2016 Drugs Requiring Prior Authorization List

Transcription

2016 Drugs Requiring Prior Authorization List
10/1/16 Edition
Status
Clinical
Definition
Prior Authorization is required.
Please submit a Pharmacy Prior Authorization Request Form.
Non-Formulary
Use another agent similar to requested agent. Specific indication might be required
Step Therapy
An adequate trial of another preferred agent(s) is required before approval.
Step Therapy
An adequate trial of another preferred agent(s) is required before approval.
Prior Authorization is required.
Specialty
Please submit a Specialty Pharmacy Prior Authorization Form.
Refer to Specialty Pharmacy Medication Policies on CareSource.com
Note: A drug is available generically if its listing includes both a generic and a brand name.
Drug
Status
Special Instructions
8-Mop 10 mg Capsule
Clinical
ABSORICA 10 mg CAPSULE
Lower Cost
Required Diagnosis= Cutaneous T-Cell Lymphoma
(CTCL) OR Psoriasis With A 30 Day Trial Of
Calcipotriene
Requires trials of 90 days total of each group below
either at the same time, separately, or overlapping
Topicals: benzoyl peroxide 5% or 10%; benzoyl
peroxide 4% or 8% liquid (Panoxyl),
erythromycin/benzoyl (Benzamycin), sulfacetamide
(Klaron), clindamycin topical (Cleocin T), erythromycin
topical, tretinoin cream or gel or adapalene 0.1% gel or
cream [or previously approved for a similar nonpreferrerd topical agent]
AND
Orals: minocycline, doxycycline, tetracycline, or
erythromycin
Lower Cost
AND
erythromycin
1
Drug
Status
Lower Cost
AND
erythromycin
Lower Cost
AND
erythromycin
ABSTRAL 100 mcg TABLET SUBLINGAL
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
ACANYA GEL PUMP 2.5%-1.2%
Lower Cost
Required diagnosis = breakthrough pain in adults with
cancer who are receiving and are tolerant to opioid
therapy
therapy
therapy
therapy
therapy
therapy
Formulary agents: BENZOYL PEROXIDE 2.5% GEL AND
CLINDAMYCIN, CLINDAMAX (CLEOCIN-T) 1% GEL
separately used together
ACETAMINOPHEN-ISOMETHEPTENECAFFEINE (PRODRIN) TAB 325-65-20
MG
Lower Cost
ACETAMINOPHEN-ISOMETHEPTENECAFFEINE (PRODRIN) TAB 500-130-20
MG
Lower Cost
Formulary Agents: Butalbital-Acetaminophen 50325MG tablet (Phrenilin, Marten tabs), ButalbitalAcetaminophen-Caffeine (Esgic-Plus) 50-500-40MG
tablet, Butalbital-Aceteminophen-Caffeine (Fioricet) 50325-40MG tablet
Formulary Agents: Butalbital-Acetaminophen 50325MG tablet (Phrenilin, Marten tabs), ButalbitalAcetaminophen-Caffeine (Esgic-Plus) 50-500-40MG
tablet, Butalbital-Aceteminophen-Caffeine (Fioricet) 50325-40MG tablet
2
Drug
Status
ACCU-CHEK TEST STRIPS/METER
Lower Cost
Formulary agents: FreeStyle or Precision products
ACETAMINOPHEN-CAFFEINEDIHYDROCODEINE (PANLOR/PANLOR
SS) 712.8-60-32 mg TABLET
ACID JELLY
Lower Cost
Formulary agent: Butalbital-Aceteminophen-CaffeineCodeine (FIORICET-COD) 30-50-325-40 capsule
Lower Cost
ACIPHEX 10 mg SPRINKLE CAPS
Lower Cost
ACIPHEX 5 mg SPRINKLE CAPS
Lower Cost
Formulary agents: ALIGN, FLORAJEN, FLORA-Q,
RESTORA, RISAQUAD, REZYST, or DIFF-STAT (oral
probiotics)
Formulary agent: RABEPRAZOLE (ACIPHEX EC) 20 MG
TABLET
Formulary agent: RABEPRAZOLE (ACIPHEX EC) 20 MG
TABLET
Formulary agent: calcipotriene (Dovonex) or previous
approval of Enbrel, Humira, or Stelara
ACITRETIN (SORIATANE) 10 mg CAPSULE Lower Cost
ACITRETIN (SORIATANE) 17.5 mg
Lower Cost
CAPSULE
ACITRETIN (SORIATANE) 25 mg CAPSULE Lower Cost
ACLARO, ACLARO PD 4% EMULSION
ACTEMRA 200/10 mL
Excluded benefit
Clinical
Specialty; follow policy on CareSource.com.
ACTEMRA 400/20 mL
Clinical
ACTEMRA 162 mg/0.9 mL
Clinical
ACTEMRA 80 mg/4 mL
Clinical
ACTHAR HP
Specialty
ACTIMMUNE 2 MILLION UNIT VIAL
Clinical
Active OB
Lower Cost
Required diagnosis = chronic granulomatous disease or
malignant osteoporosis
Formulary Agent(s): Any Formulary Prenatal Vitamin
ACTONEL 150 mg TABLET
ACTONEL 5 mg TABLET
ACTONEL WITH CALCIUM TABLET 35
mg/500 mg
ACTOPLUS MET XR 15-1,000MG TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary agent: alendronate
Formulary agent: alendronate then Actonel and OTC
calcium 500 mg tablet
Formulary agents: Metformin IR or ER (Glucophage or
Glucophage ER)
Glucophage ER)
Formulary agent: ketorolac (ACULAR) 0.5% EYE DROPS
Step Therapy
ACTOPLUS MET XR 30-1,000MG TABLET Step Therapy
ACUVAIL 0.45% OPHTH SOLUTION
Lower Cost
ACYCLOVIR (ZOVIRAX) 5% OINTMENT
Step Therapy
Required Diagnosis= Acute Outbreak Of Genital Herpes
Simplex OR Cold Sores/Oral Herpes Simplex
With A Trial Of Abreva
ACZONE 5% GEL
Lower Cost
ADAPALENE (DIFFERIN) 0.1% LOTION
Lower Cost
Formulary agents: benzoyl peroxide 5% or 10%;
benzoyl peroxide 4% or 8% liquid (Panoxyl);
erythromycin/benzoyl (Benzamycin); sulfacetamide
(Klaron); clindamycin topical (Cleocin T); erythromycin
topical; tretinoin cream or gel; adapalene 0.1% gel or
cream
Formulary agent: Adapalene (Differin) 0.1% cream or
gel
3
Drug
Status
ADAPALENE (DIFFERIN) 0.3% GEL
Lower Cost
gel
gel
Formulary agents: aripiprazole (Abilify) tablets (which
require a step through: quetiapine, risperidone,
clozapine, ziprasadone or olanzapine)
ADAPALENE (DIFFERIN) 0.3% GEL PUMP Lower Cost
ADASUVE 10MG INHALATION
Lower Cost
Adcetris 50 mg Vial
ADCIRCA 20 mg TABLET
Specialty
Specialty
Addyi Tablet
ADEMPAS 0.5 mg TABLET
Excluded Benefit
Clinical
ADEMPAS 1 mg TABLET
Clinical
Request Must Go Through Clinical Review
Specialty; Follow Policy On CareSource.com
Required diagnosis = Pulmonary Arterial Hypertension,
rx prescribed by
pulmonologist and/or cardiologist,
and WHO Group 1 with NYHA Functional class II or III
or IV symptoms
AND
PAP pressures not adequately controlled using an oral
vasodilator at maximal doses
OR
The member was not vasodilator sensitive as
determined by a epoprostenol, adenosine, or inhaled
nitric
oxide
challenge
Required
diagnosis
= Pulmonary Arterial Hypertension,
rx prescribed by
or IV symptoms
AND
OR
nitric oxide challenge
Clinical
rx prescribed by
or IV symptoms
AND
OR
4
Drug
Status
ADEMPAS 2 mg TABLET
Clinical
rx prescribed by
or IV symptoms
AND
OR
Clinical
rx prescribed by
or IV symptoms
AND
OR
ADOXA PAK 1/TAB 100 mg
Lower Cost
Lower Cost
Lower Cost
ADRENALIN 1:1,000 NASAL SOLUTION
Lower Cost
Formulary Agents: doxycycline monohydrate 50MG &
100MG capsules
100MG capsules
100MG capsules
Required Diagnosis= Nasal Congestion
Required Trial Of: OTC Nasal Decongestants (i.e.; 12 HR
Nasal, Anefrin, Nasal NoDrip (Afrin, Dristan, NeoSynephrine,), Nrs Nasal or Neo-Synephrine)
ADASUVE 10MG INHALATION
ADVAIR DISKUS 250-50MCG
Lower Cost
Lower Cost
ADVAIR DISKUS 500-50MCG
Lower Cost
ADVAIR HFA 45-21MCG
Lower Cost
ADVAIR HFA 115-21MCG
Lower Cost
Formulary agent: aripiprazole (Abilify) tablets
Required Diagnosis= Asthma, COPD (Emphysema,
Chronic Bronchitis) Or Lung Cancer
AND
Formulary Agent(s): Dulera OR Symbicort
AND
AND
AND
5
Drug
Status
ADVAIR HFA 230-21MCG
Lower Cost
ADVICOR 1,000 mg-20 mg TABLET
Lower Cost
ADVICOR 1,000 mg-40 mg TABLET
Lower Cost
ADVICOR 500 mg-20 mg TABLET
Lower Cost
ADVICOR 750 mg-20 mg TABLET
Lower Cost
ADVIL 200 mg LIQUI-GEL CAPSULE
Adzenys-XR 3.1 mg ODT Tablet
Lower Cost
Lower Cost
AND
Formulary agents : lovastatin (Mevacor) with OTC
niacin separately AND simvastatin (Zocor) or
atorvastatin (Lipitor) with OTC niacin separately
Formulary agent: IBUPROFEN 200 mg OTC tablet
Age 6 Or Older AND A Trial Of DextroamphetamineAmphetamine (Adderall) Or Adderall XR
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
AFINITOR 10 mg TABLET
Clinical
AFINITOR 2.5 mg TABLET
Clinical
AFINITOR 5 mg TABLET
Clinical
Required diagnosis = advanced hormone
receptor–positive, human epidermal growth receptor
2 (HER2)–negative breast cancer, advanced
neuroendocrine tumors of pancreatic origin, advanced
renal cell carcinoma, or renal angiomyolipoma and
tuberous sclerosis complex, adult and pediatric
patients 3 years and older with subependymal giant
cell astrocytoma
cell astrocytoma
cell astrocytoma
6
Drug
Status
AFINITOR 7.5 mg TABLET
Clinical
AFINITOR DISPERZ 2 mg TABLET
Clinical
Clinical
Clinical
AFREZZA 4 UNIT/CARTRIDGE
INHALABLE INSULIN
AGAMATRIX AMP BLOOD GLUCOSE
METER
AGAMATRIX AMP BLOOD GLUCOSE
STRIPS
AKNE-MYCIN 2% OINTMENT
Lower Cost
cell astrocytoma
cell astrocytoma
cell astrocytoma
cell astrocytoma
Formulary Agents: Humulin R or Novolin R
Lower Cost
Formulary Agent(s): FreeStyle Or Precision Products
Lower Cost
Formulary Agent(s): FreeStyle Or Precision Products
Lower Cost
AKYNZEO 300-0.5MG CAPSULE
Clinical
ALAMAST 0.1% DROPS
Lower Cost
Formulary agents: ERYTHROMYCIN 2% GEL,
ERYTHROMYCIN 2% PLEDGETS, or ERYTHROMYCIN 2%
SOLUTION
Required Dx= Treat nausea and vomiting in patients
undergoing cancer chemotherapy
Formulary agents: OTC agents with ketotifen AND
azelastine (Optivar)
ALA-QUIN 3/1% CREAM
Lower Cost
ALCORTIN A 1-2-1% GEL
Lower Cost
Required diagnosis= Atopic Dermatitis (Eczema) AND
Must use 2 different formulary corticosteroid agents
for 7 days each.
Formulary agents: OTC hydrocortisone-aloe vera with
topical anti-fungal (clotrimazole, terbinafine,
tolnaftate, or miconazole) use separately at the same
time
Formulary agents: OTC hydrocortisone-aloe vera with
topical anti-fungal (clotrimazole, terbinafine)
ALCORTIN A GEL (Contains:
Lower Cost
IODOQUINOL-HYDROCORTISONE-ALOE
POLYSACCHARIDE GEL 1-2-1%
ALDURAZYME
Specialty
Alecensa 150mg Capsule
Lower Cost
7
Drug
Status
ALINIA 100 mg/5 mL SUSPENSION
Clinical
ALINIA 500 mg TABLET
Clinical
ALLEGRA 30 mg/5 mL SUSPENSION
Lower Cost
ALLEGRA ODT 30 mg TABLET
Lower Cost
Required diagnosis = diarrhea caused by Giarda
lamblia or Cryptosporidium parvum
Required diagnosis = diarrhea caused by Giarda
lamblia or Cryptosporidium parvum
No longer available; use ALLEGRA ALLERGY 30 mg/5
mL SUSPENSION
Formulary agents: ALLEGRA ALLERGY (OTC) 30 mg
tablet OR ALLEGRA ALLERGY 30 mg/5 mL SUSPENSION
ALLFEN CD TABLET
ALOCRIL 2% EYE DROPS
Lower Cost
Lower Cost
Formulary agent: OTC guaifenesin tablet
ALOSETRON (LOTRONEX) 0.5 mg TABLET Clinical
ALOSETRON (LOTRONEX) 1 mg TABLET
Clinical
ALOXI 0.25 mg/ML
Clinical
ALPHAGAN P 0.1% DROPS
ALPRAZOLAM (XANAX) 1 mg/ML ORAL
CONCENTRATE
Lower Cost
Lower Cost
Required diagnosis = severe diarrhea, IBS with a trial of
atropine-diphenoxylate (Lomotil) or dicyclomine
(Bentyl)
Required diagnosis = severe diarrhea, IBS with a trial of
atropine-diphenoxylate (Lomotil) or dicyclomine
(Bentyl)
Required diagnosis=Chemotherapy-induced nausea
and vomiting or Postoperative nausea and vomiting
Formulary agent: brimonidine ophthalmic 0.2%
Requires an inability to swallow pills or a clinical
reason supported by chart notes why alprazolam
tablet cannot be used
ALPRAZOLAM ODT (NIRAVAM) 0.25 mg Lower Cost
ORALLY DISINTEGRATING TABLET
ALPRAZOLAM ODT (NIRAVAM) 0.5 mg
Lower Cost
ALPRAZOLAM ODT (NIRAVAM) 1 mg
Lower Cost
ALPRAZOLAM ODT (NIRAVAM) 2 mg
Lower Cost
ALREX 0.2% EYE DROPS
Lower Cost
ALTABAX 1% OINTMENT
ALTOPREV 20 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
ALVESCO 160 mcg INHALER
ALVESCO 80 mcg INHALER
AMCINONIDE 0.1% CREAM
Lower Cost
Lower Cost
Lower Cost
AMCINONIDE 0.1% LOTION
Lower Cost
AMCINONIDE 0.1% OINTMENT
Lower Cost
Formulary agent: mupirocin ointment
Formulary agents: lovastatin (Mevacor) AND
simvastatin (Zocor) OR atorvastatin (Lipitor)
Formulary Agent(s): Aerospan or Asmanex
Formulary Agent(s): Aerospan or Asmanex
for 7 days each.
for 7 days each.
for 7 days each.
8
Drug
Status
AMETHYST 90-20 mcg TABLET
Lower Cost
AMEVIVE
Clinical
Formulary agents: a formulary birth control option
(most similar agent=Sronyx)
Amitiza 24 mcg Capsule
Step Therapy
Amitiza 8 mcg Capsule
Step Therapy
AMLODIPINE-ATORVASTATIN (CADUET)
10 mg-10 mg TABLET
10 mg-20 mg TABLET
10 mg-40 mg TABLET
10 mg-80 mg TABLET
2.5 mg-10 mg TABLET
2.5 mg-20 mg TABLET
2.5 mg-40 mg TABLET
5 mg-10 mg TABLET
5 mg-20 mg TABLET
5 mg-40 mg TABLET
5 mg-80 mg TABLET
AMNESTEEM 10 mg TABLET
Lower Cost
Lower Cost
Formulary Agent(s): A 7 Day Trial Of Lactulose,
Constulose, Enulose, Generlac Or Kristalose Within The
Last 30 Days
Last 30 Days
Formulary agent: amlodipine and atorvastatin
separately taken together
AND
erythromycin
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
AND
erythromycin
9
Drug
Status
Lower Cost
AND
erythromycin
AMOXICILLIN-CLARITHROMYCINLANSOPRAZOLE (PREVPAC) PATIENT
PACK
AMPYRA ER 10 mg TABLET
Lower Cost
Formulary agents: amoxicillin, clarithromycin, and
lansoprazole separately
Clinical
Specialty; Request Must Go Through Clinical Review
AMRIX 15 mg CAPSULE
AMRIX 30 mg CAPSULE
AMTURNIDE 150-5-12.5 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
AMTURNIDE 300-10-25 mg TABLET
Lower Cost
Lower Cost
AMTURNIDE 300-5-25 mg TABLET
Lower Cost
ANABAR CAPLET
ANADROL-50 TABLET
ANALPRAM KIT ADVANCED
Lower Cost
Clinical
Lower Cost
Formulary agent: NON-ER cyclobenzaprine tablet
Formulary agent: NON-ER cyclobenzaprine tablet
Formulary agent: losartan/hctz (Hyzaar),
Irbesartan/Hctz (Avalide), valsartan/hctz (Diovan HCT),
or candesartan/Hctz (Atacand HCT) (must try 2 of the
4)
4)
4)
4)
4)
No longer available on the market
Required diagnosis = anemia
Requires clinical reason supported by chart notes why
HYDROCORTISONE Acetate 1%/Pramoxine
Hydrochloride 1% (ANALPRAM-HC) CREAM cannot be
used
ANDRODERM 2 mg/24HR PATCH
Lower Cost
Formulary agents = Testosterone TD (Fortesta) Or
Testosterone (Androgel, Testim, Vogelxo) Gel Packet
(both still require a prior authorization) with a
diagnosis of hypogonadism and total testosterone lab
value = ≤ 300 ng/dL before treatment
10
Drug
Status
ANDRODERM 4 mg/24HR PATCH
Lower Cost
ANDROGEL 1% GEL PUMP
Lower Cost
ANDROGEL 1.62% ( 20.25 MG/ACT) GEL Lower Cost
PUMP
ANDROGEL 1.62% (20.25 mg/1.25 gM)
GEL PACKET
Lower Cost
ANDROGEL 1.62% (40.5 mg/2.5 gM) GEL Lower Cost
PACKET
ANDROXY 10 mg TABLET
Required diagnosis = metastatic mammary cancer or
hypogonadism
(both still require a prior authorization)
Formulary Agent(s): AneCream, Lidocream, LC-4
Lidocaine (LMX 4) AND Transparent Dressing
Separately Used Together At The Same Time
A 7 Day Trial Of: Lidocaine 2% Gel, Lidocaine 3%
Cream, Or Lidocaine 4% Cream
Formulary agents: Femhrt or Prempro
Formulary Agent(s): Omega 3 with EPA/DHA, Vitamin
B6, Vitamin B12, and Folate taken separately used
together at the same time
Required Dx= COPD;
Required 30 day trial of either: Dulera or Symbicort
Clinical
ANECREAM, LIDOCREAM (LMX 4 PLUS) Lower Cost
KIT 4%
ANECREAM5, LC-5, LIDOCAINE
(RECTICARE, LMX 5) CREAM
ANGELIQ 0.25-0.5 mg TABLET
ANGELIQ 0.5 mg-1 mg TABLET
ANIMI-3 500-1,000-1MG CAPSULE
Lower Cost
ANORO ELLIPTA 62.2-25 MCG/INH
Lower Cost
FENOFIBRATE (ANTARA) 130 mg
CAPSULE
FENOFIBRATE (ANTARA) 30 mg
CAPSULE
ANTARA 43 mg CAPSULE
ANTARA 90 mg CAPSULE
ANTIVERT 50 mg TABLET
ANZEMET 100 mg TABLET
Lower Cost
Formulary agent: fenofibrate (Lofibra)
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
ANZEMET 50 mg TABLET
Lower Cost
APEXICON E 0.05% CREAM
Lower Cost
Formulary agent: MECLIZINE 12.5 mg OR 25 mg
Formulary agents: ondansetron, meclizine,
promethazine, prochlorperazine, granisetron
Formulary agent: DIFLORASONE 0.05% CREAM
Lower Cost
Lower Cost
Lower Cost
11
Drug
Status
APHTHASOL PST 5%
Clinical
Required diagnosis = aphthous ulcers in patients with
normal immune systems who have failed
TRIAMCINOLONE 0.1% PASTE administered 4 times
daily; doxycycline capsule of 100 mg in 10 mL of water
administered as a mouth rinse for 3 minutes;
chlorhexidine gluconate mouth rinses; vitamin B12
used orally
APLENZIN ER 174 mg TABLET
APOKYN 30 mg/3 mL CARTRIDGE
Lower Cost
Lower Cost
Lower Cost
Lower Cost
APRACLONIDINE (IOPIDINE) 0.5% EYE
DROPS
APTENSIO XR 10MG CAPSULE
Lower Cost
Formulary agent: buproprion XL
Formulary agents: bromocriptine, amantadine,
carbidopa/levodopa, pramipexole, ropinirole,
selegiline
Lower Cost
Required diagnoses: ADD/ADHD; Autism; Asperger's;
Hyperkinetic Syndrome
Trials per Ages below
Age under 6 - off label (need clinicals to support use)
and
Trial (90 days total) of any combo of:
dextroamphetamine, dextroamphetamine ER
(Dexedrine), amphetamine salt combo (ADDERALL),
dextroamphetamine-amphetamine ER (ADDERALL XR)
OR
Clinical reason supported by chart notes why (after a
90 day trial of) the below cannot be used
Methylphenidate ER tablet (Concerta),
Methylphenidate CD capsule (Metadate CD),
Methylphenidate SR capsule (Ritalin LA)
Lower Cost
and
OR
12
Drug
Status
Lower Cost
and
OR
Lower Cost
and
OR
Lower Cost
and
OR
13
Drug
Status
Lower Cost
and
OR
Lower Cost
and
OR
APTIOM 200MG TABLET
Lower Cost
APTIOM 400MG TABLET
Lower Cost
Required Diagnosis = Seizure or Epilespsy
Formulary agents:gabapentin, lamotrigine (Lamictal),
divalproex (Depakote), levetiracetam (Keppra),
levetiracetam er (Keppra XR), oxcarbazepine
(Trileptal), carbamazepine (Carbatrol), Phenytoin
(Dilantin), topiramate (Topamax), VALPROIC ACID
(Depakene) or Zonisamide
14
Drug
Status
APTIOM 600MG TABLET
Lower Cost
APTIOM 800MG TABLET
Lower Cost
ARALAST NP 1000 mg SOLUTION
Specialty
Alpha 1-proteinase inhibitor INJECTION
Specialty
Specialty
Specialty
ARANESP 10MCG/0.4ML SYRINGE
ARANESP 100 mcg/0.5 mL SYRINGE
Clinical
Clinical
ARANESP 100 mcg/ML VIAL
Clinical
Clinical
ARANESP 150 mcg/0.75 mL VIAL
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
ARANESP 500 mcg/1 mL SYRINGE
Clinical
Clinical
15
Drug
Status
Clinical
ARCALYST 220 mg INJECTION
Clinical
ARESTIN 1 mg SUBGINGIVAL
Armodafinil (Nuvigil) 50 mg Tablet
Lower Cost
Clinical
Required Diagnosis= Adult Periodontitis
Requires a diagnosis of: Narcolepsy/Cataplexy/Sleep
Apnea/OSA/ Shift Work/MS related daytime
fatigue/Hypersomnia/Excessive Daytime Sleepiness
Clinical
Clinical
Clinical
ARNUITY ELLIPTA 100MCG INHALER
Lower Cost
ARNUITY ELLIPTA 200MCG INHALER
Lower Cost
For Ages 6 And Under:
Formulary Agent(s): Asmanex
Or
For Ages 7 And Older:
Formulary Agent(s): Asmanex Or Aerospan
For Ages 6 And Under:
Formulary Agent(s): Asmanex
Or
For Ages 7 And Older:
Formulary Agent(s): Asmanex Or Aerospan
ASCENSIA Contour TEST STRIPS/METER Lower Cost
ASPIRIN-DIPYRIDAMOLE ER
(AGGRENOX) CAPSULE
Lower Cost
Formulary agent: aspirin with a diagnosis of transient
ischemia of the brain or complete ischemic stroke due
to thrombosis
ASTAGRAF XL 0.5 mg CAPSULE
Lower Cost
ASTAGRAF XL 1 mg CAPSULE
Lower Cost
ASTAGRAF XL 5 mg CAPSULE
Lower Cost
ATGAM 50 mg/ML AMPULE
Clinical
ATOPICLAIR CREAM
Lower Cost
AUBAGIO 14 mg TABLET
Specialty
Formulary agent: Tacrolimus (PROGRAF) 0.5 mg
CAPSULE
CAPSULE
CAPSULE
Required diagnosis = Diagnosis of management of
allograft rejin renal transplant patients or Aplactic
anemia
Formulary agents: Cerave; Cetaphil; Aveeno;
Lubriderm (Eucerin)
AUBAGIO 7 mg TABLET
Specialty
AURAX (AURALGAN) 5.5-1.4% OTIC
SOLUTION
AURODEX OTIC SOLUTION DAW
Lower Cost
Formulary agent: antipyrine-Benzocaine (AURODEX)
OTIC SOLUTION
Formulary agent: Antipyrine-Benzocaine (AURODEX)
OTIC SOLUTION
Lower Cost
16
Drug
Status
AURYXIA 1G (210MG FERRIC IRON)
TABLET
Lower Cost
Avalide 150-12.5 mg TABLET DAW
Lower Cost
Avalide 300-12.5 mg TABLET DAW
Lower Cost
Avalide 300-25 mg TABLET DAW
Lower Cost
AVANDAMET 2 mg-1,000 mg TABLET
Lower Cost
AVANDAMET 2 mg-500 mg TABLET
Lower Cost
AVANDAMET 4 mg-1,000 mg TABLET
Lower Cost
AVANDAMET 4 mg-500 mg TABLET
Lower Cost
AVANDARYL 4 mg-1 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
AVANDIA 2 mg TABLET
Lower Cost
AVANDIA 4 mg TABLET
Lower Cost
AVANDIA 8 mg TABLET
Lower Cost
AVAPRO 150 mg TABLET
Lower Cost
Required Diagnosis: For the control of serum
phosphorus levels in patients with chronic kidney
disease (CKD) receiving dialysis
AND
Formulary Agent(s): calcium acetate (PhosLo)
Formulary agents: 2 different manufacturers of
generic IRBESARTAN/HCTZ (Avalide) 150-12.5 mg
tablet
tablet
tablet
Glucophage ER) AND
Pioglitazone/Metformin (ActosPlusMet)
Glucophage ER) AND
Glucophage ER) AND
Glucophage ER) AND
Glucophage ER) AND
AND
pioglitazone/glimepiride (Duetact)
Glucophage ER) AND
AND
pioglitazone/glimepiride (Duetact))
Glucophage ER) AND
AND
Glucophage ER) AND
AND
pioglitazone/glimepiride (Duetact)
Glucophage ER) AND
AND
Glucophage ER)
AND
PIOGLITAZONE (ACTOS)
Glucophage ER)
AND
Glucophage ER)
AND
generic irbesartan tablet
17
Drug
Status
AVAPRO 75 mg TABLET
Lower Cost
AVAPRO 300 mg TABLET
Lower Cost
AVAR 9.5-5% Cleansing Pads
Lower Cost
AVAR 9.5-5% FOAM
Lower Cost
Avar LS 10-2% Cleansing Pads
Lower Cost
AVAR LS 10-2% FOAM
Lower Cost
AVASTIN 100 mg/4 mL
AVASTIN 400 mg/16 mL
AVC 15% VAGINAL CREAM
Specialty
Specialty
Lower Cost
MOXIFLOXACIN (AVELOX) 400 mg
TABLET
AVENOVA 0.1% SPRAY
MORPHINE SULFATE SR BEADS (AVINZA)
120 MG CAPSULE
30 MG CAPSULE
45 MG CAPSULE
60 MG CAPSULE
75 MG CAPSULE
90 MG CAPSULE
Avo Cream Emulsion
AVONEX ADMIN PACK 30 mcg VIAL
Step Therapy
Formulary agents: AVAR-E LS 10-2% CREAM,
SULFACETAMIDE SODIUM W/ SULFUR SUSPENSION 105%, SULFACETAMIDE SODIUM W/ SULFUR LOTION 105%, OR SULFACETAMIDE SODIUM W/ SULFUR
EMULSION, AVAR CLEANSER , ROSANIL, PRASCION 105%
Formulary Agent(s): Sulfacetamide Sodium W/ Sulfur
(Avar-E LS) 10-2% Cream
Formulary Agent(s): Sulfacetamide Sodium W/ Sulfur
(Avar-E LS) 10-2% Cream
Formulary agent: fluconazole oral tablet or miconazole
vaginal suppositories
Formulary agent: ciprofloxacin or levofloxacin
Non Covered
Lower Cost
Formulary agent: morphine sulfate ER (MS Contin)
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Clinical
Formulary Agent(s): Woun'Dres Wound Dressing
AVONEX PREFILLED SYRINGE 30 mcg
Clinical
AXID AR 75 mg CAPSULE
Lower Cost
AXIRON 30 mg/ACTUATION SOLUTION
Lower Cost
Formulary agent: NIZATIDINE (AXID) 150 mg CAPSULE,
NIZATIDINE (AXID) 300 mg CAPSULE OR NIZATIDINE
(AXID) 15 mg/ML SOLUTION
Formulary Agents= Testosterone TD (Androgel, Testim,
Vogelxo) 1% (50GM) Gel Packet or Fortesta (Both Still
Require A Prior Authorization) With A Diagnosis Of
Hypogonadism And Total Testosterone Lab Value = ≤
300 ng/dL Before Treatment
AXSAIN 4%-0.25% CREAM
Lower Cost
AZACITIDINE (VIDAZA) 100 mg
Suspension for INJECTION
AZASITE 1% EYE DROPS
Lower Cost
Formulary Agent(s): Arthritis Pain Relief, Capsaicin,
Muscle Relief, Theragen-HP, Trixaicin HP (Zostrix HP)
0.075% Cream
Lower Cost
Formulary agents: ciprofloxacin or ofloxacin
ophthalmic
18
Drug
Status
AZELEX 20% CREAM
Lower Cost
AZILECT 0.5 mg TABLET
Lower Cost
AZILECT 1 mg TABLET
Lower Cost
AZOPT 1% EYE DROPS
Lower Cost
AZOR 10-20 mg TABLET
Lower Cost
AZOR 10-40 mg TABLET
Lower Cost
AZOR 5-20 mg TABLET
Lower Cost
AZOR 5-40 mg TABLET
Lower Cost
BACK & BODY (BAYER BACK & BODY)
500-32.5MG TABLET
BANZEL 200 mg TABLET
Lower Cost
benzoyl peroxide 4% or 8% liquid (Panoxyl);
erythromycin/benzoyl (Benzamycin); sulfacetamide
(Klaron); clindamycin topical (Cleocin T); erythromycin
topical; tretinoin cream or gel; adapalene 0.1% gel or
cream
selegiline
selegiline
Formulary agent: DORZOLAMIDE (TRUSOPT) 2% EYE
DROPS
Formulary agents: losartan (Cozaar) or irbesartan
(Avapro) WITH amlodipine separately, Amlodipine
Besylate-Valsartan (Exforge) or TelmisartanAmlodipine (Twynsta)
Formulary Agent(s): aspirin 325mg or 500mg
Step Therapy
Requires trial of: topiramate (Topamax),
gabapentin, lamotrigine (Lamictal), divalproex
(Depakote), levetiracetam (Keppra), levetiracetam er
(Keppra XR), oxcarbazepine (Trileptal), carbamazepine
(Carbatrol), phenytoin (Dilantin), VALPROIC ACID
(Depakene) or zonisamide or previous approval of
Lyrica, Vimpat, Onfi, Stavzor, or Potiga
BANZEL 400 mg TABLET
Step Therapy
BANZEL 40 mg/ML SUSPENSION
Lower Cost
AND
Banzel tablets (Which also require a PA)
BAYER CONTOR TEST STRIPS
Lower Cost
19
Drug
Status
B-Donna, Phenohytro (Donnatal) 16.2
mg Tablet
Lower Cost
BECONASE AQ 0.042% SPRAY
Lower Cost
Formulary Agent(s): Phenobarbital 16.2 mg And
Hyoscyamine 0.125 mg Or 0.375 mg Tablet Separately
Taken Together At The Same Time
Formulary Agent(s): Ages 2-3: Nasacort OTC Allergy
24HR Spray
OR
Ages 4-5: Fluticasone (Flonase), Flonase OTC Allergy
Relief Spray, Or Nasacort OTC Allergy 24HR Spray
OR
Ages 6 And Older: 2 Of The Following 4 Drugs:
Fluticasone (Flonase), Flunisolide, Flonase OTC Allergy
BELBUCA 75MCG BUCCAL FILM
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
BELSOMRA 5MG TABLET
BELSOMRA 10MG TABLET
BELVIQ 10 mg TABLET
BENICAR 20 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Excluded benefit
Lower Cost
BENICAR 40 mg TABLET
Lower Cost
BENICAR 5 mg TABLET
Lower Cost
BENICAR HCT 20-12.5 mg TABLET
Lower Cost
BENICAR HCT 40-12.5 mg TABLET
Lower Cost
BENICAR HCT 40-25 mg TABLET
Lower Cost
BENLYSTA
Specialty
Bensal HP 6-3% Ointment
Lower Cost
Formulary Agent(s): Morphine Sulfate ER,
Oxymorphone ER, Or Fentanyl
Formulary Agents: zaleplon or zolpidem
(Avapro)
(Avapro)
(Avapro)
Formulary agents: losartan/hctz (Hyzaar),
or candesartan/Hctz (Atacand HCT). Must try 2 of the
4 Formulary agents for 60 days.
Elig:
Formulary Agent(s): OTC Salicylic Acid 6% Cream, Gel,
Or Lotion OR OTC Salicylic Acid 17.6%
20
Drug
Status
BENZACLIN 1-5% GEL PUMP and GEL
Lower Cost
Formulary agents: BENZOYL PEROXIDE 5% GEL
(Panoxyl) WITH CLINDAMYCIN, CLINDAMAX (CLEOCIN
T) 1% LOTION, CLINDAMYCIN SWAB (CLEOCIN T) 1%
PLEDGETS, CLINDAMYCIN PHOSPHATE 1% SOLUTION
BENZAMYCIN PAK GEL
Lower Cost
BENZEPRO SC, BENZOYL PEROXIDE
(BENZEFOAM ULTRA) 9.8% FOAM
Lower Cost
Formulary agent: BENZOYL PEROXIDE-ERYTHROMYCIN
(BENZAMYCIN) 5-3% GEL
Formulary agents: BENZOYL PEROXIDE 2.5% WASH or
GEL (PANOXYL), BENZOYL PEROXIDE 4% CLEANSER
(PANOXYL), BENZOYL PEROXIDE 5% GEL (PANOXYL),
BENZOYL PEROXIDE 5% LOTION, BENZOYL PEROXIDE
3%, 6%, 9% CLEANSER (TRIZ), BENZOYL PEROXIDE 10%
Wash (DESQUAM-X/PANOXYL), BENZOYL PEROXIDE
10% GEL (PANOXYL), BENZOYL PEROXIDE 10% LOTION,
OR BENZOYL PEROXIDE-ERYTHROMYCIN
BENZEPRO, BENZOYL PEROXIDE
(BENZEFOAM) 5.3% EMOLLIENT FOAM
Lower Cost
BENZIQ 5.25% GEL
Lower Cost
BENZIQ 5.25% WASH
Lower Cost
BENZONATATE (ZONATUSS) 150 mg
CAPSULE
BENZOYL PEROXIDE 7% WASH
Lower Cost
Formulary agent: benzonatate capsule
Lower Cost
21
Drug
Status
BENZOYL PEROXIDE KIT AC (BPO
CREAMY KIT) 8%-5%
Lower Cost
BENZOYL PEROXIDE KIT AC, BPO
CREAMY KIT 4%-5%
Lower Cost
Formulary agents: BENZOYL PEROXIDE 8% CLEANSER
(Panoxyl-8) with Benzoyl Peroxide 5% Lotion or
BENZOYL PEROXIDE 5% GEL (Panoxyl)
Formulary agents: BENZOYL PEROXIDE 4% CLEANSER
(Panoxyl-4) with Benzoyl Peroxide 5% Lotion or
BENZOYL PEROXIDE 5% GEL (Panoxyl)
BENZPHETAMINE (DIDREX) 50 mg
TABLET
BEPREVE 1.5% EYE DROPS
Excluded benefit
Lower Cost
BERINERT C1 Esterase Inhibitor
(Human) 500 UNIT KIT
BESIVANCE 0.6% SUSPENSION
Specialty
Lower Cost
BETAMETHASONE DP AUG 0.05% GEL
Lower Cost
BETAMETHASONE VALERATE (LUXIQ)
0.12% FOAM
BETASERON 0.3 mg KIT
Lower Cost
Required diagnosis = cataract surgery or corneal
ulcer/keratitis or conjunctivitis
ophthalmic
Formulary agents: BETAMETHASONE DP 0.05%
CREAM, LOTION OR OINTMENT
Formulary agents: BETAMETHASONE VALERATE 0.1%
CREAM, LOTION, or OINTMENT
BETHKIS 300/4 mL NEBULIZING
SOLUTION
BETIMOL 0.25% EYE DROPS
Lower Cost
BETIMOL 0.5% EYE DROPS
Lower Cost
BETOPTIC-S 0.25% EYE DROPS
BEXAROTENE (TARGRETIN) 75MG
CAPSULE
BEYAZ 28 TABLET
Lower Cost
Clinical
Clinical
Requires trial of 90 days of any birth control from the
birth control tab (Most similar: OCELLA, Zarah, Syeda)
and a clinical reason why unable to use: Gianvi, Loryna,
or Vestura (which require a PA) with folic acid
separately
Biafine Emulsion
BIDIL TABLET
Lower Cost
Lower Cost
Formulary agent: isosorbide and hydralazine
separately
Formulary Agent: Latanoprost 0.005% EYE DROPS
Specialty
Required diagnosis = Cystic Fibrosis
Formulary agent: Cayston
Formulary agents: TIMOLOL (TIMOPTIC) 0.25% EYE
DROPS or TIMOLOL (TIMOPTIC) 0.5% EYE DROPS
Formulary agents: TIMOLOL (TIMOPTIC) 0.25% EYE
DROPS or TIMOLOL (TIMOPTIC) 0.5% EYE DROPS
Formulary agent: BETAXOLOL 0.5% EYE DROP
Required diagnosis = Cutaneous T-cell lymphoma
Lower Cost
BIMATOPROST (LUMIGAN) 0.03% EYE Lower Cost
DROPS
BINOSTO 70 mg EFFERVESCENT TABLET Lower Cost
BIONECT 0.2% CREAM
Lower Cost
Required Diagnosis= Dermal Ulcers/Wounds/Skin
Irritations/Burns
With A Trial Of: Santyl, And/Or TBC (Granulex) Spray
BIONECT 0.2% FOAM
Lower Cost
Irritations/Burns
BIONECT 0.2% GEL
Lower Cost
Irritations/Burns
BIOTIN FORTE 3MG TABLET
Lower Cost
Formulary agents: DIALYVITE, RENAL TAB, FULL SPECT,
RENA-VITE (NEPHRO-VITE) 0.8MG TABLET
22
Drug
Status
BIOTIN FORTE 5MG TABLET
Lower Cost
BIVIGAM INJECTION 10%
BLINCYTO 35MCG FOR IV INFUSION
Specialty
Lower Cost
Formulary agents: DIALYVITE, RENAL TAB, FULL SPECT,
RENA-VITE (NEPHRO-VITE) 0.8MG TABLET
Required diagnosis = Chromosome-negative precursor
B-cell acute lymphoblastic leukemia (B-cell ALL)
B-NEXA, PRENAISSANCE NEXT, VP-GGR- Lower Cost
B6
BOSULIF 100 mg TABLET
Lower Cost
Required diagnosis = chronic, accelerated, or blast
phase Philadelphia chromosome-positive (Ph+) chronic
myelogenous leukemia (CML) with resistance or
intolerance to prior therapy
Required diagnosis = chronic, accelerated, or blast
phase Philadelphia chromosome-positive (Ph+) chronic
myelogenous leukemia (CML) with resistance or
intolerance to prior therapy
BOSULIF 500 mg TABLET
Lower Cost
BOTOX
Specialty
BP CLEANSING (BENZOYL PEROXIDE)
LOTION 4%
Lower Cost
B-PLEX PLUS TABLET
Lower Cost
Formulary agents: ESSENTIAL ONE DAILY tablet, ONCE
DAILY tablet, STRESS FORMULA tablet, THERA-TABS
tablet, THEREMS tablet, VICAP FORTE CAP
BRAVELLE INJECTION 75UNIT
BREO ELLIPTA 100-25 mcg INHALER
Excluded Benefit
Lower Cost
BREO ELLIPTA 200-25 mcg INHALER
Lower Cost
Required Dx= Asthma or COPD;
BREVOXYL-4 COMPLETE PACK
BREVOXYL-8 COMPLETE PACK
BRILINTA 60MG TABLET
BRILINTA 90MG TABLET
BRIMONIDINE (ALPHAGAN P) 0.15% EYE
DROPS
BRISDELLE 7.5 mg CAPSULE
Briviact 10 mg/mL Solution
Lower Cost
Lower Cost
Clinical
Clinical
Lower Cost
Formulary Agent(s): Clopidogrel (Plavix)
Formulary Agent(s): Clopidogrel (Plavix)
Formulary agent: BRIMONIDINE 0.2% EYE DROP
Lower Cost
Lower Cost
Formulary Agent(s): paroxetine IR
Required Diagnosis= Seizure Or Epilepsy AND A 30 Day
Trial Of 1 Of The Following: Gabapentin, Lamotrigine
(Lamictal), Divalproex (Depakote), Levetiracetam
(Keppra), Levetiracetam ER (Keppra XR),
Oxcarbazepine (Trileptal), Carbamazepine (Carbatrol,
Tegretol), Phenytoin (Dilantin), Topiramate (Topamax),
Valproic Acid (Depakene) Or Zonisamide
Required Dx= Asthma or COPD;
23
Drug
Status
Briviact 10 mg Tablet
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Briviact 10 mg/mL Vial
Lower Cost
BROMDAY 0.09% EYE DROPS
Lower Cost
BROMFENAC 0.09% EYE DROPS
Lower Cost
Brovana 15mcg/2mL Solution
BUNAVAIL 2.1-0.3MG
BUNAVAIL 4.2-0.7MG
BUNAVAIL 6.3-1MG
BUPAP (PROMACET) 50-650 mg TABLET
Lower Cost
Clinical
Clinical
Clinical
Lower Cost
Formulary agent: DICLOFENAC (VOLTAREN) 0.1% EYE
DROPS
DROPS
Formulary Agent(s): Arcapta Neohaler Or Serevent
BUPAP 50-300 mg TABLET
Lower Cost
Formulary agent: BUTALBITAL-ACETAMINOPHEN
(Phrenilin, Marten tabs) 50-325 mg tablet
24
Drug
Status
BUPHENYL 500 mg TABLET
Clinical
Required diagnosis=urea cycle disorders
BUPHENYL POWDER
Clinical
Required diagnosis=urea cycle disorders
BUPRENORPHINE (SUBUTEX) 2 mg
SUBLINGUAL TABLET
BUPRENORPHINE (SUBUTEX) 8 mg
SUBLINGUAL TABLET
BUPRENORPHINE-NALOXONE
(SUBOXONE) 2 mg-0.5 mg SUBLINGUAL
TABLET
BUPRENORPHINE-NALOXONE
(SUBOXONE) 8 mg-2 mg SUBLINGUAL
TABLET
BUTALBITAL-ACETAMINOPHENCAFFEINE-CODEINE (FIORICET-COD) 3050-300-40 CAPSULE
BUTISOL SODIUM 30 mg TABLET
BUTISOL SODIUM 30 mg/5 mL ELIXIR
BUTISOL SODIUM 50 mg TABLET
BUTRANS 10 mcg/HR PATCH
Clinical
Request must go through clinical review
Clinical
Clinical
Clinical
Lower Cost
Lower Cost
Lower Cost
Lower Cost
BYDUREON 2 mg WEEKLY INJECTION
Step Therapy
BYETTA 10 mcg DOSE PEN
Step Therapy
BYETTA 5 mcg DOSE PEN
Step Therapy
BYSTOLIC 10 mg TABLET
Lower Cost
Formulary agent: BUTALBITAL-ACETAMINOPHENCAFFEINE-CODEINE (FIORICET-COD) 30-50-325-40
CAPSULE
Formulary agent: phenobarbital
Formulary agents: oxycodone,
hydrocodone/acetaminophen,
oxycodone/acetaminophen, hydrocodone/ibuprofen
or tramadol
or tramadol
or tramadol
or tramadol
Requires a 30 day trial of: metformin IR or ER
(Glucophage or Glucophage XR)
Formulary agents: carvedilol, labetalol, metoprolol,
atenolol, nadolol, propranolol, sotalol, or bisoprolol
BYSTOLIC 2.5 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Byvalson 5-80 mg Tablet
Lower Cost
Required Diagnosis= Hypertension AND 30 Day Trial Of
One Of Each (Group) Separately Taken Together At The
Same Time: Valsartan, Irbesartan, Losartan, Or
Candesartan AND Carvedilol, Nadolol, Atenolol,
Metoprolol, Propranolol, Sotalol Or Bisoprolol
Lower Cost
Lower Cost
Lower Cost
Lower Cost
25
Drug
Status
C1 INHIBITOR (HUMAN) FOR IV
INJECTION 500 UNIT
Clinical
Required diagnosis = prophylaxis against angioedema
attacks in patients with hereditary angioedema (HAE)
Cafergot 1-100 mg Tablet
Lower Cost
Required Diagnosis= Prevention Of Vascular
Headaches (Migraines) AND A Trial Of At Least 2 Of
The Following Drugs: Sumatriptan Tablets, Injection, Or
Nasal Spray, Naratriptan, Rizatriptan, Almotriptan OR
Dihydroergotamine Injection Or Nasal Spray OR
Ergomar (Which Also Requires A PA)
CALCITRIOL (VECTICAL) 3 mcg/GM
OINTMENT
CAMBIA 50 mg POWDER PACKET
Lower Cost
Formulary agent: calcipotriene (Dovonex)
Lower Cost
Formulary Agents: diclofenac potassium (Cataflam)
tablet and diclofenac sodium (Voltaren) tablet
CAMPTOSAR 300 mg/15 mL VIAL
Lower Cost
CANTIL 25 mg TABLET
Capecitabine (Xeloda) 150mg Tablet
Lower Cost
Clinical
Capecitabine (Xeloda) 500mg Tablet
Clinical
CAPEX SHAMPOO
Lower Cost
Required diagnosis = metastatic carcinoma of the
colon or rectum
Formulary agent: glycopyrrolate tablet
Required Diagnosis= Colorectal, Colon Or Breast
Cancer OR Adjuvant For Colon Cancer
Required Diagnosis= Colorectal, Colon Or Breast
Cancer OR Adjuvant For Colon Cancer
Formulary agent: ketoconazole shampoo (Nizoral)
Required with a diagnosis of seborrhea on scalp
OR
Formulary agent: coal tar topical shampoo,
calcipotriene solution, OR
Age 2-11: BETAMETHASONE DP 0.05% LOTION,
BETAMETHASONE VALERATE 0.1% LOTION
BETAMETHASONE VALERATE 0.1% LOTION,
Mometasone (ELOCON) 0.1% LOTION
CAPITAL WITH CODEINE SUSPENSION
Lower Cost
CAPTRACIN 0.0375-5% PATCH
CARBAGLU 200 mg DISPER TABLET
CARBIDOPA & LEVODOPA (PARCOPA)
10 mg-100 mg ODT
CARBIDOPA & LEVODOPA (PARCOPA)
25 mg-100 mg ODT
CARBINOXAMINE, Arbinoxa (PALGIC)
4MG/5ML LIQUID
CARBINOXAMINE, Arbinoxa (PALGIC) 4
mg TABLET
CARDENE SR 30 mg CAPSULE
CARDURA XL 4 mg TABLET
CARDURA XL 8 mg TABLET
Lower Cost
Clinical
Lower Cost
Age 18 and older: FLUOCINOLONE 0.01% Topical
SOLUTION , TRIAMCINOLONE 0.025% LOTION,
BETAMETHASONE DP 0.05% LOTION,
BETAMETHASONE VALERATE 0.1% LOTION, or
Mometasone (ELOCON) 0.1% LOTION for a diagnosis of
Formulary agent: ACETAMINOPHEN-CODEINE 120
mg/5 mL ELIXIR
Formulary agent: lidocaine (Lidoderm) 5% patch
Required diagnosis = hyperammonemia
Formulary agent: carbidopa/levodopa non-ODT OR
and inability to swallow
Formulary agent: carbidopa/levodopa non-ODT OR
and inability to swallow
Formulary Agents: chlorpheniramine OR
diphenhydramine
Formulary agents: chlorpheniramine OR
diphenhydramine
Formulary agent: non-SR nicardipine
Formulary agent: non-XL doxazosin
Formulary agent: non-XL doxazosin
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
26
Drug
Status
CARIMUNE NF 12 gM VIAL
Clinical
Specialty; follow policy on CareSource.com.ets:
Clinical
Clinical
CARISOPRODOL (SOMA) 250 mg TABLET Lower Cost
Formulary agent: carisoprodol 350 mg tablet (1/2 tab)
CARISOPRODOL-ASPIRIN 200-325 mg
COMPOUND TABLET
Required diagnosis=acute musculoskeletal conditions
with a trial of carisoprodol 350 mg tablet
Clinical
CARISOPRODOL-ASPIRIN-CODEINE 200- Lower Cost
325-16 mg TABLET
CARNITOR SF 100 mg/ML ORAL
Lower Cost
CAVAN-EC VITAMIN 30-1-440 mg
Formulary agent: carisoprodol 350 mg tablet
Formulary agent: levocarnitine (Carnitor) 1000 mg/10
mL (1 gm/10 mL) solution
Lower Cost
CAVAN-FOLATE DHA COMBO PACK 65-1- Lower Cost
250 mg
CAVAN-HEME OB TABLET 22-6-1 mg
Lower Cost
CAVERJECT FOR INJECTION
CAYSTON 75 mg INHAL SOLUTION
CEDAX 90 mg/5 mL SUSPENSION
Excluded Benefit
Clinical
Lower Cost
CEFACLOR 125/5 mL SUSPENSION
Lower Cost
Lower Cost
Lower Cost
CEFPODOXIME 100 mg TABLET
Lower Cost
CEFPODOXIME 100 mg/5 mL
SUSPENSION
CEFPODOXIME 200 mg TABLET
Lower Cost
CEFPODOXIME 50 mg/5 mL
SUSPENSION
CEFTIBUTEN (CEDAX) 180 mg/5 mL
SUSPENSION
CEFTIBUTEN (CEDAX) 400 mg CAPSULE
Lower Cost
CELESTONE 0.6 mg/5 mL SOLUTION
CENESTIN 0.3 mg TABLET
CEPHALEXIN (KEFLEX) 750 mg CAPSULE
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
CEPHALEXIN 500 mg TABLET
CEPROTIN 500 UNIT VIAL
Lower Cost
Lower Cost
CEPROTIN 1000 UNIT VIAL
Lower Cost
Required diagnosis = cystic fibrosis
Formulary agents: cephalexin, cefuroxime or other
formulary cephalosporin
Required trial of: Cefaclor 250MG and 500MG capsule
or cephalexin 125MG/5mL suspension
Formulary agent: prednisone tablet
Formulary agent: Premarin
Formulary agent: cephalexin 500 MG capsule
Lower Cost
Lower Cost
Lower Cost
Formulary agent: cephalexin 500 MG capsule
Required diagnosis: Prevention of Severe Congenital
Protein C Deficiency, Treatment of Venous
Thrombosis, or Purpura Fulminans
Required diagnosis: Prevention of Severe Congenital
Protein C Deficiency, Treatment of Venous
Thrombosis, or Purpura Fulminans
27
Drug
Status
CERDELGA 84MG CAPSULE
CEREDASE INJECTION 80UNT/ML
CEREFOLIN NAC CAPELET 600-2-6 mg
Specialty
Clinical
Lower Cost
CEREFOLIN TABLET
Lower Cost
CEREZYME
Specialty
Specialty
CERISA WASH 10-1%, BP 10-1%
Emulsion
Lower Cost
CEROVEL, X-VIATE, UREA
40% GEL
CESAMET 1 mg CAPSULE
Lower Cost
Formulary agent: urea 40% cream
Lower Cost
promethazine, prochlorperazine, or granisetron
CETROTIDE KIT 0.25 mg
Excluded Benefit
CEVIMELINE (EVOXAC) 30 mg CAPSULE Lower Cost
CHENODAL 250 mg TABLET
CHILD DELSYM COUGH-COLD NIGHT
Lower Cost
Lower Cost
CHILDREN'S MUCINEX 5 mg-10 mg-325
mg-200 mg/10 mL
CHILDREN'S ZYRTEC ALLERGY 10MG
RAPDIS TAB
CHOLBAM 50MG CAPSULE
CHOLBAM 250MG CAPSULE
CHORIONIC GONADOTROPIN,
NOVAREL, PREGNYL 10,000 UNIT
INJECTION
CIALIS 10 mg TABLET
CIALIS 2.5 mg TABLET
Lower Cost
Formulary agents: PILOCARPINE TABLET OR OTC saliva
substitute (examples: SALIVASURE, SALESE
(NUMOISYN) lozenges, AQUORAL AEROSOL SOLUTION,
or CAPHOSOL, NUMOISYN, BIOTENE, MOUTHKOTE,
MOI-STIR SOLUTION)
Formulary agent: ursodiol
Formulary agent: ROBITUSSIN PEDIATRIC COUGH
7.5MG/5ML
Formulary agent: CHILD'S MUCINEX 100 mg/5 mL
LIQUID
Formulary agent: cetirizine (Zyrtec) 10MG chewable
tablet
Lower Cost
Clinical
Clinical
Excluded benefit
Excluded benefit
Excluded benefit
CIALIS 20 mg TABLET
CIALIS 5 mg TABLET
Lower Cost
Excluded benefit
Excluded benefit
CICLOPIROX KIT 8%
Lower Cost
Lower Cost
Excluded benefit except for diagnosis of Benign
Prostatic Hypertrophy (BPH)
with a trial of doxazosin, terazosin, tamsulosin, or
prazosin
Excluded benefit except for diagnosis of Benign
Prostatic Hypertrophy (BPH)
with a trial of doxazosin, terazosin, tamsulosin, or
prazosin
Formulary agents: CICLOPIROX (Penlac, Ciclodan) 8%
SOLUTION AND vitamin E separatelyFormulary agents:
CICLOPIROX (Penlac, Ciclodan) 8% SOLUTION AND
vitamin E separately
Formulary agent: ciprofloxacin solution
Specialty; follow policy on CareSource.com
CILOXAN 0.3% OINTMENT
Lower Cost
CIMZIA 200 mg/ML SYRINGE KIT
Specialty
CINRYZE C1 Esterase Inhibitor (Human) Clinical
500 UNIT SOLUTION
28
Drug
Status
CIPRO HC OTIC SUSPENSION
Lower Cost
CITRACAL MAXIMUM
Lower Cost
Required 7 day trial of: ciprofloxacin (Cetraxal) 0.2%
OTIC Solution or Neomycin-Polymyxin-HC (Cortisporin)
1% Otic Solution
THEN
7 day trial of: Ciprodex
Formulary agent: CALCIUM + D TAB 315 mg-200 UNIT
CITRANATAL 90 DHA PACK 90-1-300 mg Lower Cost
CITRANATAL ASSURE COMBO PACK 35-1- Lower Cost
50 mg
CITRANATAL B-CALM PACK
Lower Cost
CITRANATAL DHA PACK 27-1-50 mg
Lower Cost
CitraNatal Harmony 27-1-50 mg Capsule Lower Cost
CitraNatal Harmony 29-1-50 mg Capsule Lower Cost
CITRANATAL RX TABLET
Lower Cost
CLARAVIS or ACCUTANE 30 mg CAPSULE Lower Cost
AND
erythromycin
CLARAVIS, ZENATANE or ACCUTANE 10 Lower Cost
mg CAPSULE
AND
erythromycin
29
Drug
Status
mg CAPSULE
AND
erythromycin
mg CAPSULE
AND
erythromycin
CLARINEX 0.5 mg/ML (2.5 mg/5 mL)
CLARINEX-D 12 HOUR TABLET
Lower Cost
Lower Cost
CLARINEX-D 24 HOUR TABLET
Lower Cost
Formulary agents: desloratadine (Clarinex)
Formulary agents: desloratadine (Clarinex) and
pseudoephedrine separately taken together
Formulary agents: desloratadine reditabs or tablets
and pseudoephedrine separately taken together
CLARIS CLARIFYING WASH
Lower Cost
CLARITIN 10 mg LIQUI-GEL CAPSULE
CLARITIN 5 mg REDI-TABLET
Lower Cost
Lower Cost
CLENIA EMOLLIENT CREAM
Lower Cost
CLIMARA PRO PATCH
Step Therapy
CLINDACIN ETZ 1% KIT
Lower Cost
CLINDACIN PAC 1% KIT
Lower Cost
CLINDAMYCIN (EVOCLIN) 1% FOAM
Lower Cost
Formulary agent: OTC loratadine
Formulary agent: CHILD'S CLARITIN 5 mg CHEWABLE
tablet
Formulary agent: AVAR-E LS 10-2% CREAM,
Requires trial of: COMBIPATCH, Prempro, Premarin, or
FemHRT
Formulary agent: clindamycin swab (Cleocin T) 1%
pledgets
Formulary agent: clindamycin swab (Cleocin T) 1%
pledgets
Formulary agent: clindamycin gel or solution
30
Drug
Status
CLINDAMYCIN, CLINDAMAX (CLEOCIN T, Lower Cost
CLINDAGEL) 1% GEL
Formulary agent: CLINDAMYCIN, CLINDAMAX
(CLEOCIN T)
1% LOTION, CLINDAMYCIN SWAB (CLEOCIN T) 1%
CLINDAMYCIN/BENZOYL PEROXIDE
(BENZACLIN) GEL 50 gram jar
Lower Cost
Formulary agents: BENZOYL PEROXIDE 5% GEL
T) 1% LOTION, CLINDAMYCIN SWAB (CLEOCIN T) 1%
CLINDAMYCIN -BENZOYL PEROXIDE
(DUAC) 1-5% GEL
Lower Cost
Formulary agent: BENZOYL PEROXIDE 5% GEL (Panoxyl)
WITH CLINDAMYCIN, CLINDAMAX (CLEOCIN T) 1%
LOTION, CLINDAMYCIN SWAB (CLEOCIN T) 1%
Clindamycin-Tretinoin (Veltin, Ziana) 1.2- Lower Cost
0.025% Gel
A 30 Day Trial Of: Clindamycin Pledgets Or Clindamycin
Topical Solution AND Tretinoin Gel Or Cream
CLINDESSE 2% VAGINAL CREAM
ClinPro 5000 (Prevident 5000 Booster
Plus) 1.1% Paste
Formulary Agent(s): ACT AntiCavity Fluoride Rinse, ACT
Restoring Fluoride Rinse, ACT Total Care Rinse, Denta
5000 Plus 1.1% Cream, Phos-Flur 0.02% Rinse, Or SF
5000 Plus 1.1% Cream
Formulary agent: CLOBETASOL, CORMAX SCALP
(TEMOVATE) 0.05% SOLUTION
Formulary option: CLOBETASOL (OLUX) 0.05% FOAM
Lower Cost
Lower Cost
CLOBETASOL (CLOBEX) 0.05%
Lower Cost
SHAMPOO
CLOBETASOL (CLOBEX) 0.05% TOPICAL Lower Cost
LOTION
CLOBETASOL AERO (OLUX AERO) 0.05% Lower Cost
FOAM
CLOBETASOL EMULSION (OLUX-E)
0.05% FOAM
Lower Cost
CLOBETASOL (CLOBEX) 0.05% SPRAY
Lower Cost
CLOCORTOLONE (CLODERM) 0.1%
CREAM
Lower Cost
CLODAN 0.05% KIT
Lower Cost
Clomiphene (Clomid)
CLONAZEPAM (KLONOPIN) 0.125 mg
DISINTEGRATING TABLET
Excluded benefit
Lower Cost
Lower Cost
Lower Cost
CLONAZEPAM (KLONOPIN) 1 mg
Lower Cost
Formulary agents: CLOBETASOL (TEMOVATE) 0.05%
CREAM, CLOBETASOL (TEMOVATE) 0.05% GEL,
CLOBETASOL (TEMOVATE) 0.05% OINTMENT or
CLOBETASOL, CORMAX SCALP (TEMOVATE) 0.05%
SOLUTION
Formulary option: CLOBETASOL (TEMOVATE) 0.05%
CREAM, CLOBETASOL (TEMOVATE) 0.05% GEL,
CLOBETASOL (TEMOVATE) 0.05% OINTMENT or
CLOBETASOL, CORMAX SCALP (TEMOVATE) 0.05%
SOLUTION
Formulary agents: clobetasol topical cream, gel,
ointment, or solution
for 7 days each.
Required trial of: clobetasol, cormax scalp (Temovate)
0.05% solution
Formulary agent: CLONAZEPAM tablet unless for
use during seizures
OR inability to swallow
use during seizures
use during seizures
use during seizures
31
Drug
Status
CLONAZEPAM (KLONOPIN) 2 mg
Lower Cost
CLORPRES 0.2-15 TABLET
Lower Cost
CLORPRES 0.3-15 TABLET
Lower Cost
use during seizures
Formulary agent: clonidine and chlorthalidone
separately
Formulary agent: clonidine and chlorthalidone
separately
Formulary agent: clozapine
CLOZAPINE ODT (FAZACLO ODT) 100 mg Lower Cost
CLOZAPINE ODT (FAZACLO ODT) 12.5
Lower Cost
mg
CNL8 NAIL 8 % KIT
Lower Cost
COCET 650-30 mg TABLET
Lower Cost
Coenzyme Q10 200 mg SoftGel
Lower Cost
Coenzyme Q10 400 mg SoftGel
Lower Cost
COLCHICINE (MITIGARE) 0.6MG
CAPSULE
COLESTIPOL (COLESTID) FLAVORED
GRANULES
COLESTIPOL (COLESTID) GRANULES
COLESTIPOL (COLESTID) GRANULES
PACKET
COLY-MYCIN EAR DROPS
Lower Cost
Formulary agent: CICLOPIROX (Penlac, Ciclodan) 8%
SOLUTION AND vitamin E separately
No longer available on the market: use
ACETAMINOPHEN-CODEINE #3 tablet
A 30 Day Trial Of: Coenzyme Q10 SoftGel (10 mg, 30
mg, 50 mg, 60 mg, Or 100 mg)
A 30 Day Trial Of: Coenzyme Q10 SoftGel (10 mg, 30
mg, 50 mg, 60 mg, Or 100 mg)
*Formulary Agent(s): Colchicine (Colcrys) 0.6mg Tablet
Lower Cost
Formulary agent: COLESTIPOL tablet
Lower Cost
Lower Cost
Lower Cost
COLYTE/FLAVR SOLUTION 227.1 gM
3785 mL
COMETRIQ 100 MG DAILY-DOSE
Lower Cost
Formulary agent: neomycin/hydrocortisone/polymyxin
otic
Formulary agent: Colyte with Flavor Packs 4000 mL
Clinical
Clinical
COMPLETE-RF PRENATAL
Lower Cost
Required diagnosis = progressive, metastatic medullary
thyroid cancer
thyroid cancer
thyroid cancer
COMPLETE NATAL DHA 29-1-250 mg
Lower Cost
CONCEPT DHA CAPSULE 35-1-200 mg
Lower Cost
CONCERTA 18MG ER TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
CONDYLOX 0.5% GEL
COPAXONE 40 mg INJECTION
Lower Cost
Clinical
Formulary Agent: methylphenidate ER tablet by
Actavis
Actavis
Actavis
Actavis
Formulary agent: podofilox (solution)
COPEGUS TABLET 200 mg
Clinical
Specialty
Clinical
32
Drug
Status
CORDRAN 0.05% LOTION
Lower Cost
CORDRAN 4 mcg/SQ CM TAPE
Lower Cost
COREG CR 10 mg CAPSULE
CORIFACT KIT
CORLANOR 5MG TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Clinical
Lower Cost
for 7 days each.
for 7 days each.
Formulary agent: non-cr carvedilol
Specialty
Required diagnosis = Worsening heart failure with left
ventricular ejection fraction of 35% or less
*Sinus rhythm with resting heart rate at least 70 beats
per minute
*Currently taking or are unable to take a beta-blocker
(i.e. carvedilol, labetalol, metoprolol, atenolol, nadolol,
propranololm sotalol, or bisoprolol)
CORLANOR 7.5MG TABLET
Lower Cost
Required diagnosis = Worsening heart failure with left
ventricular ejection fraction of 35% or less
*Sinus rhythm with resting heart rate at least 70 beats
per minute
*Currently taking or are unable to take a beta-blocker
(i.e. carvedilol, labetalol, metoprolol, atenolol, nadolol,
propranololm sotalol, or bisoprolol)
CORTISPORIN 0.5% CREAM
CORTISPORIN 1% OINTMENT
Lower Cost
Lower Cost
CORTISPORIN-TC EAR SUSPENSION,
COLY-MYCIN S
COSENTYX 150MG/ML PEN INJECTOR
COSENTYX 150MG/ML SYRINGE
COSOPT PF SOLUTION
Lower Cost
COTAB AX 4-20 MG TABLET
Lower Cost
COTELLIC 20MG TABLET
COVERA-HS ER 180 mg TABLET
Lower Cost
Lower Cost
Formulary agent: OTC topical cream
Formulary agent: OTC triple antibiotic ointment and
hydrocortisone separately
Formulary agent: neomycin/hydrocortisone/polymyxin
otic
Specialty
Specialty
Formulary agent: dorzolamide HCl/timolol Maleate
(COSOPT)
Formulary agent: CHLORPHENIRAMINEACETAMINOPHEN
COVERA-HS ER 240 mg TABLET
CRESEMBA 186MG CAPSULE
CROMOLYN SODIUM (GASTROCROM)
20MG/ML CONCENTRATE
CROMOLYN SODIUM (GASTROCROM)
100 mg/5 mL CONCENTRATE
CUVPOSA 1 mg/5 mL SOLUTION
Lower Cost
Lower Cost
Clinical
CYCLIVERT TABLET 25 mg
CYCLOBENZAPRINE (FEXMID) 7.5 mg
TABLET
CYCLOGYL 0.5% EYE DROPS
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary Agent(s): itraconazole
Required diagnosis = diagnosis of mastocytosis
Formulary agent: diphenhydramine (Benadryl)
Required diagnosis = diagnosis of mastocytosis
Formulary agent: diphenhydramine (Benadryl)
Required Diagnosis= Drooling With Neurological
Conditions Associated With Problem Drooling
(Cerebral Palsy) Or Frey Syndrome. Must Be Between 316 Years Of Age AND Inability To Swallow
Glycopyrrolate Tablet
Formulary agents: meclizine or dimenhydrinate
Formulary agents: cyclobenzaprine tablet 5 mg and 10
mg
Formulary agent: 1% ATROPINE EYE DROPS
Clinical
Clinical
Lower Cost
33
Drug
Status
CYCLOMYDRIL EYE DROPS
Lower Cost
Formulary agent: 1% ATROPINE EYE DROPS/2.5%
PHENYLEPHRINE EYE DROPS separately taken together
Cycloserine (SEROMYCIN) 250 mg
CAPSULE
Cycloset 0.8 mg TABLET
Lower Cost
Formulary agent: rifampin
Lower Cost
CYRAMZA 100MG/10ML VIAL
Lower Cost
CYRAMZA 500MG/10ML VIAL
Lower Cost
CYSTADANE POWDER
CYSTAGON 150 mg CAPSULE
Lower Cost
Lower Cost
Required diagnosis = Type 2 Diabetes (Trials of at least
2 agents Including orals and/or injectables)
Required diagnosis= Advanced Gastric Cancer or
Gastoesphogeal Junction Adenocarcinoma OR
metastatic non–small cell lung cancer (NSCLC) in
patients with disease progression on or after platinumbased chemotherapy
*Prescribed by an oncologist
Required diagnosis= Advanced Gastric Cancer or
Gastoesphogeal Junction Adenocarcinoma OR
metastatic non–small cell lung cancer (NSCLC) in
patients with disease progression on or after platinumbased chemotherapy
*Prescribed by an oncologist
Required diagnosis= Homocystinuria
Formulary agent=cuprimine with a diagnosis of
Nephropathic cystinosis
CYSTAGON 50 mg CAPSULE
Lower Cost
CYSTARAN 0.44% SOLUTION
Lower Cost
CYTOGAM 2.5 gM/50 mL VIAL
Clinical
DAKLINZA 30MG TABLET
DAKLINZA 60MG TABLET
Daliresp 500mcg
Lower Cost
Lower Cost
Step Therapy
Dallergy 12.5-5 mg Chewables
Lower Cost
DAILY PRENATAL COMBO PACK
Lower Cost
DALLERGY 25-10 mg TABLET
DALVANCE 500MG VIAL
Lower Cost
Lower Cost
DARAPRIM 25 mg TABLET
Lower Cost
DARIFENACIN ER (ENABLEX) 15 MG
TABLET
Lower Cost
Nephropathic cystinosis
Required diagnosis= corneal cystine crystal
accumulation in patients with cystinosis
Required Diagnosis = Severe COPD
*Currently On Albuterol (i.e., Albuterol Inhalation,
Ventolin, ProAir, Proventil, Or Combivent)
WITH
*30 Day Trial From Two Of The Following Four Groups:
Symbicort/Dulera/Advair OR
Asmanex/Aerospan/Qvar/Flovent/Pulmicort OR Spiriva
HandiHaler/Spiriva Respimat (Respimat Is
Preferred)/Tudorza OR Montelukast
(Singulair)/Theophylline With Continued Exacerbations
Formulary agents: OTC phenylephrine,
chlorpheniramine, or methoscopolamine
Formulary agents: NOHIST OR ACTIFIED
*Required 7 day trial of: Vancomycin IV or IV/Oral
Zyvox
Requires diagnosis of chemoprophylaxis of malaria due
to it not being suitable as a prophylactic agent for
travelers, toxoplasmosis (with a trial of a sulfonamide
within the past 30 days), or acute malaria (with a trial
of a sulfonamide)
Formulary Agents: OXYBUTYNIN, OXYBUTYNIN ER,
TOLTERODINE, TROSPIUM, or TROSPIUM SR
34
Drug
Status
DARIFENACIN ER (ENABLEX) 7.5 MG
TABLET
DARZALEX 100MG/5ML VIAL
DARZALEX 400MG/20ML VIAL
DAYTRANA 10 mg/9 HR PATCH
Lower Cost
Formulary Agents: OXYBUTYNIN, OXYBUTYNIN ER,
Requires diagnosis of ADD/ADHD; autism; Asperger's;
hyperkinetic syndrome with trials if age under 6 of of
any combo of: dextroamphetamine,
dextroamphetamine ER (Dexedrine), amphetamine salt
combo (ADDERALL), dextroamphetamineamphetamine ER (ADDERALL XR) and if age 6 or older,
any combo of: Methylphenidate ER tablet (Concerta),
Methylphenidate CD capsule (Metadate CD), or
DAYTRANA 15 mg/9 HR PATCH
Lower Cost
DAYTRANA 20 mg/9 HOUR PATCH
Lower Cost
DAYTRANA 30 mg/9 HOUR PATCH
Lower Cost
DEMECLOCYCLINE (DECLOMYCIN) 150
mg TABLET
DEMECLOCYCLINE (DECLOMYCIN) 300
mg TABLET
DEMSER 250 mg CAPSULE
DENAVIR 1% CREAM
Lower Cost
Formulary agents: minocycline or doxycycline
Lower Cost
Formulary agents: minocycline or doxycycline
Clinical
Step Therapy
Required diagnosis = Pheochromocytoma
Required diagnosis = cold sores
Required trial of: OTC Abreva
Wilson's Disease, RA, or cystinuria
Lower Cost
Lower Cost
Lower Cost
DentaGel, Fluoridex Daily Defense,
Lower Cost
Fluoridex Defense Whitening, Phos-Flur,
SF (Prevident, Prevident 5000,
Prevident 5000 Dry Mouth) 1.1% Gel
DEPEN 250 mg TITRATAB
Lower Cost
35
Drug
Status
DEPLIN, L-METHYLFOLATE 15 mg
CAPSULE
Lower Cost
DEPLIN, L-METHYLFOLATE 15 mg
TABLET
Lower Cost
DEPLIN, L-METHYLFOLATE 7.5 mg
CAPSULE
Lower Cost
DEPLIN, L-METHYLFOLATE 7.5 mg
TABLET
Lower Cost
DEPO-SQ PROVERA 104MG INJECTION
Lower Cost
DERMASORB XM 39% CREAM KIT
Lower Cost
DERMAZENE, HYDROCORTISONEIODOQUINOL 1-1% CREAM
Lower Cost
DESLORATADINE (CLARINEX) 2.5 mg
REDITABLETS
DESLORATADINE (CLARINEX) 5 mg
REDITABLETS
DESLORATADINE (CLARINEX) 5 mg
TABLET
DESONATE 0.05% GEL
Lower Cost
DESONIDE (DESOWEN) 0.05% LOTION
Lower Cost
DESOWEN 0.05% LOTION KIT
Lower Cost
DESOXIMETASONE (TOPICORT LP)
0.05% CREAM
Lower Cost
DESOXIMETASONE (TOPICORT) 0.05%
GEL
Lower Cost
OINTMENT
Lower Cost
CREAM
Lower Cost
OINTMENT
Lower Cost
Required diagnosis = Anemia
OR
Required diagnosis = Depression/Anxiety
AND
Currently on an anti-depressant
OR
AND
OR
AND
OR
AND
Formulary Agent(s): Medroxyprogesterone Acetate
(Depo-Provera) IM 150mg/mL Suspension
Formulary Agents: UREA , U-KERA, X-VIATE 40%
CREAM or CEROVEL, X-VIATE, UREA-C40 , UREA 40%
LOTION
*30 day trial of: OTC Hydrocortisone with OTC antifungal (clotrimazole, tolnaftate, miconazole) used
separately at the same time
Formulary agents: loratadine, cetirizine or
fexofenadine
fexofenadine
fexofenadine
Formulary agents: DESONIDE (DESOWEN) 0.05%
CREAM OR OINTMENT
Formulary agents: DESONIDE (DESOWEN) 0.05%
CREAM OR OINTMENT
Formulary agent: desonide cream or ointment with
generic OTC Cetaphil Lotion
for 7 days each.
for 7 days each.
for 7 days each.
for 7 days each.
for 7 days each.
Lower Cost
Lower Cost
Lower Cost
36
Drug
Status
DESVENLAFAXINE ER 100 mg TABLET
Lower Cost
DESVENLAFAXINE ER 50 mg TABLET
Lower Cost
DESVENLAFAXINE ER (KHEDEZLA) 100
mg TABLET
Lower Cost
TOLTERODINE ER (DETROL LA) 2 MG
CAPSULE
TOLTERODINE ER (DETROL LA) 4 MG
CAPSULE
DEXCHLORPHENIRAMINE 2 mg/5 mL
SYRUP
DEXILANT DR 30 mg CAPSULE
Step Therapy
Formulary Agent(s): Require a trial of at least two of
the three antidepressant catergories: 1) SSRI
(Citalopram, Escitalopram, Fluoxetine, Paroxetine,
Fluvoxamine, Sertraline) 2) SNRI (Duloxetine,
Venlafaxine ER Capsules, Venlafaxine tablets) 3)
Dopamine Reuptake Blocking Agents (Bupropion SR,
Bupropion XL)
Bupropion XL)
Bupropion XL)
Bupropion XL)
Formulary agent: tolterodine IR
Step Therapy
Formulary agent: tolterodine IR
Lower Cost
Age 10-11:
Lower Cost
A 60 Day Trial Of 2 Of The Following 5 Formulary
Options: Esomeprazole (Nexium), Pantoprazole 40 mg,
Nexium 20 mg OTC, Lansoprazole 30 mg, Omeprazole
40 mg (Or 20mg BID) Or Rabeprazole 20 mg
DEXILANT DR 60 mg CAPSULE
Lower Cost
A 60 Day Trial Of 2 Of The Following 5 Formulary
Options: Esomeprazole (Nexium), Pantoprazole 40 mg,
Nexium 20 mg OTC, Lansoprazole 30 mg, Omeprazole
40 mg (Or 20mg BID) Or Rabeprazole 20 mg
DEXPAK 13 DAY 1.5 mg TABLET
DEXPAK 6 DAY 1.5 mg TABLET
Lower Cost
Lower Cost
Age 12-15:
FLUOCINONIDE 0.05%, FLUOCINONIDE-E 0.05%,
CLOBETASOL (TEMOVATE) 0.05%, PREDNICARBATE
(DERMATOP) 0.1% OINTMENT, HYDROCORTISONE
0.1%, HYDROCORTISONE 2.5%, FLUTICASONE
Propionate (CUTIVATE) 0.05% CREAM,
PREDNICARBATE (DERMATOP) 0.1% CREAM,
BETAMETHASONE DP 0.05%, BETAMETHASONE
VALERATE 0.1%, AMCINONIDE 0.1%
DESVENLAFAXINE ER (KHEDEZLA) 50 mg Lower Cost
TABLET
DEXTROAMPHETAMINE (PROCENTRA) 5 Lower Cost
mg/5 mL SOLUTION
DEXTROMETHORPHAN SYRUP 15 mg/5 Lower Cost
mL
Age 16-17:
37
Drug
Status
DIALYVITE 3,000 TABLET
Lower Cost
DIALYVITE 5000 TABLET
DIALYVITE SUPREME D TABLET
DIALYVITE W/ZINC, BIOTIN FORTE
W/ZINC 0.8 mg TABLET
Lower Cost
Lower Cost
Lower Cost
CLOBETASOL-E (TEMOVATE E) 0.05%, FLUOCINONIDE
0.05%, FLUOCINONIDE-E 0.05%, CLOBETASOL
(TEMOVATE) 0.05%, PREDNICARBATE (DERMATOP)
0.1% OINTMENT, HYDROCORTISONE 0.1%,
HYDROCORTISONE 2.5%, FLUTICASONE Propionate
(CUTIVATE) 0.05% CREAM, PREDNICARBATE
(DERMATOP) 0.1% CREAM, BETAMETHASONE DP
0.05%, BETAMETHASONE VALERATE 0.1%,
AMCINONIDE 0.1%
DIALYVITE W/ZINC, NEPHPLEX TABLET
Lower Cost
DIALYVITE, VOL-CARE, NEPHRONEX,
RENA-VITE (NEPHRO-VITE) TABLET
Lower Cost
DIATX ZN TABLET
Lower Cost
DICLEGIS 10-10 mg TABLET
Lower Cost
DICLOFENAC (SOLARAZE) 3% GEL
Lower Cost
DIFFERIN 0.1% LOTION
Lower Cost
DIFFERIN 0.3% GEL
Lower Cost
DIFFERIN 0.3% GEL PUMP
Lower Cost
DIFICID 200 mg TABLET
Lower Cost
DIFIL-G 400 TABLET
Lower Cost
Age over 18:
FLUOCINOLONE 0.01%, TRIAMCINOLONE 0.025%,
TRIAMCINOLONE 0.1%, TRIAMCINOLONE 0.5%,
FLUTICASONE Propionate (CUTIVATE) 0.005%
OINTMENT, DIFLORASONE 0.05%, CLOBETASOL-E
(TEMOVATE E) 0.05%, FLUOCINONIDE 0.05%,
FLUOCINONIDE-E 0.05%, CLOBETASOL (TEMOVATE)
0.05%, PREDNICARBATE (DERMATOP) 0.1%
OINTMENT, HYDROCORTISONE 0.1%,
HYDROCORTISONE 2.5%, FLUTICASONE Propionate
(CUTIVATE) 0.05% CREAM, PREDNICARBATE
(DERMATOP) 0.1% CREAM, BETAMETHASONE DP
0.05%, BETAMETHASONE VALERATE 0.1%,
AMCINONIDE 0.1% (Accepted trials but not
recommended:MOMETASONE AND ALCLOMETASONE)
Formulary agent: DIALYVITE, RENAL TAB, FULL SPECT,
RENA-VITE, BIOTIN FORTE (NEPHRO-VITE) 0.8 mg
TABLET
Formulary agent: DIALYVITE, RENAL TAB, FULL SPECT,
RENA-VITE, BIOTIN FORTE (NEPHRO-VITE) 0.8 mg
TABLET
Formulary agent: ESSENTIAL ONE DAILY tablet, ONCE
Formulary agents: OTC DOXYLAMINE (UNISOM) AND
PYRIDOXINE (VITAMIN B6) separately
Formulary agents: FLUOROURACIL (EFUDEX) 5%
CREAM with a diagnosis of Actinic keratoses
Formulary agents: adapalene (DIFFERIN) 0.1% CREAM
OR GEL
OR GEL
OR GEL
Formulary agents: oral Metronidazole (Flagyl) and oral
VANCOMYCIN (Vancocin) for a diagnosis of C.Diff
(Clostridium Difficile) Colitis/Diarrhea
DIHYDROCODEINE COMPOUND CAP
Lower Cost
(SYNALGOS-DC) CAPSULE 16-356-30 mg
DILATRATE-SR 40 mg CAPSULE
DIPENTUM 250 MG CAPSULE
DIVIGEL 0.25 mg GEL PACKET
Lower Cost
Step Therapy
Lower Cost
DIVIGEL 0.5 mg GEL PACKET
Lower Cost
Formulary agent: ACETAMINOPHEN-CAFFEINEDIHYDROCODEINE (PANLOR/PANLOR SS) 712.8-60-32
mg TABLET
Formulary agent: isosorbide dinitrate
Must first try sulfasalazine
Formulary agents: estradiol tablet, patches (Climara) or
Alora
Alora
38
Drug
Status
DIVIGEL 1 mg GEL PACKET
Lower Cost
DONEPEZIL (ARICEPT) 23 mg TABLET
Lower Cost
DONNATAL 16.2 mg/5 mL ELIXIR
Lower Cost
DORYX DR 50MG TABLET
Lower Cost
DORYX DR 200MG TABLET
Lower Cost
DOXYCYCLINE (ORACEA) DR 40MG
CAPSULE
DOXYCYCLINE HYCLATE 20MG TABLET
Lower Cost
Alora
Formulary agent: DONEPEZIL (ARICEPT)
5 mg or 10 mg
Formulary agent: PHENOBARBITAL 20 mg/5 mL ELIXIR
and HYOSCYAMINE, Hyosyne 125 mcg/5 mL Elixir
Formulary Agent(s): Doxycycline Monohydrate 50mg
Or 100mg Capsule
Formulary Agent(s): Doxycycline Monohydrate 50mg
Or 100mg Capsule
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
100MG capsules
Formulary agent: CALCIPOTRIENE (DOVONEX) 0.005%
CREAM
Required diagnosis = appetite stimulation in AIDS
patients or cancer chemotherapy-induced nausea and
vomiting
vomiting
vomiting
Required diagnosis = sickle cell anemia
No Longer available on market
Formulary agents: COMBIPATCH, Prempro, PREMARIN,
or FemHRT
Lower Cost
DOXYCYCLINE HYCLATE 100MG TABLET Non-Formuarly
DOXYCYCLINE HYCLATE DELAYED
RELEASE (DORYX) 75MG TABLET
DOXYCYCLINE HYCLATE 50MG CAPSULE
Lower Cost
DOXYCYCLINE HYCLATE 100MG
CAPSULE
DOXYCYCLINE MONOHYDRATE (ADOXA)
150 mg TABLET
DOXYCYCLINE MONOHYDRATE (ADOXA)
75 mg TABLET
DOXYCYCLINE MONOHYDRATE 75MG
CAPSULE
DOXYCYCLINE MONOHYDRATE CAPSULE
150 mg
DOXYCYCLINE MONOHYDRATE,
AVIDOXY (ADOXA) 100 mg TABLET
Dritho-Crème HP 1% CREAM
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
DRONABINOL (Marinol) 10 mg CAPSULE Clinical
DRONABINOL (Marinol) 2.5 mg
CAPSULE
Clinical
DRONABINOL (Marinol) 5 mg CAPSULE
Clinical
DROXIA 200 mg CAPSULE
DUAC CS KIT 1-5%
DUAVEE 0.45-20 MG Tablet
Clinical
Clinical
Clinical
Lower Cost
Lower Cost
DUET DHA BALANCED COMBO PACK 27- Lower Cost
1-380 mg
DUET DHA COMPLETE COMBO PACK 27- Lower Cost
1-300 mg
DUET DHA COMPLETE COMBO PACK 27- Lower Cost
1-430 mg
39
Drug
Status
DUEXIS 800/26.6 mg TABLET
Lower Cost
Formulary agent: famotidine and ibuprofen separately
DUOPA 4.63-20MG/ML SUSPENSION
Lower Cost
DURAFLU TABLET 60-20-200-500 mg
Lower Cost
DUREZOL 0.05% EYE DROPS
Lower Cost
DURLAZA 162.5MG ER CAPSULE
DUTASTERIDE (AVODART) 0.5 mg
SOFTGEL
Dutasteride-Tamsulosin (Jalyn) 05mg0.4mg Capsule
DUTOPROL 100 mg-12.5 mg
Lower Cost
Lower Cost
Lower cost agent: carbidopa-levodopa (Sinemet)
tablets
Formulary agent: MUCINEX DM ER and
Acetaminophen separately
Formulary agents: DEXAMETHASONE 0.1%
OPHTHALMIC SOLUTION, PREDNISOLONE ACETATE
(PRED FORTE, OMNIPRED) 1%, or PREDNISOLONE
SODIUM PHOSPHATE 1%
Formulary Agent(s): Aspirin 81mg
Formulary Agent(s): Doxazosin, Terazosin, Tamsulosin,
or Prazosin
Formulary Agent(s): Tamsulosin AND Dutasteride
(Avodart)
Formulary agent: METOPROLOL and
HYDROCHLOROTHIAZIDE separately taken together
Lower Cost
Lower Cost
Dyanavel XR 2.5 mg/mL Suspension
Lower Cost
DYLIX 100 mg/15 mL ELIXIR
DYMISTA 50/137 mcg
Lower Cost
Lower Cost
Formulary Agent(s): Fluticasone (Flonase) Or Flonase
OTC Allergy Relief Spray AND Azelastine (Astelin)
Separately Taken Together At The Same Time
DYNACIRC CR 10 mg TABLET
Lower Cost
Formulary agents: amlodipine, felodipine, or nifedipine
DYNACIRC CR 5 mg TABLET
Lower Cost
Formulary agents: amlodipine, felodipine, or nifedipine
DYRENIUM 100 mg CAPSULE
Lower Cost
DYRENIUM 50 mg CAPSULE
Lower Cost
DYSPORT
Specialty
Formulary agents: spironolactone, triamterene-hctz, or
amiloride
Formulary agents: spironolactone, triamterene-hctz, or
amiloride
ED CHLORPED D PEDIATRIC DROPS
Lower Cost
ED CYTE F TABLET
Lower Cost
EDARBI 40 mg TABLET
Lower Cost
EDARBI 80 mg TABLET
Lower Cost
Edarbyclor 40-12.5 mg TABLET
Lower Cost
Edarbyclor 40-25 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Formulary agent: TRIAMINIC COLD-ALLERGY PE
LIQUID
Formulary agent: FERROUS FUMARATE 324 mg-FOLIC
ACID 1 mg-DOCUSATE SODIUM 50 mg separately
Formulary agent: losartan (Cozaar) or irbesartan
(Avapro)
Formulary agent: losartan (Cozaar) or irbesartan
(Avapro)
4)
4)
40
Drug
Status
EDECRIN 25 mg TABLET
EDEX
ED-FLEX CAPSULE
Lower Cost
Excluded benefit
Lower Cost
Formulary agents: furosemide or torsemide
Formulary agents: BIPHENOX, BIOGESIC, or DOLOGESIC
EDLUAR 10 mg SL TABLET
Lower Cost
EDLUAR 5 mg SL TABLET
Lower Cost
EFFER-K 10 MEQ TABLET EFFERVESCENT Lower Cost
Formulary agent: non-CR zolpidem
Formulary agent: non-CR zolpidem
Formulary agent: formulary potassium supplement
EFFER-K 20 MEQ TABLET EFFERVESCENT Lower Cost
ELAPRASE
Specialty
ELDERCAP CAPSULE
Lower Cost
Formulary agent: multivitamin and fish oil separately
ELELYSO INJ 200 UNIT
ELESTRIN 0.06% GEL
Specialty
Lower Cost
ELETONE CREAM
Lower Cost
ELIDEL 1% CREAM
Step Therapy
ELIGARD 22.5 mg SUBQ INJECTION
ELIGARD 30 mg SUBQ INJECTION
ELIGARD 45 mg SUBQ INJECTION
ELIGARD 7.5 mg SUBQ INJECTION
ELITEK 1.5 MG VIAL
ELITEK 7.5 MG VIAL
ELITE OB DHA SOFTGEL 28-1.25 mg
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary Agent(s): Estradiol Tablets, Estradiol Patches
(Climara) Or Alora
Formulary Agent(s): Theraplex, Velvachol, Nutraderm,
Cetaphil, Or Aveeno
Required Diagnosis= Atopic Dermatitis Or Eczema
AND
Required 7 Day Trial Of: Tacrolimus (Protopic) 0.1% Or
0.03% Ointment
Required Diagnosis= Advanced Prostate Cancer
ELITE-OB 400 CAPSULE 35-5-1.2 mg
Lower Cost
EMADINE 0.05% EYE DROPS
Lower Cost
EMBEDA 20-0.8MG ER CAPSULE
Lower Cost
Lower Cost
EMBEDA 50-2MG ER CAPSULE
Lower Cost
Lower Cost
Lower Cost
EMBEDA 100-4MG ER CAPSULE
Lower Cost
azelastine (Optivar) unless patient is pregnant
Formulary agents: Fentanyl Patches, Morphine Sulfate
ER (MS Contin), or Oxymorphone ER
EMBRACE BLOOD GLUCOSE TEST STRIPS Lower Cost
EMBRACE METER
EMEND 125 mg CAPSULE
Lower Cost
Clinical
EMEND 40 mg CAPSULE
Clinical
Required diagnosis= nausea/vomiting due to chemo or
surgery
Required trial of: formulary agents ondansetron,
promethazine, etc
surgery
promethazine, etc
41
Drug
Status
EMEND 80 mg CAPSULE
Clinical
EMEND TRIFOLD PACK (80 mg and 125
mg)
Clinical
EMPLICITI 300MG SOLUTION FOR
INJECTION
EMPLICITI 400MG SOLUTION FOR
INJECTION
EMSAM 12 mg/24 HOURS PATCH
Lower Cost
surgery
promethazine, etc
surgery
promethazine, etc
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Emverm 100 mg Chewable Tablet
Lower Cost
Bupropion XL)
Bupropion XL)
Bupropion XL)
30 Day Trial Of: Pin-X, Pamix 144 mg/mL (50 mg/mL)
OTC Or Pinworm Tab Medicine 180 mg OTC
ENBRACE HR 1.5-8.73MG Capsule
Lower Cost
ENBREL 25 mg KIT
ENBREL 25 mg/0.5 mL SYRINGE
Clinical
Clinical
ENBREL 50 mg/ML SURECLICK
Clinical
ENBREL 50 mg/ML SYRINGE
Clinical
ENJUVIA 0.3 mg TABLET
ENOVARX-LIDOCAINE HCL 5% CREAM
ENOVARX-LIDOCAINE HCL 10% CREAM
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary agent: Formulary Lidocaine Product
Formulary agent: Formulary Lidocaine Product
Enstilar 0.005-0.064% Aerosol Foam
Lower Cost
Required Diagnosis= Plaque Psoriasis, Age= 18 Years Or
Older AND Formulary Agent(s): Calcipotriene
ENTRESTO 24MG-26MG TABLET
Clinical
Formulary Agent(s): Formulary Ace Inhibitor or
Formulary ARB Agent
42
Drug
Status
Clinical
Clinical
ENTYVIO 300MG VIAL
ENVARSUS XR 0.75MG TABLET
Lower Cost
Lower Cost
ENVARSUS XR 1MG TABLET
Lower Cost
ENVARSUS XR 4MG TABLET
Lower Cost
EPANED 1 mg/ML SOLUTION
Clinical
Epclusa 400-100 mg Tablet
EPICERAM
Lower Cost
Lower Cost
Formulary ARB Agent
Formulary ARB Agent
Formulary Agent(s): Tacrolimus (Prograf) 0.5mg
Capsule
Capsule
Capsule
Formulary agent: ENALAPRIL tablet for those over age
12
Required Diagnosis= atopic dermatitis, irritant contact
dermatitis, and radiation dermatitis or eczema
Required trial of: THERAPLEX, VELVACHOL,
NUTRADERM, CETAPHIL, or AVEENO
EPIDUO FORTE 0.3%-2.5% GEL
Lower Cost
EPIDUO 0.1%-2.5% GEL
Lower Cost
EPIFOAM 1-1%
Lower Cost
EPINASTINE (ELESTAT) 0.05% EYE
DROPS
Lower Cost
EPOGEN 10,000 UNITS/ML VIAL
Clinical
Clinical
EPOGEN 20,000 UNITS/2 mL VIAL
Clinical
Clinical
Clinical
Clinical
ERGOLOID MESYLATES 1 mg TABLET
Lower Cost
ERGOMAR 2 mg SUBLINGUAL TABLET
Lower Cost
Formulary agents: Namenda, generic Aricept,
galantamine, generic Exelon
Formulary agents: propranolol or topiramate for
migraine prevention
OR sumatriptan or naratriptan for migraine abortion
ERIVEDGE 150 mg CAPSULE
ERTACZO 2% CREAM
Clinical
Lower Cost
ESBRIET 267 MG CAPSULE
Esomeprazole 24.65 mg Capsule
Clinical
Lower Cost
Esomeprazole 49.3 mg Capsule
Lower Cost
ESTRADERM 0.05 mg PATCH
ESTRADERM 0.1 mg PATCH
Lower Cost
Lower Cost
Formulary Agents: benzoyl peroxide gel 2.5% and
adapalene gel 0.1%
Formulary Agents: benzoyl peroxide gel 2.5% and
adapalene gel 0.1%
Formulary agent: PRAMOXINE AEROSOL (Proctofoam)
1% with Procto-Pak (PROCTOCORT) 1% CREAM
separately
Required diagnosis = basal cell carcinoma
Formulary agents: ketoconazole or clotrimazole for a
diagnosis of tinea pedis
A 30 Day Trial Of: OTC Nexium 20MG, Or
Esomeprazole (Nexium) 20 mg Or 40 mg Capsules At
Maximum Dosing
A 30 Day Trial Of: OTC Nexium 20MG, Or
Esomeprazole (Nexium) 20 mg Or 40 mg Capsules At
Maximum Dosing
43
Drug
Status
ESTRADIOL (MINIVELLE DIS) 0.1 mg
PATCH
PATCH
PATCH
PATCH
Estradiol Valerate (DELESTROGEN) IM
OIL INJECTION
ESTRASORB PACKET
Lower Cost
Formulary agents: Alora or Estradiol (Climara) patches
Lower Cost
Lower Cost
Lower Cost
Clinical
ESTRING 2 mg VAGINAL RING
Lower Cost
ESTROGEL 0.6% GEL
Lower Cost
ESZOPICLONE (LUNESTA) 1 mg TABLET
ETIDRONATE (Didronel) 400 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary agents: estradiol tablets, patches (Climara)
or Alora
or Alora
or Alora
or Alora
Formulary agents: zolpidem or zaleplon
ETIDRONATE 200 mg TABLET
EUFLEXXA
Lower Cost
Lower Cost
EURAX 10% CREAM
Lower Cost
EURAX 10% LOTION
Lower Cost
EVAMIST 1.53 mg/SPRAY
Lower Cost
Evzio 0.4 mg/0.4 mL Injection
HYDROMORPHONE ER (EXALGO ER)
8MG TABLET
12MG TABLET
16MG TABLET
32MG TABLET
ERBITUX 2MG/ML VIAL
EXELDERM 1% CREAM
Lower Cost
Lower Cost
EXELDERM 1% SOLUTION
Lower Cost
Required diagnosis = tinea pedis (athlete's foot), tinea
cruris, and tinea corporis and tinea versicolor
Formulary agents: ketoconazole, clotrimazole,
metronidazole
EXJADE 125 mg TABLET
Clinical
Required diagnosis = Chronic iron overload
Lower Cost
Formulary agents: Supartz & Gel-One
for 7 days each
OR
Required Diagnosis= Scabies AND Must Use
Permethrin (Elimite) 5% Cream For 7 Days
for 7 days each
OR
Required Diagnosis= Scabies AND Must Use
Permethrin (Elimite) 5% Cream For 7 Days
or Alora
Formulary Agent(s): Narcan Nasal Spray
Required diagnosis = tinea pedis (athlete's foot), tinea
cruris, and tinea corporis and tinea versicolor
Formulary agents: ketoconazole, clotrimazole,
metronidazole
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
44
Drug
Status
EXTAVIA 0.3 mg KIT
Clinical
Clinical
Clinical
EYLEA INJECTION 2/0.05 mL
FABB, TL GARD RX, VIRT-GARD
(FOLGARD RX) 1-5.2-25MG TABLET
FABIOR 0.1% AEROSOL FOAM
Specialty
Lower Cost
Formulary Agent(s): Folgard OS Or TL G-Fol OS Tablet
Lower Cost
FABIOR 0.1% AEROSOL FOAM
Lower Cost
FABRAZYME
Specialty
Required diagnosis = Acne
Formulary agent: Tazorac 0.1% cream or gel
Required diagnosis = Acne
Formulary agent: Tazorac 0.1% cream or gel
FACTIVE 320 mg TABLET
FaLessa
FANAPT 10 mg TABLET
Lower Cost
Lower Cost
Step Therapy
FANAPT 12 mg TABLET
Step Therapy
FANAPT 1 mg TABLET
Step Therapy
FANAPT 2 mg TABLET
Step Therapy
FANAPT 4 mg TABLET
Step Therapy
FANAPT 6 mg TABLET
Step Therapy
FANAPT 8 mg TABLET
Step Therapy
FANAPT TITRATION PACK
Step Therapy
FARXIGA 10MG TABLET
Lower Cost
FARXIGA 5MG TABLET
Lower Cost
FARYDAK 10MG CAPSULE
FEMECAL OB TABLET 22-6-1 mg
Clinical
Clinical
Clinical
Lower Cost
FEMCAP 22MM CERVICAL CAP
FEM PH 0.9-0.025% VAGINAL GEL
Excluded Benefit
Excluded Benefit
Excluded Benefit
Lower Cost
FEMRING 0.05 mg VAGINAL RING
FEMTRACE 0.45 mg TABLET
Lower Cost
Lower Cost
Formulary agent: ciprofloxacin or levofloxacin
Use a formulary oral contraceptive
Requires a diagnosis of Bipolar Disorder,
Schizophrenia, or Autism with a trial of aripiprazole
(Abilify)
(Abilify)
(Abilify)
(Abilify)
(Abilify)
(Abilify)
(Abilify)
(Abilify)
Formulary agents: Metformin IR or ER (Glucophage)
then Invokana
Formulary agents: Metformin IR or ER (Glucophage)
then Invokana
Required 14 day trial of: povidone-iodine douch
(Summer's Eve) 0.3% solution
or Alora
45
Drug
Status
Lower Cost
or Alora
Lower Cost
or Alora
FENOFIBRIC ACID (TRILIPIX DR) 135 mg
CAPSULE
FENOFIBRIC ACID (TRILIPIX DR) 45 mg
CAPSULE
Fentanyl Citrate (ACTIQ) 1,200 mcg
LOZENGE
Lower Cost
Lower Cost
Clinical
Fentanyl Citrate (ACTIQ) 400 mcg
LOZENGE
Clinical
LOZENGE
Clinical
LOZENGE
Clinical
Fentanyl Citrate (ACTIQ)1,600 mcg
LOZENGE
Clinical
FENTANYL CITRATE OTFC 200 mcg
Clinical
FENTORA 100 mcg BUCCAL TABLET
Clinical
Clinical
Clinical
Clinical
Clinical
FERAHEME IRON INJECTION
Clinical
FERIVA 75-1 MG CAPSULE
Lower Cost
FERRALET 90 DUAL-IRON 90-1 mg
TABLET
Lower Cost
FERRAPLUS 90 TABLET
Lower Cost
FERREX 150 FORTE PLUS CAPSULE
Lower Cost
therapy
therapy
therapy
therapy
therapy
therapy
therapy
therapy
therapy
therapy
therapy
Required diagnosis = iron deficiency anemia in adults
with chronic kidney disease
Required trial of: INFED 50 mg/MI VIAL
Formulary agents: FERREX 150 CAP, FERROUS
GLUCONATE tablet 240MG, FERROUS FUMARATE
tablet 325MG, FERROUS SULFATE tablet 134MG, or
SLOW RELEASE IRON 160GM
Formulary agents: Formulary Iron (Examples: FERREX
150 CAP, FERROUS GLUCONATE tablet 240 mg,
FERROUS FUMARATE tablet 325 mg , FERROUS
SULFATE tablet 134 mg, etc)
Formulary agent: FERREX 150 PLUS capsule and a BCOMPLEX W/ FOLIC ACID TAB separately
46
Drug
Status
FERREX 28 TABLET
Lower Cost
FERRIC GLUCONATE (FERRLECIT) 62.5
mg/5 mL VIAL
Clinical
FERRIPROX 500 mg TABLET
FERROGELS FORTE, TRIGELS-F FORTE,
HEMATOGEN FORTE 460 (151 FE)-600.01-1 mg SOFTGEL
Lower Cost
Lower Cost
FETZIMA 120 mg CAPSULE
Lower Cost
Lower Cost
Lower Cost
Lower Cost
FETZIMA TITRATION KIT
Lower Cost
FEXOFENADINE (ALLEGRA) 180 mg
TABLET RX
TABLET RX
TABLET RX
FENOFIBRATE (FIBRICOR) 105 mg
TABLET
FENOFIBRATE (FIBRICOR) 35 mg TABLET
Lower Cost
Lower Cost
Formulary agent: Formulary Iron (Examples: FERREX
Required diagnosis = iron deficiency anemia in patients
6 years and older with chronic kidney disease receiving
hemodialysis who are receiving supplemental epoetin
therapy
Bupropion XL)
Bupropion XL)
Bupropion XL)
Bupropion XL)
Bupropion XL)
Formulary agent: FEXOFENADINE (Allegra) 30 mg or 60
mg tablet OTC
Formulary agent: FEXOFENADINE (Allegra) 30 mg
tablet OTC
Formulary agent: Fexofenadine (Allegra) 60 mg tablet
OTC
Lower Cost
FENTANYL 37.5MCG/HR PATCH
Lower Cost
Formulary Agent(s): Fentanyl (Duragesic) Patch
(12mcg/HR, 25mcg/HR, 50mcg/HR, 75mcg/HR, Or
100mcg/HR)
Lower Cost
Lower Cost
47
Drug
Status
Lower Cost
Lower Cost
FERIVA 21-7 75-1-175MG TABLET
Finacea 15% Foam
Finacea 15% Gel
FINACEA PLUS KIT
Lower Cost
Lower Cost
Lower Cost
Lower Cost
100mcg/HR)
100mcg/HR)
*Formulary Agent(s): Daily Vite With Iron Tablet
A 30 Day Trial Of: Metronidazole Topical
A 30 Day Trial Of: Metronidazole Topical
Must provide clinical reason supported by chart notes
why Finacea 15% gel cannot be used (which also
requires a step through metronidazole topical)
FINASTERIDE 1 mg (PROPECIA) TABLET
Excluded benefit
FIORICET-COD 30-50-325-40 CAPSULE
Lower Cost
FIRAZYR 30 mg/3 mL SYRINGE
Lower Cost
Formulary agent: FIORICET-COD 30-50-325-40
CAPSULE
FIRMAGON (DEGARELIX ACETATE) FOR Clinical
INJECTION 120 mg (BASE EQUIV)
Specialty
FIRMAGON (DEGARELIX ACETATE) FOR Clinical
INJECTION 80 mg (BASE EQUIV)
Specialty
FIRST-HYDROCORTISONE 10% GEL
Lower Cost
Formulary agents: formulary topical hydrocortisone
FIRST-TESTOSTERONE 2% CREAM
Lower Cost
Required diagnosis = hypogonadism with total
testosterone lab value = ≤ 300 ng/dL before treatment
Formulary agents: Testosterone TD (Fortesta) Or
FIRST-TESTOSTERONE 2% OINTMENT
Lower Cost
Required diagnosis = hypogonadism with total
testosterone lab value = ≤ 300 ng/dL before treatment
FIRST-VANCOMYCIN 25 MG/ML
SOLUTION
FIRST VANCOMYCIN 50 MG/ML
SOLUTION
FLAGYL ER 750 mg TABLET
FLAREX 0.1% ophthalmic SUSPENSION
Lower Cost
FLEBOGAMMA DIF 5% VIAL
Clinical
Required Diagnosis= C.Diff (Clostridium Difficile)
Colitis/Diarrhea AND Oral Metronidazole Trial
Required Diagnosis= C.Diff (Clostridium Difficile)
Colitis/Diarrhea AND Oral Metronidazole Trial
Formulary agent: Metronidazole 500 mg
Formulary agent: FLUOROMETHOLONE, FLUOR-OP
(FML LIQUIFLM) 0.1% DROPS
FLEBOGAMMA DIF 10% VIAL
Clinical
Lower Cost
Lower Cost
Lower Cost
48
Drug
Status
FLECTOR 1.3% PATCH
Lower Cost
FLOLAN, VELETRI (EPOPROSTENOL
SODIUM) FOR INJECTION 0.5MG
Clinical
Formulary agents: 30 DAY TRIAL OF NSAIDS (celecoxib
(Celebrex), naproxen, ibuprofen, flurbiprofen,
nabumetone, diclofenac, etodolac, indomethacin,
ketoprofen, meloxicam, oxaprozin, Sulindac or
piroxicam);
AND topical Voltaren Gel for a diagnosis of pain
OR
Formulary agents: 30 DAY TRIAL OF NSAIDS (celecoxib
(Celebrex), naproxen, ibuprofen, flurbiprofen,
nabumetone, diclofenac, etodolac, indomethacin,
ketoprofen, meloxicam, oxaprozin, Sulindac or
piroxicam) for a diagnosis of low back pain
FLOLAN, VELETRI (EPOPROSTENOL
SODIUM) FOR INJECTION 1.5MG
FLO-PRED 15 mg/5 mL
FLOVENT DISKUS 50MCG
Clinical
Lower Cost
Lower Cost
Formulary agent: prednisolone suspension
Required diagnosis: Eosinophilic Esophagitis (EoC)
OR
*30 day trial of: Aerospan or Asmanex
*Members 8 y/o and younger will not require a PA*
Lower Cost
OR
Lower Cost
OR
FLOVENT HFA 44MCG
Lower Cost
OR
FLOVENT HFA 110MCG
Lower Cost
OR
FLOVENT HFA 220MCG
Lower Cost
OR
FLOWTUSS 200-2.5MG/5ML SOLUTION Lower Cost
FLUARIX QUAD IM SYRINGE
Formulary Agent(s): Guaifenesin-Codeine 20010MG/5mL Liquid
Formulary Agent(s): Afluria, Flublok, Flucelvax, Fluvirin,
Fluzone, Fluzone HD
Lower Cost
49
Drug
Status
FLUCYTOSINE (ANCOBON) 250 mg
CAPSULE
Lower Cost
Required diagnosis= Cryptococcus Meningitis
AND
Formulary Agent(s): fluconazole
OR
Required diagnosis= Candida, UTI, Septicemia and
Pulmonary
AND
Formulary Agent(s): fluconazole or ketoconazole
FLUCYTOSINE (ANCOBON) 500 mg
CAPSULE
Lower Cost
Required diagnosis= Cryptococcus Meningitis
AND
Formulary Agent(s): fluconazole
OR
Required diagnosis= Candida, UTI, Septicemia and
Pulmonary
AND
Formulary Agent(s): fluconazole or ketoconazole
FLULAVAL QUAD IM SYRINGE
Lower Cost
Fluzone, Fluzone HD
Fluzone, Fluzone HD
Required diagnosis= chronic eczematous external
otitis
Formulary agent: fluocinolone cream
FLUMIST QUAD INTRANASAL
Lower Cost
SUSPENSION
FLUOCINOLONE (DERMOTIC) OIL 0.01% Lower Cost
EAR DROP
FLUOCINONIDE (VANOS) 0.1% CREAM Lower Cost
Fluoridex Sensitivity Relief (Prevident
5000 Enamel Protect, Prevident 5000
Sensitive) 1.1%-5% Paste
Lower Cost
FLUOROPLEX 1% CREAM
Lower Cost
FLUOROURACIL (CARAC) 0.5% CREAM
Lower Cost
FLUOXETINE 60 mg TABLET
Lower Cost
FLUOXETINE DR (PROZAC) 60 mg
CAPSULE
FLUOXETINE DR (PROZAC) 90 mg
CAPSULE
Flurandrenolide (Cordran) Cream
Lower Cost
Formulary agent: FLUOROURACIL (EFUDEX) 5% CREAM
Required diagnosis= Actinic Keratosis AND a 14 day
trial of imiquimod (Aldara) 5% cream packet
Formulary agent: fluoxetine (10 mg, 20 mg, 40 mg, or
20 mg/5 ml soln)
20 mg/5 ml soln)
20 mg/5 ml soln)
for 7 days each.
Will Approve For Procedures In Which A Topical
Ophthalmic Anesthetic Agent In Conjunction With A
Disclosing Agent Is Indicated, Such As Corneal
Anesthesia Of Short Duration (i.e., Tonometry,
Gonioscopy, Removal Of Foreign Bodies) And Short
Corneal And Conjunctival Procedures
Lower Cost
Lower Cost
FLUROX, ALTAFLUOR, FLUORESCEIN W/ Lower Cost
BENOXINATE 0.25-0.4% OPHTHALMIC
SOLUTION
50
Drug
Status
FLUTICASONE Propionate (CUTIVATE)
0.05% LOTION
Lower Cost
Formulary agents:
BETAMETHASONE VALERATE 0.1% LOTION
BETAMETHASONE VALERATE 0.1% LOTION,
Mometasone (ELOCON) 0.1% LOTION
Age 18 and older: BETAMETHASONE DP 0.05%
LOTION, BETAMETHASONE VALERATE 0.1% LOTION,
Mometasone (ELOCON) 0.1% LOTION, FLUOCINOLONE
0.01% Topical SOLUTION, CLOBETASOL FOAM
Fluvastatin (LESCOL) 20 mg CAPSULE
Lower Cost
Fluvastatin (LESCOL) 40 mg CAPSULE
Lower Cost
Fluvastatin ER (Lescol XL) 80mg Tablet
Lower Cost
Formulary agents: simvastatin (Zocor) or
ATORVASTATIN (Lipitor)
Formulary Agent(s): Simvastatin OR Atorvastatin
FLUVOXAMINE SR (LUVOX CR) 100 mg
CAPSULE
Lower Cost
FLUVOXAMINE SR (LUVOX CR) 150 mg
CAPSULE
Lower Cost
FLUZONE ID QUAD PF SYRINGE
Lower Cost
FLUZONE QUAD PF INJECTION
Lower Cost
FLUZONE QUAD VIAL FOR INJECTION
Lower Cost
FML FORTE 0.25% EYE DROPS
Lower Cost
Bupropion XL)
Bupropion XL)
Fluzone, Fluzone HD
Fluzone, Fluzone HD
Fluzone, Fluzone HD
Formulary agent: FLUOROMETHOLONE, FLUOR-OP
(FML LIQUIFLM) 0.1% DROPS
FOCALGIN 90 DHA 90-1-300MG COMBO Lower Cost
PACK
FOCALGIN CA 35-1-50MG COMBO PACK Lower Cost
FOCALIN XR 25 mg CAPSULE
Lower Cost
Must first try:
and required trial of
OR Age 6 and older trial of Methylphenidate ER tablet (Concerta),
51
Drug
Status
FOCALIN XR 35 mg CAPSULE
Lower Cost
FOLAST TABLET 2-2.8-25 mg
FOLBEE PLUS TABLET
FOLCAP, FOLPLEX, FA-B6-B12 TABLET
FOLGARD 2000-800 TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Must first try:
and required trial of
OR Age 6 and older trial of Methylphenidate ER tablet (Concerta),
Methylphenidate
SR capsule
Formulary agent: folic
acid (Ritalin LA)
Formulary agent: folic acid
Formulary agent: folic acid
Formulary Agent(s): Folgard OS Or TL G-Fol OS Tablet
FOLIVANE-EC CALCIUM DHA COMBO 27- Lower Cost
1-250 mg
FOLIVANE-OB CAPSULE 85 mg-1 mg
Lower Cost
FOLIVANE-PRX DHA NF CAPSULE 301.24-55
FOLLISTIM AQ INJECTION 600UNIT
FORFIVO XL 450 mg TABLET
Lower Cost
FORMALDEHYDE 10% SOLUTION
(Lazerformaldehyde)
FORTEO 600 mcg/2.4 mL PEN
Lower Cost
Formulary Agent(s): Bupropion XL 150 mg (3 Tablets)
OR Bupropion XL 150 mg AND Bupropion XL 300 mg
Tablet
Formulary agent: FORMALDEHYDE 37% SOLUTION
Specialty
FORTESTA 10 mg GEL PUMP
Clinical
Required diagnosis = hypogonadism with Total
Testosterone lab value = ≤ 300 ng/dL before treatment
FOSAMAX 70 mg ORAL SOLUTION
FOSAMAX PLUS D 70 mg-2,800 TABLET
Lower Cost
Lower Cost
FOSAMAX PLUS D 70 mg-5,600 TABLET
Lower Cost
FOSTEUM CAP
Lower Cost
FRAGMIN 10,000 UNITS SYRING
Clinical
Formulary agent: alendronate AND OTC vitamin D
separately
Formulary agent: alendronate AND OTC vitamin D
separately
Formulary agent: VP-GSTN CAP [which requires a trial
of OTC Vitamin D (CHOLECALCIFEROL) with OTC ZINC
GLUCONATE TAB separately]
Required diagnosis = VTE/ Unstable angina /non-Q
wave MI
Required trial: oral warfarin or enoxaparin (Lovenox)
OR
Required diagnosis = DVT
Required trial: enoxaparin (Lovenox)
Clinical
Excluded Benefit
Excluded Benefit
Excluded Benefit
Lower Cost
wave MI
OR
52
Drug
Status
Clinical
wave MI
OR
Clinical
wave MI
OR
FRAGMIN 2,500 UNITS SYRINGE
Clinical
wave MI
OR
FRAGMIN 25,000 UNITS/ML VIAL
Clinical
wave MI
OR
Clinical
wave MI
OR
Clinical
wave MI
OR
FRAGMIN 95,000 UNIT SYRINGE
Clinical
wave MI
OR
FreeStyle Precision Neo Meter
FreeStyle Precision Neo Test Strips
FRESHKOTE EYE DROPS
FROVA 2.5 mg TABLET
Non-Covered Benefit
Non-Covered Benefit
Lower Cost
Lower Cost
FULYZAQ 125 MG DR TABLET
FUMATINIC ER CAPSULE
FUSION 130-25-30MG CAPSULE
Lower Cost
Lower Cost
Lower Cost
Formulary agent: OTC artificial tears
Formulary agents: sumatriptan, naratriptan,
rizatriptan, or almotriptan (trial of 2 of 4)
Required diagnosis = HIV/AIDs related Diarrhea
53
Drug
Status
Fycompa 0.5 mg/mL Solution
Step Therapy
Formulary agents:
(Keppra XR) oxcarbazepine (Trileptal), carbamazepine
(Carbatrol), Phenytoin (Dilantin), topiramate
(Topamax), VALPROIC ACID (Depakene) or Zonisamide
FYCOMPA 2 mg TABLET
Step Therapy
Formulary agents:
FYCOMPA 4 mg TABLET
Step Therapy
Formulary agents:
FYCOMPA 6 mg TABLET
Step Therapy
Formulary agents:
FYCOMPA 8 mg TABLET
Step Therapy
Formulary agents:
FYCOMPA 10 mg TABLET
Step Therapy
Formulary agents:
FYCOMPA 12 mg TABLET
Step Therapy
Formulary agents:
GALZIN 25 mg CAPSULE
Clinical
(Depakote), levetiracetam (Keppra), oxcarbazepine
GALZIN 50 mg CAPSULE
Clinical
GAMASTAN S/D SYRINGE
Clinical
Required diagnosis = Wilson's Disease with a trial of
cupriine 250 mg capsule
54
Drug
Status
GAMASTAN S-D VIAL
Clinical
GAMMAGARD LIQUID 10% VIAL
Clinical
GAMMAGARD S-D 5 GM VIAL
Specialty
GAMMAGARD S-D 10 GM VIAL
Specialty
GAMMAKED 1 GM/10 ML VIAL
GAMMAPLEX 2.5 GM/50 ML VIAL
Specialty
Specialty
Specialty
Specialty
Specialty
GAMMAPLEX 5 GM/100 ML VIAL
Specialty
GAMMAPLEX 10 GM/200 ML VIAL
GAMUNEX 10% VIAL
Specialty
Clinical
GAMUNEX-C 1 GRAM/10 mL VIAL
Clinical
Clinical
GAMUNEX-C 2.5 GRAM/25 mL VIAL
Clinical
Clinical
Clinical
GANIRELIX AC INJECTION
GATIFLOXACIN (ZYMAXID) 0.5% EYE
DROPS
Excluded Benefit
Lower Cost
GATTEX 5 mg KIT
GAVILYTE-H AND BISACODYL 5MG210(G) KIT
GAZYVA 25 mg/ML INJECTION
Specialty
Lower Cost
*Formulary Agent(s): Peg-3350, Gavilyte-G (Golytely)
Lower Cost
GELCLAIR GEL PACKETS
Lower Cost
GELNIQUE 10% GEL SACHETS
Lower Cost
Diagnosis = Previously untreated chronic lymphocytic
leukemia (CLL)
Provider Specialty = Oncologist
Required Diagnosis= Treating Sores And Ulcers In The
Mouth Caused By Various Conditions (i.e., Radiation,
Chemotherapy, Canker Sores, Surgery, Poorly Fitting
Dentures)
why OXYBUTYNIN, OXYBUTYNIN ER, or OXYBUTYNIN
SYRUP cannot be used
GELNIQUE 3% GEL SACHETS
Lower Cost
GEL-KAM 0.4% GEL
Lower Cost
GEL-ONE 10MG/ML
GEL-ONE 30MG/3ML
Clinical
Clinical
ophthalmic with a diagnosis of conjunctivitis OR a
diagnosis of cataract surgery or Corneal ulcer/Keratitis
why OXYBUTYNIN, OXYBUTYNIN ER, or OXYBUTYNIN
SYRUP cannot be used
Formulary agents: Denta 5000 Plus, SF 5000 Plus
(Prevident 5000 Plus) 1.1% Cream
55
Drug
Status
GENOTROPIN 12 mg CARTRIDGE
Specialty
GENOTROPIN 5 mg CARTRIDGE
Specialty
GENOTROPIN MINIQUICK 0.2 mg
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
GENOTROPIN MINIQUICK 1 mg
Specialty
GENOTROPIN MINIQUICK 2 mg
Specialty
GENTIAN VIOLET 2% SOLUTION
GenVisc 850 10mg/mL Syringe
Lower Cost
Lower Cost
GIAZO 1.1 gM TABLET
Lower Cost
GILENYA 0.5 mg CAPSULE
Clinical
Formulary agent: Gentian Violet 1% (OTC)
Formulary Agent(s): Supartz & Gel-One
Formulary agents: BALSALAZIDE (COLAZAL) 750 mg
capsule for exclusively for the treatment of mildly to
moderately active ulcerative colitis disease in adult
males
GILOTRIF 20 mg TABLET
Clinical
Clinical
Clinical
Required diagnosis = Metastatic non-small lung cancer
- Test results required
GLASSIA 1000 mg/50 mL IV SOLUTION Specialty
GLATOPA (COPAXONE) 20MG SYRINGE Specialty
GLUCOSE METER BATTERIES
GLYCATE 1.5 mg TABLET
Bill as DME
Lower Cost
GLYCINE 1.5% IRRIGATION
GLYXAMBI 10MG-5MG TABLET
Lower Cost
Step Therapy
why GLYCOPYRROLATE tablet cannot be used
Formulary agent: Normal Saline
THEN
A 60 day trial of: Invokana
THEN
A 60 day trial of: Tradjenta AND Jardiance taken
56
Drug
Status
GLYXAMBI 25MG-5MG TABLET
Step Therapy
GONAL-F INJECTION 1050UNIT
GONAL-F INJECTION 450UNIT
GONAL-F RFF INJECTION 300UNIT
GONAL-F RFF INJECTION 450
GONAL-F RFF INJECTION 75UNIT
GONAL-F RFF INJECTION 900 UNIT
GRAFCO (ARZOL) 75-25% SILVER
NITRATE APPLICATOR STICKS
Excluded Benefit
Excluded Benefit
Excluded Benefit
Excluded Benefit
Excluded Benefit
Excluded Benefit
Lower Cost
THEN
A 60 day trial of: Invokana
THEN
A 60 day trial of: Tradjenta AND Jardiance taken
GRALISE 300 mg
Lower Cost
GRALISE 600 mg
Lower Cost
Required use= cauterization of skin or mucous
membranes and for removing warts and granulated
tissue
Formulary agent: gabapentin with a diagnosis of Post
Herpetic Neuralgia
Formulary agent: gabapentin with a diagnosis of Post
Herpetic Neuralgia
why Gralise tablet (requires a PA with diagnosis = PHN
and step through gabapentin) cannot be used
GRALISE Starter Kit 300 mg and 600 mg Lower Cost
GRANIX 300MCG/0.5ML SYRINGE
Clinical
GRANIX 480MCG/0.8ML SYRINGE
GRASTEK SUB 2800BAU
Clinical
Clinical
GUANIDINE 125 mg TABLET
Lower Cost
GYNAZOLE-1 CREAM
Lower Cost
HALOBETASOL (ULTRAVATE) 0.05%
CREAM
Lower Cost
HALOBETASOL (ULTRAVATE) 0.05%
OINTMENT
Lower Cost
HALOG 0.1% CREAM
Lower Cost
HALOG 0.1% OINTMENT
Lower Cost
HARVONI 90-400MG TABLET
HC AC/ ALOE, CORTALO (NUZON) 2%
GEL
Clinical
Lower Cost
Required diagnosis = grass pollen-induced allergic
rhinitis
Required diagnosis = Myasthenic syndrome of EatonLambert
Formulary agents: MICONAZOLE NITRATE VAGINAL
SUPPOSITORIES, CLOTRIMAZOLE VAGINAL CREAM 1%
or 2%, TERCONAZOLE 0.4% or 0.8% CREAM, or
TIOCONAZOLE (VAGISTAT-1, MONISTAT-1) 6.5%
OINTMENT
for 7 days each.
for 7 days each.
for 7 days each.
for 7 days each.
Formulary agents: HYDROCORTISONE , PROCTOSOLHC, Proctozone, Proctocream, Proctocare (Anusol-HC)
2.5% CREAM, HYDROCORTISONE 2.5% LOTION,
HYDROCORTISONE 2.5% OINTMENT
HEARING AID BATTERIES
HELIDAC THERAPY
Bill as DME
Lower Cost
Will currently approve due to backorder of tetracycline
57
Drug
Status
HELIXATE FS 1,000 UNIT VIAL
Specialty
HELIXATE FS 2,000 UNIT VIAL
HELIXATE FS 250 UNIT VIAL
Specialty
Specialty
HELIXATE FS 3,000 UNITS VIAL
HELIXATE FS 500 UNIT VIAL
HEMATOGEN FA 200-250 mg SOFTGEL
Specialty
Specialty
Lower Cost
HERCEPTIN 440MG VIAL
HETLIOZ 20 MG
Lower Cost
Clinical
HEPAGAM B VIAL
Clinical
Formulary agents: Examples: FERREX 150 CAP,
FERROUS GLUCONATE tablet 240 MG, FERROUS
FUMARATE tablet 325 MG , FERROUS SULFATE tablet
134 MG
Required diagnosis= non-24-hour sleep-wake disorder
Or Insomnia Related To Blindness
Specialty
HIZENTRA 1 GRAM/5 mL VIAL
Clinical
Clinical
HIZENTRA 20% (200 mg/ML) VIAL
Clinical
Clinical
HORIZANT ER TABLET 300 mg
Lower Cost
HORIZANT ER TABLET 600 mg
Lower Cost
Required Diagnosis= RLS AND Ropinirole Or
Pramipexole OR Required Diagnosis= Post-Herpetic
Neuralgia AND Gabapentin
Formulary agents for diagnosis of RLS (Restless leg
syndrome): gabapentin, ropinirole, or pramipexole
HUMATROPE 12 mg CARTRIDGE
Specialty
Specialty
HUMATROPE 5 mg VIAL
Specialty
Specialty
HUMIRA 20 mg/0.4 mL SYRINGE
Clinical
HUMIRA 40 mg/0.8 mL PEN
Clinical
HUMIRA 40 mg/0.8 mL SYRINGE
Clinical
HYALGAN
Lower Cost
HYCAMTIN 0.25 mg CAPSULE
Clinical
Required diagnosis=relapsed small cell lung cancer
58
Drug
Status
HYCAMTIN 1 mg CAPSULE
Clinical
Required diagnosis=relapsed small cell lung cancer
HYCOFENIX 30-2.5-200MG/5ML
SOLUTION
HYDRO 40 AREOSOL FOAM
Lower Cost
HYDROCODONE W/ HOMATROPINE
(TUSSIGON) TABLET
HYDROCODONE-ACETAMINOPHEN
(MAXIDONE) 10-750 mg TABLET
HYDROCODONE-ACETAMINOPHEN,
VICODIN (XODOL) 5-300 mg TABLET
VICODIN ES (XODOL)7.5-300 mg TABLET
Lower Cost
Formulary Agent(s): Guaifenesin-Codeine 20010MG/5mL Liquid
Formulary agents: UREA , U-KERA, X-VIATE 40%
LOTION
Lower Cost
Lower Cost
Formulary agent: HYDROCODONE-ACETAMINOPHEN
(LORTAB) 10-500 TABLET
(NORCO) 5-325 MG
(NORCO) 7.5-325 MG
Lower Cost
Lower Cost
Lower Cost
VICODIN HP (XODOL) 10-300 mg TABLET
(NORCO) 10-325 M
HYDROCODONE-CHLORPHENIRAMINE Lower Cost
(TUSSIONEX) PENNKINETIC SUSPENSION
Formulary agents:
Age: 26 = off label (can use Dextromethorphan)
Age: 612 = Dextromethorphan
Age over
12 = Dextromethorphan or Benzonatate capsules
HYDROCODONE-IBUPROFEN,
Lower Cost
(REPREXAIN) 2.5-200 mg TABLET
HYDROCODONE-IBUPROFEN, IBUDONE Lower Cost
(REPREXAIN) 5-200 mg TABLET
2.5-500 mg
Formulary agents: HYDROCODONE-ACETAMINOPHEN
(VICODIN, Anexsia, Lortab) 5-500 tablet or
HYDROCODONE-ACETAMINOPHEN 5-325 MG (Norco)
HYDROCODONE-IBUPROFEN,
Lower Cost
REPREXAIN, IBUDONE 10-200 mg
TABLET
HYDROCORTISONE BUTYRATE
Lower Cost
HYDROPHILIC LIPO BASE (LOCOID
LIPOCREAM) 0.1% CREAM
HYDROCORTISONE VALERATE
Lower Cost
(WESTCORT) 0.2% OINTMENT
HYDROGEL GEL
Lower Cost
HYDROGESIC, STAGESIC (MARGESIC H) 5- Lower Cost
500 mg CAPSULE
10-325 MG
8MG TABLET
12MG TABLET
16MG TABLET
32MG TABLET
HYDROQUINONE 4% CREAM TIME
RELEASE
(EpiQuin Micro, EpiQuin Micro/Pump)
Formulary Agent(s): Hydrocortisone Butyrate (Locoid)
0.1% Cream
Formulary agent: HYDROCORTISONE VALERATE
(WESTCORT) 0.2% CREAM
(VICODIN, Anexsia, Lortab) 5-500 MG tablet
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Excluded benefit
HYDROQUINONE 4% CREAM
Excluded benefit
(TL HYDROQUINONE, SKIN BLEACHING,
REMERGENT HQ, MELQUIN HP,
MELPAQUE HP, LUSTRA-ULTRA,
LUSTRA, ELDOPAQUE FORTE,
ELDOQUIN FORTE)
59
Drug
Status
HYGEL, HYALURONATE GEL (HYLIRA)
0.2% GEL
HYLAN INTRA-ARTICULAR INJECTION 8
mg/ML
Lower Cost
Clinical
Formulary agents: Supartz or Gel-One
HYLATOPIC AREOSOL FOAM
Lower Cost
HYLATOPIC PLUS CREAM
Lower Cost
HYLIRA 0.2% LOTION
HYOPHEN (PROSED-DS) TABLET
Lower Cost
Lower Cost
HYPERHEP B INJECTION S/D
HYPERRHO S/D SYRINGE 50 mcg
Lower Cost
Clinical
Lubriderm (Eucerin)
Lubriderm (Eucerin)
Formulary agents: URELLE tablet, UROGESIC-BLUE or
UTRONA-C
Specialty
HYQVIA INJECTION KIT
IBANDRONATE (BONIVA) SYRINGE
IBANDRONATE (BONIVA) VIAL
IBRANCE 75MG CAPSULE
ICLUSIG 15 mg TABLET
Lower Cost
Specialty
Specialty
Clinical
Clinical
Clinical
Clinical
Required diagnosis= Philadelphia
chromosome–positive acute lymphoblastic leukemia
(Ph+ALL) OR diagnosis = chronic phase, accelerated
phase, or blast phase chronic myeloid leukemia (CML)
with T3151 mutation with resistance or intolerance to
prior therapy (Gleevec, Sprycel, Tasigna)
ICLUSIG 45 mg TABLET
Clinical
Required diagnosis= Philadelphia
(Ph+ALL) OR diagnosis = chronic phase, accelerated
phase, or blast phase chronic myeloid leukemia (CML)
with T3151 mutation with resistance or intolerance to
prior therapy (Gleevec, Sprycel, Tasigna)
ILARIS FOR INJECTION 180 mg
ILEVRO 0.3% ophthalmic SUSPENSION
Clinical
Lower Cost
ILUVIEN 0.19MG INTRAVITREAL
IMPLANT
Lower Cost
Imatinib Mesylate (Gleevec) 100mg
Tablet
Clinical
DROPS
Required diagnosis= Diabetic Macular Edema
AND
Required trial of: Avastin
Required Diagnosis= Acute Lymphoblastic Leukemia;
Aggressive Systemic Mastocytosis; Chronic Myeloid
Leukemia; Dermatofibrosarcoma Protuberans; GI
Stromal Tumors; Hypereosinophilic Syndrome And/Or
Chronic Eosinophilic Leukemia; Or
Myelodysplastic/Myeloproliferative Diseases
Imatinib Mesylate (Gleevec) 400mg
Tablet
Clinical
Required Diagnosis= Acute Lymphoblastic Leukemia;
Aggressive Systemic Mastocytosis; Chronic Myeloid
Leukemia; Dermatofibrosarcoma Protuberans; GI
Stromal Tumors; Hypereosinophilic Syndrome And/Or
Chronic Eosinophilic Leukemia; Or
Myelodysplastic/Myeloproliferative Diseases
60
Drug
Status
IMBRUVICA 140 mg CAPSULE
Clinical
Required diagnosis = MCL (Mantle Cell Lymphoma)
IMIQUIMOD (ALDARA) 5% CREAM
PACKET
Clinical
IMLYGIC 1M UNITS/ML VIAL
IMLYGIC 100M UNITS/ML VIAL
IMPLANON IMPLANT 68 mg
INCRELEX 40 mg/4 mL VIAL
Lower Cost
Lower Cost
Medical Benefit
Clinical
*Dx= Actinic Keratosis
OR
*Dx= Genital and Perianal Warts (Condyloma
Acuminata)
OR
*Dx= Superficial Basal Cell Carcinoma
Bill on medical benefit and no PA is required
Incruse Ellipta 62.5mcg Inhaler
Lower Cost
INFERGEN 15 mcg/0.5 mL VIAL
Specialty
INFERGEN 9 mcg/0.3ML VIAL
INJECTAFER 750/15 mL INJECTION
Specialty
Lower Cost
INLYTA TABLET 1 mg
Clinical
INLYTA TABLET 5 mg
INNOPRAN XL 120 mg CAPSULE
INNOPRAN XL 80 mg CAPSULE
INOVA 4 and 5% EASY PAD KIT
Clinical
Lower Cost
Lower Cost
Lower Cost
Required diagnosis= Advanced renal cell cancer
Formulary agent: propranolol SR 120 MG
Formulary agent: propranolol SR 80 MG
or BENZOYL PEROXIDE-ERYTHROMYCIN (BENZAMYCIN)
5-3% GEL
INOVA 4/1 EASY PAD KIT
Lower Cost
5-3% GEL
INOVA 8 and 5 % EASY PAD KIT
Lower Cost
5-3% GEL
Formulary Agent(s): Tudorza, Spiriva Or Spiriva
Respimat (Respimat Is Preferred)
Formulary agents: Infed or Venofer prescribed by
oncologist
Required diagnosis= Advanced renal cell cancer
61
Drug
Status
INOVA 8/2 EASY PAD KIT
Lower Cost
5-3% GEL
INTERMEZZO 1.75 mg SUBLINGUAL
TABLET
INTERMEZZO 3.5 mg SUBLINGUAL
TABLET
INTRALIPID
Lower Cost
Formulary agent: 7 day trial of IR & ER zolpidem
Lower Cost
Formulary agent: 7 day trial of IR & ER zolpidem
Clinical
Typically TPN and Additives (including vitamins and
Intralipids) need to all be billed on the same benefit:
If Pharmacy must bill TPN Medical and Additives
Pharmacy First
INTRON A 10 MILLION UNIT PEN
Clinical
Specialty
INTRON A 10 MILLION UNIT/ML
Clinical
Specialty
INTRON A 10 MILLION UNITS VIAL
Clinical
Clinical
Clinical
Specialty
Specialty
Specialty
INVOKAMET 50-500MG TABLET
Clinical
Clinical
Clinical
Step Therapy
Step Therapy
Step Therapy
Step Therapy
INVOKANA 100 mg TABLET
Step Therapy
INVOKANA 300 mg TABLET
Step Therapy
IOPIDINE 1% EYE DROPS
IQUIX 1.5% EYE DROPS
IRESSA 250 mg TABLET
IRINOTECAN (CAMPTOSAR) 100 mg/5
mL VIAL
IRINOTECAN (CAMPTOSAR) 40 mg/2 mL
VIAL
IRINOTECAN 500 mg/25 mL VIAL
Lower Cost
Lower Cost
Clinical
Lower Cost
ISOPTO CARBACHOL 1.5% DROPS
Lower Cost
ISOPTO CARBACHOL 3% DROPS
Lower Cost
ISRADIPINE 2.5 mg CAPSULE
Lower Cost
Specialty
Specialty
Specialty
Formulary Agent(s): Metformin IR or ER (Glucophage
or Glucophage XR)
or Glucophage XR)
or Glucophage XR)
or Glucophage XR)
or Glucophage XR)
or Glucophage XR)
Required diagnosis=non-small cell lung cancer
Required diagnosis=metastatic carcinoma of the colon
or rectum
or rectum
or rectum
Formulary agent: PILOCARPINE 1%, 2%, or 4% EYE
DROPS
Formulary agent: PILOCARPINE 1%, 2%, or 4% EYE
DROPS
Formulary agents: amlodipine, felodipine, or
nifedipine
Lower Cost
Lower Cost
62
Drug
Status
ISRADIPINE 5 mg CAPSULE
Lower Cost
ISTALOL 0.5% EYE DROPS
Lower Cost
ISTODAX INJECTION 10 mg
Clinical
IVACAFTOR
Clinical
IXINITY 500UNIT VIAL
IXINITY 1,000UNIT VIAL
IXINITY 1,500UNIT VIAL
JADENU 90MG TABLET
JADENU 180MG TABLET
JADENU 360MG TABLET
JANUMET 50-1,000 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
nifedipine
Formulary agent: TIMOLOL (TIMOPTIC) 0.5% EYE
DROPS or TIMOLOL (TIMOPTIC-XE) 0.5% GEL EYE
SOLUTION
Required diagnosis=Cutaneous T-cell lymphoma (CTCL)
OR Peripheral T-cell lymphoma (PTCL)
* MD Specialty = Oncology
Required diagnosis = Cystic Fibrosis with the G551D
mutation
*Dx= Hemophilia B control and Preventation
Formulary agents: metformin IR or ER (Glucophage or
Glucophage ER)
THEN
Jentadueto
JANUMET 50-500 mg TABLET
Lower Cost
Glucophage ER)
THEN
Jentadueto
JANUMET XR 100-1,000 mg TABLET
Lower Cost
Glucophage ER)
THEN
Jentadueto
JANUMET XR 50-1,000 mg TABLET
Lower Cost
Glucophage ER)
THEN
Jentadueto
JANUMET XR 50-500 mg TABLET
Lower Cost
Glucophage ER)
THEN
Jentadueto
JANUVIA 100 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Formulary Agent(s): Metformin IR Or ER (Glucophage
Or Glucophage ER)
THEN
Alogliptin (Nesina), Alogliptin-Metformin (Kazano),
Alogliptin-Pioglitazone (Oseni), Or Tradjenta Tablets
(Which Also Requires A PA)
Or Glucophage ER)
THEN
Or Glucophage ER)
THEN
63
Drug
Status
JARDIANCE 10MG TABLET
Lower Cost
JARDIANCE 25MG TABLET
Lower Cost
JENTADUETO 2.5-500MG TABLET
Step Therapy
Step Therapy
Step Therapy
Glucophage ER)
THEN
Invokana
Glucophage ER)
THEN
Invokana
Formulary agent: metformin IR (Glucophage IR) or
metformin ER (Glucophage ER)
Required Diagnosis= Diabetes Type 2 AND 18 Years Of
Age Or Older WITH Formulary Agent(s): Metformin IR
Or ER (Glucophage Or Glucophage ER)
AND Jentadueto Tablet
Jentadueto XR 2.5 mg - 1,000 mg Tablet Lower Cost
Jentadueto XR 5 mg - 1,000 mg Tablet
Lower Cost
Required Diagnosis= Diabetes Type 2 AND 18 Years Of
Age Or Older WITH Formulary Agent(s): Metformin IR
Or ER (Glucophage Or Glucophage ER)
AND Jentadueto Tablet
JETREA 2.5 mg/ML INTRAOCULAR
INJECTION
Clinical
JUBLIA 10% SOLUTION
Lower Cost
Required diagnosis = symptomatic vitreo-macular
adhesion (379.27)
*Age ≥ 18 yrs old
*vitreous adhesion to the macula within a 6-mm
central retinal field surrounded by elevation of the
posterior vitreous cortex, as seen on optical coherence
tomography (OCT)
*best-corrected visual acuity of 20/25 or less in the
affected eye
*Vitreomacular adhesion has been observed over a
period of six or more weeks for spontaneous
resolution
*None of the following: Proliferative diabetic
retinopathy, Neovascular age-related macular
degeneration, Retinal vascular occlusion, Aphakia, High
myopia (more than −8 diopters), Uncontrolled
glaucoma, Macular hole greater than 400 μm in
diameter, Vitreous opacification, Lenticular or zonular
instability, History of retinal detachment in either eye,
Prior vitrectomy, Prior laser photocoagulation of the
macula, Prior treatment with ocriplasmin; or
Treatment with ocular surgery, intravitreal injection, or
retinal laser photocoagulation in the previous 3
months
Formulary Agent(s): Ciclopirox (Penlac, Ciclodan) 8%
Solution AND Oral Terbinafine Or Oral Itraconazole
JUVISYNC 100 mg-10 mg
Lower Cost
Lower Cost
Lower Cost
why Tradjenta (which also requires a PA) cannot be
used
used
used
64
Drug
Status
JUVISYNC 50-10 MG TABLET
Step Therapy
Step Therapy
Step Therapy
JUXTAPID 5MG CAPSULE
KADCYLA 100 mg INJECTION
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
Lower Cost
KADCYLA 160 mg INJECTION
Lower Cost
KALBITOR C1 Esterase Inhibitor
(Human) 10 mg/ML SOLUTION
KALYDECO 150MG TABLET
Kanuma 20 mg/10 mL Vial
KAPVAY ER 0.1/0.2 mg TITRATION KIT
Lower Cost
used
used
used
Required diagnosis = HER2 protein overexpression or
gene amplification
with a trial of Herceptin
Required diagnosis = HER2 protein overexpression or
gene amplification
with a trial of Herceptin
Clinical
Lower Cost
Lower Cost
Must provide a clinical reason supported by chart
notes why CLONIDINE SR (KAPVAY ER) 0.1 mg TABLET
(which requires a step through Intuniv) cannot be used
KENALOG AREOSOL SPRAY
Lower Cost
KERAFOAM 30% AREOSOL
Lower Cost
KERAFOAM 42 AREOSOL 42%
Lower Cost
KEROL AD 45% EMULSION
Kerydin 5% Solution With Applicator
Lower Cost
Lower Cost
KETEK 300 mg TABLET
Lower Cost
KETEK 400 mg TABLET
Lower Cost
KETOCONAZOLE POWDER
Lower Cost
Formulary agents: topical triamcinolone
ointment/cream/lotion
LOTION
LOTION
Formulary agent: Urea 40% cream
Formulary Agent(s): A 90 Day Trial Of: Ciclopirox
(Penlac, Ciclodan) 8% Solution AND A 30 Day Trial Of
Oral Terbinafine Or Oral Itraconazole
Formulary agents: clarithromycin, azithromycin, or
erythromycin
Formulary agents: clarithromycin, azithromycin, or
erythromycin
Formulary Agent(s): ketoconazole (Kuric) 2% cream
KETODAN, KETOCONAZOLE (EXTINA) 2%
FOAM
KEVEYIS 50MG TABLET
KEYTRUDA 50MG VIAL
KEYTRUDA 100MG/4ML VIAL
KINERET 100 mg/0.67 mL SYRINGE
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Specialty
Formulary agents: KETOCONAZOLE (NIZORAL) 2%
SHAMPOO or KETOCONAZOLE (KURIC) 2% CREAM
Formulary Agent(s): Acetazolamide
KOATE-DVI INJECTION 1000UNIT
Specialty
Specialty
65
Drug
Status
KOMBIGLYZE XR 2.5-1,000 mg TABLET
Specialty
Lower Cost
KOMBIGLYZE XR 5-1,000 mg TABLET
Lower Cost
KOMBIGLYZE XR 5-500 mg TABLET
Lower Cost
KORLYM 300MG TABLET
K-PHOS #2 TABLET
Lower Cost
Lower Cost
Formulary agent: metformin IR or ER (Glucophage or
Glucophage XR) for 30 days then Jentadueto for 60
days
days
days
K-PHOS M.F. TABLET
Lower Cost
K-PHOS ORIGINAL 500 mg TABLET
Lower Cost
KRYSTEXXA INJECTION 8 mg/ML
Lower Cost
KUVAN 100 mg TABLET
Clinical
KYNAMRO 200 mg/ML
Clinical
Required diagnosis = Gout with a trial of allopurinol
and then Colcrys OR Uloric
Prescriber Specialty = Rheumatology
Required diagnosis = Hyperphenylalaninemia or PKU
(phenylketonuria)
Formulary agents: Simvastatin or Atorvastatin
KYPROLIS 60 mg POWDER FOR
INJECTION
LACRISERT 5 mg EYE INSERT
LACTIC ACID 10% LOTION
Clinical
Required diagnosis = multiple myeloma
Lower Cost
Lower Cost
LACTOCAL-F
Lower Cost
Formulary agents: OTC artificial tears
Formulary Agents: Ammonium Lactate, LacLotion,
Amlactin, Geri-Hydrolac, AL-12 (Lac-Hydrin,Lac-Hydrin
Twelve) 12 % Lotion
LAMICTAL STARTER KIT (BLUE)
Lower Cost
LAMICTAL STARTER KIT (GREEN)
Lower Cost
LAMICTAL STARTER KIT (ORANGE)
Lower Cost
LAMICTAL XR STARTER KIT (BLUE)
Lower Cost
LAMICTAL XR STARTER KIT (GREEN)
Lower Cost
why LAMOTRIGINE tablets then LAMOTRIGINE SR
(LAMICTAL XR) tablets cannot be used
LAMICTAL XR STARTER KIT (ORANGE)
Lower Cost
LAMISIL 125 mg GRANULES PACKETS
Lower Cost
LAMISIL 187.5 mg GRANULES PACKETS
Lower Cost
LAMOTRIGINE (LAMICTAL) ODT
STARTER KIT (BLUE)
Lower Cost
STARTER KIT (GREEN)
Lower Cost
Formulary agent: GRISEOFULVIN 125 mg/5 mL
SUSPENSION
Formulary agent: GRISEOFULVIN 125 mg/5 mL
SUSPENSION
why LAMOTRIGINE tablets then LAMICTAL ODT tablets
cannot be used
cannot be used
why LAMOTRIGINE tablets cannot be used
66
Drug
Status
STARTER KT (ORANGE)
Lower Cost
LAMOTRIGINE (LAMICTAL) ODT 25MG
TABLET
TABLET
TABLET
TABLET
LAMOTRIGINE SR (LAMICTAL XR) 100
mg TABLET
mg TABLET
mg TABLET
LAMOTRIGINE SR (LAMICTAL XR) 25 mg
TABLET
mg TABLET
LAMOTRIGINE SR (LAMICTAL XR) 50 mg
TABLET
LARIN FE 1/20 TABLET
Lower Cost
cannot be used
Formulary Agent: Lamotrigine Tablets
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Must use a formulary birth control agent (Most similar:
Balziva)
LASTACAFT 0.25% EYE DROPS
Lower Cost
azelastine (Optivar) unless patient is pregnant or for a
child aged 2 to 3 years
Latisse
LATRIX XM
45% EMULSION
Excluded benefit
Lower Cost
LATRIX, UREA
50% TOPICAL SUSPENSION
LATUDA 120 mg TABLET
Lower Cost
LATUDA 20 mg TABLET
Step Therapy
LATUDA 40 mg TABLET
Step Therapy
LATUDA 60 mg TABLET
Step Therapy
LATUDA 80 mg TABLET
Step Therapy
LAYOLIS FE, KAITLIB FE,
NORETHINDRONE & ETHINYL
ESTRADIOL FERROUS FUMARATE
(GENERESS FE) CHEWABLE TABLET
LAZANDA 100MCG SPRAY
Lower Cost
why Urea 40% cream cannot be used
why Urea 40% cream cannot be used
Must have a 60 day trial of one the following generic
agents: risperidone, clozapine, olanzapine, quetiapine,
OR ziprasidone
Step Therapy
OR ziprasidone
OR ziprasidone
OR ziprasidone
OR ziprasidone
Formulary Agent(s): Formulary Birth Control Agent
Lower Cost
*Dx = breakthrough pain in adults with cancer who are
receiving and are tolerant to opioid therapy
AND
*30 day trial of: fentanyl (Actiq) lozenge
67
Drug
Status
LAZANDA 400MCG SPRAY
Lower Cost
*Dx = breakthrough pain in adults with cancer who are
receiving and are tolerant to opioid therapy
AND
*30 day trial of: fentanyl (Actiq) lozenge
LEMTRADA 12MG/1.2ML SOLUTION
Lower Cost
LENVIMA 10MG/DAY CAPSULE
Clinical
LETAIRIS 10 mg TABLET
Clinical
Required Dx = Advanced pancreatic neuroendocrine
tumors; Advanced renal cell carcinoma; GI stromal
tumor
LETAIRIS 5 mg TABLET
Clinical
Letrozole (Femara) 2.5 mg Tablet
LEUKINE 250 mcg/ML VIAL
Clinical
Clinical
Required Diagnosis= Breast Cancer
Required diagnosis = Acute myelogenous leukemia;
transplantation of autologous peripheral blood;
Myeloid reconstitution after autologous bone marrow
transplantation ; Bone marrow transplantation failure
or engraftment delay
LEUKINE 500 mcg/ML VIAL
Clinical
Required diagnosis = Acute myelogenous leukemia;
transplantation of autologous peripheral blood;
Myeloid reconstitution after autologous bone marrow
transplantation ; Bone marrow transplantation failure
or engraftment delay
LEUPROLIDE 5MG/ML INJECTION
LEVALBUTEROL (XOPENEX) 0.31 mg/3
mL SOLUTION
mL SOLUTION
mL SOLUTION
LEVALBUTEROL (XOPENEX)
CONCENTRATED 1.25 mg/0.5 mL
LEVAQUIN 25 mg/ML SOLUTION
Clinical
Lower Cost
Formulary agent: albuterol inhalation solution
Lower Cost
Lower Cost
Lower Cost
Lower Cost
LEVATOL 20 mg TABLET
Lower Cost
Formulary agent: 2 different manufacturers of generic
levofloxacin solution
LEVEMIR 100 UNITS/ML VIAL
Lower Cost
LEVEMIR FLEXPEN 100 UNITS/M
Lower Cost
LEVITRA
Excluded benefit
Formulary agent: Lantus (trial of 60 days; unless
pregnant)
Formulary agent: Lantus (trial of 60 days; unless
pregnant)
68
Drug
Status
LEVOCETIRIZINE (XYZAL)
2.5 mg/5 mL SOLUTION
Lower Cost
LEVOFLOXACIN 0.5% EYE DROPS
Lower Cost
LEVORPHANOL 2 mg TABLET
Lower Cost
Formulary agents for Allergies/Allergic Rhinitis:
loratadine, cetirizine or fexofenadine
Formulary agents for urticaria: loratadine, cetirizine,
fexofenadine, diphenhydramine, chlorpheniramine,
carbinoxamine or hydroxyzine AND 30 day trial of
topicals:
FLUTICASONE Propionate (CUTIVATE) 0.05% CREAM,
PREDNICARBATE (DERMATOP) 0.1% CREAM,
BETAMETHASONE DP 0.05%, BETAMETHASONE
VALERATE 0.1%, HYDROCORTISONE 0.1%,
HYDROCORTISONE 2.5%, PREDNICARBATE
(DERMATOP) 0.1% OINTMENT, FLUOCINONIDE 0.05%,
FLUOCINONIDE-E 0.05%, CLOBETASOL (TEMOVATE)
0.05%, CLOBETASOL-E (TEMOVATE E) 0.05%,
FLUOCINOLONE 0.01%, TRIAMCINOLONE 0.025%,
TRIAMCINOLONE 0.1%, TRIAMCINOLONE 0.5%,
FLUTICASONE Propionate (CUTIVATE) 0.005%
OINTMENT, DIFLORASONE 0.05% (Accepted trials but
not recommended:MOMETASONE AND
ALCLOMETASONE)
Formulary agent: ciprofloxacin or ofloxacin
ophthalmic
Formulary agent: morphine sulfate IR
LEXAPRO 10 mg TABLET DAW
Lower Cost
Lower Cost
Lower Cost
LEXAPRO 5 mg/5 mL SOLUTION DAW
Lower Cost
LIALDA DR 1.2GM TABLET
Lower Cost
Lidocaine 3% Lotion
Lower Cost
Lidocaine 5% Ointment
Lower Cost
LIDOCAINE-HYDROCORTISONE RECTAL
CREAM KIT 2-2%
Lower Cost
CREAM KIT 3-0.5%
Lower Cost
why LIDOCAINE 3% CREAM WITH HYDROCORTISONE
0.5% CREAM separately used together cannot be used
CREAM KIT 3-1%
Lower Cost
why LIDOCAINE 3% CREAM WITH HYDROCORTISONE
1% CREAM separately used together cannot be used
GEL KIT 3-2.5%
Lower Cost
why LIDOCAINE 3% CREAM WITH HYDROCORTISONE ,
PROCTOSOL-HC, Proctozone, Proctocream, Proctocare
(AnuSOL-HC) 2.5% CREAM separately used
togethercannot be used
Required trial of 2 different manufacturers of generic
escitalopram
escitalopram
escitalopram
escitalopram
Formulary Agent(s): Mesalamine (Asacol HD), Delzicol
Or Apriso ER
Must provide a clinical reason supported by chart
notes why LIDOCAINE 2% GEL JELLY or VISCOUS
SOLUTION WITH HYDROCORTISONE , PROCTOSOL-HC,
Proctozone, Proctocream, Proctocare (AnuSOL-HC)
2.5% CREAM separately used together cannot be used
69
Drug
Status
LIDOCAINE-TETRACAINE (PLIAGLIS) 77% CREAM
LIDOVIR 4-4% OINTMENT
Lower Cost
LIMBREL 250 mg CAPSULE
Lower Cost
Formulary agent: LIDOCAINE-PRILOCAINE CREAM 2.52.5%
Formulary agents: ZOVIRAX 5% OINTMENT and
LIDOCAINE 5% OINTMENT separately
Required 30 day trial of one of the following: celecoxib,
naproxen, ibuprofen, flurbiprofen, nabumetone,
diclofenac, etodolac, indomethacin, ketoprofen,
meloxicam, oxaprozin, sulindac, or piroxicam
LIMBREL 500 mg CAPSULE
Lower Cost
LIMBREL 250-50 mg CAPSULE
Lower Cost
Lower Cost
Lower Cost
Lincomycin (Lincocin) 300 mg/mL Vial
Lower Cost
LINDANE 1% LOTION
Lower Cost
Required diagnosis: Serious Infections Caused By
Susceptible Strains Of Streptococci, Pneumococci, And
Staphylococci Or In Members Who Are Allergic To
Penicillin
Formulary agent: permethrin cream with a diagnosis
of scabies
LINDANE 1% SHAMPOO
Lower Cost
Lower Cost
Formulary agents for head lice per age group below:
Age 2 months - 2 years old: permethrin
Age 2 years - 3 years: ACTICIN, PERMETHRIN (ELIMITE),
permethrin (RID FOAM), PYRETHRINS-PIPERONYL
BUTOXIDE, PRONTO PLUS (RID LIQUID), LICE-AID
(TEGRIN-LT), LICE KILLING SHAMPOO (PRONTO), STOP
LICE KIT (RID COMPLETE KIT)
Age 4 years to 5 years old: ACTICIN, PERMETHRIN
(ELIMITE), permethrin (RID FOAM), PYRETHRINSPIPERONYL BUTOXIDE, PRONTO PLUS (RID LIQUID),
LICE-AID (TEGRIN-LT), LICE KILLING SHAMPOO
(PRONTO), STOP LICE KIT (RID COMPLETE KIT) or
spinosad (Natroba)
Age 6 years and older: ACTICIN, PERMETHRIN
(PRONTO), STOP LICE KIT (RID COMPLETE KIT),
spinosad (Natroba) or malathion (Ovide)
70
Drug
Status
LINEZOLID (ZYVOX) 2MG/ML IV SOL FOR Lower Cost
INJECTION
Linezolid (ZYVOX) 100 mg/5 mL
SUSPENSION
Lower Cost
LINEZOLID (ZYVOX) 600 mg TABLET
Lower Cost
Linzess 145 mcg Capsule
Step Therapy
Linzess 290 mcg Capsule
Step Therapy
LIPOFEN 150 mg CAPSULE
LIPOFEN 50 mg CAPSULE
LIPTRUZET 10-10 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
LITHOSTAT 250 mg TABLET
Lower Cost
LIVALO 1 mg TABLET
Lower Cost
LIVALO 2 mg TABLET
Lower Cost
LIVALO 4 mg TABLET
Lower Cost
LO LOESTRIN FE 1-10 TABLET
Lower Cost
LO MINASTRIN PAK FE CHEWABLE
Lower Cost
LOCOID LOTION 0.1%
Lower Cost
CARBIDOPA (LODOSYN) 25 mg TABLET
Lower Cost
LONSURF 15-6.14MG TABLET
LONSURF 20-8.19MG TABLET
LORZONE 375 mg TABLET
Lower Cost
Lower Cost
Lower Cost
LORZONE 750 mg TABLET
Lower Cost
LOSEASONIQUE TABLET DAW
Lower Cost
LOTEMAX 0.5% EYE DROPS
Lower Cost
Required Dx = VANCOMYCIN IV-resistant enterococcus
(VRE)
OR
Dx= Pneumonia; Skin & skin structure infections
(including but not limited to MRSA)
Formulary agent: Vancomyin IV in-patient or
outpatient with a diagnosis of Pneumonia; Skin and
Skin structure infections OR a diagnosis of
VANCOMYCIN IV -resistant eneterococcus (VRE)
outpatient with a diagnosis of Pneumonia; Skin and
Skin structure infections OR a diagnosis of
VANCOMYCIN IV -resistant eneterococcus (VRE)
Last 30 Days
Last 30 Days
Formulary agent: atorvastatin and Zetia separately
taken together
taken together
taken together
taken together
Required diagnosis=Chronic urea-splitting urinary
infection
(most similar agent=Balziva)
(most similar agent=Balziva)
Formulary agent: HYDROCORTISONE BUTYRATE 0.1%
CREAM (LOCOID)
Formulary agent: carbidopa/levodopa (Sinemet)
Formulary agent: chlorzoxazone 250 mg or 500 mg
tablet
Formulary agent: chlorzoxazone 250 mg or 500 mg
tablet
generic Camrese Lo, Amethia Lo
A One Time Trial Of: Pred Mild 0.12%, Prednisolone
Acetate (Pred Forte, Omnipred) 1%, Prednisolone
Sodium Phosphate 1%, Dexamethasone 0.1%, Or
Fluorometholone, Fluor-Op (FML Liquifilm) 0.1%
Ophthalmic Drops
71
Drug
Status
Lotemax 0.5% Ophthalmic Gel
Lower Cost
LOTEMAX 0.5% OPHTHALMIC
OINTMENT
Lower Cost
Loutrex, Promiseb, TL Triseb Cream
LUCENTIS SOLUTION 0.3 mg
LUCENTIS SOLUTION 0.5 mg
LUMIGAN 0.01% EYE DROPS
LUMIZYME
Non-Covered Benefit
Specialty
Specialty
Lower Cost
Specialty
Ophthalmic Drops
Ophthalmic Drops
LUPANETA KIT 3.75-5MG
Lower Cost
Formulary agent: Latanoprost 0.005% EYE DROPS
Required Diagnosis= Endometriosis AND Required Trial
Of Both Formulary NSAIDs And Contraceptives
LUPRON DEPOT INJECTION KIT 11.25 mg Specialty
(3 - MONTH)
(3 - MONTH)
LUPRON DEPOT INJECTION KIT 30 mg (4 - Specialty
MONTH)
LUPRON DEPOT INJECTION KIT 45 mg (6- Specialty
MONTH)
LUPRON DEPOT INJJ KIT 3.75 mg
LUPRON DEPOT-PED INJECTION KIT
11.25 mg
LUPRON DEPOT-PED INJECTION KIT
11.25 mg (3 - MONTH)
LUPRON DEPOT-PED INJECTION KIT 15
mg
LUPRON DEPOT-PED INJECTION KIT 30
mg (3 - MONTH)
LUPRON DEPOT-PED INJECTION KIT 7.5
mg
LUVERIS INJECTION 75UNIT
LUZU 1% CREAM
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
LYBREL 90-20 mcg TABLET
Lower Cost
Clinical
Clinical
Clinical
LYNPARZA 50MG CAPSULE
Lower Cost
Excluded benefit
Lower Cost
Formulary agents: Ketoconazole Clotrimazole, Lamisil
gel, or Terbinafine cream
tumor
tumor
tumor
Required Dx= Advanced Ovarian Cancer associated
with defective BRCA genes
72
Drug
Status
LYRICA 100 mg CAPSULE
Step Therapy
For diagnosis of:
fibromyalgia/neuropathy/neuralgia/sciatica, must first
try 30 day Trial of: gabapentin at accepted daily doses
of 1200mg to 2400mg, amitriptyline, or duloxetine
capsule For diagnosis of seizure or epilepsy, must first
try gabapentin, lamotrigine (Lamictal), divalproex
Step Therapy
For diagnosis of:
Step Therapy
For diagnosis of:
LYRICA 20 mg/ML SOLUTION
Lower Cost
For diagnosis of:
Step Therapy
For diagnosis of:
73
Drug
Status
Step Therapy
For diagnosis of:
Step Therapy
For diagnosis of:
Step Therapy
For diagnosis of:
Step Therapy
For diagnosis of:
MACUGEN INJECTION 0.3 mg/90
MICROLITER
MAGNACET 10 mg-400 mg TABLET
Specialty
Lower Cost
Formulary agent: Oxycodone-Acetaminophen
(PERCOCET) 10-325 mg tablet
MAGNACET 5 mg-400 mg TABLET
Lower Cost
(PERCOCET) 5-325 mg tablet
74
Drug
Status
MAGNACET 7.5 mg-400 mg TABLET
Lower Cost
(PERCOCET) 7.5-325 mg tablet
MAGNEBIND 400 RX TABLET
Lower Cost
MAKENA 250 mg/ML IMTRAMUSCULAR Clinical
OIL
Lower Cost
MARNATAL-F CAPSULE 60 mg-1 mg
Lower Cost
MARPLAN 10 mg TABLET
MATERNITY VITAMIN 27 mg-1 mg
Lower Cost
Lower Cost
Formulary agent: Parnate
MAXARON FORTE CAPSULE
LowerCost
MAXIDEX 0.1% EYE DROPS
Lower Cost
MAXIFED-G CD TABLET
MAXIFLU CD TABLET
Lower Cost
Lower Cost
MEBARAL 32 mg TABLET
MEBARAL 50 mg TABLET
MEDERMA SPF 30 CREAM
MEDROL 2MG TABLET
MEFENAMIC (Ponstel) 250 mg CAPSULE
Lower Cost
Lower Cost
Excluded benefit
Lower Cost
Lower Cost
Formulary agent: DEXAMETHASONE 0.1%
OPHTHALMIC SOLUTION
Formulary agent: CHERATUSSIN DAC SYRUP
Formulary agent: CAPMIST DM tablet and
acetaminophen separately
Megestrol Acetate (Megace ES)
625mg/5mL Suspension
MEKINIST 0.5 mg TABLET
Lower Cost
MEKINIST 2 mg TABLET
Clinical
Melquin 3% SOLUTION
M-END DM SYRUP
M-END PE LIQUID
M-END WC LIQUID
MENOPUR INJECTION 75UNIT
MENOSTAR 1 mg PATCH
Excluded benefit
Lower Cost
Lower Cost
Lower Cost
Excluded benefit
Lower Cost
MENTAX 1% CREAM
Lower Cost
Formulary agent: methylprednisolone 4MG tablet
Formulary Agent(s): Megestrol Acetate (Megace)
40mg/mL Suspension
Required diagnosis = advanced melanoma that is
unresectable (cannot be removed by surgery) or
metastatic (late-stage)
with BRAF V600E or V600K mutations detected by an
FDA approved test as a single agent OR concurrently
with Tafinlar (dabrafenib)
Clinical
Required diagnosis = advanced melanoma that is
unresectable (cannot be removed by surgery) or
metastatic (late-stage)
with BRAF V600E or V600K mutations detected by an
FDA approved test as a single agent OR concurrently
with Tafinlar (dabrafenib)
Formulary agent: RESCON-DM SYRUP
Formulary agent: DIMAPHEN ELIXIR
Formulary agent: BROMFED SYRUP
Formulary agents:
clotrimazole/ketoconazole/miconazole
75
Drug
Status
MESALAMINE (Rowasa) 4 gM/60 mL KIT Lower Cost
why MESALAMINE (Rowasa) 4 gM/60 mL ENEMA
cannot be used
METANX, METHYLFOL/ME, FOLTANX RF Lower Cost
CAPSULE
METAXALONE (Skelaxin) 800 mg TABLET Lower Cost
METFORMIN ER (FORTAMET) 1,000 mg Lower Cost
TABLET
Formulary agents: METHYLFOL/ME, VITACIRC-B,
FOLTANX,L-METHYL-B6 TABLET
Formulary agents: cyclobenzaprine, baclofen,
methocarbamol, or tizanidine (carisoprodol- accepted
trial but not preferred agent)
why Metformin ER (Glucophage ER) cannot be used
METFORMIN ER (FORTAMET) 500 mg
TABLET
why Metformin ER (Glucophage ER) cannot be used
Lower Cost
Metformin HCL (Glumetza) ER 500 mg Lower Cost
Tablet
Metformin HCL (Glumetza) ER 1,000 mg Lower Cost
Tablet
MethAMPHETAMINE (DESOXYN) 5 mg Lower Cost
TABLET
Formulary Agent(s): Metformin ER (Glucophage ER)
Formulary Agent(s): Metformin ER (Glucophage ER)
Formulary agents for diagnosis of ADD/ADHD; Autism;
Asperger's; Hyperkinetic Syndrome: WITH trials per
age group below:
Age under 6
Age 6 and older
(Dexedrine), dexmethylphenidate (Focalin),
amphetamine salt combo (ADDERALL),
dextroamphetamine-amphetamine ER (ADDERALL XR),
methlphenidate ER (Concerta), methlphenidate CR
(Metadate CD), methlphenidate SR (Ritalin LA),
methlphenidate (Methylin, Ritalin), Methylin ER, or
Vyvanse
(both still require a PA also) with a diagnosis of
hypogonadism and Total Testosterone lab value = ≤
300 ng/dL before treatment
METHITEST 10 mg TABLET
Lower Cost
Methyltestosterone (Android, Testred)
10mg Capsule
Lower Cost
Metoclopramide ODT (Metozolv ODT)
5mg Tablet
Metoclopramide ODT (Metozolv ODT)
10mg Tablet
Metoprolol Tartrate 37.5 mg Tablet
Lower Cost
Required Diagnosis= Hypogonadism, Total
Testosterone Level ≤ 300ng/dL Before Treatment AND
Formulary Agent(s): Testosterone TD (Fortesta) Or
(Both Still Require A PA Also)
Formulary Agent(s): Metoclopramide Tablet
Lower Cost
Formulary Agent(s): Metoclopramide Tablet
Lower Cost
Formulary Agent(s): Metoprolol Tartrate 25 mg, 50 mg,
Or 100 mg Tablet
76
Drug
Status
Metoprolol Tartrate 75 mg Tablet
Lower Cost
METRONIDAZOLE (METROGEL) 1%
TOPICAL GEL (TUBE AND PUMP)
Lower Cost
Formulary Agent(s): Metoprolol Tartrate 25 mg, 50 mg,
Or 100 mg Tablet
why metronidazole 0.75% topical lotion, cream, or gel
cannot be used
MICRHOGAM ULTR-FILTERED PLUS 50
mcg
Clinical
Specialty
MICRO-BUMIN TEST KIT
Lower Cost
MIDAZOLAM 2 mg/ML SYRUP
Clinical
Miglitol (Glyset) 25 mg Tablet
Step Therapy
Required diagnosis = Need for home albumin in urine
testing
Requires diagnosis of sedation and unable to take
tablet form
Requires a 30 day trial of metformin IR or ER
(Glucophage or Glucophage XR) unless renal/kidney
disease/Increased Creatinine OR
HbA1c (Hemaglobin A1c) with a value greater than
7.5% within the last 90 days
Step Therapy
Step Therapy
MILLIPRED 10 mg/5 mL SOLUTION
MILLIPRED 5 mg TABLET
MILLIPRED DP 5 mg DOSE PACK 21
COUNT
MILLIPRED DP 5 mg DOSE PACK 48
COUNT
MINASTRIN 24 FE CHEWABLE TABLET
Lower Cost
Lower Cost
Lower Cost
Formulary agent: prednisolone liquid
Lower Cost
Lower Cost
Formulary agent: a formulary birth control agent
(Most similar: Balziva)
MINOCIN 100MG COMBO PACK
MINOCYCLINE ER (SOLODYN ER) 135 mg
TABLET
TABLET
TABLET
MINOXIDIL TOPICAL SOLUTION
MIRCERA 50MCG SYRINGE
MIRVASO 0.33% GEL
Lower Cost
Lower Cost
Formulary Agent(s): Minocycline Capsule
Formulary agent: minocycline
Lower Cost
Lower Cost
MISSION PRENATAL
Lower Cost
Formulary agent: metronidazole 0.75% for a diagnosis
of rosacea
MISSION PRENATAL FA
Lower Cost
MISSION PRENATAL HP
Lower Cost
Excluded benefit
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
77
Drug
Status
MITOMYCIN 20 mg IV SOLUTION
Lower Cost
Required Dx= Disseminated Adenocarcinoma Of The
Stomach Or Pancreas OR Dx= Anal Cancer. Must Be
Prescribed By Or In Consultation With An Oncologist.
Lower Cost
Lower Cost
MODAFINIL (PROVIGIL) 100 mg TABLET Clinical
Required diagnosis = Narcolepsy/Cataplexy/Sleep
MODAFINIL (PROVIGIL) 200 mg TABLET Clinical
MODERIBA PAK 1000/DAY
MODERIBA TAB 200MG
MOMETASONE FUROATE (NASONEX) 50
mcg NASAL SPRAY
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
24HR Spray
OR
OR
Ages 6 And Older: Fluticasone (Flonase), Flonase OTC
Allergy Relief Spray, Flunisolide, Or Nasacort OTC
Allergy 24HR Spray
MONOCLATE-P 1,000 UNITS KIT
Specialty
MONOCLATE-P 1,500 UNITS KIT
MONUROL 3 gM SACHET
Specialty
Lower Cost
MOTOFEN TABLET
Lower Cost
Movantik 12.5 mg Tablet
Lower Cost
Movantik 25 mg Tablet
Lower Cost
MOVIPREP POWDER KIT
MOXATAG ER 775 mg TABLET
MOXEZA 0.5% EYE DROPS
Lower Cost
Lower Cost
Lower Cost
MOZOBIL INJECTION 24 mg/1.2 mL (20
mg/ML)
Lower Cost
MST 600 TABLET
MUCINEX COLD & SINUS
Lower Cost
Lower Cost
Formulary agents: Bactrim, ciprofloxacin,
metronidazole or nitrofurantoin
Formulary agent: atropine with diphenoxylate
(Lomotil)
Last 30 Days
Last 30 Days
Formulary Agents: Gavilyte-H or Peg-Prep Kit
Formulary agent: amoxicillin 500 mg
ophthalmic
Required diagnosis = Autologous transplantation in
patients with non-Hodgkin lymphoma (NHL) and
multiple myeloma who need hematopoietic stem cells
mobilization
Prescriber Specialty = Oncology
Formulary agent: Mag-Ox
Formulary agent: MUCINEX ER 600 MG tablet
78
Drug
Status
MUCINEX COLD-FLU & SORE THROAT
MUCINEX FAST-MAX COLD-SINUS
MUGARD LIQUID RINSE
Lower Cost
Lower Cost
Lower Cost
MULTAQ 400 mg TABLET
Lower Cost
MULTIGEN CAPELET 70-150-10 mg
Lower Cost
Required diagnosis = Treating sores and ulcers in the
mouth caused by various conditions (eg, radiation,
chemotherapy, canker sores, surgery, poorly fitting
dentures)
Formulary agents: flecainide, propafenone, sotalol, or
digoxin
MULTIGEN FOLIC CAPELET 70-150-1 mg Lower Cost
MULTIGEN PLUS CAPELET 151-60-1 mg Lower Cost
Muse
MYDRIACYL 1% EYE DROPS DAW
Excluded benefit
Lower Cost
generic tropicamide
MYKIDZ IRON FL SUSPENSION 10-0.25/2 Lower Cost
MYOBLOC
Specialty
MYORISAN 10 mg CAPSULE
Lower Cost
AND
erythromycin
Lower Cost
AND
erythromycin
79
Drug
Status
Lower Cost
AND
erythromycin
MYOZYME
Specialty
MYRBETRIQ 25 mg
Lower Cost
MYRBETRIQ 50 mg
Lower Cost
MYTELASE 10 mg CAPELET
Lower Cost
NABI-HB INJECTION
NafRinse Daily Neutral 0.02% Rinse
Lower Cost
Lower Cost
NAFTIFINE (NAFTIN) 1% CREAM
Lower Cost
NAFTIN 1% GEL
Lower Cost
NAFTIN 2% GEL
Lower Cost
NAFTIN 2% CREAM
Lower Cost
NAGLAZYME
Specialty
Formulary agents: OXYBUTYNIN, OXYBUTYNIN ER,
Formulary agent: Prostigmin with a diagnosis of
myasthenia gravis
Formulary Agents: ketoconazole, clotrimazole, Lamisil
gel, terbinafine cream
Formulary agents: ketoconazole, clotrimazole, Lamisil
NALBUPHINE INJECTION
Lower Cost
NALFON 200 mg PULVULE
Lower Cost
NALFON 400 mg CAPSULE
NAMENDA XR 14 mg CAPSULE
Lower Cost
Lower Cost
Required diagnosis = Pain and an inability to use oral
medications with a trial of Formulary oral pain
medications
This medication has been discontinued-No longer
available
Formulary agent: FENOPROFEN 600 MG TABLET
Formulary agent: memantine hcl (Namenda) tablet
NAMENDA XR 21 MG CAPSULE
Lower Cost
Lower Cost
Lower Cost
NAMENDA XR TITRATION PACK
Lower Cost
Formulary agent: memantine hcl (Namenda) Titration
Pack
80
Drug
Status
NAMZARIC 14-10MG CAPSULE
Lower Cost
Required 90 day trial of: Namenda, donepezil (Aricept),
galantamine (Razadyne) or rivastigmine (Exelon)
NAMZARIC 28-10MG CAPSULE
Lower Cost
Required 90 day trial of: Namenda, donepezil (Aricept),
galantamine (Razadyne) or rivastigmine (Exelon)
NAPRELAN CR DOSECARD 500-750 mg
Lower Cost
why NAPRELAN CR (which require use of - NAPROXEN
DR (EC-NAPROSYN) 375 mg tablet or NAPROXEN DR
(EC-NAPROSYN) 500 mg tablet) cannot be used
Naproxen Sodium CR (Naprelan) 375mg Lower Cost
Tablet
NATACHEW 28-1MG CHEWABLE TABLET Lower Cost
Formulary Agent(s): Naproxen DR (EC-Naprosyn)
375mg Tablet Or Naproxen DR (EC-Naprosyn) 500mg
Tablet
Tablet
Tablet
Formulary agent: OTC cyanocobalamin (b12) AND
cyanocobalamine (B12) injection
NATAZIA 28 TABLET
Lower Cost
NATELLE-EZ
Lower Cost
NATELLE ONE CAPSULE
Lower Cost
Tablet
Tablet
NASCOBAL 500 mcg NASAL SPRAY
Lower Cost
NATESTO 5.5MG TESTOSTERONE NASAL Lower Cost
GEL
Required 90 day trial of: Testosterone TD (Fortesta) Or
NATPARA 25MCG/DOSE CARTRIDGE
Lower Cost
Lower Cost
Lower Cost
Lower Cost
NATURE-THROID 113.75mg TABLET
NATURE-THROID 130mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Required diagnosis= hypocalcemia with
hypoparathyroidism
AND
Required 30 day trial of: calcium and vitamin D
separately taken together at the same time
hypoparathyroidism
AND
hypoparathyroidism
AND
hypoparathyroidism
AND
Formulary Agent(s): Armour Thyroid Tablet
81
Drug
Status
NEBUPENT 300 mg INHALED POWDER
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Clinical
NECON 10-11-28 TABLET
Lower Cost
Diagnosis of Pneumocystis carinii pneumonia (PCP) in
high-risk, HIV-infected patients
(most similar agents= Mircette, Kariva, Azurette)
NEEVO DHA GELCAP 27-1.13 mg
Lower Cost
NEOBENZ MICRO SD 5.5% CREAM
Lower Cost
NEOBENZ MICRO WASH PLUS PACK
Lower Cost
NEO-FRADIN 125 mg/5 mL SOLUTION
NEOSALUS AEROSOL FOAM
Lower Cost
Lower Cost
NEOSALUS CREAM
Lower Cost
NEOSALUS LOTION
Lower Cost
NEO-SYNALAR 0.5-0.025% CREAM
Lower Cost
NEPHPLEX RX TABLET
Lower Cost
NEPHROCAPSULE QT TABLET
Lower Cost
NEPHRON FA TABLET
Lower Cost
NEPHRONEX 1 mg CAPSULE
Lower Cost
NESTABS ABC TABLET
Lower Cost
benzoyl peroxide 4% or 8% liquid (Panoxyl),
erythromycin/benzoyl (Benzamycin)
Formulary agent: metronidazole
Lubriderm (Eucerin)
Lubriderm (Eucerin)
Lubriderm (Eucerin)
for 7 days each
NESTABS DHA, NUTRI-TAB OB +DHA, V- Lower Cost
NATAL DHA TABLET
NESTABS, NUTRI-TAB OB, V-NATAL
Lower Cost
TABLET
NEUAC 1.2-5% GEL
Lower Cost
NEUAC 1.2-5% KIT
Requires a trial of: BENZOYL PEROXIDE 5% GEL
T)
Requires a trial of: BENZOYL PEROXIDE 5% GEL
T)
Lower Cost
82
Drug
Status
Neutral Sodium Fluoride, Sodium
Fluoride (Prevident) 0.2% Rinse
Lower Cost
NEULASTA 6 mg/0.6 mL SYRINGE
Clinical
Specialty
NEULASTA DELIVERY KIT 6MG/0.6ML
NEUMEGA 5 mg VIAL
Clinical
Clinical
Specialty
Specialty
NEUPOGEN 300 mcg/0.5 mL SYRINGE
Clinical
Specialty
NEUPOGEN 300 mcg/ML VIAL
NEUPOGEN 480 mcg/0.8 mL SYRINGE
Clinical
Clinical
Specialty
Specialty
NEUPOGEN 480 mcg/1.6 mL VIAL
NEUPRO PATCH 1 mg PER 24 HOUR
Clinical
Lower Cost
Specialty
Formulary agents: ropinirole or pramipexole with a
diagnosis of restless leg syndrome (RLS) or Parkinson's
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
NEVANAC 0.1% DROPTAINER
Lower Cost
NEUVAXIN 0.0375-5% PATCH
Lower Cost
DROPS
Required 30 day trial of: Trixaicin HP, Arthritis Pain,
Theragen HP, Capsuleacicin (Zostrix HP) 0.075% cream
NEXA SELECT 29-1.25-337.5 MG
CAPSULE
Lower Cost
NEXAVAR 200 mg TABLET
Clinical
NEXICLON XR 0.09 mg/ML SUSP
Lower Cost
Required diagnosis = Renal Cell Carcinoma,
Hepatocellular carcinoma, Thyroid Carcinoma, or
progressive differentiated thyroid cancer refractory to
radioactive iodine treatment
NEXICLON XR 0.17 mg TABLET
Lower Cost
83
Drug
Status
NEXIUM DR 10 mg PACKET
Lower Cost
For Members who are pregnant or on clopidogrel
(Plavix): Formulary agent=pantoprazole 40 mg, then
lansoprazole 30 mg
Under 18 years old: Formulary agents=omeprazole 40
mg once a day or omeprazole 20 mg twice a day , then
lansoprazole 30 mg
Over 18 years old: Formulary agents=omeprazole 40
mg once a day or omeprazole 20 mg twice a day ,
pantoprazole 40 mg, then lansoprazole 30 mg
NEXIUM DR 2.5 mg PACKET
Lower Cost
lansoprazole 30 mg
lansoprazole 30 mg
Lower Cost
lansoprazole 30 mg
lansoprazole 30 mg
Lower Cost
lansoprazole 30 mg
lansoprazole 30 mg
Lower Cost
lansoprazole 30 mg
lansoprazole 30 mg
NIACIN ER (NIASPAN ER) 1,000 mg
Lower Cost
TABLET
NIACIN ER (NIASPAN ER) 500 mg TABLET Lower Cost
Formulary agent: OTC Niacin
NIACIN ER (NIASPAN ER) 750 mg TABLET Lower Cost
84
Drug
Status
NICOMIDE 0.5MG-750MG TABLET
Lower Cost
NICOTROL CARTRIDGE INHALER
Lower Cost
Formulary agents: Formulary Acne Topicals and
Formulary Multi-Vitamin
Requires a trial of: nicotine patches-each strength
separately
Formulary agents: nicotine gum, lozenges, or patches
NICOTROL NS 10 mg/ML SPRAY
Lower Cost
Formulary agents: nicotine gum, lozenges, or patches
Nilutamide (Nilandron) 150 mg Tablet
Clinical
Required diagnosis = metastatic prostate cancer
NICOTINE 21-14-7MG/24 HR PATCH KIT Lower Cost
NIMODIPINE (Nimotop) 30 mg CAPSULE Lower Cost
Required diagnosis = subarachnoid hemorrhage (SAH)
NINLARO 2.3MG CAPSULE
NINLARO 3MG CAPSULE
NINLARO 4MG CAPSULE
NISOLDIPINE ER 17 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
NISOLDIPINE ER 25.5 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
NISOLDIPINE ER 8.5 mg TABLET
Lower Cost
Nitromist
Lower Cost
NORDITROPIN NORDIFLEX 30 mg
Clinical
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
nifedipine
Formulary agent: NITROGLYCERIN LINGUAL 0.4 mg
SPRAY (NitroLingual Spray)
NORDITROPIN NORDIFLEX 5 mg
Clinical
NORDITROPIN NORDIFLX 10 mg
Clinical
NORDITROPIN NORDIFLX 15 mg
Clinical
Norgestimate-Ethinyl Estradiol, Tri-Lo- Lower Cost
Estarylla, Tri-Lo-Marzia, Tri-Lo-Sprintec,
Trinessa Lo (Ortho Tri-Cyclen Lo) 0.1825/0.215-25/0.25-25mg-mcg Tablet
Formulary Agent(s): Formulary Birth Control Agent
NORITATE 1% CREAM
Lower Cost
Formulary agent: METRONIDAZOLE (METROCREAM)
0.75% CREAM
NOROXIN 400 mg TABLET
NORTHERA 100MG CAPSULE
Lower Cost
Lower Cost
Formulary agents: ciprofloxacin or levofloxacin
Required diagnosis of: orthostatic dizziness,
lightheadedness, or the “feeling that you are about to
black out” in adult patients with symptomatic
neurogenic orthostatic hypotension (NOH) caused by
primary autonomic failure [Parkinson's disease,
multiple system atrophy, and pure autonomic failure],
dopamine beta-hydroxylase deficiency, and nondiabetic autonomic neuropathy
85
Drug
Status
Lower Cost
Lower Cost
NOVA MAX TEST STRIPS
Lower Cost
NOVAFERRUM PEDIATRIC 10MG/ML
DROPS
NOXAFIL 100 mg TABLET
NOXAFIL 40 mg/ML SUSPENSION (200
mg/5 mL)
NPLATE 250 mcg SUBQ SOLUTION
Lower Cost
*Formulary Agent(s): Ferrous Sulfate 220mg/5mL Elixir
Lower Cost
Lower Cost
Formulary agent: fluconazole
Formulary agent: fluconazole
Specialty
NPLATE 500 mcg SUBQ SOLUTION
Nucala 100mg Vial
NUCORT 2% LOTION
NUCYNTA 100 mg TABLET
Specialty
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
NUCYNTA ER 100 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
NUEDEXTA 20-10 mg CAPSULE
Clinical
Formulary agent: HYDROCORTISONE 2.5% LOTION
Formulary agent: morphine sulfate IR or oxycodone or
oxycodone/APAP
oxycodone/APAP
oxycodone/APAP
Formulary agents: morphine sulfate ER (MS Contin) or
fentanyl patches
fentanyl patches
fentanyl patches
fentanyl patches
fentanyl patches
Required Diagnosis= Pseudobulbar Affect (PBA)
Secondary To Multiple Sclerosis (MS) Or Amyotrophic
Lateral Sclerosis (ALS) Or Head/Brain Trauma, Stroke,
Or Alzheimer’s Disease
*Prescribed By Or Under The Consultation Of A
Neurologist
NULOJIX 250MG VIAL
Lower Cost
Required diagnosis= Prophylaxis of organ rejection in
adults receiving a kidney transplant
*Used in combination with basiliximab induction,
mycophenolate mofetil [MMF], and corticosteroids
*Used only in patients who are Epstein-Barr virus
(EBV) seropositive
86
Drug
Status
NUOX GEL
Lower Cost
Nuplazid 17 mg Tablet
NUTROPIN AQ 20 mg/2 mL PEN
Lower Cost
Specialty
Medication Must Go Through Clinical Review
NUTROPIN AQ 5 mg/ML VIAL
Specialty
NUTROPIN AQ NUSPIN 5 PEN
Specialty
NUTROPIN AQ PEN CARTRIDGE
Specialty
NUVESSA 1.3% VAGINAL GEL
Lower Cost
NYMALIZE 60 MG/20ML
Clinical
NYSTATIN 50,000,000 ORAL POWDER
NYSTATIN-TRIAMCINOLONE
0.1units/gm - 0.1% CREAM
NYSTATIN-TRIAMCINOLONE
0.1units/gm - 0.1% OINTMENT
O-CAL PRENATAL
Lower Cost
Lower Cost
Lower Cost
Required trial of: metronidazole 0.75% vaginal gel
(Metro-Gel Vaginal)
Formulary agent: NIMODIPINE (Nimotop) 30MG
CAPSULE
*Required trial of: nystatin oral tablet
Formulary agents: nystatin and triamcinolone
Formulary agents: nystatin and triamcinolone
OB COMPLETE CHEWABLE TABLET 20-1100 mg
OB Complete Gold 27.5 mg-1 mg
Capsule
OB COMPLETE ONE SOFTGEL 40-10-1
mg
OB COMPLETE PETITE SOFTGEL
Lower Cost
Lower Cost
Formulary Agent(s): Prenate Products
Lower Cost
Lower Cost
OB COMPLETE PREMIER TABLET 30-20-1 Lower Cost
mg
OBREDON 2.5-200MG/5ML SOLUTION Lower Cost
Lower Cost
Required trial of: guaifenesin-codeine 200-10MG/5mL
liquid
Age 18 And Older With A Required Diagnosis Of
Primary Biliary Cholangitis AND Formulary Agent
Ursodiol
Age 18 And Older With A Required Diagnosis Of
Primary Biliary Cholangitis AND Formulary Agent
Ursodiol
Ocaliva 5 mg Tablet
Lower Cost
Ocaliva 10 mg Tablet
Lower Cost
OCTAGAM
Clinical
OCTREOTIDE (SANDOSTATIN) 0.05
mg/ML AMPULE
Clinical
Required diagnosis = Acromegaly; Carcinoid tumors;
Vasoactive intestinal peptide tumors (VIPomas)
mg/ML AMPULE
Clinical
Vasoactive intestinal peptide tumors (VIPomas):
mg/ML VIAL
Clinical
mg/ML AMPULE
Clinical
87
Drug
Status
OCTREOTIDE (SANDOSTATIN) 1 mg/ML Clinical
VIAL
OCUCOAT (CELLUGEL) 2%
INTRAOCULAR SOLUTION
ODOMZO 200MG CAPSULE
OFEV 100MG CAPSULE
OFEV 150MG CAPSULE
OFORTA 10 mg TABLET
Lower Cost
Formulary Agent(s): Goniovisc (Gonak) 2.5% Drops
Lower Cost
Clinical
Clinical
Clinical
OLANZAPINE ODT (ZYPREXA ZYDIS) 10
mg TABLET
Lower Cost
available
why non-ZYDIS Zyprexa cannot be used
mg TABLET
mg TABLET
mg TABLET
OLANZAPINE/FLUOXETINE (SYMBYAX)
12-25 mg CAPSULE
Lower Cost
OLANZAPINE/FLUOXETINE (SYMBYAX)
12-50 mg CAPSULE
Lower Cost
why fluoxetine/olanzapine(Zyprexa) separately taken
together cannot be used
Lower Cost
Lower Cost
Lower Cost
This medication has been discontinued
This medication has been discontinued
Formulary Agent(s): Azelastine (Astelin)
OLANZAPINE/FLUOXETINE (SYMBYAX) 3- Lower Cost
25 mg CAPSULE
25 mg CAPSULE
50 mg CAPSULE
OLEPTRO ER 150 mg TABLET
OLEPTRO ER 300 mg TABLET
Olopatadine (Patanase) 0.6% Nasal
Spray
Olopatadine (Patanol) 0.1% Drops
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary Agent(s): OTC Drops With Ketotifen AND
Azelastine (Optivar)
OLYSIO 150 mg CAPSULE
OMECLAMOX-PAK COMBO PACK
Lower Cost
Lower Cost
OMEPRAZOLE-BICARB (Zegerid RX) 401,100 mg
Lower Cost
OMNARIS 50 mcg NASAL SPRAY
Lower Cost
Formulary agents: AMOXICILLIN CAP,
CLARITHROMYCIN TAB AND OMEPRAZOLE capsule
separately
Formulary agents: omeprazole-sodium bicarb 20/1100
mg AND omeprazole 20 mg SEPARATELY taken
together
24HR Spray
OR
OR
Fluticasone (Flonase), Flonase OTC Allergy Relief Spray,
Flunisolide, Or Nasacort OTC Allergy 24HR Spray
88
Drug
Status
OMNITROPE 10 mg/1.5 mL CATRIDGE
Specialty
OMNITROPE 5.8 mg VIAL
Specialty
OMNITROPE 5 mg/1.5 mL CATRIDGE
Specialty
ONETOUCH AND ONETOUCH ULTRA
TEST STRIPS/METER
ONEXTON GEL 1.2-3.75% PUMP
Lower Cost
Lower Cost
ONFI 10 mg TABLET
Step Therapy
*Formulary Agent(s): Benzoyl Peroxide 5% Gel
(Panoxyl) With Clindamycin, Clindamax (Cleocin T) 1%
Lotion, Clindamycin Swab (Cleocin T) 1% Pledgets,
Clindamycin Phosphate 1% Solution Separately Used
Together At The Same Time
Formulary agents: gabapentin, lamotrigine (Lamictal),
(Depakene) or zonisamide or previously approved for
Lyrica, Vimpat, Stavzor, Banzel or Potiga
ONFI 2.5 mg/ML SUSPENSION
Step Therapy
ONFI 20 mg TABLET
Step Therapy
ONFI 5 mg TABLET
Step Therapy
ONGLYZA 2.5 mg TABLET
Lower Cost
ONGLYZA 5 mg TABLET
Lower Cost
ONIVYDE 43MG/10ML VIAL
Lower Cost
Or Glucophage ER)
THEN
Or Glucophage ER)
THEN
89
Drug
Status
ONMEL 200 mg TABLET
Lower Cost
Onzetra Xsail 11 mg Nasal Powder
Lower Cost
Formulary agent: itraconazole (Sporanox) capsule with
a diagnosis of onychomycosis
Age 18 And Older AND A Trial Of At Least 2 Of The
Following 3 Drugs: Sumatriptan Tablets, Injection Or
Nasal Spray, Naratriptan, Almotriptan, Or Rizatriptan
OPANA ER 10 mg CRUSH RESISTANT
TABLET
Lower Cost
TABLET
Lower Cost
TABLET
Lower Cost
TABLET
Lower Cost
TABLET
Lower Cost
TABLET
Lower Cost
OPANA ER 7.5 mg CRUSH RESISTANT
TABLET
Lower Cost
Opdivo 40mg/4mL Vial
Opdivo 100mg/10mL Vial
Opium Tincture 10 mg/mL
Lower Cost
Lower Cost
Lower Cost
OPSUMIT 10 mg TABLET
Clinical
Oralair Children's Starter Pack 100IR
Sublingual Tablet
Lower Cost
*Dx= Need For Skin Test Or In Vitro Testing For PollenSpecific IgE Antibodies For Any Of The Five Grass
Species
And
*Formulary Agent(s): Oralair 300IR Sublingual Tablet
Oralair 300IR Sublingual Tablet
Lower Cost
ORAPRED ODT 10 mg TABLET
Lower Cost
Lower Cost
*Dx= Need For Skin Test Or In Vitro Testing For PollenSpecific IgE Antibodies For Any Of The Five Grass
Species
Formulary agents: prednisone tablet or liquid or
methylprednisolone tablet
Formulary agent: OXYMORPHONE SR (OPANA ER) noncrush resistant (which requires a trial of morphine
sulfate ER (MS Contin) )
Formulary Agent(s): 7 Day Trial Of AtropineDiphenoxylate (Lomotil) Or Dicyclomine (Bentyl) WITH
A Diagnosis Of Severe-Diarrhea or IBS (Irritable Bowel
Syndrome)
Age over 18 yrs old, prescribed by pulmonologist
and/or cardiologist, WHO Group 1 with NYHA
Functional class II or III or IV symptoms
AND PAP pressures not adequately controlled using an
oral vasodilator (e.g. calcium channel blocker) at
maximal doses
OR The member was not vasodilator sensitive as
90
Drug
Status
Lower Cost
ORAVIG 50 mg BUCCAL TABLET
Lower Cost
Formulary agents: oral nystatin tablet or suspension
ORBACTIVE 400MG VIAL
ORBIVAN 50-300-40 mg CAPSULE
Lower Cost
Lower Cost
ORBIVAN CF 50-300 mg TABLET
Lower Cost
ORENCIA 125 mg/1 mL SYRINGE
Specialty
Formulary agent: Butalbital-Acetaminophen-Caffeine
(Fioricet) 50-325-40mg Tablet
Formulary agent: BUTALBITAL-ACETAMINOPHEN
(Phrenilin, Marten tablet) 50-325 MG tablet
ORENCIA 250 mg VIAL
Specialty
ORENITRAM 0.125 MG
ORENITRAM 0.25 MG
ORENITRAM 1 MG
ORENITRAM 2.5 MG
ORFADIN 10 mg CAPSULE
Specialty
Specialty
Specialty
Specialty
Clinical
Clinical
Clinical
ORKAMBI 200MG-125MG TABLET
ORLISTAT, ALLI, XENICAL
ORPHENADINRE 30 mg/ML VIAL
Lower Cost
Excluded benefit
Lower Cost
See Tyvaso Policy on CareSource.com
Required diagnosis =Hereditary tyrosinemia type 1 (HT1)
ORPHENADRINE COMPOUND FORTE
TABLET 50-770-60
Lower Cost
ORPHENADRINE COMPOUND TABLET
25-385-30
Lower Cost
ORTHOVISC
Lower Cost
OSMOPREP, VISICOL 1.5 mg TABLET
OSPHENA 60 mg TABLET
OTEZLA 30MG TABLET
OTEZLA Starter Pack
OVIDREL INJECTION 250 mcg/0.5 mL
OXANDROLONE 10 mg TABLET
Lower Cost
Excluded benefit
Lower Cost
Lower Cost
Excluded benefit
Clinical
OXANDROLONE 2.5 mg TABLET
Clinical
OXAYDO 5MG TABLET
OXAYDO 7.5MG TABLET
OXECTA 5 mg TABLET
OXECTA 7.5 mg TABLET
Oxiconazole Nitrate (Oxistat) 1% Cream
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Requires diagnosis of acute painful musculoskeletal
conditions with an inability to use tablet
trial not preferred agent)
trial not preferred agent)
Formulary agents: Supartz or Gel-One
Formulary agents: Gavilyte-H or Peg-Prep Kit
Requires diagnosis = Bone pain with osteoporosis,
protein catabolism, or need for weight gain with a trial
of megestrol
Requires diagnosis = Bone pain with osteoporosis,
protein catabolism, or need for weight gain with a trial
of megestrol
Formulary Agent(s): Oxycodone IR Tablet
Formulary Agent(s): Oxycodone IR Tablet
Formulary agent: oxycodone IR tablet
Formulary agent: oxycodone IR tablet
Required Diagnosis= Tinea Pedis, Tinea Cruris, Tinea
Corporis, Or Tinea (Pityriasis) Versicolor AND
Formulary Agent(s): Ketoconazole Cream, Clotrimazole
Cream, Or Miconazole Cream
91
Drug
Status
OXISTAT 1% LOTION
Lower Cost
OXSORALEN 1% LOTION
Clinical
Formulary agents: ketoconazole cream, clotrimazole
cream, or miconazole cream with a diagnosis of tinea
pedis, tinea cruris, tinea corporis, or tinea (pityriasis)
versicolor
Excluded for cosmetic use
OXSORALEN-ULTRA 10 mg CAPSULE
Lower Cost
OXTELLAR XR 150 mg TABLET
OTREXUP 10 MG/0.4 ML AUTO
OVACE PLUS 9.8% LOTION
Step therapy
Step therapy
Step Therapy
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
OVACE PLUS 10% CREAM
Lower Cost
OXYCODONE ER (OXYCONTIN) 10MG
TABLET
Clinical
TABLET
Clinical
Requires a diagnosis of pain with a 30 day trial of:
Fenantyl Patches, Morphine Sulfate ER (MS Contin) or
Oxymorphone ER
TABLET
Clinical
Oxymorphone ER
TABLET
Clinical
Oxymorphone ER
TABLET
Clinical
Oxymorphone ER
TABLET
Clinical
Oxymorphone ER
TABLET
Clinical
Oxymorphone ER
Formulary agent: calcipotriene (Dovonex) with a
diagnosis of psoriasis
Must first try non-SR oxcarbazepine (Trileptal)
Formulary agent: METHOTREXATE INJECTION
Required trial of: sulfacetamide sodium (Klarion) 10%
lotion
lotion
Oxymorphone ER
OXYCODONE-IBUPROFEN 5-400 TABLET Lower Cost
OXYCONTIN 15 mg TABLET
Clinical
Clinical
Formulary agent: oxycodone/acetaminophen or
fentanyl
Oxymorphone ER
Oxymorphone ER
92
Drug
Status
Clinical
Oxymorphone ER
OXYMORPHONE IR (OPANA) 10 mg
TABLET
OXYMORPHONE IR (OPANA) 5 mg
TABLET
OXYMORPHONE SR (OPANA ER) 10 mg
TABLET
Lower Cost
Lower Cost
Lower Cost
Formulary agent: morphine sulfate ER
OXYTROL 3.9 mg/24HR PATCH
Lower Cost
Ozurdex 0.7mg Implant
PACERONE 100 mg TABLET
Lower Cost
Lower Cost
PACNEX 7% WASH
Lower Cost
TOLTERODINE, TROSPIUM, or TROSPIUM SR for men;
Oxytrol for Women patch for women
Formulary agent: amiodarone 200 MG or 400 MG
TABLET
BENZOYL PEROXIDE-ERYTHROMYCIN (BENZAMYCIN) 53% GEL
PACNEX HP 7% CLEANSING PADS
Lower Cost
PACNEX LP 4.25% CLEANSING PADS
Lower Cost
PACNEX MX 4.25% CLEANSER
Lower Cost
PAIN EASE (GEBAUERS) SPRAY
Clinical
Required diagnosis=Controlling pain associated with
injections and certain other procedures such as dialysis
93
Drug
Status
PAIRE OB PLUS DHA COMBO PACK
Lower Cost
PALIPERIDONE ER (INVEGA ER) 1.5MG
TABLET
Step Therapy
PALIPERIDONE ER (INVEGA ER) 3MG
TABLET
Step Therapy
TABLET
Step Therapy
TABLET
Step Therapy
PANCREAZE 10,500 UNIT CAPSULE
PANDEL 0.1% CREAM
PANRETIN 0.1% GEL
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Clinical
PAREGORIC 2 mg/5 mL LIQUID
PAROXETINE CR (PAXIL CR) 12.5 mg
TABLET
PAROXETINE CR (PAXIL CR) 25 mg
TABLET
PAROXETINE CR (PAXIL CR) 37.5 mg
TABLET
PASER GRANULES 4 gM PACKET
PATANOL 0.1% EYE DROPS
Lower Cost
Lower Cost
(Abilify)
(Abilify)
(Abilify)
(Abilify)
Formulary agents: VIOKACE, Zenpep or ULTRESA
Formulary agent: hydrocortisone topical
Required diagnosis = Kaposi sarcoma (KS) cutaneous
lesions
Formulary agents: imodium or loperamide
Formulary agents: non- CR paroxetine
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary agent: rifampin
PAZEO 0.7% EYE DROPS
Lower Cost
PCE 333 mg DISPERTABLET
PCE 500 mg DISPERTABLET
PEDIADERM AF KIT
Lower Cost
Lower Cost
Lower Cost
* 15 day trial of OTC Ketotifen (Alaway/Claritin Eye
Drops/Refresh/RiteAid or CVS Eye Itch Eye Drops
(Zaditor)/Wal-Zyr/Zyrtec Eye Drops)
AND
* 15 day trial of azelastine (Optivar)
Formulary agent: erythromycin tabs
Formulary agent: erythromycin tabs
Formulary agents used separately: hydrocortisone 2%
lotion and an emollient lotion or ointment (Cerave;
Cetaphil; Aveeno; Lubriderm, Eucerin)
PEDIADERM HC 2% KIT
Lower Cost
PEDIADERM TA KIT
Lower Cost
PEDIA-LAX SUP 2.8 gM
Lower Cost
PEDIPIROX-4 NAIL KIT
Lower Cost
PEG 3350 , GAVILYTE-C (COLYTE) WITH
FLAVOR PACKETS 4000 mL 240-22.72
Lower Cost
Formulary agents: GLYCERIN PED SUP 1.2 gM or
GLYCERIN SUPPOS 2.1 GM
Formulary agents: CICLOPIROX (Penlac, Ciclodan) 8%
SOLUTION AND vitamin E separately
Must provice clinical reason supported by chart notes
why PEG-3350 , GAVILYTE-G (GOLYTELY) cannot be
used
94
Drug
Status
PEGASYS 135 mcg/0.5 mL PROCLICK
Clinical
PEGASYS 180 mcg/0.5 mL KIT
Clinical
PEGASYS 180 mcg/0.5 mL PROCLICK
Clinical
PEGASYS 180 mcg/0.5 mL SYRINGE
Clinical
PEGASYS 180 mcg/ML VIAL
Clinical
PegIntron 50 mcg/0.5 mL Subcutaneous Clinical
Kit
PENNSAID SOLUTION 2% PUMP
Lower Cost
PENTASA 250MG CAPSULE
Lower Cost
PENTASA 500MG CAPSULE
Lower Cost
PENTAZOCINE-ACETAMINOPHEN 25650 mg
Perforomist 20mcg/2mL Solution
PERJETA 420MG/14ML VIAL
Lower Cost
*Formulary Agent(s): Voltaren 1% Gel
*Required Diagnosis = Crohn's Disease Of The Small
Intestine AND *Formulary Agent(s): Mesalamine
(Asacol HD), Delzicol Or Apriso ER
*Required Diagnosis = Crohn's Disease Of The Small
Intestine AND *Formulary Agent(s): Mesalamine
(Asacol HD), Delzicol Or Apriso ER
Formulary agent: ACETAMINOPHEN-CODEINE
Lower Cost
Clinical
Formulary Agent(s): Arcapta Neohaler
Authorization is required on Medical Benefit Only
Required diagnosis= estrogen receptor (ER)-positive,
human epidermal growth factor receptor 2 (HER2)negative advanced breast cancer (in combination with
trastuzumab and docetaxel)
Perlane, Perlane-L, Restylane, Restylane- Excluded Benefit
L Gel For Injection
PERTZYE 16000-57500-60500 Units
Lower Cost
PERTZYE 8000-28750-30250 Units
Lower Cost
PEXEVA 10 mg TABLET
Lower Cost
PEXEVA 20 mg TABLET
Lower Cost
PEXEVA 30 mg TABLET
Lower Cost
PEXEVA 40 mg TABLET
Lower Cost
PHENDIMETRAZINE (BONTRIL PDM) 35 Excluded benefit
mg TABLET
PHENDIMETRAZINE ER 105 mg TABLET Excluded benefit
Formulary agents: Viokace, Zenpep or Ultresa
Formulary agents: Viokace, Zenpep or Ultresa
Formulary agent: non- CR paroxetine
PHENELZINE SULFATE (NARDIL) 15 mg Lower Cost
TABLET
PHENOXYBENZAMINE HYDROCHLORIDE Lower Cost
(DIBENZYLINE) CAPSULE
PHENTERMINE (ADIPEX-P) 37.5 mg
CAPSULE
PHENTERMINE (ADIPEX-P) 37.5 mg
TABLET
PHENTERMINE 15 mg CAPSULE
PHENTERMINE 30 mg CAPSULE
PHISOHEX 3% CLEANSER
Excluded benefit
PHOSLYRA 667 mg/5 mL SOLUTION
PHRENILIN FORTE CAPSULE 50-650 mg
Lower Cost
Lower Cost
PICATO 0.015% Gel
Lower Cost
PICATO 0.05% Gel
Lower Cost
Formulary agent: Parnate
Required Dx= Pheochromocytoma
Excluded benefit
Excluded benefit
Excluded benefit
Lower Cost
Formulary agents: CHLORHEXIDINE GLUCONATE,
BETASEPT (HIBICLENS) LIQUID 4% OTC
Formulary agent: calcium acetate (PhosLo)
Formulary agents: BUTALBITAL-ACETAMINOPHEN
(Phrenilin, Marten tabs) 50-325 mg tablet
CREAM with a diagnosis of actinic keratoses
CREAM with a diagnosis of actinic keratoses
95
Drug
Status
PILOPINE HS 4% EYE GEL
PINNACAINE 20% OTIC DROPS
Lower Cost
Lower Cost
Formulary agent: PILOCARPINE 4% EYE DROPS
Formulary agent: antipyrine-Benzocaine (AURODEX)
OTIC SOLUTION
disease/Increased Creatinine
OR
7.5% from within the last 90 days
PIOGLITAZONE-GLIMEPIRIDE (DUETACT) Step Therapy
30-2 mg TABLET
PIOGLITAZONE-GLIMEPIRIDE (DUETACT) Step Therapy
30-4 mg TABLET
Plegridy 63 & 94 mcg/0.5 mL Pen
Injector
Plegridy 125 mcg/0.5 mL Pen Injector
Lower Cost
OR
Lower Cost
Plegridy 63 & 94 mcg/0.5 mL Syringe
Lower Cost
Plegridy 125 mcg /0.5 mL Syringe
Lower Cost
PLEXION CLEANSING CLOTHS
Lower Cost
PNV-DHA PLUS SOFTGEL 27-1.13 mg
Lower Cost
Formulary Agent(s): Avar-E LS 10-2% cream,
Sulfacetamide Sodium w/ Sulfur Suspension 10-5%,
Sulfacetamide Sodium w/ Sulfur lotion 10-5%, Or
Sulfacetamide Sodium w/ Sulfur emulsion, Avar
cleanser, Rosanil, Prascion 10-5%
PNV FE FUM/DOCUSATE
Lower Cost
PNV-DHA PLUS SOFTGEL 27-400-1
Lower Cost
PNV-DHA PLUS SOFTGEL 27 mg-400
Lower Cost
PNV-IRON TABLET 29-1.13 mg
Lower Cost
PNV-IRON TABLET 29-400-1
Lower Cost
PODIAPN CAPSULE
Lower Cost
Formulary agents: METHYLFOL/ME, VITACIRC-B,
FOLTANX, or L-METHYL-B6 TABLET
POLY IRON PN FORTE TABLET
Lower Cost
POLYGAM S/D
Clinical
Poly-Tussin AC 10-4-10 mg/5 mL Liquid Lower Cost
Formulary Agent(s): Dimaphen Elixir
POLY-VI-FLOR FS 0.25MG FILM
Lower Cost
POLY-VI-FLOR FS 0.5MG FILM
Lower Cost
POLY-VI-FLOR FS 1MG FILM
Lower Cost
POLY-VI-FLOR 0.25MG CHEWABLE
TABLET
POLY-VI-FLOR 0.5MG CHEWABLE
TABLET
Lower Cost
Formulary Agent(s): Multi-Vit/Fluor, Poly-Vit-Fluor
0.25mg/mL Drops
0.25mg/mL Drops
0.25mg/mL Drops
Formulary agent: Multivit-Fluor 0.25MG tablet
Lower Cost
Formulary agent: Multivit-Fluor 0.5MG tablet
96
Drug
Status
POLY-VI-FLOR 1MG CHEWABLE TABLET Lower Cost
Formulary agent: Multivit-Fluor 1MG tablet
POLY-VI-FLOR W/ IRON 0.5-10MG
CHEWABLE TABLET
Lower Cost
*Required trial of: ESCAVITE , MULTI-VIT/FLUOR/FE
(IRON), POLY-VIT/FLUOR/FE (IRON) 0.25MG-10MG/ML
POLY-VI-FLOR/IRON 0.25-7 mg/ML
SUSPENSION
Lower Cost
why MULTI-VIT/FE/FL 0.25-10 mg/ML DROPS,
POLYVITS/FE, ESCAVITE be used
POMALYST 1 mg CAPSULE
Clinical
Clinical
Clinical
Clinical
Portrazza 800mg/50mL IV Solution
Lower Cost
Required Diagnosis= Metastatic Squamous Non-Small
Cell Lung Cancer (NSCLC) AND MD Specialty= Oncology
POTABLETA 500 mg
POTASSIUM CL 25 MEQ TABLET
EFFERVESCENT
POTIGA 200 mg
Excluded benefit
Lower Cost
Clinical
Requires diagnosis of Partial-onset seizures in adults
and currently on at least one other anti-epileptic
(gabapentin, lamotrigine, divalproex (Depakote),
levetiracetam (Keppra), oxcarbazepine (Trileptal),
carbamazepine (Carbatrol), Phenytoin (Dilantin),
topiramate (Topamax), VALPROIC ACID (Depakene) or
Zonisamide) or Previously approved for Lyrica, Stavzor,
Vimpat, Onfi or Banzel
POTIGA 300 mg
Clinical
POTIGA 400 mg
Clinical
POTIGA 50 mg
Clinical
Formulary agent: a formulary potassium supplement
97
Drug
Status
PR NATAL 400 COMBO PACK
Lower Cost
PR NATAL 400 EC COMBO PACK
Lower Cost
PR NATAL 430 EC COMBO PACK
Lower Cost
PRALUENT PEN-INJECTOR
PRALUENT SYRINGE
Pramipexole ER (Mirapex ER) 0.375mg
Tablet
Tablet
Tablet
Tablet
Pramipexole ER (Mirapex ER) 3mg
Tablet
Tablet
Pramosone 2.5%-1% Lotion
Lower Cost
Lower Cost
Lower Cost
Formulary Agent(s): Non-ER Pramipexole
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Pramosone E 1-2.5% Cream
Lower Cost
PRASCION FC PAD 10-5% CLOTH
Lower Cost
PRASCION RA CREAM 10%-5%
Lower Cost
PREFERA OB TABLET
Lower Cost
A 30 Day Trial Of: Hydrocortisone 2.5% Lotion AND
Pramoxine HCl 1% Lotion Separately Used Together At
The Same Time
A 30 Day Trial Of: Hydrocortisone 2.5% Lotion AND
Pramoxine HCl 1% Lotion Separately Used Together At
The Same Time
PREFERA-OB ONE SOFTGEL
Lower Cost
PREFERA-OB PLUS DHA COMBO Pack 22- Lower Cost
6-1-200
PREFERA-OB PLUS DHA COMBO Pack 28- Lower Cost
6-1-203
PREGNITUDE 200-2,000MG POWDER
Non-Covered
PACK
PRENACARE
Lower Cost
PRENAFIRST
Lower Cost
PRENAISSANCE PLUS, MACNATAL CN
DHA 28-1-250 mg CAPSULE
PRENATAL-1 30-975-200MG CAPSULE
Lower Cost
Lower Cost
PRENEXA CAPSULE 26-1.2-55
Lower Cost
98
Drug
Status
PRENEXA, VEMAVITE, PNV-DHA,
FOLCAL DHA CAPSULE 27-1.25-55-300
mg
PREPOPIK PAK
Lower Cost
Lower Cost
PREQUE 10 TABLET
Lower Cost
*Required trial within the last 30 days of: Gavilyte-H or
Peg-Prep Kit
PREVACID SOLUTAB 15 mg TABLET
Lower Cost
PREVACID SOLUTAB 30 mg TABLET
Lower Cost
PRIALT 25MCG/ML VIAL
PRIALT 100MCG/ML VIAL
PRIFTIN 150 mg TABLET
PRIMLEV 10-300 mg TABLET
Clinical
Clinical
Clinical
Lower Cost
PRIMLEV 5-300 mg TABLET
Lower Cost
PRIMLEV 7.5-300 mg TABLET
Lower Cost
PRIMSOL 50 mg/5 mL ORAL SOLUTION
Lower Cost
PRISTIQ 25MG TABLET
Lower Cost
For Ages 8-11: Formulary Agent(s)= Fluoxetine
For Ages 12-17: Formulary Agents(s)= Fluoxetine Or
Escitalopram
For Ages 18+: Formulary Agent(s)= Trials Each Of 2 Of
The 3 Following Preferred Formulary Groups (One Of
Which Must Have Occurred Within The Last Year)
-Group-1: Generic SSRI (Escitalopram, Citalopram,
Fluoxetine, Paroxetine, Fluvoxamine, Sertraline)
-Group-2: Generic SNRI (Venlafaxine Tablet,
Venlafaxine ER Capsule Or Duloxetine (Cymbalta);
-Group-3: Bupropion XL Or SR (Wellbutrin SR Or XL)
PRISTIQ 100 mg TABLET
Lower Cost
Escitalopram
Formulary Agent(s): Lansoprazole Capsules Or First
Lansoprazole 3 mg/mL Suspension
Formulary Agent(s): Lansoprazole Capsules Or First
Lansoprazole 3 mg/mL Suspension
Required diagnosis=pulmonary tuberculosis
Formulary agent: oxycodone with acetaminophen
10/325 mg
5/325 mg
7.5/325 mg
Formulary agent: trimethoprim tablet
99
Drug
Status
PRISTIQ 50 mg TABLET
Lower Cost
Escitalopram
PRIVIGEN 10% VIAL
Clinical
PROAIR HFA 90MCG INHALER (8.5GM)
Lower Cost
Formulary Agent(s): Ventolin HFA Inhaler
PROAIR 90MCG RESPICLICK
PROCORT CREAM 1.85-1.15%
Lower Cost
Lower Cost
PROCRIT 10,000 UNITS/ML (20,000
UNITS/2 mL) VIAL
Clinical
Formulary Agent(s): Ventolin HFA Inhaler
Formulary agents: PRAMOXINE AEROSOL 1%
(Proctofoam) with Procto-Pak (PROCTOCORT) 1%
CREAM separately
PROCRIT 10,000 UNITS/ML VIAL
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
PROCTOCORT 1% CREAM
Lower Cost
PROCYSBI 25 mg CAPSULE
PROCYSBI 75 mg CAPSULE
PRODIGY METER
PRODIGY NO CODE TEST STRIPS
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary agents: 2 different manufacturers of generic
Procto-Pak (PROCTOCORT) 1% CREAM
Required diagnosis=Relief of inflammatory and pruritic
manifestations of corticosteroid-responsive
dermatoses
with a trial of HYDROCORTISONE Acetate
1%/Pramoxine Hydrochloride 1% (ANALPRAM-HC)
CREAM
Required diagnosis=nephropathic cystinosis
Required diagnosis=nephropathic cystinosis
PRODIGY TEST STRIPS
Lower Cost
PROFILNINE SD 1,000 UNITS VIAL
Specialty
PROFILNINE SD 1,500 UNITS VIAL
PROFILNINE SD 500 UNITS VIAL
PROGLYCEM 50 mg/ML ORAL
SUSPENSION
Specialty
Specialty
Lower Cost
Required diagnosis=hypoglycemia due to extenuating
circumstances
PROCTOFOAM AREOSOL HC 1-1% FOAM Lower Cost
100
Drug
Status
PROLASTIN 1000 mg
Specialty
PROLASTIN 500 mg
Specialty
PROLASTIN-C 1000 mg
Specialty
PROLENSA 0.07% ophthalmic SOLUTION Lower Cost
DROPS
PROLIA
Specialty
Promacta 12.5mg Tablet
Promacta 25mg Tablet
PROPARACAINE 0.5% EYE DROPS
PROQUIN XR 500 mg TABLET
PROTONIX PAK 40 mg
SUSPENSION PACKET
Clinical
Clinical
Clinical
Clinical
Lower Cost
Lower Cost
Lower Cost
PROVENTIL HFA 90 mcg INHALER
Lower Cost
Formulary agent: tetracain
Formulary agents: ciprofloxacin or levofloxacin
Formulary agents: omeprazole 40 mg daily or 20 mg
twice a day or First-Omeprazole suspension, AND
lansoprazole 30 mg or First-Lansoprazole suspension
AND a clinical reason why pantoprazole tablets cannot
be used
Formulary agent: Ventolin
PROVIDA DHA 32-1.25MG CAPSULE
Lower Cost
PRUDOXIN (ZONALON) 5% CREAM
Lower Cost
PRUMYX CREAM
Lower Cost
Prutect Emulsion
PULMICORT 180 mcg FLEXHALER
Lower Cost
Lower Cost
Formulary agents: OTC topical antihistamine
(DIPHENHYDRAMINE HCL CREAM 2%, ANTI-ITCH
(BENADRYL) 1% CREAM, or ANTI-ITCH (BENADRYL) 2%
CREAM)
why the below cannot be used:
Cerave; Cetaphil; Aveeno; Lubriderm (Eucerin)
Required 30 day trial of either: Aerospan or Asmanex
PULMICORT 90 mcg FLEXHALER
Lower Cost
Required 30 day trial of either: Aerospan or Asmanex
PV Vitamin D 400 Unit tablet
Lower Cost
PYLERA CAPSULE
Lower Cost
Qbrelis 1 mg/mL Solution
Lower Cost
Will currently approve for a diagnosis of H. Pylori due
to tetracycline's unavailability
Ages 6-17: Required Diagnosis= Hypertension
AND Formulary Agent(s): Lisinopril Oral Tablet
OR
Ages 18 And Older: Required Diagnosis= Hypertension,
Heart Failure, Or Post Myocardial Infarction AND
Formulary Agent(s): Lisinopril Oral Tablet
101
Drug
Status
QNASL CHILDREN 40MCG SPRAY
Lower Cost
24HR Spray
OR
OR
QNASL 80 mcg SPRAY
Lower Cost
24HR Spray
OR
OR
QSYMIA 11.25-69 mg TABLET
QSYMIA 15-92 mg TABLET
QSYMIA CAPSULE 11.25-69 mg
QSYMIA CAPSULE 15-92 mg
QUARTETTE TABLET
QUAZEPAM (DORAL) 15 mg TABLET
Excluded benefit
Excluded benefit
Excluded benefit
Excluded benefit
Excluded benefit
Excluded benefit
Excluded benefit
Excluded benefit
Lower Cost
Lower Cost
QUFLORA 0.25MG DROPS
Lower Cost
QUFLORA 0.5MG DROPS
Lower Cost
Quillichew ER 20 mg Chewable Tablet
Lower Cost
Lower Cost
Lower Cost
Formulary agents: any formulary birth control
Formulary Agents: Multi-Vit/Flur 0.25MG/ML Drops,
Poly-Vit/Flur 0.25MG/ML Drops
Formulary Agents: Multi-Vit/Flur 0.25MG/ML Drops,
Poly-Vit/Flur 0.25MG/ML Drops
Required Diagnosis Of: ADD/ADHD; Autism;
Asperger's; Hyperkinetic Syndrome; Age Of 6 And
Older; AND Formulary Agent(s): Methylphenidate ER
(Concerta) Tablet
(Concerta) Tablet
(Concerta) Tablet
102
Drug
Status
Quillivant XR 25 mg/5 mL Suspension
Lower Cost
Required Diagnosis: ADD/ADHD; Autism; Asperger's;
*Age Under 6 - Off Label (Need Clinical Info To Support
Use) And 30 Day Trial Of Any Combo Of:
Dextroamphetamine, Dextroamphetamine ER
(Dexedrine), Amphetamine Salt Combo (Adderall),
Dextroamphetamine-Amphetamine ER (Adderall XR)
OR
*Age 6 And Older
Clinical Reason Why The Below Cannot Be Used:
Methylphenidate ER Tablet (Concerta),
Methylphenidate CD Capsule (Metadate CD),
Methylphenidate SR Capsule (Ritalin LA)
Formulary options: non-ER quinidine
Formulary agent: mefloquine with a diagnosis of
malaria
OR
diagnosis of Restless Leg Syndrome
Formulary agent: LEVOFLOXACIN 0.5% EYE DROPS
Formulary Agents: Aerospan 80mcg Inhaler or
Asmanex 110mcg or 220mcg Twisthaler
QUINIDINE SULF ER 300 mg TABLET
QUININE (QUALAQUIN) 324 mg
CAPSULE
Lower Cost
Lower Cost
QUIXIN SOLUTION 0.5%
QVAR 40MCG HFA
Lower Cost
Lower Cost
QVAR 80MCG HFA
Lower Cost
Formulary Agents: Aerospan 80mcg Inhaler or
Asmanex 110mcg or 220mcg Twisthaler
RAGWITEK
Clinical
RAPAFLO 4 mg CAPSULE
Lower Cost
RAPAFLO 8 mg CAPSULE
Lower Cost
RAPIVAB 200MG/ML INJECTION
Lower Cost
Required diagnosis=ragweed pollen-induced allergic
rhinitis
Formulary agents: tamsulosin, doxazosin, terazosin, or
prazosin
Formulary agents: tamsulosin, doxazosin, terazosin, or
prazosin
Required diagnosis: Treatment of acute,
uncomplicated influenza in adults who have been
symptomatic 2 days or less
Requires a diagnosis of: RA, pJIA or psoriasis and a trial
of: methotrexate injection
RASUVO 7.5MG/0.15ML AUTO
Lower Cost
INJECTOR
RASUVO 10MG/0.2ML AUTO INJECTOR Lower Cost
Lower Cost
INJECTOR
Lower Cost
INJECTOR
Lower Cost
INJECTOR
Lower Cost
INJECTOR
103
Drug
Status
RAVICTI 1.1 GM/ML
Lower Cost
RAYOS 1 mg TABLET
Lower Cost
RAYOS 2 mg TABLET
Lower Cost
RAYOS 5 mg TABLET
Lower Cost
REBETOL 40MG/ML SOLUTION
Rebif 22 mcg/0.5 mL Prefilled Syringe
Clinical
Lower Cost
*Required Diagnosis= Urea Cycle Disorders
AND
*Formulary Agent(s): Buphenyl 500mg Tablet Or
Powder
Must provide Clinical reason supported by chart notes
prednisone tablets
prednisone tablets
prednisone tablets
Rebif 44 mcg/0.5 mL Prefilled Syringe
Lower Cost
Rebif Titration Pack
Lower Cost
REBIF REBIDOSE 22 mcg/0.5 mL
SYRINGE
Lower Cost
REBIF REBIDOSE 44 mcg/0.5 mL
SYRINGE
Lower Cost
REBIF Rebidose TITRATION PACK
Lower Cost
RECTIV 0.4% RECTAL OINTMENT
REGENECARE 2% WOUND GEL
REGIMEX 25 mg TABLET
REGRANEX 0.01% GEL
RELEEVIA MC 0.0375-5% PATCH
RELEEVIA ML 4-1% PATCH
Relistor 12 mg/0.6 mL Kit
Lower Cost
Lower Cost
Excluded benefit
Clinical
Lower Cost
Lower Cost
Lower Cost
Required diagnosis= anal fissures
Formulary agent: lidocaine
Relistor 8 mg/0.4 mL Syringe
Lower Cost
Required Diagnosis= Opioid-Induced Constipation AND
A 7 Day Trial Of Lactulose Within The Last 30 Days
Relistor 12 mg/0.6 mL Syringe
Lower Cost
Relistor 12 mg/0.6 mL Vial
Lower Cost
RELPAX 20 mg TABLET
Lower Cost
Formulary Agent(s): *Ages 6-17 = Sumatriptan Tablets,
Injection, Or Nasal Spray Or Rizatriptan OR *Ages 18 &
Older = Must Try 2 Of The Following 4: Sumatriptan
Tablets, Injection, Or Nasal Spray, Naratriptan,
Rizatriptan Or Almotriptan
RELPAX 40 mg TABLET
Lower Cost
Formulary Agent(s): *Ages 6-17 = Sumatriptan Tablets,
Injection, Or Nasal Spray Or Rizatriptan OR *Ages 18 &
Older = Must Try 2 Of The Following 4: Sumatriptan
Tablets, Injection, Or Nasal Spray, Naratriptan,
Rizatriptan Or Almotriptan
RELYYT 0.025-5% PATCH
Lower Cost
*30 day trial of: lidocaine (Lidoderm) 5% patch
Required diagnosis = Diabetic neuropathic ulcers
104
Drug
Status
REMICADE 100MG VIAL
REMODULIN 10 mg/ML VIAL
REMODULIN 2.5 mg/ML VIAL
RENACIDIN IRRIGATION SOLUTION
Specialty
Clinical
Clinical
Clinical
Clinical
Lower Cost
RENAGEL 400 mg TABLET
RENAGEL 800 mg TABLET
RENAX CAPELET
Lower Cost
Lower Cost
Lower Cost
Required diagnosis = the need for dissolution of renal
calculi
Renova 0.02% Cream
Renova 0.02% Cream Pump
RENOVO 0.0375-5% PATCH
RENVELA 0.8G POWDER PACKET
RENVELA 2.4G POWDER PACKET
RENVELA 800MG TABLET
Excluded benefit
Excluded benefit
Lower Cost
Step Therapy
Step Therapy
Lower Cost
Repaglinide-Metformin (Prandimet) 1500mg Tablet
Lower Cost
Formulary Agents: metformin IR or ER (Glucophage or
Glucophage XR) unless HbA1c (Hemaglobin A1c) with a
value greater than 7.5% from within the last 30 days
Repaglinide-Metformin (Prandimet) 2500mg Tablet
Lower Cost
Formulary Agents: metformin IR or ER (Glucophage or
Glucophage XR) unless HbA1c (Hemaglobin A1c) with a
value greater than 7.5% from within the last 30 days
REPATHA 140MG/ML SURECLICK
REPATHA 140MG/ML SYRINGE
REPLESTA 14,000UNIT WAFER
Specialty
Specialty
Lower Cost
Formulary agent: OTC Vitamin D3 10,000 unit product
REPLESTA 50,000UNIT WAFER
Lower Cost
REPLESTA NX 14,000UNIT WAFER
Lower Cost
Formulary agent: VITAMIN D2, ERGOCALCIFEROL
(DRISDOL) 1.25 mg (50,000 UNIT) CAPSULE or OTC
Vitamin D3 50,000 unit product
Formulary agent: OTC Vitamin D3 10,000 unit product
REPRONEX INJECTION 75UNIT
RESCULA 0.15% ophthalmic SOLUTION
Excluded Benefit
Lower Cost
RESPAIRE-30 CAPSULE
Lower Cost
RESTASIS 0.05% EYE EMULSION
RETISERT 0.59MG IMPANT
Lower Cost
Lower Cost
REVATIO 10MG/ML SUSPENSION
REVATIO 10 mg/12.5 mL VIAL
Lower Cost
Clinical
Formulary agents: Latanoprost (XALATAN) 0.005% EYE
DROPS
AND
TIMOLOL (TIMOPTIC) or TIMOLOL (TIMOPTIC-XE)
Formulary agents: OTC pseudoephedrine/guaifenesin
combos
Formulary agents: OTC artificial tears
Required diagnosis = Chronic non-infectious uveitis
affecting the posterior segment of the eye
REVLIMID 20 mg CAPSULE
REVLIMID 2.5 mg CAPSULE
Clinical
Clinical
Clinical
Clinical
Required diagnosis = Multiple Myeloma
Requires trial of: calcium acetate (PhosLo)
Requires trial of: calcium acetate (PhosLo)
Required Diagnosis= Reduction Or Control Of Serum
Phosphorous In Patients With CKD On Dialysis AND
Formulary Agent(s): Calcium Acetate (PhosLo)
105
Drug
Status
REXULTI 0.25MG TABLET
Clinical
Clinical
Lower Cost
REXULTI 0.5MG TABLET
Lower Cost
REXULTI 1MG TABLET
Lower Cost
REXULTI 2MG TABLET
Lower Cost
REXULTI 3MG TABLET
Lower Cost
REXULTI 4MG TABLET
Lower Cost
REYATAZ 50MG POWDER PACKET
REZIRA SOLUTION
RHEUMATREX 2.5 mg TABLET
RHINARIS NASAL GEL 0.2%
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Requires A Diagnosis Of Schizophrenia With A Trial Of
Aripiprazole (Abilify)
For Major Depressive Disorder, In Addition To The
Above, Concurrent Therapy With Formulary AntiDepressants (i.e., Escitalopram, Citalopram, Fluoxetine,
Paroxetine, Fluvoxamine, Sertraline, Venlafaxine
Tablet, Venlafaxine ER Capsule, Duloxetine Or
Bupropion
Bupropion
Bupropion
Bupropion
Bupropion
Bupropion
Formulary Agent(s): Reyataz capsule
Formulary agent: CHERATUSSIN DAC SYRUP
Formulary agent: METHOTREXATE 2.5 mg TABLET
Formulary agent: SALINE NASAL GEL
106
Drug
Status
BUDESONIDE (RHINOCORT) AQUA
NASAL SPRAY
Lower Cost
Formulary agents:
Age 2-3: 30 day trial of triamcinolone (Nasacort AQ)
Age 4-5: 30 day trial of fluticasone (Flonase) or
triamcinolone (Nasacort AQ)
Age 6 and older: 30 day trial of 2 of the following 3
drugs: fluticasone (Flonase), flunisolide, or
triamcinolone (Nasacort AQ)
RIASTAP SOLUTION 1 gM (900-1300 mg) Clinical
Specialty
RIBAPAK 200-400MG DOSEPACK
RIBASPHERE 400MG TABLET
RIBASPHERE 600MG TABLET
RIBAVIRIN 200MG CAPSULE
RIBAVIRIN 200MG TABLET
RIFAMATE CAPSULE 300-150 mg
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Clinical
Clinical
Clinical
Clinical
Lower Cost
Formulary agents: separately rifampin and isoniazid
RIFATER TABLET 120-50-300
Lower Cost
RILUZOLE (RILUTEK) 50 mg TABLET
Clinical
Formulary agents: separately rifampin and isoniazid
and pyrazinamide
Required diagnosis = Amyotrophic lateral sclerosis
RIOMET 500 mg/5 mL LIQUID
Lower Cost
Required diagnosis=diabetes with a clinical reason why
metformin ER tablet cannot be used
Formulary agent: ZINC OXIDE OINT 20%
RISAMINE (CALMOSEPTINE) 0.44Lower Cost
20.625% OINTMENT
RISEDRONATE SODIUM (ATELVIA) DR 35 Lower Cost
mg TABLET
RITALIN LA 10MG CAPSULE
Lower Cost
RITALIN LA 60MG CAPSULE
Lower Cost
RITUXAN 10 mg/ML
Clinical
Formulary Agent(s): Methylphenidate CD (Metadate
CD) 10 mg Or 60 mg
Formulary Agent(s): Methylphenidate CD (Metadate
CD) 10 mg Or 60 mg
RIVASTIGMINE (EXELON) 13.3 mg/24HR
PATCH
PATCH
PATCH
RIXUBUS
Lower Cost
Required trial : RIVASTIGMINE (Exelon) CAPSULE
Lower Cost
Lower Cost
Specialty
Required diagnosis=hemophilia B or Factor IX
deficiency prescribed by hematologist
Formulary agent: Adult Robitussin Cough Syrup
Formulary agent: ADT ROBITUSSIN COUGH-COLD D
LIQUID
Required Diagnosis= Parkinson's Disease AND
Formulary Agent: Immediate Release Ropinirole
ROBAFEN 15MG COUGH CAPSULE
Lower Cost
ROBITUSSIN COUGH-COLD-FLU 6.25-2.5- Lower Cost
160 mg/5 mL
ROPINIROLE ER (REQUIP XL) 12 mg
Lower Cost
TABLET
Lower Cost
TABLET
Lower Cost
TABLET
Lower Cost
TABLET
Lower Cost
TABLET
107
Drug
Status
ROSADAN 0.75% KIT
Lower Cost
ROSANIL CLEANSER KIT 10-5%
Lower Cost
ROSULA 10-4.5% WASH
Lower Cost
Formulary agents: metronidazole 0.75% topical lotion,
cream, or gel
*Formulary Agent(s): Avar-E LS 10-2% Cream,
Sulfacetamide Sodium W/ Sulfur Suspension 10-5%,
Sulfacetamide Sodium W/ Sulfur Lotion 10-5%, Or
Sulfacetamide Sodium W/ Sulfur Emulsion, Avar
Cleanser, Rosanil, Or Prascion 10-5%
ROVIN-A DHA 35 mg iron-1 mg-50 mg300 mg
ROVIN-NV DHA CAPSULE
Lower Cost
Lower Cost
ROXICET 5-500 CAPELET
Lower Cost
Formulary agent: oxycodone/acetaminophen tablet
ROZEREM 8 mg TABLET
Ruconest 2,100 Unit Vial
Lower Cost
Lower Cost
RYBIX ODT 50 mg TABLET
RYNATAN PEDIATRIC CHEWABLE 5 mg4.5 mg
RYNATAN PEDIATRIC ORAL SUSPENSION
5-4.5 mg/5 mL
RYTARY 23.75-95MG CAPSULE
Lower Cost
Lower Cost
Formulary agent: tramadol IR 50 mg
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
SABRIL 500 mg POWDER PACKET
Lower Cost
Required 90 day trial of: carbidopa/levodopa ER
(Sinemet CR)
(Sinemet CR)
(Sinemet CR)
(Sinemet CR)
SABRIL 500 mg TABLET
Lower Cost
SAFYRAL TABLET
Lower Cost
SAIZEN 5 mg VIAL
Specialty
(most similar agents= Ocella, Zarah and folate
separately)
SAIZEN 8.8 mg CLICK
Specialty
SAIZEN 8.8 mg VIAL
Specialty
SALICYLIC ACID (SALVAX) 6% FOAM
Lower Cost
SALICYLIC ACID 6% CREAM KIT
SALICYLIC ACID 6% LOTION KIT
SALICYLIC ACID WART REMOVER
(VIRASAL) 26% LIQUID FILM
Lower Cost
Lower Cost
Lower Cost
Formulary agents: OTC SALICYLIC ACID 6% CREAM,
GEL, OR LOTION
Formulary agent: OTC SALICYLIC ACID 6% CREAM
Formulary agent: OTC SALICYLIC ACID 6% LOTION
Formulary Agent(s): Salicylic Acid 17% Gel Or Liquid
108
Drug
Status
SALIVAMAX 351 MG POWDER PACKET
Lower Cost
Formulary Agent(s): Pilocarpine Tablet Or OTC Saliva
Substitute (i.e., Salivasure, Salese (Numoisyn)
Lozenges, Aquoral Aerosol Solution, Or Caphosol,
Numoisyn, Biotene, Mouthkote, Moi-Stir Solution)
SALKERA 6% FOAM
Lower Cost
SAMSCA 15 mg TABLET
Clinical
SAMSCA 30 mg TABLET
Clinical
SANCUSO 3.1 mg/24 HR PATCH
Lower Cost
SAPHRIS 2.5MG SUBLINGUAL TABLET
Step Therapy
SAPHRIS 10 mg TABLET SUBLINGUAL
Step Therapy
SAPHRIS 5 mg TABLET SUBLINGUAL
Step Therapy
SARAFEM 10 mg TABLET
Lower Cost
SARAFEM 20 mg TABLET
Lower Cost
SAVAYSA 15MG TABLET
Lower Cost
SAVAYSA 30MG TABLET
Lower Cost
SAVAYSA 60MG TABLET
Lower Cost
SAVELLA 100 mg TABLET
Lower Cost
SAVELLA 12.5 mg TABLET
Lower Cost
Lower Cost
Lower Cost
SAVELLA TITRATION PACK
Lower Cost
SAXENDA
SCALACORT (ALA SCALP) 2% LOTION
SCULPTRA 367.5MG INJECTION
Excluded benefit
Lower Cost
Lower Cost
Formulary agents: OTC SALICYLIC ACID 6% CREAM,
GEL, OR LOTION
Required diagnosis = Hypervolemic and euvolemic
hyponatremia
Required diagnosis = Hypervolemic and euvolemic
hyponatremia
(Abilify)
(Abilify)
(Abilify)
Formulary agent: FLUOXETINE 10 MG TABLET OR
CAPSULES
Formulary agent: FLUOXETINE 10 MG TABLET OR
CAPSULES
Lower cost agents: Eliquis tablet, fondaparinux
(Arixtra) syringe, or Xarelto tablet
For diagnosis of fibromyalgia, must first try
amitriptyline, venlafaxine ER, or gabapentin (must try
two)
For diagnosis of fibromyalgia, 30 day Trial of:
gabapentin at accepted daily doses of 1200mg to
2400mg, amitriptyline, or duloxetine capsule
why below cannot be used:
Savella tablet (which require a prior authorization for
the use of Formulary amitriptyline, venlafaxine ER, or
gabapentin)
Excluded benefit
Formulary agent: HYDROCORTISONE 2.5% LOTION
Required diagnosis: Restoration and/or correction of
the signs of facial fat loss (lipoatrophy) in HIV patients
SCOPACE 0.4 mg TABLET
Lower Cost
SEA OMEGA + D SOFTGEL
SEA-OMEGA 30 CAPSULE
SEA-OMEGA 50 CAPSULE
Lower Cost
Lower Cost
Lower Cost
available
Formulary agent: OTC Fish Oil
109
Drug
Status
SEASONALE 0.15-0.03 mg TABLET DAW Lower Cost
Lower Cost
generic Quasense, Jolessa
generic Camrese, Amethia
SE-CARE CONCEIVE TABLET 30 mg-1 mg Lower Cost
SECONAL SODIUM 100 mg CAPSULE
Seebri 15.6 mcg Neohaler
Lower Cost
Lower Cost
SELECT-OB+ PAK DHA 29-1-250 mg
CHEWABLE CAPLET
SELENIUM SULFIDE 2.25% SHAMPOO
FOAM
SELRX 2.3% SHAMPOO
Lower Cost
Required Diagnosis= COPD
AND
*Formulary Agent(s): Spiriva Respimat, Spiriva
Handihaler, Or Tudorza
SENSIPAR 30 mg TABLET
Clinical
Clinical
Required diagnosis = Hypercalcemia in parathyroid
carcinoma or Primary/Secondary (due to renal disease,
kidney disease) Hyperparathyroidism
Clinical
Sernivo 0.05% Spray
Lower Cost
SEROQUEL XR 150 mg TABLET
Step Therapy
A 30 Day Trial Of: Betamethasone Valerate 0.1%
Cream, Lotion, Or Ointment
(Abilify)
For depression, in addition to above must currently be
on (60 days of claims): escitalopram, citalopram,
fluoxetine, paroxetine, fluvoxamine, sertraline,
venlafaxine tablet, venlafaxine ER capsule or
bupropion (or recently approved for Pristiq,
venlafaxine ER tablets, Viibryd, desvenlafaxine ER,
fluvoxamine ER (Luvox), or Khedezla)
Step Therapy
SEASONIQUE 0.15-0.03-0.01 TABLET
DAW
SE-CARE CHEWABLE TABLET 40-1 mg
Lower Cost
Lower Cost
Formulary agent: SELENIUM SULFIDE (SELSUN) 2.5%
LOTION/SHAMPOO
SHAMPOO
Lower Cost
(Abilify)
110
Drug
Status
Step Therapy
(Abilify)
Step Therapy
(Abilify)
Step Therapy
(Abilify)
SEROSTIM 4 mg VIAL
Specialty
SEROSTIM 5 mg VIAL
Specialty
SEROSTIM 6 mg VIAL
Specialty
SE-TAN DHA CAPSULE
Lower Cost
SE-TAN PLUS CAPSULE
Lower Cost
SETONET PRENATAL VITAMIN
Lower Cost
SETONET-EC PRENATAL VITAMIN
Lower Cost
SIGNIFOR INJECTION 0.3 mg/ML
Lower Cost
Required diagnosis = treatment of patients with
acromegaly who have had an inadequate response to
surgery and/or for whom surgery is not an option OR
Treatment of adult patients with Cushing disease for
whom pituitary surgery is not an option or has not
been curative
111
Drug
Status
Lower Cost
been curative
Lower Cost
been curative
SILDENAFIL (REVATIO) 20 mg TABLET
Clinical
SILENOR 3 mg TABLET
Lower Cost
Formulary agents: 7 day trial of zolpidem or zaleplon
SILENOR 6 mg TABLET
Lower Cost
Formulary agents: 7 day trial of zolpidem or zaleplon
SIMBRINZA SUSPENSION 1-0.2% DROPS Lower Cost
SIMCOR 1,000-20 mg TABLET
Lower Cost
SIMCOR 1,000-40 mg TABLET
Lower Cost
SIMCOR 500-20 mg TABLET
Lower Cost
Lower Cost
Lower Cost
SIMPONI 100 mg/ML
Specialty
Formulary agent: 30 day trial of BRIMONIDINE 0.2%
EYE DROP WITH DORZOLAMIDE (TRUSOPT) 2% EYE
DROPS
simvastatin (Zocor) and OTC niacin separately taken
together
together
together
together
together
SIMPONI 50 mg/0.5 mL
Specialty
SIMPONI ARIA 50 mg/4 mL
Specialty
SINELEE 0.0375-5% PATCH
Lower Cost
SINELEE 0.05-5% PATCH
Lower Cost
SINUS RELIEF CONGESTION & PAIN 5 mg- Lower Cost
325 mg (day)/5 mg-325 mg-2 mg (night)
Formulary agent: CHLORPHEN-PHENYLEPHRINE W/
APAP TAB 2-5-325 mg
SIRTURO 100 mg TABLET
Required diagnosis = as part of combination therapy in
adults (≥18 years) with pulmonary multi-drug resistant
tuberculosis
Clinical
112
Drug
Status
SITAVIG 50MG BUCCAL TABLET
Lower Cost
SITZMARKS CAPSULE
Lower Cost
SIVEXTRO 200MG SOLUTION
Clinical
SIVEXTRO 200MG TABLET
Clinical
SKELID 200 mg TABLET
SKLICE
Lower Cost
Lower Cost
Required one time trial of: ACYCLOVIR (ZOVIRAX)
200MG CAPSULE, ACYCLOVIR (ZOVIRAX) 400MG
TABLET, OR ACYCLOVIR (ZOVIRAX) 800MG TABLET
Required diagnosis = Need for use as a diagnostic aid
for computed tomography or x-ray examinations of
the GI tract
Formulary Agent(s): Vancomycin IV Or IV/Oral
Linezolid (Zyvox)
Formulary Agent(s): Vancomycin IV Or IV/Oral
Linezolid (Zyvox)
Required diagnosis = Head Lice with trials below:
Age 2 months up to 2 years old: ACTICIN, PERMETHRIN
(ELIMITE)
spinosad (Natroba)
SODIUM CHLORIDE 10% VIAL
SODIUM SULFACETAMIDE, SEB-PREV,
RE 10 WASH, MEXAR (OVACE) 10%
WASH
Lower Cost
Lower Cost
SOLAICE 0.05-5% PATCH
SOLESTA INJECTION 50-15 mL
SOLIRIS (ECULIZUMAB) IV SOLUTIONN
10 mg/ML (FOR INFUSION)
Lower Cost
Clinical
Clinical
SOLODYN ER 105 mg TABLET
Lower Cost
Lower Cost
Lower Cost
(PRONTO),
STOP LICE
KIT (RID
COMPLETE
KIT),
Formulary agent:
SODIUM
CHLORIDE
3% VIAL
Specialty
Specialty
Must provide clinical reason why the below cannot be
used: MINOCYCLINE ER (SOLODYN ER) tablet (which
requires use of minocycline tablet)
113
Drug
Status
Lower Cost
Lower Cost
SOMATULINE INJECTION 120/.5 mL
SOMATULINE INJECTION 60/0.2 mL
SOMATULINE INJECTION 90/0.3 mL
SOMAVERT 10MG VIAL
SOMAVERT 15MG VIAL
SOMAVERT 20MG VIAL
SOMAVERT 25MG VIAL
SOMAVERT 30MG VIAL
SOMNOTE 500 mg SOFTGEL
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
Lower Cost
Sonafine Emulsion
Soolantra 1% Cream
Lower Cost
Lower Cost
Discontinued - could make compound with CHLORAL
HYDRATE CRYSTALS
or use zolpidem or zaleplon
Required Dx= Rosacea
AND Formulary Agent(s): Metronidazole 0.75% or
Tretinoin (Retin-A)
OR
Required Dx= Head Lice
AND
Formulary Agent(s):
*Age 2 Months Up To 2 Years Old: Lice Treatment
Liquid 1%
Age 2 Years - 3 Years: Lice Treatment Liquid 1%,
Permethrin (Rid Foam), Pyrethrins-Piperonyl Butoxide,
Pronto Plus (Rid Liquid), Lice-Aid (Tegrin-LT, Lice Killing
Shampoo (Pronto), Stop Lice Kit (Rid Complete Kit)
*Age 4 Years To 5 Years Old: Lice Treatment Liquid 1%,
Pronto Plus (Rid Liquid), Lice-Aid (Tegrin-LT), Lice
Killing Shampoo (Pronto), Stop Lice Kit (Rid Complete
Kit) Or Spinosad (Natroba)
SORBITOL 3% UROLOGIC IRRIGATION
SORBITOL 3.3% UROLOGIC SOLUTION
Clinical
Clinical
*Age 6 Years And Older: Lice Treatment Liquid 1%,
Pronto Plus (Rid Liquid), Lice-Aid (Tegrin-LT), Lice
Killing Shampoo (Pronto), Stop Lice Kit (Rid Complete
Kit), Spinosad (Natroba) Or Malathion (Ovide)
Required diagnosis= urologic irrigation
Required diagnosis= urologic irrigation
SORILUX 0.005% FOAM
Lower Cost
114
Drug
Status
SOTRET 10 mg
Lower Cost
SOTRET 20 mg
Lower Cost
SOTRET 30 mg
Lower Cost
SALICYLIC ACID WART REMOVER
(VIRASAL) 27.5% LIQUID FILM
SOTYLIZE 5MG/ML SOLUTION
SOVALDI 400 MG TABLET
SPECTRACEF 200 mg DOSE PACK
Lower Cost
Formulary agents:
cream [Or Previously approved for and currently using:
Tazorac, Benzamycin, Acanya, Akne-Mycin, or
Tretinoin Microsphere]
AND
erythromycin
Formulary agents:
AND
erythromycin
Formulary agents:
AND
erythromycin
Formulary Agent(s): Salicylic Acid 17% Gel Or Liquid
SPECTRACEF 400 mg DOSE PACK
Lower Cost
SPORANOX 10 mg/ML SOLUTION
Spritam 250 mg Soluble Disintegrating
Tablet
Tablet
Tablet
Spritam 1,000 mg Soluble Disintegrating
Tablet
SPRIX 15.75 mg/SPRAY
Lower Cost
Lower Cost
Lower Cost
Clinical
Lower Cost
*30 Day Trial Of: Sotalol (Betapace) Tablet
Formulary agent: fluconazole oral solution
Formulary Agent(s): 30 Day Trial Of Levetiracetam
(Keppra) Solution
(Keppra) Solution
(Keppra) Solution
(Keppra) Solution
Required diagnosis=moderate to Severe Pain
and clinical reason supported by chart notes why the
below cannot be used:
ketorolac tablet
Lower Cost
Lower Cost
Lower Cost
Clinical
115
Drug
Status
SPRYCEL 100 mg TABLET
Clinical
Clinical
Clinical
Clinical
Clinical
Clinical
STAVZOR DR 125 mg CAPSULE
Lower Cost
Lower Cost
Lower Cost
Required diagnosis = ALL (Acute Lymphoblastic
Leukemia) or Cml (Chronic Myeloid Leukemia)
Diagnosis = Mania (due to Bipolar disorder)
Formulary agent: Valproic acid
OR
Diagnosis= Migraine
Formulary agent: propranolol
OR
Diagnosis= Seizure or Epilespy
levetiracetam er (Keppra XR) oxcarbazepine (Trileptal),
Zonisamide
OR
Diagnosis= Migraine
OR
Zonisamide
OR
Diagnosis= Migraine
OR
Zonisamide
STAXYN 10 mg DISPERSIBLE TABLET
STELARA 45MG/0.5ML INJECTION
STELARA 90MG/ML INJECTION
STENDRA 100 MG TABLET
Excluded benefit
Specialty
Specialty
Excluded benefit
Excluded benefit
Excluded benefit
116
Drug
Status
STERILE WATER FOR IRRIGATION
STIVARGA 40 mg TABLET
Lower Cost
Lower Cost
Required diagnosis = Need for irrigation
Required diagnosis = Metastatic colorectal cancer who
have been previously treated with FOLFIRI
STRATTERA 100 mg CAPSULE
Step Therapy
Required diagnosis = ADD/ADHD; Autism; Asperger's;
Hyperkinetic Syndrome WITH (Trials per age group
below)
Ages 6-17: Trial of any combo of: Intuniv,
dexmethylphenidate ER (Focalin XR), amphetamine
salt combo (ADDERALL), dextroamphetamineamphetamine ER (ADDERALL XR), methlphenidate ER
(Concerta), methlphenidate CR (Metadate CD),
methlphenidate SR (Ritalin LA), methlphenidate
(Methylin, Ritalin), Methylin ER, or Vyvanse
Age 18 and older: Trial of any combo of:
Step Therapy
below)
117
Drug
Status
Step Therapy
below)
Step Therapy
below)
118
Drug
Status
Step Therapy
below)
Step Therapy
below)
119
Drug
Status
Step Therapy
below)
STRIANT 30 mg BUCCAL
MUCOADHESIVE
Lower Cost
STRENSIQ 18MG/0.45ML VIAL FOR
INJECTION
INJECTION
STRENSIQ 40MG/ML VIAL FOR
INJECTION
INJECTION
SUBOXONE 12 mg-3 mg SUBLINGUAL
FILM
SUBOXONE 2 mg-0.5 mg SUBLINGUAL
FILM
FILM
FILM
SUBSYS SPRAY 1600 mcg
Lower Cost
Required diagnosis = hypogonadism
with Total Testosterone lab value = ≤ 300 ng/dL before
treatment
(both still require a PA also)
Lower Cost
Lower Cost
Lower Cost
Clinical
Clinical
Clinical
Clinical
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
therapy
therapy
therapy
therapy
therapy
120
Drug
Status
Lower Cost
Lower Cost
SUCLEAR KIT
Lower Cost
SUCRAID 8,500 UNITS/ML SOLUTION
SODIUM SULFACETAMIDE (OVACE
PLUS) 10% LIQUID WASH
SODIUM SULFACETAMIDE (OVACE
PLUS) 10% SHAMPOO
SODIUM SULFACETAMIDE (OVACE PLUS
WASH) 10% LIQUID WASH
SULFACETAMIDE SODIUM W/ SULFUR
(AVAR LS) 10-2% CLEANSER
(CLARIFOAM EF) 10-5% EMOLLIENT
FOAM
Clinical
Lower Cost
(SUMADAN) 9% - 4.5%
Lower Cost
(SUMAXIN) CLEANSING PADS 10-4%
Step Therapy
therapy
therapy
Formulary agents: Golytely, Half-Lytely, TRILYTE,
GAVILYTE-N, or PEG-3350/KCL
Required diagnosis= Sucrase deficiency
lotion
lotion
lotion
Formulary agent: SULFACETAMIDE SODIUM W/
SULFUR (AVAR-E LS) 10-2% CREAM
Formulary agents: SULFACETAMIDE SODIUM W/
SULFUR SUSPENSION 10-5%, SULFACETAMIDE SODIUM
W/ SULFUR LOTION 10-5%, OR SULFACETAMIDE
SODIUM W/ SULFUR EMULSION, AVAR CLEANSER ,
ROSANIL, PRASCION 10-5%
Must first try: AVAR-E LS 10-2% CREAM,
Formulary agents: SULFACETAMIDE SODIUM W/
SULFUR (SUMADAN) 9% - 4.5% (which requires a prior
authorization) WITH a formulary skin cleanser used
Must first try: AVAR-E LS 10-2% CREAM,
Formulary agent: silver sulfadiazine
Formulary agent: silver sulfadiazine
Formulary agent: sumatriptan injection, tablet AND
nasal spray
Lower Cost
Lower Cost
Lower Cost
Lower Cost
SULFACETAMIDE SODIUM W/ SULFUR Lower Cost
WASH PLUS SKIN CLEANSER (SUMADAN
KIT) 9% - 4.5%
SULFACETAMIDE SODIUM W/ SULFUR,
SULFACLEANS (SUMAXIN TS) 8-4%
TOPICAL SUSPENSION
Step Therapy
SULFACETAMIDE SODIUM W/ SULFUR,
ZENCIA (SUMAXIN) WASH 9-4%
Step Therapy
SULFAMYLON 8.5% CREAM
SULFAMYLON POWDER PACKET
SUMAVEL DOSEPRO 6 mg/0.5 mL
Lower Cost
Lower Cost
Lower Cost
SUMAXIN CP KIT 10-4%
Lower Cost
121
Drug
Status
SODIUM SULFACETAMIDE WITH
SULFUR (PLEXION) 9.8-4.8% CLEANSER
Lower Cost
SULFUR (PLEXION) 9.8-4.8% CREAM
Lower Cost
SULFUR (PLEXION) 9.8-4.8% LOTION
Lower Cost
SUNSCREEN
SUPARTZ
Non-Covered
Clinical
SUPPRELIN LA
SUPRAX 100 mg CHEWABLE TABLET
Lower Cost
Lower Cost
SUPRAX 500 mg/5 mL SUSPENSION
Lower Cost
Lower Cost
SUPRAX 200 mg CHEWABLE TABLET
Lower Cost
Lower Cost
SUPRAX 400 mg TABLET
Lower Cost
SUPRAX 400 mg CAPSULE
Lower Cost
SUPRENZA 15 mg ODT
SUPRENZA 30 mg ODT
SUPREP BOWEL PREP KIT
Excluded benefit
Excluded benefit
Lower Cost
SUTENT 12.5 mg CAPSULE
Clinical
SUTENT 25 mg CAPSULE
Clinical
SUTENT 37.5MG CAPSULE
Clinical
SUTENT 50 mg CAPSULE
Clinical
SYLATRON 296MCG KIT
SYLATRON 444MCG KIT
SYLATRON 888MCG KIT
Clinical
Clinical
Clinical
Required diagnosis = Central precocious puberty
formulary cephalosporin. Covered for diagnosis of
Gonorrhea and/or Chlamydia
formulary cephalosporin.
Formulary agents: Golytely, Half-Lytely, TRILYTE,
GAVILYTE-N, COLYTE/FLAVR SOLUTION, or PEG3350/KCL
Required diagnosis = Advanced pancreatic
neuroendocrine tumors; Advanced renal cell
carcinoma; GI stromal tumor
Required Dx= Melanoma
122
Drug
Status
SYMAX DUOTABLET (HYOMAX-DT)
0.375 mg TABLET
SYMLIN 0.6 mg/ML VIAL
Lower Cost
Formulary agent: hyoscyamine SR 0.375 mg
Step Therapy
SYMLINPEN 120 PEN INJECTOR
Step Therapy
SYMLINPEN 60 PEN INJECTOR
Step Therapy
SYNAGIS 100 mg/1 mL VIAL 2013-2014
Clinical
Must first try a 60 day trial of Humalog, Novolog or
Apidra
Apidra
Apidra
SYNAGIS 50 mg/0.5 mL VIAL 2013-2014 Clinical
SYNAREL 2 mg/ML NASAL SPRAY
Synera Patches
Clinical
Lower Cost
SYNERCID 500 mg INJECTION
Lower Cost
SYNJARDY 5-500MG TABLET
Lower Cost
SYNJARDY 5-1,000MG TABLET
Lower Cost
SYNJARDY 12.5-500MG TABLET
Lower Cost
SYNJARDY 12.5-1,000MG TABLET
Lower Cost
SYNRIBO 3.5 mg INJECTION
Lower Cost
Required diagnosis = Endometriosis
Required diagnosis = Local dermal analgesia on intact
skin before superficial venous access and superficial
dermatologic procedures
outpatient for diagnosis of Skin and Skin structure
infections
Formulary Agent(s): Metformin IR Or ER THEN
Invokana With Metformin Separately Taken Together
At The Same Time
At The Same Time
At The Same Time
At The Same Time
Required diagnosis = Philadelphia
(Ph+ALL) OR chronic phase, accelerated phase, or blast
phase chronic myeloid leukemia (CML) with T3151
mutation
SYNVISC
Lower Cost
SYNVISC-ONE
Lower Cost
SYPRINE 250 mg CAPSULE
Lower Cost
TABLOID 40 mg TABLET
Clinical
Formulary agent: cupirimine with a diagnosis of
Wilson's disease
Required diagnosis = Acute nonlymphocytic leukemias
Tabradol FusePaq 1 mg/mL Suspension Lower Cost
A 30 Day Trial Of: Non-ER Cyclobenzaprine Tablet
CALCIPOTRIENE-BETAMETHASONE
DIPROPIONATE (TACLONEX)
0.005%/0.064% OINTMENT
TACLONEX SCALP 0.005%/0.064%
SUSPENSION
TAFINLAR 50 mg CAPSULE
Lower Cost
Lower Cost
Formulary agent: CALCIPOTRIENE (DOVONEX) 0.005%
SOLUTION
Required diagnosis = BRAFV600E-mutated melanomas
that are either nonresectable stage III or stage IV
(monotherapy)
Clinical
123
Drug
Status
TAFINLAR 75 mg CAPSULE
Clinical
TAGRISSO 40MG TABLET
TAGRISSO 80MG TABLET
TANDEM OB CAPSULE 106 mg-1 mg
Lower Cost
Lower Cost
Lower Cost
Required diagnosis = BRAFV600E-mutated melanomas
that are either nonresectable stage III or stage IV
(monotherapy)
TANZEUM 30MG/0.5ML PEN
Lower Cost
TANZEUM 50MG/0.5ML PEN
Lower Cost
TARCEVA 100 mg TABLET
Clinical
Clinical
Clinical
TARGRETIN 1% GEL
Tarka ER (TRANDOLAPRIL-VERAPAMIL
ER)
1-240 mg
ER)
2-180 mg
ER)
2-240 mg
ER)
4-240 mg
TARON EC CALCIUM DHA COMBO 28-1
mg/250 mg
TARON-DUO EC COMB PACK
Clinical
Lower Cost
Requires a 60 day trial of: Byetta, Bydureon or Victoza
(which require a 30 day trial of Metformin or
Metformin ER)
Metformin ER)
Required diagnosis = Pancreatic Cancer
Required diagnosis = Non-Small Cell Lung Cancer
Required diagnosis = Non-Small Cell Lung Cancer OR
Pancreatic Cancer
Required diagnosis = Cutaneous T-cell lymphoma
Formulary agent: trandolapril and verapamil
separately
Lower Cost
separately
Lower Cost
separately
Lower Cost
separately
Lower Cost
Lower Cost
TARON-EC CAL TABLET 28-1 mg
Lower Cost
TARON-PREX PRENATAL DHA CAPSULE
30-1.2-265 mg
TASIGNA 150 mg CAPSULE
Lower Cost
Clinical
Required diagnosis = Chronic myelogenous leukemia
TASIGNA 200 mg CAPSULE
Clinical
Required diagnosis = Chronic myelogenous leukemia
TAZORAC 0.05% CREAM
Lower Cost
OR
Formulary agents: tretinoin cream or gel or adapalene
0.1% gel or cream with a diagnosis of acne
TAZORAC 0.05% GEL
Lower Cost
OR
TAZORAC 0.1% CREAM
Lower Cost
OR
124
Drug
Status
TAZORAC 0.1% GEL
Lower Cost
OR
TECFIDERA 120 mg CAPSULE
Specialty
TECFIDERA 240 mg CAPSULE
Specialty
TECFIDERA STARTER KIT
Specialty
TECHNIVIE 12.5-75MG TABLET
TEKAMLO 150 mg-10 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
TEKTURNA 150 mg TABLET
Lower Cost
TEKTURNA 300 mg TABLET
Lower Cost
TEKTURNA HCT 150-12.5 mg TABLET
Lower Cost
(Avapro)
(Avapro)
or candesartan/Hctz (Atacand HCT); must try 2 of 4
TEKTURNA HCT 150-25 mg TABLET
Lower Cost
TEKTURNA HCT 300-12.5 mg TABLET
Lower Cost
TEKTURNA HCT 300-25 mg TABLET
Lower Cost
TEMAZEPAM (Restoril) 22.5 mg
Lower Cost
CAPSULE
TEMAZEPAM (Restoril) 7.5 mg CAPSULE Lower Cost
Formulary agents: temazepam (15 mg and 30 mg)
TEMOZOLOMIDE (TEMODAR) 100 mg
CAPSULE
CAPSULE
CAPSULE
CAPSULE
Required diagnosis = Anaplastic astrocytoma;
Glioblastoma multiforme
Formulary agents: temazepam (15 mg and 30 mg)
Clinical
Clinical
Clinical
Clinical
125
Drug
Status
CAPSULE
CAPSULE
TERSI FOAM 2.25%
Clinical
TESTOPEL (Pellet Implant)
Lower Cost
LOTION/SHAMPOO
Required diagnosis=hypogonadism and Total
Testosterone lab value = ≤ 300 ng/dL before treatment
and clinical reason why Testosterone TD (Fortesta) Or
cannot be used
Formulary Agents = Testosterone TD (Fortesta) Or
Clinical
Lower Cost
TESTOSTERONE TD (ANDROGEL) 1% (25 Lower Cost
gM) GEL PACKET
Testosterone TD (Androgel) 1% (25
mg/2.5 GM) Gel Packet
Lower Cost
Formulary Agents = Testosterone TD (Fortesta) Or
Testosterone TD (Androgel, Testim,
Vogelxo) 1% (50 GM) Gel Packet
Clinical
Required Diagnosis= Hypogonadism With Total
Testosterone Lab Value = ≤ 300 ng/dL Before
Treatment
Required Diagnosis= Chorea Associated With
Huntington's Disease
Required Diagnosis= Chorea Associated With
Huntington's Disease
(Avapro)
(Avapro)
or candesartan/Hctz (Atacand HCT); must try two of
four agents
four agents
Tetrabenazine (Xenazine) 12.5mg Tablet Clinical
Tetrabenazine (Xenazine) 25mg Tablet
Clinical
TEVETEN 400 mg TABLET
Lower Cost
TEVETEN 600 mg TABLET
Lower Cost
TEVETEN HCT 600-12.5 mg TABLET
Lower Cost
TEVETEN HCT 600-25 mg TABLET
Lower Cost
TEV-TROPIN 5 mg VIAL
Specialty
TEXACORT 2.5% SOLUTION
THALITONE 15 mg TABLET
THALOMID 100 mg CAPSULE
Lower Cost
Lower Cost
Clinical
Formulary agent: hydrocortisone topical
Formulary agent: chlorthalidone
Required diagnosis = Multiple myeloma or Erythema
nodosum leprosum
Clinical
nodosum leprosum
Clinical
nodosum leprosum
Clinical
nodosum leprosum
126
Drug
Status
THEROBEC TABLET
Lower Cost
THIOLA 100 mg TABLET
Lower Cost
For prevention of cystine (kidney) stone formation in
patients with severe homozygous cystinuria
THRIVITE 19 29-1-25MG TABLET
Lower Cost
THRIVITE RX 29-1MG TABLET
Lower Cost
TIMOPTIC 0.25% OCUDOSE DROP
Lower Cost
TIMOPTIC 0.5% OCUDOSE DROP
Lower Cost
TINIDAZOLE (TINDAMAX) 250MG
TABLET
Lower Cost
SOLUTION
SOLUTION
Required diagnosis= Amebiasis; Bacterial vaginosis;
Giardiasis; Trichomoniasis
AND
Formulary Agent(s): metronidazole (Flagyl)
TINIDAZOLE (TINDAMAX) 500MG
TABLET
Lower Cost
Required diagnosis= Amebiasis; Bacterial vaginosis;
Giardiasis; Trichomoniasis
AND
Formulary Agent(s): metronidazole (Flagyl)
TIROSINT 100 mcg CAPSULE
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Tivorbex 20mg Capsule
Lower Cost
Tivorbex 40mg Capsule
Lower Cost
TIZANIDINE (ZANAFLEX) 2 mg CAPSULE Lower Cost
Formulary agents: levothyroxine, Armour thyroid, or
liothyronine
liothyronine
liothyronine
liothyronine
liothyronine
liothyronine
liothyronine
liothyronine
liothyronine
liothyronine
Formulary Agent(s): Indomethacin 25mg Or 50mg
Capsule
Formulary Agent(s): Indomethacin 25mg Or 50mg
Capsule
Formulary agent: tizanidine tablet
TL-ASSURE + DHA 29 mg iron-1 mg-250 Lower Cost
mg
TL-FOL, FOLITAB 500 TABLET
Lower Cost
127
Drug
Status
Tobi Podhaler
Lower Cost
Formulary agent:
TOBRAMYCIN (TOBI) 300 mg/5 mL SOLUTION
TOLAK 4% CREAM
Lower Cost
Formulary Agent(s): Fluorouracil (Efudex) 5% Cream
TOLCAPONE (TASMAR) 100 mg TABLET Lower Cost
Formulary Agent: entacapsuleone (Comtan) tablet
TOLMETIN SODIUM 200 mg TABLET
Lower Cost
TOLMETIN SODIUM 400 mg CAPSULE
Lower Cost
TOLMETIN SODIUM 600 mg TABLET
Lower Cost
TOPICAINE 4% GEL
Lower Cost
TOPICORT 0.25% SPRAY
Lower Cost
TOPIRAMATE ER (QUDEXY XR) 25MG
CAPSULE
Lower Cost
CAPSULE
Lower Cost
CAPSULE
Lower Cost
CAPSULE
Lower Cost
CAPSULE
Lower Cost
TOUJEO SOLOSTAR 300IU/ML
TOVIAZ ER 4 mg TABLET
Lower Cost
Lower Cost
TOVIAZ ER 8 mg TABLET
Lower Cost
Formulary agents: LIDOCAINE SOLUTION 4% or
ANECREAM, LIDOCREAM, LC-4 LIDOCAINE (LMX 4) 4%
CREAM
for 7 days each.
Required diagnosis= Seizures
AND
Required 30 day trial of: topiramate IR tablets
AND
AND
AND
AND
Required 60 day trial of: Lantus
TPN
S9365
TPN
S9366
TPN
S9367
TPN
S9368
TRACLEER 125 mg TABLET
Billed as Medical
Billed as Medical
Billed as Medical
Billed as Medical
Clinical
128
Drug
Status
TRACLEER 62.5 mg TABLET
Clinical
TRADJENTA 5MG TABLET
Tramadol HCL ER (Conzip) 100 mg
Capsule
Capsule
Capsule
TRAMADOL ER (ULTRAM ER) 100 mg
TABLET
Step Therapy
Lower Cost
Lower Cost
Formulary agent: metformin IR or metformin ER
Formulary Agents: tramadol IR or tramadol ER (which
requires a PA)
requires a PA)
requires a PA)
Formulary agent: non-ER tramadol (Ultram)
TABLET
Lower Cost
TABLET
Lower Cost
TRAMADOL SR (RYZOLT ER) 100 mg
TABLET
TABLET
TABLET
TRANEXAMIC ACID (LYSTEDA) 650 mg
TABLET
TRAVATAN Z 0.004% EYE DROP
TRAVOPROST 0.004% EYE DROP
TRECATOR 250 mg TABLET
TRELSTAR (TRIPTORELIN PAMOATE)
FOR IM SUSPENION 11.25 mg
Lower Cost
Formulary agent: tramadol ER (Ultram ER)
Lower Cost
Lower Cost
Lower Cost
Must first try medroxyprogesterone
Lower Cost
Lower Cost
Clinical
Clinical
Required diagnosis = Tuberculosis
Specialty
Lower Cost
Lower Cost
Clinical
Clinical
TRESIBA FLEXTOUCH 100 UNITS/ML PEN Lower Cost
Specialty
TRESIBA FLEXTOUCH 200 UNITS/ML PEN Lower Cost
Formulary Agent(s): Lantus
Tretinoin (ATRALIN) 0.05% GEL
Lower Cost
Required Diagnosis= Acne, Molluscum Contagiosum
(Warts), Verruca Plana (Plantar Warts), Verruca
Vulgaris (Vaginal Warts), Or Rosacea AND Formulary
Agent: tretinoin (RETIN-A) gel or cream
TRETINOIN EMOLLIENT (REFISSA)
(FACIAL WRINKLES) CREAM 0.05%
TRETINOIN MICROSPHERE (RETIN-A
MICRO) 0.04% GEL
Excluded benefit
Lower Cost
TRETINOIN MICROSPHERE (RETIN-A
MICRO) 0.1% GEL
Lower Cost
Specialty
Formulary Agent(s): Lantus
129
Drug
Status
TRETIN-X 0.01% GEL W/ CLEANSER &
MOISTURIZER KIT
Lower Cost
TRETIN-X 0.025% CREAM W/ CLEANSER Lower Cost
& MOISTURIZER KIT
TRETIN-X 0.025% GEL W/ CLEANSER &
MOISTURIZER KIT
Lower Cost
TRETIN-X 0.0375% CREAM
Lower Cost
TRETIN-X 0.05% CREAM W/ CLEANSER
& MOISTURIZER KIT
Lower Cost
TRETIN-X 0.1% CREAM W/ CLEANSER & Lower Cost
MOISTURIZER KIT
TRETTEN 2000-3125 UNIT INJECTION
TREXIMET 85-500 mg TABLET
TRIAMCINOLONE ACETONIDE
Lower Cost
(KENALOG) 0.147MG/G AEROSOL SPRAY
Specialty
Formulary agent: naproxen and sumatriptan
Formulary Agents: topical triamcinolone
ointment/cream/lotion
TRI-TABS DHA COMBO PACK
Lower Cost
TRIANEX 0.05% OINTMENT
Lower Cost
TRIAZ 3% FOAMING CLOTHS
Lower Cost
TRIAZ 3% PAD
Lower Cost
Lower Cost
TRIAZ 6% PAD
Lower Cost
Lower Cost
TRIAZ 9% PAD
Lower Cost
TRIBENZOR 20-5-12.5 mg TABLET
Lower Cost
Formulary agents: TRIAMCINOLONE 0.5% OINTMENT
or TRIAMCINOLONE 0.1% OINTMENT
Formulary agents: Benzoyl Peroxide, Oscion (TRIAZ)
3% CLEANSER
3% CLEANSER
3% CLEANSER
3% CLEANSER
3% CLEANSER
3% CLEANSER
four agents with AMLODIPINE taken separately at the
same time
Specialty
Lower Cost
130
Drug
Status
Lower Cost
TRIBENZOR 40-10-25 mg TABLET
Lower Cost
Lower Cost
TRIBENZOR 40-5-25 mg TABLET
Lower Cost
TRICARE PRENATAL DHA ONE SF
Lower Cost
same time
same time
same time
same time
TRICARE PRENATAL TABLET
Lower Cost
TRICARE PRENATAL COMPLEAT
Lower Cost
TRICITRATES ORAL SOLUTION
TRIGLIDE 160 mg TABLET
TRIGLIDE 50 mg TABLET
TRI-LUMA CREAM
TRIMESIS RX, BP FOLINATAL, FOLBECAL
TABLET
Lower Cost
Lower Cost
Lower Cost
Clinical
Lower Cost
Formulary agent: citric acid solution
Required diagnosis must be non-cosmetic
Trimipramine (SURMONTIL) 100 mg
CAPSULE
TriMix Injection
Trintellix 5 mg Tablet
(Formerly Known As Brintellix)
Lower Cost
Formulary agents: amitriptyline, doxepin, nortriptyline,
or clomipramine
Lower Cost
Lower Cost
TRIPHROCAP, RENAL CAPSULE,
RENALPREN (NEPHROCAP) SOFTGEL
Lower Cost
Excluded benefit
Lower Cost
Bupropion XL)
Bupropion XL)
Bupropion XL)
Formulary agent: RENO CAP
131
Drug
Status
TRISTART DHA 31-1-200MG CAPSULE
Lower Cost
TRIVEEN-ONE CAPSULE
Lower Cost
TRIVEEN-U
Lower Cost
TROKENDI XR 100 mg CAPSULE
Lower Cost
Formulary agent: Topiramate IR tablets
Lower Cost
Lower Cost
Lower Cost
TRONOLANE 1%-5% CREAM
Lower Cost
Formulary agents: HYDROCORTISONE Acetate
1%/Pramoxine Hydrochloride 1% (ANALPRAM-HC)
CREAM or PRAMOXINE AEROSOL 1% (PROCTOFOAM)
TRUETRACK or TRUETEST TEST
STRIPS/METER
TRULICITY 0.75MG/0.5ML PEN
Lower Cost
Lower Cost
TRULICITY 1.5MG/0.5ML PEN
Lower Cost
TUSSICAP 10-8 mg
TUSSICAP 5-4 mg
TUZISTRA XR 14.7-2.8MG/5ML
SUSPENSION
TYKERB 250 mg TABLET
TYSABRI 300 mg/15 mL IV INJECTION
Lower Cost
Lower Cost
Lower Cost
Clinical
Specialty
Metformin ER)
Metformin ER)
Formulary Agent(s): Dextromethorphan Or
Benzonatate Capsule
Required diagnosis = Breast Cancer
TYVASO 1.74 mg/2.9 mL SOLUTION
Clinical
TYVASO INHALATION REFILL KIT
Clinical
TYVASO INHALATION STARTER KIT
Clinical
TYZINE 0.1% NOSE DROPS
Lower Cost
TYZINE 0.1% NOSE SPRAY
Lower Cost
TYZINE PEDIATRIC 0.05% DROPS
UCERIS 2MG FOAM
Lower Cost
Lower Cost
Uceris 9 mg Tablet
Lower Cost
U-Cort (Carmol HC) 1% Cream
Lower Cost
Formulary agents: ANEFRIN, 12 HR NASAL, SINUS
NASAL, NRS NASAL, NASAL NODRIP (NEO-SYNEPHRINE,
AFRIN, DRISTAN) or SM NASAL SPRAY, SM NOSE
DROPS (NEO-SYNEPHRINE)
Formulary agents: ANEFRIN, 12 HR NASAL, SINUS
NASAL, NRS NASAL, NASAL NODRIP (NEO-SYNEPHRINE,
AFRIN, DRISTAN)or SM NASAL SPRAY, SM NOSE DROPS
(NEO-SYNEPHRINE)
Formulary agents: Little Noses or Afrin Child
Formulary Agent(s): Budesonide EC (Entocort EC) 3mg
Capsule
A 30 Day Trial Of: Apriso ER, Mesalamine (Asacol HD),
Delzicol, Or Balsalazide (Colazal)
A 30 Day Trial Of: Hydrocortisone 1% Cream
132
Drug
Status
ULESFIA 5% LOTION
Step Therapy
Required diagnosis = Head Lice with trials of:
Age 2 months up to 2 years old: ACTICIN, PERMETHRIN
(ELIMITE)
spinosad (Natroba)
(PRONTO),
STOP
KIT (RID COMPLETE KIT),
A 30 Day Trial
Of:LICE
Allopurinol
Uloric 40 mg Tablet
Uloric 80 mg Tablet
Ultimatecare One Capsule
Step Therapy
Step Therapy
Lower Cost
ULTRACIN 0.025% LOTION
Lower Cost
Ultravate Pac 0.05%-12% Ointment
Lower Cost
Ultravate X 0.05%-10% Cream
Lower Cost
Ultravate X 0.05%-10% Ointment
Lower Cost
Uptravi 200 & 800 mcg DosePak
Uptravi 200 mcg Tablet
Uptravi 1,000 mcg Tablet
Urea 50% Emulsion
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Urea (Uramaxin GT) 45% Nail Gel
Lower Cost
A 30 Day Trial Of: Urea, U-Kera, X-Viate 40% Cream Or
Cerovel, X-Viate, Urea-C40, Or Urea 40% Lotion
Urea (Uramaxin) 45% Cream
Lower Cost
Urea (Uramaxin) 45% Lotion
Lower Cost
A 30 Day Trial Of: Allopurinol
A 30 Day Trial Of: Any Formulary Prenatal Vitamin
Formulary Agent(s): Ziks Arthritis Pain Relief 0.0251.12% Cream
A 30 Day Trial Of: Halobetasol Cream (Which Requires
A PA) WITH Lactic Acid 5% or 12% OTC
133
Drug
Status
Urea 50% NailStik
Lower Cost
Urea 50% Topical Suspension
Lower Cost
URIBEL, URAMIT MB, URO-MP 118-1036 mg CAPSULE
UROQID-ACID NO.2 500-500 TABLET
Utibron 27.5-15.6 mcg Neohaler
Lower Cost
VAGIFEM 10 mcg VAGINAL TABLET
Clinical
VALCHLOR 0.016% GEL
Clinical
Formulary agents: URELLE tablet, UROGESIC-BLUE or
UTRONA-C
Formulary agent: methamine
Required Diagnosis= COPD AND
Formulary Agent(s): Spiriva (Respimat Preferred)
Required diagnosis = atrophic vaginitis
Formulary agents = Estradiol tablets, Alora, or Estradiol
(Climara) patches
Required diagnosis = The topical treatment of Stage IA
and IB mycosis fungoides-type cutaneous T-cell
lymphoma with a trial of TARGRETIN 1% GEL
VALTURNA 150-160 mg TABLET
Lower Cost
30 Day Trial EACH Of 2 Of The Following 4 Within The
Last Year: Losartan (Cozaar), Irbesartan (Avapro),
Candesartan (Atacand), Or Valsartan (Diovan)
VALTURNA 300-320 mg TABLET
Lower Cost
31 Day Trial EACH Of 2 Of The Following 4 Within The
Last Year: Losartan (Cozaar), Irbesartan (Avapro),
Candesartan (Atacand), Or Valsartan (Diovan)
VANAHIST PD 0.625 mg/mL DROP
VANATOL LQ 50-325-40MG/15ML
SOLUTION
Lower Cost
Lower Cost
VANCOMYCIN (VANCOCIN)
125 mg CAPSULE
Clinical
VANCOMYCIN (VANCOCIN)
250 mg CAPSULE
Clinical
VANDETANIB (CAPRELSA) 100 mg
TABLET
VANDETANIB (CAPRELSA) 300 mg
TABLET
Vaniqa Cream
VANOS 0.1% CREAM
VANOXIDE-HC LOT 5-0.5%
Clinical
Required diagnosis = C.Diff (Clostridium Difficile)
Colitis/Diarrhea
Requires a 7 day Trial within the last 30 days of: oral
Metronidazole (Flagyl)
Required diagnosis = C.Diff (Clostridium Difficile)
Colitis/Diarrhea
Requires a 7 day Trial within the last 30 days of: oral
Metronidazole (Flagyl)
Required diagnosis = Medullary thyroid cancer
Clinical
Required diagnosis = Medullary thyroid cancer
VANTAS KIT 50 mg
VARITHENA FOAM 180MG/18ML
VARUBI 90MG TABLET
Lower Cost
Lower Cost
Lower Cost
VASCEPA 1G CAPSULE
Lower Cost
Formulary agent: fluocinolone cream
Formulary agents: BENZOYL PEROXIDE and
HYDROCORTISONE separately at the same time
*Dx= Nausea/Vomiting Due To Chemotherapy Or
Surgery Or Currently Receiving Chemotherapy Or *Dx=
Nausea/Vomiting AND A One Time Trial Of A
Formulary Agent Such As Ondansetron Or
Promethazine
Formulary agent: OTC Fish Oils or Omega-3 (Lovaza)
Vasculera 630mg Tablet
VASOLEX, REVINA (XENADERM)
OINTMENT
Excluded Benefit
Lower Cost
Required diagnosis = Wound debridement
Lower Cost
Lower Cost
Formulary Agent(s): Butalbital-AcetaminophenCaffeine 50-325-40mg Capsule Or Tablet
Excluded benefit
Lower Cost
Lower Cost
134
Drug
Status
Vecamyl 2.5 mg
Lower Cost
VECTIBIX 100MG/5ML VIAL
VECTIBIX 20MG/ML VIAL
VELTASSA 8.4GM POWDER PACK FOR
SUSPENSION
SUSPENSION
SUSPENSION
VELPHORO 500MG CHEWABLE TAB
Venclexta 10 mg Tablet
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Venclexta 10-50-100 mg Starting Pack
Lower Cost
VENELEX 87-788MG OINTMENT
Lower Cost
Required Diagnosis= Malignant Hypertension Or
Moderate-Severe Hypertension AND A 30 Day Trial Of:
Minoxidil
Required DX= metastatic colorectal cancer
Required DX= metastatic colorectal cancer
Required Diagnosis= Hyperkalemia AND Formulary
Agent(s): Sodium Polystyrene Sulfonate
Required Diagnosis= Chronic Lymphocytic Leukemia
(CLL) AND Member Is Positive For The 17p
Chromosome Deletion AND Has Received At Least One
Prior Therapy For CLL
Formulary Agent(s): Cerave, Cetaphil, Aveeno,
Lubriderm (Eucerin), TheraPlex, Velvachol, NutraDerm,
Ammonium Lactate, LacLotion, AmLactin, GeriHydrolac, AL-12 (LacHydrin, Lac-Hydrin Twelve) lotion
VENLAFAXINE ER 150 mg TABLET
Lower Cost
Formulary agent: venlafaxine ER capsules or Must first
try the following Formulary agent(s): fluoxetine if age
8-11; escitalopram OR fluoxetine if age 12-17; if age 18
years old and older, will require a trial of at least two
of the three antidepressant catergories: 1) SSRI
Venlafaxine ER Capsules) 3) Dopamine Reuptake
Blocking Agents (Bupropion, Bupropion SR, Bupropion
XL)
Lower Cost
XL)
Lower Cost
Lower Cost
Lower Cost
Lower Cost
135
Drug
Status
VENLAFAXINE ER 37.5 mg TABLET
Lower Cost
XL)
Lower Cost
XL)
VENTAVIS 10 mcg/1 mL SOLUTION
Clinical
VENTAVIS 20 mcg/1 mL SOLUTION
Clinical
VERAMYST 27.5 mcg NASAL SPRAY
Lower Cost
24HR Spray
OR
OR
VERAPAMIL CR (VERELAN PM)
100 mg CAPSULE
200 mg CAPSULE
300 mg CAPSULE
VERDESO 0.05% FOAM
Lower Cost
VEREGEN 15% OINTMENT
Clinical
VERIPRED 20 20 mg/5 mL SOLUTION
Lower Cost
Formulary agent: VERAPAMIL CR (CALAN SR) 120 mg
TABLET
TABLET
TABLET
for 7 days each.
Required diagnosis = External genital and perianal
warts
Required trial of: Podofilox (Condylox) solution
Formulary agent: prednisolone 15 mg/5 mL solution
VERSACLOZ 50MG/ML SUSPENSION
VESICARE 10 mg TABLET
Lower Cost
Lower Cost
VESICARE 5 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Formulary agent: clozapine tablets
Formulary agents: oxybutynin (IR or ER), tolterodine,
trospium, or trospium xr
Formulary agents: oxybutynin (IR or ER), tolterodine,
trospium, or trospium xr
136
Drug
Status
VH ESSENTIALS UTI STICK
VIAGRA
Viberzi 75mg Tablet
Lower Cost
Excluded benefit
Lower Cost
Required diagnosis = Suspected UTI
Viberzi 100mg Tablet
Lower Cost
Required Diagnosis= Severe-Diarrhea OR IBS (Irritable
Bowel Syndrome) AND Formulary Agent(s): AtropineDiphenoxylate (Lomotil) Or Dicyclomine (Bentyl)
VIBRAMYCIN 50 mg/5 mL SYRUP
Lower Cost
VICTOZA 2-PAK 18 mg/3 mL PEN
Step Therapy
Formulary agent: VIBRAMYCIN 25 mg/5 mL
SUSPENSION
(Glucophage or Glucophage XR) unless Renal/kidney
OR
VICTRELIS 200MG CAPSULE
Lower Cost
VIEKIRA PAK 12.5-75-50 & 250MG
VIGAMOX 0.5% EYE DROPS
Lower Cost
Step Therapy
Required diagnosis = cataract surgery or Corneal
ulcer/Keratitis
OR
Required diagnosis = conjunctivitis
Required trial of: ciprofloxacin or ofloxacin ophthalmic
VIIBRYD 10 mg TABLET
Lower Cost
Lower Cost
Lower Cost
VIIBRYD TITRATION KIT 10/20/40 mg
Lower Cost
VIMIZIM 5MG/5ML INJECTION
Lower Cost
Bupropion XL)
Bupropion XL)
Bupropion XL)
Bupropion XL)
Required diagnosis = Morquio A Syndrome or
mucopolysaccharidosis(MPS) by a pediatiric specialist
Required Diagnosis= Severe-Diarrhea OR IBS (Irritable
Bowel Syndrome) AND Formulary Agent(s): AtropineDiphenoxylate (Lomotil) Or Dicyclomine (Bentyl)
137
Drug
Status
Vimovo 375 mg-20 mg Tablet
Lower Cost
Vimovo 500 mg-20 mg Tablet
Lower Cost
VIMPAT 10 mg/ML SOLUTION
Clinical
A 30 Day Trial Of: Omeprazole, Lansoprazole,
Pantoprazole, Rabeprazole, OTC Nexium 20mg Or
Esomeprazole (Nexium) 20 mg Or 40 mg AND
Naproxen Separately Taken Together At The Same
Time
A 30 Day Trial Of: Omeprazole, Lansoprazole,
Pantoprazole, Rabeprazole, OTC Nexium 20mg Or
Esomeprazole (Nexium) 20 mg Or 40 mg AND
Naproxen Separately Taken Together At The Same
Time
Required Diagnosis= Seizure or Epilepsy AND
Formulary Agent(s): Gabapentin, Lamotrigine
Valproic Acid (Depakene) Or Zonisamide OR Previously
Approved For And Currently Using Aptiom, Banzel,
Fycompa, Lyrica, Onfi, Or Potiga
VIMPAT 100 mg TABLET
Step Therapy
Step Therapy
Step Therapy
VIMPAT 50 mg TABLET
Step Therapy
138
Drug
Status
Vimizim 5mg/5mL Vial
Clinical
VINATE AZ EXTRA TABLET
Lower Cost
Required Diagnosis= Morquio A Syndrome or
Mucopolysaccharidosis (MPS)
VINATE AZ TABLET
Lower Cost
VINATE DHA RF
Lower Cost
VINATE PN CARE TABLET
Lower Cost
VIRAZOLE 6 GM INHLATION SOLUTION
Lower Cost
Required Diagnosis= Hospitalized Infants And Young
Children With Severe Lower Respiratory Tract Infection
Due To Respiratory Syncytial Virus (RSV)
Vistogard 10 GM Granules Packet
Visudyne 15mg Vial
VITAFOL-NANO TABLET
Lower Cost
Specialty
Lower Cost
Required Diagnosis= 5-FU/Capecitabine Toxicity
Vitafol-OB + DHA 65-1 mg & 250 mg
Pack
VITAFOL-OB
Lower Cost
Lower Cost
VITAFOL ULTRA
Lower Cost
VITAFOL SYRUP
Lower Cost
VITAFOL-ONE, PNV-FIRST CAPSULE
Lower Cost
VITAL-D RX TABLET
Lower Cost
VITAMIN D3 400 UNIT CHEWABLE
TABLET
VITAMIN D3 1,000 UNIT CHEWABLE
TABLET
VITUZ 5-4 mg SOLUTION
Lower Cost
Formulary Agent(s): Vitamin D3 tablet
Lower Cost
Formulary Agent(s): Vitamin D3 tablet
Lower Cost
VIVELLE-DOT 0.025 mg PATCH
Lower Cost
Formulary agents: benzonatate capsule or
DEXTROMETHORPHAN
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Vivlodex 5 mg Capsule
Lower Cost
Formulary Agent(s): Meloxicam Suspension OR Tablet
Vivlodex 10 mg Capsule
Lower Cost
Formulary Agent(s): Meloxicam Suspension OR Tablet
VIVOTIF BERNA CAPSULE
Lower Cost
VOL-CARE RX TABLET
Lower Cost
Required diagnosis = For immunization of adults and
children older than 6 years against disease caused by
Salmonella typhi
VOL-NATE TABLET
Lower Cost
VOPAC 10-2% CREAM KIT
Lower Cost
A 30 Day Trial Of: Diclofenac (Voltaren) Gel With
Lidocaine 2% Gel Jelly, Lidocaine 3% Cream, Or
Lidocaine 3% Lotion
139
Drug
Status
VOPAC 5 5% CREAM
VOPAC GB 5-2-5% CREAM KIT
Lower Cost
Lower Cost
VORICONAZOLE (VFEND) 200 mg
TABLET
Lower Cost
A 30 Day Trial Of: Diclofenac (Voltaren) Gel
A 30 Day Trial Of: Diclofenac (Voltaren) Gel With
Lidocaine 2% Gel Jelly, Lidocaine 3% Cream, Or
Lidocaine 3% Lotion
Formulary agents: fluconazole or itraconazole with a
diagnosis of Candidemia and other Candida infections;
Esophageal candidiasis; Invasive aspergillosis OR a
diagnosis of Post Transplant aspergillosis prophylaxis
or Fungal Meningitis
VORICONAZOLE (VFEND) 40 mg/ML
SUSPENSION
Lower Cost
Formulary agents: fluconazole or itraconazole
VORICONAZOLE (VFEND) 50 mg TABLET Lower Cost
Formulary agents: fluconazole or itraconazole with a
diagnosis of Candidemia and other Candida infections;
Esophageal candidiasis; Invasive aspergillosis OR a
diagnosis of Post Transplant aspergillosis prophylaxis
or Fungal Meningitis
Votrient 200mg Tablet
Clinical
VP-GSTN CAP
Lower Cost
VP-PRECIP CAPSULE (TEARS AGAIN)
Lower Cost
Vpriv 400 Units Vial
Specialty
Required Diagnosis= Renal Cell Carcinoma OR Soft
Tissue Sarcoma
Formulary Agent: OTC Vitamin D (CHOLECALCIFEROL)
with OTC ZINC GLUCONATE TAB separately Taken
Together At The Same Time
Formulary agents: ICAPS CAP, ICAPS LUTEIN,
PROSIGHT, OCUVITE EYE
Vraylar 1.5 mg Capsule
Step Therapy
Vraylar 3 mg Capsule
Step Therapy
Vraylar 4.5 mg Capsule
Step Therapy
Vraylar 6 mg Capsule
Step Therapy
Vraylar 1.5 mg & 3 mg Capsule Dose
Pack
Step Therapy
VUSION OINTMENT
VYTONE GEL
Lower Cost
Lower Cost
VYTORIN 10-10 mg TABLET
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Required Diagnosis= Bipolar I Disorder OR
Schizophrenia AND 30 Day Trial Of: Aripiprazole
(Abilify)
(Abilify)
(Abilify)
(Abilify)
(Abilify)
Required diagnosis=Diaper Rash
Must first try: 30 day trial of OTC Hydrocortisone-Aloe
Vera with OTC anti-fungal (Clotrimazole, Tolnafate,
Miconazole) used separately at the same time
Formulary Agents: SIMVASTATIN AND ZETIA separately
140
Drug
Status
WELCHOL 3.75 g PACKET
Lower Cost
WELCHOL 625 mg TABLET
Lower Cost
Required Diagnosis= Hyperlipidemia
*30 day trial of: simvastatin or atorvastatin
AND
*30 day trial of: Cholesytramine or Colestipol
OR
Required Diagnosis= Liver Disease
*30 day trial of: Colestyramine
OR
Required Diagnosis= Diabetes
*30
day trial
of metformin
IR or ER
Required
Diagnosis=
Hyperlipidemia
*30 day trial of: simvastatin or atorvastatin
AND
*30 day trial of: Cholesytramine or Colestipol
OR
Required Diagnosis= Liver Disease
*30 day trial of: Colestyramine
OR
Required Diagnosis= Diabetes
*30
day trial
of metformin
IRThyroid
or ER Tablet
Formulary
Agent(s):
Armour
WESTHROID 32.5mg TABLET
WESTHROID 65mg TABLET
WP THYROID 16.25mg TABLET
WP THYROID 65mg TABLET
WP THYROID 130mg TABLET
Xalkori 200mg Capsule
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Clinical
Xalkori 250mg Capsule
Clinical
XARTEMIS XR 7.5MG-325 MG
Lower Cost
Xeljanz 5 mg Tablet
Xeljanz XR 11 mg Tablet
Xeomin 50 Units Vial
Lower Cost
Lower Cost
Specialty
Required Diagnosis= Advanced Or Metastatic NonSmall Cell Lung Cancer (NSCLC)
Required Diagnosis= Advanced Or Metastatic NonSmall Cell Lung Cancer (NSCLC)
(Percocet) 7.5-325 MG Tablet
Specialty
Specialty
XERAC AC 6.25%
XERESE 5%-1% CREAM
Lower Cost
Lower Cost
Formulary agents: Drysol or HyperCare
Formulary agents: Abreva for a diagnosis of cold sores
Xgeva 120mg/1.7mL Vial
Xiaflex 0.9mg Vial
Specialty
Lower Cost
Required Diagnosis= Adult Patients With Dupuytren
Contracture Of Palmar Fascia With A Palpable Cord OR
Peyronie's Disease
141
Drug
Status
XIBROM 0.09% EYE DROPS
Lower Cost
XIFAXAN 200 mg TABLET
Clinical
XIFAXAN 550 mg TABLET
Clinical
XIGDUO XR 5MG-500MG TABLET
Lower Cost
XIGDUO XR 5MG-1,000MG TABLET
Lower Cost
XIGDUO XR 10MG-500MG TABLET
Lower Cost
XIGDUO XR 10MG-1,000MG TABLET
Lower Cost
Xiidra 5% Ophthalmic Solution
XOFIGO INJECTION 1000 KBQ/ML
Lower Cost
Lower Cost
Xolair 150mg Vial
Clinical
DROPS
Required Diagnosis= Hepatic Encephalopathy
OR Required Diagnois= IBS/Crohn's/SIBO With A On
Time Trial Of: Ciprofloxacin Or Metronidazole
Required Diagnosis= Hepatic Encephalopathy
OR Required Diagnois= IBS/Crohn's/SIBO With A On
Time Trial Of: Ciprofloxacin Or Metronidazole
At The Same Time
At The Same Time
At The Same Time
At The Same Time
Formulary Agent(s): OTC Artificial Tears
Required Diagnosis= Castration-Resistant Prostate
Cancer, Symptomatic Bone Metastases, And No Known
Visceral Metastatic Disease
XOLEGEL 2% GEL
XOLOX 10-500 mg TABLET
Lower Cost
Lower Cost
XOPENEX HFA 45 mcg INHALER
Lower Cost
Xtandi 40mg Capsule
Clinical
Xuriden Granules 2 GM Packet
XYREM 500 mg/ML ORAL SOLUTION
Lower Cost
Clinical
YERVOY INJECTION 200 mg
YERVOY INJECTION 50 mg
Yocon (Yohimbine)
Yondelis 1mg Vial
Lower Cost
Lower Cost
Excluded benefit
Lower Cost
Zaltrap 100 mg/4 mL Vial
Lower Cost
Zaltrap 200 mg/8 mL Vial
Lower Cost
Zamicet 10-325 mg/15 mL Solution
Lower Cost
Zarxio 300 mcg/0.5 mL Syringe
Specialty
Zarxio 480 mcg/0.8 mL Syringe
Specialty
Formulary agent: ketoconazole cream
Formulary agent: Oxycodone-Acetaminophen 10-650
mg tablet
Formulary agents: Ventolin
Required Diagnosis = Metastatic Castration-Resistant
Prostate Cancer
Required Diagnosis= Hereditary Orotic Aciduria
Formulary Agents = Modafinil (Provigil) AND
(Armodafinil) Nuvigil
Required Diagnosis= Unresectable Or Metastatic
Liposarcoma Or Leiomyosarcoma Who Received A
Prior Anthracycline-Containing Regimen
Required Diagnosis= Metastatic Colorectal Cancer That
Is Resistant To Or Has Progressed Following An
Oxaliplatin-Containing Regimen
Required Diagnosis= Metastatic Colorectal Cancer That
Is Resistant To Or Has Progressed Following An
Oxaliplatin-Containing Regimen
Formulary Agent(s): A 30 Day Trial Of: HydrocodoneAcetaminophen (Lortab) Solution 7.5-500 mg/15 mL
142
Drug
Status
Zatean-PN DHA, PNV-DHA, Virt-PN DHA Lower Cost
27-1-300 mg Capsule
Zatean-PN Plus, PNV-Omega, Virt-PN
Lower Cost
Plus Capsule
Zavesca 100 mg Capsule
Clinical
Zecuity Iontophoretic 6.5 mg/4 HR
Patch
Lower Cost
Zegerid 20 mg-1,680 mg Powder
Packets
Lower Cost
A 30 Day Trial Each Of 2 Of The 3 Agents: Sumatriptan,
Naratriptan, Or Rizatriptan At Maximum
Recommended Doses
A 30 Day Trial Of: Omeprazole Capsules Or FirstOmeprazole 2 mg/mL Suspension AND Lansoprazole
Capsule Or First-Lansoprazole 3 mg/mL Suspension
Zegerid 40 mg-1,680 mg Powder
Packets
Lower Cost
A 30 Day Trial Of: Omeprazole Capsules Or FirstOmeprazole 2 mg/mL Suspension AND Lansoprazole
Capsule Or First-Lansoprazole 3 mg/mL Suspension
Zelapar 1.25 mg ODT Tablet
Zelboraf 240 mg Tablet
Lower Cost
Clinical
A 30 Day Trial Of: Selegiline Tablet
Required Diagnosis= 4800 BRAF V600E-Mutated
Metastatic Melanoma AND MD Specialty= Oncology
Zemaira 1,000 mg Vial
Specialty
Zema-Pak 10 Day 1.5 mg Tablet
Lower Cost
Zembrace SymTouch 3 mg/0.5 mL Auto- Lower Cost
Injector
Zenatane 10 mg Capsule
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Zenzedi 2.5 mg Tablet
Lower Cost
Zenzedi 7.5 mg Tablet
Lower Cost
Zenzedi 15 mg Tablet
Lower Cost
Lower Cost
Lower Cost
Zeosa , Zenchent Fe, Wymzya Fe
(Femcon Fe) 0.4 mg-35 mcg Chewable
Tablet
Zepatier 50-100 mg Tablet
Zetia 10 mg Tablet
Lower Cost
A 30 Day Trial Of: Dexamethasone Tablet
Medication Must Go Through Clinical Review
A 30 Day Trial Of: Formulary Topicals AND Formulary
Orals
Orals
Orals
Orals
A 30 Day Trial Of: Dextroamphetamine, Zenzedi 5 mg
Or 10 mg Tablet
Or 10 mg Tablet
Or 10 mg Tablet
Or 10 mg Tablet
Or 10 mg Tablet
A 30 Day Trial Of: A Formulary Birth Control Agent
Clinical
Step Therapy
A 30 Day Trial Of: Atorvastatin (Lipitor), Fenofibrate
(Fenoglide, Lofibra, Lipofen, Tricor, Triglide), Fenofibric
Acid (Fibricor, Trilipix), Gemfibrozil, Lovastatin
(Mevacor), Pravastatin (Pravachol), Rosuvastatin
(Crestor) Or Simvastatin (Zocor)
143
Drug
Status
Zetonna 37 mcg Nasal Spray
Lower Cost
24HR Spray
OR
OR
Zinbryta 150 mg/mL Prefilled Syringe
Lower Cost
Zioptan 0.015 mg/mL Ophthalmic
Solution
Zipsor 25 mg Capsule
Lower Cost
A 30 Day Trial Of: Latanoprost 0.005% Eye Drops
Lower Cost
A 30 Day Trial Of: Diclofenac Potassium (Cataflam)
Tablet AND Diclofenac Sodium (Voltaren) Tablet
Zirgan 0.15% Ophthalmic Gel
Clinical
Zithranol 1% Shampoo
Lower Cost
Zithranol-RR 1.2% Cream
Lower Cost
Zohydro ER 10 mg Tablet
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Lower Cost
Zohydro ER 50MG TABLET
Lower Cost
Zoladex 3.6 mg Implant
Zoladex 10.8 mg Implant
Zoledronic Acid (Reclast) 5 mg/100 mL
Vial
Clinical
Clinical
Specialty
Required Diagnosis= Acute Herpetic Keratitis (Dendritic
Ulcers)
A 30 Day Trial Of: Calcipotriene (Dovonex) 0.005%
Solution
A 30 Day Trial Of: Calcipotriene (Dovonex) 0.005%
Cream
A 30 Day Trial Of: Morphine Sulfate ER (MS Contin),
Oxymorphone ER Or Fentanyl Patches
Zoledronic Acid (Zometa) 4 mg/5 mL
Vial
Specialty
Zolinza 100 mg Capsule
Clinical
Zolmitriptan (Zomig) 2.5 mg Tablet
Lower Cost
Required Diagnosis= Cutaneous T-Cell Lymphoma
(CTCL)
A One Time Trial Of 2 Of The 4 Agents: Sumatriptan,
Naratriptan, Rizatriptan, Or Almotriptan
Zolmitriptan (Zomig) 5 mg Tablet
Lower Cost
Zolmitriptan Orally Disintegrating
(Zomig ZMT) 2.5 mg Tablet
Lower Cost
Zolmitriptan Orally Disintegrating
(Zomig ZMT) 5 mg Tablet
Lower Cost
144
Drug
Status
Zolpimist 5 mg Oral Spray
Zolvit 10-300 mg/15 mL Syrup
Lower Cost
Lower Cost
Zomacton 5 mg Vial
Zomacton 10 mg Vial
Zomig 2.5 mg Nasal Spray
Zomig 5 mg Nasal Spray
Zontivity 2.08 mg Tablet
Zorbtive 8.8 mg Vial
Specialty
Specialty
Lower Cost
Lower Cost
Lower Cost
Specialty
A 7 Day Trial Of: Non-CR Zolpidem
A 30 Day Trial Of: Hydrocodone-Acetaminophen
(Lortab) Solution 7.5-500 mg/15 mL
A One Time Trial Of: Sumatriptan Nasal Spray
A One Time Trial Of: Sumatriptan Nasal Spray
A 30 Day Trial Of: Clopidogrel (Plavix)
Zorvolex 18 mg Capsule
Lower Cost
Zorvolex 35 mg Capsule
Lower Cost
Zostrix Neuropathy (Axsain) 0.25%
Cream
Lower Cost
Zovirax 5% Cream
Lower Cost
A 7 Day Trial Of: Arthritis Pain Relief, Capsaicin, Muscle
Relief, Theragen-HP, Trixaicin HP (Zostrix HP) 0.075%
Cream
Required Diagnosis= Cold Sores/Oral Herpes Simplex
With A 3 Day Trial Of Abreva AND A 30 Day Trial Of
Acyclovir 5% Ointment (Which Also Requires A PA)
Z-Tuss AC 2 mg-9 mg/5 mL
Lower Cost
Zubsolv 1.4-0.36 mg SL Tablet
Lower Cost
Lower Cost
Lower Cost
Zubsolv 8.6MG-2.1 mg SL Tablet
Lower Cost
Lower Cost
Zuplenz 4 mg Soluable Film
Lower Cost
Zuplenz 8 mg Soluable Film
Lower Cost
Zyclara 3.75% Cream
Lower Cost
Zyclara 2.5% Cream Pump
Lower Cost
Required Diagnosis= Actinic Keratosis Or Genital And
Perianal Warts AND A 30 Day Trial Of: Imiquimod
(Aldara) 5% Cream Packet (Which Also Requires A PA)
Zyclara 3.75% Cream Pump
Lower Cost
Zydelig 100 mg Tablet
Zydelig 150 mg Tablet
Zyflo 600 mg FilmTab
Zyflo CR 600 mg Tablet
Lower Cost
Lower Cost
Lower Cost
Lower Cost
A 30 Day Trial Of: Montelukast (Singulair)
A 30 Day Trial Of: Montelukast (Singulair)
Ages 2-6: Off-Label (Can Try Dextromethorphan)
Ages 6-12: Dextromethorphan
Ages Over 12: Dextromethorphan Or Benzonatate
Capsule
Required 90 Day Trial Of: Buprenorphine-Naloxone
Tabets, Suboxone Film, Or Bunavail
A One Time Trial Of: Ondansetron (Zofran) 4 mg Tablet
Or ODTs
A One Time Trial Of: Ondansetron (Zofran) 8 mg Tablet
Or ODTs
145
Drug
Status
Zykadia 150 mg Capsule
Clinical
Zylet 0.3%-0.5% Eye Drops
Lower Cost
Required Diagnosis= Advanced Or Metastatic NonSmall Cell Lung Cancer (NSCLC) AND MD Specialty=
Oncology
Required Diagnosis= Pre-Op Use Or Bacterial Infection
Of The Eye AND A One Time Trial Of Tobradex Or
Neomycin/Polymyxin/Dexamethasone Ophthalmic
Drops
Zytiga 250 mg Tablet
Clinical
Required Diagnosis= Metastatic Prostate Cancer AND
MD Specialty= Oncology
146

2016 Drugs Requiring Prior Authorization List

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