUTRAGARD ADVANCED
............................................................................................... 72
nevirapine ............................................................... 36
NEXT CHOICE ONE DOSE
............................................................................................... 48
niacin ............................................................................ 88
niacin er .................................................................... 88
NIACOR ............................................................... 23
nicotine ...................................................................... 83
nicotine polacrilex
............................................................................................... 83
NIFEDIAC CC
............................................................................................... 40
NIFEDICAL XL
............................................................................................... 40
nifedipine ................................................................. 40
nifedipine er ......................................................... 40
nifedipine er osmotic
............................................................................................... 40
NITRO-BID
................................................................................................... 8
nitrofurantoin macrocrystal
............................................................................................... 86
nitrofurantoin monohyd macro
............................................................................................... 86
nitroglycerin
................................................................................................... 8
...............................................................................................
NITROSTAT
...................................................................................................
no flush niacin
8
............................................................................................... 41
NORA-BE ........................................................... 48
norethindrone
............................................................................................... 48
norethindrone acetate
............................................................................................... 81
norgestimate-eth estradiol
............................................................................................... 44
norgestim-eth estrad triphasic
............................................................................................... 47
normal saline flush
............................................................................................... 71
NOR-QD ............................................................... 48
nortemp infants
................................................................................................... 4
NORTREL 0.5/35 (28)
............................................................................................... 44
NORTREL 1/35 (21)
............................................................................................... 44
NORTREL 1/35 (28)
............................................................................................... 44
NORTREL 7/7/7
............................................................................................... 47
nortriptyline hcl
............................................................................................... 16
NORVIR ............................................................... 35
np thyroid ............................................................... 84
NUVARING
............................................................................................... 47
nystatin ...................................................................... 21
OCELLA ............................................................... 44
ofloxacin .................................................................. 76
OGESTREL
............................................................................................... 45
olanzapine .............................................................. 33
OLYSIO ................................................................. 37
omeprazole ........................................................... 86
omeprazole magnesium
............................................................................................... 86
OMNIFLEX DIAPHRAGM
............................................................................................... 67
ondansetron ......................................................... 21
ondansetron hcl
............................................................................................... 21
OPTICHAMBER
ADVANTAGE
............................................................................................... 69
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
99
OPTICHAMBER
ADVANTAGE-LG MASK
...............................................................................................
OPTICHAMBER
ADVANTAGE-MED MASK
...............................................................................................
OPTICHAMBER
ADVANTAGE-SM MASK
...............................................................................................
OPTICHAMBER FACE
MASK-LARGE
...............................................................................................
OPTICHAMBER FACE
MASK-MEDIUM
...............................................................................................
OPTICHAMBER FACE
MASK-SMALL
...............................................................................................
OPTIHALER
...............................................................................................
OPTIONS CONCEPTROL
...............................................................................................
OPTIONS GYNOL II CONTRACEPTIVE
oxycodone-acetaminophen
...................................................................................................
69
...................................................................................................
69
PACERONE
...............................................................................................
pain & fever childrens
pantoprazole sodium
...............................................................................................
69
paroxetine hcl
...............................................................................................
peak flow meter
...............................................................................................
69
peg 3350/electrolytes
...............................................................................................
69
69
87
peg 3350-kcl-na bicarb-nacl
...............................................................................................
peg-3350/electrolytes
...............................................................................................
PEGANONE
6
6
10
...................................................................................................
69
87
ORALYTE ......................................................... 70
ORALYTE FREEZER POPS
............................................................................................... 70
ORAP ......................................................................... 83
ORSYTHIA
............................................................................................... 45
ORTHO DIAPHRAGM COIL
............................................................................................... 67
ORTHO DIAPHRAGM FLAT
............................................................................................... 67
ORTHO TRI-CYCLEN LO
............................................................................................... 47
oticin ............................................................................. 79
oxacillin sodium
............................................................................................... 81
oxandrolone ............................................................ 6
oxaprozin ................................................................... 3
oxazepam ................................................................... 9
oxcarbazepine
............................................................................................... 14
oxybutynin chloride
............................................................................................... 86
oxybutynin chloride er
............................................................................................... 86
oxycodone hcl
................................................................................................... 5
...............................................................................................
oxycodone-aspirin
4
86
16
69
65
64
65
............................................................................................... 14
PEGASYS ........................................................... 37
PEGASYS PROCLICK
............................................................................................... 37
penicillin g procaine
............................................................................................... 80
penicillin v potassium
............................................................................................... 80
pentazocine-naloxone hcl
................................................................................................... 6
pentoxifylline er
............................................................................................... 62
PERIOGARD
............................................................................................... 72
permethrin ............................................................. 56
perphenazine
............................................................................................... 33
perphenazine-amitriptyline
............................................................................................... 82
PERTZYE ........................................................... 57
PFIZERPEN-G
............................................................................................... 80
phenazopyridine hcl
............................................................................................... 61
phenelzine sulfate
............................................................................................... 15
phenobarbital
............................................................................................... 64
phenobarbital sodium
............................................................................................... 64
phenytoin ................................................................ 14
phenytoin sodium
...............................................................................................
phenytoin sodium extended
14
............................................................................................... 14
PHILITH .............................................................. 45
PHOS-FLUR
............................................................................................... 72
pilocarpine hcl
............................................................................................... 72
PIMTREA .......................................................... 42
pindolol ...................................................................... 39
PIN-X ............................................................................ 8
pioglitazone hcl
............................................................................................... 19
pioglitazone hcl-metformin hcl
............................................................................................... 18
PIRMELLA 1/35
............................................................................................... 45
PIRMELLA 7/7/7
............................................................................................... 47
piroxicam ................................................................... 3
PLAN B ONE-STEP
............................................................................................... 48
podofilox ................................................................. 55
polycin b ................................................................... 77
poly-dex .................................................................... 77
polyethylene glycol 3350
............................................................................................... 65
POLY-IRON 150
............................................................................................... 63
poly-iron 150 forte
............................................................................................... 63
polymyxin b-trimethoprim
............................................................................................... 77
poly-vitamin ........................................................ 73
polyvitamin/iron
............................................................................................... 73
PORTIA-28
............................................................................................... 45
potassium chloride
............................................................................................... 71
potassium chloride crys er
............................................................................................... 71
potassium chloride er
............................................................................................... 71
PR NATAL 400 EC
............................................................................................... 74
pramipexole dihydrochloride
............................................................................................... 31
pravastatin sodium
............................................................................................... 23
prazosin hcl .......................................................... 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
100
PRECISION XTRA
............................................................................................... 68
PRECISION XTRA BLOOD
GLUCOSE ......................................................... 57
PRECISION XTRA KETONE
............................................................................................... 57
PRED-G ................................................................. 77
prednisolone ........................................................ 49
prednisolone acetate
............................................................................................... 78
prednisolone sodium phosphate
............................................................................................... 49
prednisone .............................................................. 49
PREMARIN
............................................................................................... 60
premium condoms lubricated
............................................................................................... 67
PREMPHASE
............................................................................................... 59
PREMPRO ........................................................ 59
PRENATABS RX
............................................................................................... 74
prenatal ..................................................................... 74
prenatal 19 ............................................................ 74
prenatal low iron
............................................................................................... 74
prenatal plus
............................................................................................... 74
prenatal plus iron
............................................................................................... 74
PRENATAL-U
............................................................................................... 74
PRENTIF CAVITY-RIM
CERV CAP ........................................................ 67
PRENTIF FITTING SET
............................................................................................... 67
PREVIFEM
............................................................................................... 45
PREZISTA ......................................................... 35
primaquine phosphate
............................................................................................... 26
primidone ................................................................ 14
probenecid ............................................................. 62
procainamide hcl
................................................................................................... 9
prochlorperazine
............................................................................................... 33
prochlorperazine maleate
............................................................................................... 33
PROCRIT ............................................................ 63
PROCTOSOL HC
................................................................................................... 7
PROCTOZONE-HC
................................................................................................... 7
PROLIA ................................................................. 59
promethazine hcl
.................................................................................... 22, 23
PROMETHEGAN
............................................................................................... 23
propafenone hcl
................................................................................................... 9
propantheline bromide
............................................................................................... 85
propranolol hcl
............................................................................................... 39
propranolol hcl er
............................................................................................... 39
propranolol-hctz
............................................................................................... 25
propylthiouracil
............................................................................................... 84
protriptyline hcl
............................................................................................... 16
pseudoephedrine hcl
............................................................................................... 75
PULMICORT
............................................................................................... 11
PULMOZYME
............................................................................................... 83
px enteric aspirin
................................................................................................... 4
pyrazinamide
............................................................................................... 27
pyridostigmine bromide
............................................................................................... 26
q-pap infants
................................................................................................... 4
QUASENSE
............................................................................................... 46
quetiapine fumarate
............................................................................................... 33
quinapril hcl ........................................................ 24
quinidine gluconate
................................................................................................... 9
quinidine gluconate er
................................................................................................... 9
quinidine sulfate
................................................................................................... 9
ra col-rite ................................................................ 65
ra nighttime sleep aid
............................................................................................... 63
raloxifene hcl
............................................................................................... 59
ramipril ...................................................................... 24
ranitidine acid reducer
...............................................................................................
ranitidine hcl
85
............................................................................................... 85
REBIF ....................................................................... 82
REBIF REBIDOSE
............................................................................................... 82
REBIF REBIDOSE
TITRATION PACK
............................................................................................... 82
REBIF TITRATION PACK
............................................................................................... 82
RECLIPSEN
............................................................................................... 45
reeses pinworm medicine
................................................................................................... 8
refenesen .................................................................. 49
refenesen 400
............................................................................................... 50
RELENZA DISKHALER
............................................................................................... 37
REMEVEN
............................................................................................... 54
rena-vite ................................................................... 72
RENVELA ......................................................... 61
RESCRIPTOR
............................................................................................... 36
RESTASIS .......................................................... 77
REVLIMID
............................................................................................... 38
REYATAZ ......................................................... 35
RIBASPHERE
............................................................................................... 37
ribavirin .................................................................... 37
RIDAURA ............................................................ 2
rifabutin .................................................................... 27
rifampin .................................................................... 27
rimantadine hcl
............................................................................................... 37
RIOMET ............................................................... 18
risperidone ............................................................. 32
RISPERIDONE M-TAB
............................................................................................... 32
rivastigmine tartrate
............................................................................................... 81
robafen ....................................................................... 50
ropinirole hcl
............................................................................................... 31
ROXICET ............................................................... 6
SALACTIC FILM
............................................................................................... 55
saline flush ............................................................ 71
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
101
saline nasal spray
............................................................................................... 75
salsalate ........................................................................ 4
SANDIMMUNE
............................................................................................... 38
SANI-SUPP PEDIATRIC
............................................................................................... 65
SANTYL ............................................................... 54
SAPHRIS ............................................................. 33
SAVELLA ........................................................... 82
SAVELLA TITRATION PACK
............................................................................................... 82
selegiline hcl
............................................................................................... 31
selenium sulfide
............................................................................................... 52
SELZENTRY
............................................................................................... 35
senna ............................................................................. 65
senna laxative
............................................................................................... 65
senna s ........................................................................ 65
SEREVENT DISKUS
............................................................................................... 12
sertraline hcl
............................................................................................... 16
sf ......................................................................................... 72
SHUR-SEAL
CONTRACEPTIVE
............................................................................................... 87
silace ............................................................................. 65
sildenafil citrate
............................................................................................... 41
silver sulfadiazine
............................................................................................... 53
simethicone ........................................................... 60
simponi .......................................................................... 2
simvastatin ............................................................ 23
SIVEXTRO
............................................................................................... 26
sleep tabs ................................................................. 63
slow release iron
............................................................................................... 63
sm magnesium oxide
............................................................................................... 70
sodium bicarbonate
................................................................................................... 7
sodium chloride
............................................................................................... 50
sodium chloride (hypertonic)
............................................................................................... 78
sodium fluoride
...............................................................................................
sodium polystyrene sulfonate
70
............................................................................................... 38
SOLIA ....................................................................... 45
sorbitol ....................................................................... 65
SORINE ................................................................. 39
sotalol hcl ............................................................... 39
sotalol hcl (af)
............................................................................................... 39
SOVALDI ............................................................ 37
spinosad .................................................................... 56
spironolactone
............................................................................................... 58
spironolactone-hctz
............................................................................................... 58
SPRINTEC 28
­
............................................................................................... 45
SPRYCEL ........................................................... 30
SPS .................................................................................. 38
SRONYX ............................................................. 45
SSD ................................................................................ 53
SSKI ............................................................................. 70
stavudine .................................................................. 36
stimulant laxative
............................................................................................... 65
STIVARGA
............................................................................................... 29
stool softener
............................................................................................... 65
stool softener laxative dc
.................................................................................... 65, 66
STRIBILD .......................................................... 34
sucralfate ................................................................ 85
sulfacetamide sodium
............................................................................................... 50
sulfacetamide-prednisolone
............................................................................................... 77
sulfamethoxazole-tmp ds
............................................................................................... 25
sulfamethoxazole-trimethoprim
.................................................................................... 25, 26
sulfasalazine
............................................................................................... 60
sulindac ......................................................................... 3
sumatriptan .......................................................... 69
sumatriptan succinate
.................................................................................... 69, 70
supartz ........................................................................ 75
SUSTIVA ............................................................. 36
SUTENT ............................................................... 29
SYEDA .................................................................... 45
SYMBICORT
............................................................................................... 11
SYNAGIS ............................................................ 79
TABLOID ........................................................... 28
tacrolimus .............................................................. 38
TAMIFLU .......................................................... 37
tamoxifen citrate
............................................................................................... 28
tamsulosin hcl
............................................................................................... 61
TARCEVA ......................................................... 30
TASIGNA ........................................................... 30
TAZORAC ........................................................ 52
temazepam ............................................................ 64
temozolomide
............................................................................................... 27
terazosin hcl ........................................................ 24
terbinafine hcl
............................................................................................... 21
terbutaline sulfate
............................................................................................... 12
terconazole ........................................................... 87
TESTIM ..................................................................... 7
testosterone ............................................................. 7
testosterone cypionate
................................................................................................... 7
testosterone enanthate
................................................................................................... 7
tetracycline hcl
............................................................................................... 84
TEV-TROPIN
............................................................................................... 59
THALOMID
............................................................................................... 38
theophylline ......................................................... 12
theophylline er
............................................................................................... 12
thera-m ...................................................................... 73
thiamine hcl ......................................................... 88
thioridazine hcl
............................................................................................... 33
thiothixene ............................................................ 34
THYROLAR-1
............................................................................................... 84
THYROLAR-1/2
............................................................................................... 84
THYROLAR-1/4
............................................................................................... 84
THYROLAR-2
............................................................................................... 84
THYROLAR-3
............................................................................................... 84
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
102
tiagabine hcl
............................................................................................... 14
TILIA FE ............................................................. 47
timolol maleate
............................................................................................... 39
TIVICAY .............................................................. 35
tizanidine hcl
............................................................................................... 74
TOBRADEX
............................................................................................... 78
tobramycin ............................................................ 76
TODAY SPONGE
............................................................................................... 67
tolmetin sodium
................................................................................................... 3
topiramate ............................................................. 14
torsemide ................................................................. 58
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 .................................................................... 51
triamcinolone acetonide
............................................................................................... 54
triamterene-hctz
............................................................................................... 58
triazolam ................................................................. 64
TRI-ESTARYLLA
............................................................................................... 47
trifluoperazine hcl
............................................................................................... 34
trifluridine ............................................................. 77
trihexyphenidyl hcl
............................................................................................... 31
TRI-LEGEST FE
............................................................................................... 47
TRI-LINYAH
............................................................................................... 47
TRILYTE ............................................................ 65
trimethoprim
............................................................................................... 25
trinatal rx 1 ......................................................... 74
TRINATE ........................................................... 74
TRINESSA (28)
............................................................................................... 47
triple antibiotic
............................................................................................... 51
TRI-PREVIFEM
............................................................................................... 47
triprolidine-pse
............................................................................................... 49
TRI-SPRINTEC
............................................................................................... 47
tri-vit/fluoride
............................................................................................... 73
tri-vit/fluoride/iron
............................................................................................... 73
tri-vitamin .............................................................. 73
tri-vitamin/fluoride
............................................................................................... 73
TRIVORA (28)
............................................................................................... 47
TROJAN ............................................................... 67
TROJAN NATURALAMB
............................................................................................... 67
trospium chloride
............................................................................................... 87
TRUVADA
............................................................................................... 34
TUDORZA PRESSAIR
............................................................................................... 10
tybost ........................................................................... 37
TYKERB .............................................................. 30
UNITHROID
............................................................................................... 85
urea ................................................................................. 54
URETRON D/S
............................................................................................... 86
ursodiol ...................................................................... 60
uticap ............................................................................ 86
valacyclovir hcl
............................................................................................... 37
valproic acid
............................................................................................... 15
vancomycin hcl
............................................................................................... 25
VANDAZOLE
............................................................................................... 87
VCF VAGINAL
CONTRACEPTIVE
............................................................................................... 87
VELIVET ............................................................. 47
venlafaxine hcl
............................................................................................... 16
venlafaxine hcl er
............................................................................................... 16
VENTOLIN HFA
............................................................................................... 12
verapamil hcl
............................................................................................... 40
verapamil hcl er
............................................................................................... 40
VESTURA .......................................................... 45
VEXOL .................................................................... 78
VIDEX ..................................................................... 36
­
VINATE AZ EXTRA
............................................................................................... 74
VINATE II ......................................................... 74
VINATE M
............................................................................................... 74
viorele .......................................................................... 42
VIRACEPT
............................................................................................... 35
VIREAD ................................................................ 36
vitamin a .................................................................. 88
vitamin b complex-c
............................................................................................... 72
vitamin b-1 ............................................................ 88
vitamin b-12 ........................................................ 62
vitamin b-6 ............................................................ 89
vitamin b-6 er
............................................................................................... 89
vitamin c .................................................................. 89
­
vitamin d (ergocalciferol)
............................................................................................... 88
vitamin d3 .............................................................. 88
vitamin k (phytonadione)
............................................................................................... 88
vitamins acd-fluoride
............................................................................................... 73
vitatrum .................................................................... 73
VOLTAREN
............................................................................................... 52
VYFEMLA
............................................................................................... 45
VYVANSE ............................................................. 1
warfarin sodium
............................................................................................... 12
WERA ....................................................................... 45
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
103
WESTHROID
............................................................................................... 85
WIDE-SEAL DIAPHRAGM 60
............................................................................................... 67
WIDE-SEAL DIAPHRAGM 65
............................................................................................... 67
WIDE-SEAL DIAPHRAGM 70
............................................................................................... 67
WIDE-SEAL DIAPHRAGM 75
............................................................................................... 67
WIDE-SEAL DIAPHRAGM 80
............................................................................................... 67
WIDE-SEAL DIAPHRAGM 85
............................................................................................... 67
WIDE-SEAL DIAPHRAGM 90
............................................................................................... 68
WIDE-SEAL DIAPHRAGM 95
............................................................................................... 68
WYMZYA FE
............................................................................................... 45
XALKORI .......................................................... 30
XARELTO ......................................................... 12
XOLAIR ................................................................ 10
XTANDI ............................................................... 28
XULANE ............................................................. 47
X-VIATE .............................................................. 54
zafirlukast ............................................................. 10
ZARAH .................................................................. 45
ZELBORAF
............................................................................................... 29
ZENCHENT
............................................................................................... 45
ZENCHENT FE
............................................................................................... 45
ZETIA ....................................................................... 23
ZIAGEN ................................................................ 36
zidovudine .............................................................. 36
zinc sulfate ............................................................ 71
ZOLINZA ........................................................... 29
zolpidem tartrate
............................................................................................... 64
zonisamide ............................................................. 14
ZOVIA 1/35E (28)
............................................................................................... 45
ZOVIRAX .......................................................... 52
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
104

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