Peach State Health Plan Preferred Drug List

Transcription

Peach State Health Plan
Preferred Drug List
Effective October 1, 2013
Preferred Drug List Medication Locator Instructions:
1. With the PDF open, click on the Edit menu, then click Find
2. In the Find box type the name of the medication you want to locate
3. Click the Next button until you find the medication(s) you are looking for
Pharmacy Program
Peach State Health Plan (Peach State) is committed to providing appropriate, high quality, and cost
effective drug therapy to all Peach State members. Peach State works with providers and pharmacists to
ensure that medications used to treat a variety of conditions and diseases are covered. Peach State covers
prescription medications and certain over-the-counter (OTC) medications when ordered by a Georgia
Medicaid enrolled, Peach State practitioner. The pharmacy program does not cover all medications. Some
medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.
Preferred Drug List
The Peach State Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs
members can receive at retail pharmacies. The Peach State PDL is continually evaluated by the Peach State
Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of
medications. The Committee is composed of the Peach State Medical Director, Peach State Pharmacy
Director, and several Georgia physicians, pharmacists, and other healthcare professionals.
Pharmacy Benefit Manager
Peach State works with US Script to process pharmacy claims for prescribed drugs. Some drugs on the
Peach State PDL may require PA, US Script is responsible for administering this process. US Script is our
Pharmacy Benefit Manager.
Specialty Drugs
Certain medications are only covered when supplied by Peach State specialty pharmacy provider.
AcariaHealth is the preferred specialty pharmacy provider of Peach State. All specialty drugs, such as
biopharmaceuticals and injectables, require PA to be approved for payment by Peach State. The Peach State
Medical Director and Peach State Pharmacy Director oversee the clinical review of these PA request.
AcariaHealth provides the following services:

A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of
each patient

Disease-specific product education and training

Customized treatment programs and compliance monitoring

Prior authorization support

Timely delivery to your office or the patient’s home, as requested
Drug or disease state specific enrollment forms can be found on the Peach State website.
Dispensing Limits
Drugs may be dispensed up to a maximum of thirty-one (31) days supply for each new prescription or
refill. A total of 80% of the days supply or 25 days must have elapsed before the prescription can be
refilled for non-controlled-substance PDL drugs. A total of 90% of the days supply must have elapsed
before the prescription can be refilled for controlled substances and narcotic PDL drugs.
1
Appropriate Use and Safety Edits
The health and safety the member is a priority for Peach State. One of the ways we address member safety
is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are
based on FDA recommendations and promote safe and effective medication utilization.
Prior Authorizations
Some medications listed on the Peach State PDL may require PA. The information should be submitted
by the practitioner or pharmacist to US Script on the Medication Prior Authorization Form. This form
should be faxed to US Script at 1-866-399-0929. This document can be found on the Peach State
website.
Peach State will cover the medication if it is determined that:
1.
There is a medical reason the member needs the specific medication.
2. Depending on the medication, other medications on the PDL have not worked.
Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the
Peach State P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the
clinical information provided does not meet the coverage criteria for the requested medication, Peach State
will notify the member and their practitioner of alternatives and provide information regarding the appeal
process.
Step Therapy
Some medications listed on the Peach State PDL may require specific medications to be used before the
member can receive the step therapy medication. If Peach State has a record that the required medication
was tried first the step therapy medications are automatically covered. If Peach State does not have a
record that the required medication was tried, the member’s practitioner may be required to provide
additional information. If authorization is not granted, Peach State will notify the member and their
practitioner and provide information regarding the appeal process.
Quantity Limits
Peach State may limit how much of a certain medication a member can get at one time. If the practitioner
feels the member has a medical reason for getting a greater amount, a PA may be requested. If Peach State
does not grant PA we will notify the member and their practitioner and provide information regarding the
appeal process.
Age Limits
Some medications on the Peach State PDL may have age limits. These are set for certain drugs based on
FDA approved labeling and for safety concerns and quality standards of care. Age limits align with
current FDA alerts for the appropriate use of pharmaceuticals.
2
Gender Limits
Some medications on the Peach State PDL may be limited to one gender. These limits are set for certain
drugs based on FDA approved labeling and for safety concerns and quality standards of care. Gender
limits align with current FDA alerts for the appropriate use of pharmaceuticals.
Medical Necessity Requests
If the member requires a medication that does not appear on the PDL, the member’s practitioner can
make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be
rare as the PDL medications are appropriate to treat the vast majority of medical conditions.
For a MN request Peach State requires:

Documentation of failure of at least two PDL agents within the same therapeutic class (provided
two agents exist in the therapeutic category with comparable labeled indications) for the same
diagnosis (e.g. migraine, neuropathic pain, etc.); or

Documented intolerance or contraindication to at least two PDL agents within the same
therapeutic class (provided two agents exist in the therapeutic category with comparable labeled
indications); or

Documented clinical history or presentation where the patient is not a candidate for any of the
PDL agents for the indication.
These requests are reviewed by a licensed clinical pharmacist using the criteria established by the Peach
State P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical
information provided does not meet the coverage criteria for the requested medication, Peach State will
notify the member and their practitioner of alternatives and provide information regarding the appeal
process.
72 Hour Emergency Supply Policy
State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any
member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the
initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication
and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication,
whether or not the PA request is ultimately approved or denied. The pharmacy must call US Script at 1888-929-3790 for a prescription override to submit the 72 hour medication supply for payment.
Exclusions
The following drug categories are not part of the Peach State PDL and are not covered by the 72 hour
emergency supply policy:

Cough and cold products are not covered for members age 21 and older.

Fertility enhancing drugs

Anorexia, weight loss, or weight gain drugs

Experimental or investigational drugs

Immunizations and vaccines (except flu vaccine)
3

Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that
are classified as ineffective

Infusion therapy and supplies

Oral vitamins and minerals (except those listed in the PDL)

Drugs and other agents used for cosmetic purposes or for hair growth

Erectile dysfunction drugs prescribed to treat impotence

Over-the-Counter (OTC) drugs (except those listed in the PDL)

Medical supplies and DME (except those listed in the PDL)

Injectables (except those listed in the PDL)

Biologicals

Blood and blood plasma

Nutritional and dietary supplements

Diagnostic products (except those listed in the PDL)

Smoking cessation drug products

Drugs not FDA approved for the requested condition unless there is compelling clinical evidence
to support the experimental use
Newly Approved Products
Peach State reviews new drugs for safety and effectiveness before adding them to the PDL. During this
period, access to these medications will be considered through the PA review process. If Peach State does
not grant PA we will notify the member and their practitioner and provide information regarding the
appeal process.
Over-the-Counter Medications
Peach State covers a variety of OTC medications. These medications can be found throughout the Peach
State PDL. Peach State covers OTC products listed in the PDL if the member has a prescription from a
licensed practitioner that meets all the legal requirements for a prescription.
Generic Drugs
When generic drugs are available, the brand name drug will not be covered without Peach State
authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If
the member or their practitioner feels a brand name drug is medically necessary, the practitioner request
the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if
there is a medical reason the member needs the particular brand-name drug. If Peach State does not grant
authorization, we will notify the member and their practitioner and provide information regarding the
appeal process.
The provision is waived for the following products due to their narrow therapeutic index (NTI) as
recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine,
Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, Lithium, Phenytoin,
Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin.
4
Drug Efficacy Study and Implementation Drugs
DESI products and known related drug products are defined as less than effective by the Food and Drug
Administration because there is a lack of substantial evidence of effectiveness for all labeling indications
and because a compelling justification for their medical need has not been established. DESI products are
not covered by Peach State.
Filling a Prescription
A member can have prescriptions filled at a Peach State network pharmacy. If the member decides to
have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting
Peach State Member Services. At the pharmacy the member will need to provide the pharmacist with the
prescription and their Peach State ID card.
Copayments
The table below lists the copayment for the drugs according to the actual cost of the prescription.
Copayments are not required for family planning services, children under the age of 21, pregnant women,
members with breast or cervical cancer, nursing home residents, or hospice care members.
Actual Cost of Prescription
Member Copayment
Less than $10.01
$0.50
Between $10.01 and $25.00
$1.00
Between $25.01 and $50.00
$2.00
More than $50.01
$3.00
Abbreviations
The following notations and abbreviations may be found throughout the drug listing in the limitations and
restrictions column.
DS/DU: Days Supply per Dosage Unit
Max Days Sply: Maximum Days Supply
Max Fills: Maximum Fills (per time period)
Max Qty: Maximum Quantity (per claim or time period)
Min DS: Minimum Days Supply
PA: Prior Authorization
Pkg Size: Package Size
Contact Information
Peach State
US Script
Phone:
1-800-704-1484
TDD:
1-800-255-0056
Fax:
1-800-659-7518
Website:
www.PSHPGeorgia.com
PA Phone:
1-866-399-0928
PA Fax:
1-866-399-0929
Help Desk:
1-800-460-8988
5
Product Description
PENICILLINS
Penicillin V Potassium Tab 250 MG
Penicillin V Potassium Tab 500 MG
Penicillin V Potassium For Soln 125 MG/5ML
Penicillin V Potassium For Soln 250 MG/5ML
Amoxicillin (Trihydrate) Cap 250 MG
Amoxicillin (Trihydrate) Cap 500 MG
Amoxicillin (Trihydrate) Tab 875 MG
Amoxicillin (Trihydrate) Chew Tab 125 MG
Amoxicillin (Trihydrate) Chew Tab 250 MG
Amoxicillin (Trihydrate) For Susp 125 MG/5ML
Ampicillin Cap 250 MG
Ampicillin Cap 500 MG
Ampicillin For Susp 125 MG/5ML
Ampicillin For Susp 250 MG/5ML
Dicloxacillin Sodium Cap 250 MG
Dicloxacillin Sodium Cap 500 MG
Amoxicillin & K Clavulanate Tab 250 MG
Amoxicillin & K Clavulanate Chew Tab 200 MG
Amoxicillin & K Clavulanate Chew Tab 400 MG
Amoxicillin & K Clavulanate For Susp 125 MG/5ML
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Amoxicillin & K Clavulanate Tab SR 12HR 1000-62.5 MG Generic
CEPHALOSPORINS
Cephalexin Cap 250 MG
Cephalexin Cap 500 MG
Cephalexin For Susp 125 MG/5ML
Cephalexin For Susp 250 MG/5ML
Cefaclor Cap 250 MG
Cefaclor Cap 500 MG
Cefaclor For Susp 125 MG/5ML
Cefprozil Tab 250 MG
Cefprozil Tab 500 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
Limitations/Restrictions
AUGMENTIN
AUGMENTIN
AUGMENTIN
Max Qty=30/claim
Max Qty=30/claim
Max Qty=20/claim
Max Qty=20/claim
Max Qty=20/claim
Package Limit=1/claim
AUGMENTIN
Max Qty=40/30 days
AUGMENTIN
KEFLEX
KEFLEX
Cefprozil For Susp 125 MG/5ML
Generic
Cefprozil For Susp 250 MG/5ML
Cefuroxime Axetil Tab 250 MG
Cefuroxime Axetil Tab 500 MG
Generic
Generic
Generic
CEFTIN
CEFTIN
Cefuroxime Axetil For Susp 125 MG/5ML
Generic
CEFTIN
Cefuroxime Axetil For Susp 250 MG/5ML
Generic
CEFTIN
Cefdinir Cap 300 MG
Generic
OMNICEF
Cefdinir For Susp 125 MG/5ML
Generic
OMNICEF
Cefdinir For Susp 250 MG/5ML
Generic
OMNICEF
Ceftriaxone Sodium For Inj 250 MG
Generic
Ceftriaxone Sodium For Inj 500 MG
Generic
ROCEPHIN
Ceftriaxone Sodium For Inj 1 GM
Generic
ROCEPHIN
6
Max Qty=20/claim
Max Qty=20/claim
Limited to Ages 12 and Under;
Max Qty=20/claim
Max Qty=20/claim
Max Qty=20/claim; Step
Therapy
Package Limit=1/claim; Step
Therapy
Package Limit=1/claim; Step
Therapy
Max Qty=3/claim; Max
Fills=1/30 days
Fills=1/30 days
Fills=1/30 days
Product Description
MACROLIDES
Erythromycin Tab 250 MG
Erythromycin Tab 500 MG
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Generic
Generic
Erythromycin Tab Delayed Release 250 MG
Brand
E-MYCIN, ERY-TAB
ERY-TAB,
ERYTHROMYCIN
ERY-TAB
Brand
Brand
Erythromycin w/ Enteric Coated Particles Cap 250 MG
Generic
Erythromycin w/ Enteric Coated Particles Tab 333 MG
Brand
PCE
Erythromycin w/ Enteric Coated Particles Tab 500 MG
Erythromycin Stearate Tab 250 MG
Brand
Generic
PCE
Erythromycin Stearate Tab 500 MG
Erythromycin Ethylsuccinate Tab 400 MG
Erythromycin Ethylsuccinate Susp 400 MG/5ML
Erythromycin Ethylsuccinate For Susp 200 MG/5ML
Erythromycin Ethylsuccinate For Susp 400 MG/5ML
Azithromycin Tab 250 MG
Azithromycin For Susp 100 MG/5ML
Azithromycin For Susp 200 MG/5ML
Azithromycin Powd Pack for Susp 1 GM
Clarithromycin Tab 250 MG
Clarithromycin Tab 500 MG
Clarithromycin For Susp 125 MG/5ML
Clarithromycin For Susp 250 MG/5ML
Clarithromycin Tab SR 24HR 500 MG
Brand
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ERYC
ERYTHROCIN,
ERYTHROM ST
ERYPED
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
BIAXIN
BIAXIN
BIAXIN
BIAXIN
BIAXIN XL
TETRACYCLINES
Doxycycline Hyclate Cap 50 MG
Doxycycline Hyclate Cap 100 MG
Doxycycline Hyclate Tab 100 MG
Minocycline HCl Cap 50 MG
Tetracycline HCl Cap 250 MG
Tetracycline HCl Cap 500 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
FLUOROQUINOLONES
Ciprofloxacin HCl Tab 100 MG (Base Equiv)
Generic
Generic
Generic
Generic
CIPRO
CIPRO
CIPRO
Levofloxacin Tab 250 MG
Generic
LEVAQUIN
Generic
LEVAQUIN
Ofloxacin Tab 200 MG
Generic
Generic
Generic
Generic
LEVAQUIN
AMINOGLYCOSIDES
Neomycin Sulfate Tab 500 MG
Generic
SULFONAMIDES
Sulfisoxazole Acetyl Susp 500 MG/5ML
Brand
ANTIMYCOBACTERIAL AGENTS
Ethambutol HCl Tab 100 MG
Generic
Max Qty=6/claim
Daily Dosage=4
Max Qty=8/28 days
Package Limit=1-2/claim
Max Qty=2/claim
Max Qty=28/claim
Max Qty=28/claim
Package Limit=1-2/claim
Max Qty=14/claim
VIBRAMYCIN
VIBRATAB
MINOCIN
MINOCIN
Max Qty=6/claim
Max Qty=14/claim; Daily
Dosage=1
Dosage=1
Dosage=1
Max Qty=56/claim
Max Qty=56/claim
Max Qty=56/claim
GANTRIS PED
MYAMBUTOL
7
Product Description
Ethambutol HCl Tab 400 MG
Ethionamide Tab 250mg
Isoniazid Tab 100 MG
Isoniazid Tab 300 MG
Isoniazid Syrup 50 MG/5ML
Pyrazinamide Tab 500 MG
Rifampin Cap 150 MG
Rifampin Cap 300 MG
ANTIFUNGALS
Griseofulvin Microsize Tab 500 MG
Griseofulvin Microsize Susp 125 MG/5ML
Griseofulvin Ultramicrosize Tab 125 MG
Griseofulvin Ultramicrosize Tab 250 MG
Nystatin Tab 500000 U
Terbinafine HCl Tab 250 MG
Ketoconazole Tab 200 MG
Fluconazole Tab 50 MG
Fluconazole For Susp 10 MG/ML
Fluconazole For Susp 40 MG/ML
Itraconazole Cap 100 MG
ANTIVIRALS
Maraviroc Tab 150 MG
Maraviroc Tab 300 MG
Raltegravir Potassium Tab 400 MG (Base Equiv)
Atazanavir Sulfate Cap 100 MG (Base Equiv)
Darunavir Ethanolate Tab 75 MG (Base Equiv)
Fosamprenavir Calcium Tab 700 MG (Base Equiv)
Fosamprenavir Calcium Susp 50 MG/ML (Base Equiv)
Indinavir Sulfate Cap 100 MG
Nelfinavir Mesylate Tab 250 MG
Nelfinavir Mesylate Tab 625 MG
Nelfinavir Mesylate Oral Powder 50 MG/GM
Ritonavir Cap 100 MG
Ritonavir Tab 100 MG
Ritonavir Oral Soln 80 MG/ML
Saquinavir Mesylate Cap 200 MG
Saquinavir Mesylate Tab 500 MG
Tipranavir Cap 250 MG
Tipranavir Oral Soln 100 MG/ML
Abacavir Sulfate Tab 300 MG (Base Equiv)
Abacavir Sulfate Soln 20 MG/ML (Base Equiv)
Didanosine For Soln 2 GM
Didanosine For Soln 4 GM
Didanosine Delayed Release Capsule 125 MG
Emtricitabine Caps 200 MG
Emtricitabine Soln 10 MG/ML
Lamivudine Tab 150 MG
Brand/ Non-Preferred Brand
Covered Brand
Generic
Equivalent(s)
Product
Generic
MYAMBUTOL
Brand
TRECATOR
Generic
Generic
Brand
ISONIAZID
Generic
Generic
RIFADIN
Generic
RIFADIN
Generic
Generic
Generic
Generic
Generic
GRIFULVIN V
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LAMISIL
GRIS-PEG
GRIS-PEG
Daily Dosage=6
Max Qty=90/120 days; Daily
Dosage=1
Daily Dosage=1
Max Qty=3/14 days
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
SPORANOX
Max Qty=2/claim
Max Qty=70/claim
Max Qty=70/claim
PA; Daily Dosage=1
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
SELZENTRY
SELZENTRY
ISENTRESS
REYATAZ
REYATAZ
REYATAZ
REYATAZ
PREZISTA
PREZISTA
PREZISTA
PREZISTA
PREZISTA
PREZISTA
LEXIVA
Daily Dosage=2
Daily Dosage=4
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Generic
LEXIVA
CRIXIVAN
CRIXIVAN
CRIXIVAN
VIRACEPT
VIRACEPT
VIRACEPT
NORVIR
NORVIR
NORVIR
INVIRASE
INVIRASE
APTIVUS
APTIVUS
Daily Dosage=56
Daily Dosage=6
Daily Dosage=9
Daily Dosage=6
Daily Dosage=9
Daily Dosage=4
Daily Dosage=36
Daily Dosage=12
Daily Dosage=12
Daily Dosage=15
Daily Dosage=10
Daily Dosage=4
Daily Dosage=4
Daily Dosage=10
Daily Dosage=2
Daily Dosage=30
Daily Dosage=20
Daily Dosage=20
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=24
Daily Dosage=2
ZIAGEN
ZIAGEN
VIDEX
VIDEX
VIDEX EC
VIDEX EC
VIDEX EC
VIDEX EC
EMTRIVA
EMTRIVA
EPIVIR
8
Daily Dosage=2
Daily Dosage=3
Daily Dosage=4
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=4
Product Description
Lamivudine Tab 300 MG
Lamivudine Oral Soln 10 MG/ML
Stavudine Cap 15 MG
Stavudine Cap 20 MG
Stavudine Cap 30 MG
Stavudine Cap 40 MG
Stavudine Soln 1 MG/ML
Stavudine For Oral Soln 1 MG/ML
Zidovudine Cap 100 MG
Zidovudine Tab 300 MG
Zidovudine Syrup 10 MG/ML
Tenofovir Disoproxil Fumarate Tab 150 MG
Tenofovir Disoproxil Fumarate Powder 40 MG/GM
Delavirdine Mesylate Tab 100 MG
Delavirdine Mesylate Tab 200 MG
Efavirenz Cap 50 MG
Efavirenz Cap 200 MG
Efavirenz Tab 600 MG
Etravirine Tab 100 MG
Etravirine Tab 200 MG
Nevirapine Tab 200 MG
Nevirapine Susp 50 MG/5ML
Nevirapine Tab SR 24HR 400 MG
Rilpivirine HCl Tab 25 MG (Base Equivalent)
Abacavir Sulfate-Lamivudine Tab 600-300 MG
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300
MG
Lamivudine-Zidovudine Tab 150-300 MG
Lopinavir-Ritonavir Tab 100-25 MG
Lopinavir-Ritonavir Tab 200-50 MG
Lopinavir-Ritonavir Soln 400-100 MG/5ML (80-20
MG/ML)
Abacavir Sulfate-Lamivudine-Zidovudine Tab 300-150-300
MG
Efavirenz-Emtricitabine-Tenofovir DF Tab 600-200-300
MG
Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300
MG
Elvitegrav-Cobicis-Emtricitab-Tenofov Tab 150-150-200300 MG
Ganciclovir Cap 250 MG
Ganciclovir Cap 500 MG
Valganciclovir HCl Tab 450 MG
Acyclovir Cap 200 MG
Acyclovir Tab 400 MG
Acyclovir Tab 800 MG
Acyclovir Susp 200 MG/5ML
Valacyclovir HCl Tab 500 MG
Valacyclovir HCl Tab 1 GM
Brand/
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Brand
Brand
Non-Preferred Brand
Equivalent(s)
EPIVIR
Covered Brand
Product
EPIVIR
ZERIT
ZERIT
ZERIT
ZERIT
ZERIT
ZERIT
RETROVIR
RETROVIR
RETROVIR
VIREAD
VIREAD
VIREAD
VIREAD
VIREAD
RESCRIPTOR
RESCRIPTOR
SUSTIVA
SUSTIVA
SUSTIVA
INTELENCE
INTELENCE
VIRAMUNE
VIRAMUNE
VIRAMUNE XR
EDURANT
EPZICOM
TRUVADA
Daily Dosage=1
Daily Dosage=30
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=80
Daily Dosage=30
Daily Dosage=6
Daily Dosage=2
Daily Dosage=60
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosag= 240/30 days
Daily Dosage=12
Daily Dosage=6
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=4
Daily Dosage=2
Daily Dosage=2
Daily Dosage=40
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
KALETRA
KALETRA
Daily Dosage=1
Daily Dosage=2
Daily Dosage=4
Daily Dosage=6
Brand
KALETRA
Max Qty=480/30 days
Brand
TRIZIVIR
Daily Dosage=2
Brand
ATRIPLA
Daily Dosage=1
Brand
COMPLERA
Daily Dosage=1
Brand
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
STRIBILD
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
VALTREX
VALTREX
Daily Dosage=1
Daily Dosage=6
Daily Dosage=6
Daily Dosage=2
Max Qty=50/30 days
Daily Dosage=2
Max Qty=50/30 days
Max Qty=400/30 days
Max Qty=42/31 days
Max Qty=21/31 days
Rimantadine Hydrochloride Tab 100 MG
Generic
FLUMADINE
Oseltamivir Phosphate Cap 30 MG (Base Equiv)
Brand
TAMIFLU
Brand
TAMIFLU
Brand
TAMIFLU
Oseltamivir Phosphate For Susp 6 MG/ML (Base Equiv)
Brand
TAMIFLU
Oseltamivir Phosphate For Susp 12 MG/ML (Base Equiv) Brand
TAMIFLU
Zanamivir Aero Powder Breath Activated 5 MG/BLISTER Brand
RELENZA
COMBIVIR
VALCYTE
9
Max DS/DU=Lesser Of Max
Days Sply=10/Max Qty=20
Max Qty=20/30 days; Max
Fills=1/180 days
Fills=1/180 days
Fills=1/180 days
Fills=1/180 days
Max Qty=75/30 days
Limited to Ages 5 and Older;
Package Limit=1/30 days
Product Description
ANTIMALARIALS
Chloroquine Phosphate Tab 250 MG
Chloroquine Phosphate Tab 500 MG
Hydroxychloroquine Sulfate Tab 200 MG
Mefloquine HCl Tab 250 MG
Primaquine Phosphate Tab 26.3 MG
Artemether-Lumefantrine Tab 20-120 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
ARALEN
PLAQUENIL
Daily Dosage=1
COARTEM
Max Qty=24/claim
ANTHELMINTICS
Pyrantel Pamoate Tab 180 MG
Pyrantel Pamoate Chew Tab 720.5 MG (250 MG Base
Equiv)
Pyrantel Pamoate Susp 250 MG/5ML (50 MG/ML Base
Equiv)
ANTI-INFECTIVE AGENTS - MISC.
Metronidazole Tab 250 MG
Metronidazole Tab 500 MG
Trimethoprim Tab 100 MG
Vancomycin HCl For Inj 500 MG
Vancomycin HCl For Inj 1000 MG
Clindamycin HCl Cap 150 MG
Clindamycin HCl Cap 300 MG
Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base
Equiv)
Dapsone Tab 25 MG
Dapsone Tab 100 MG
Brand
PINWORM
Brand
PIN-X
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
FLAGYL
FLAGYL
TRIMPEX
Generic
Generic
Generic
CLEOCIN PED
Erythromycin & Sulfisoxazole For Susp 200-600 MG/5ML Generic
Sulfamethoxazole-Trimethoprim Tab 400-80 MG
Generic
Sulfamethoxazole-Trimethoprim Tab 800-160 MG
Generic
Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML
Generic
Fills=1/30 days
Fills=1/30 days
Fills=1/30 days
Max Qty=14/30 days
Max Qty=14/claim
VANCOCIN HCL
CLEOCIN
CLEOCIN
Max Qty=300/claim
BACTRIM, SEPTRA
BACTRIM DS,
SEPTRA DS
PASSIVE IMMUNIZING AGENTS
Rho D Immune Globulin (Human) IM Inj 300 MCG
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Busulfan Tab 2 MG
Chlorambucil Tab 2 MG
Cyclophosphamide Tab 25 MG
Cyclophosphamide Tab 50 MG
Melphalan Tab 2 MG
Mercaptopurine Tab 50 MG
Methotrexate Sodium Tab 2.5 MG (Base Equiv)
Methotrexate Sodium Tab 5 MG (Base Equiv)
Methotrexate Sodium Tab 7.5 MG (Base Equiv)
Methotrexate Sodium Inj 25 MG/ML
Methotrexate Sodium Inj PF 25 MG/ML
Bicalutamide Tab 50 MG
Flutamide Cap 125 MG
Tamoxifen Citrate Tab 10 MG (Base Equivalent)
Tamoxifen Citrate Tab 20 MG (Base Equivalent)
Toremifene Citrate Tab 60 MG (Base Equivalent)
Anastrozole Tab 1 MG
Exemestane Tab 25 MG
Letrozole Tab 2.5 MG
Megestrol Acetate Tab 20 MG
Megestrol Acetate Tab 40 MG
Megestrol Acetate Susp 40 MG/ML
Hydroxyurea Cap 500 MG
HYPERRHO S/D,
RHOGAM PLUS
Brand
Brand
Brand
Generic
Generic
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MYLERAN
LEUKERAN
ALKERAN
PURINETHOL
TREXALL
TREXALL
TREXALL
TREXALL
CASODEX
Daily Dosage=1
FARESTON
ARIMIDEX
AROMASIN
FEMARA
MEGACE ORAL
HYDREA
10
PA
Product Description
Leucovorin Calcium Tab 5 MG
CORTICOSTEROIDS
Cortisone Acetate Tab 25 MG
Dexamethasone Tab 0.5 MG
Dexamethasone Tab 1 MG
Dexamethasone Elixir 0.5 MG/5ML
Dexamethasone Soln 0.5 MG/5ML
Hydrocortisone Tab 5 MG
Methylprednisolone Tab 4 MG
Methylprednisolone Tab 8 MG
Methylprednisolone Tab 4 MG Dose Pack
Prednisolone Tab 5 MG
Prednisolone Syrup 5 MG/5ML
Prednisolone Syrup 15 MG/5ML
Prednisolone Sod Phosphate Oral Soln 15 MG/5ML (Base
Equiv)
Prednisolone Sod Phosph Oral Soln 6.7 MG/5ML (5
MG/5ML Base)
Prednisolone Sod Phosphate Oral Soln 20 MG/5ML (Base
Equiv)
Prednisone Tab 1 MG
Prednisone Tab 2.5 MG
Prednisone Tab 5 MG
Prednisone Tab 10 MG
Prednisone Conc 5 MG/ML
Prednisone Oral Soln 5 MG/5ML
Prednisone Tab 5 MG Dose Pack
Prednisone Tab 10 MG Dose Pack
Fludrocortisone Acetate Tab 0.1 MG
ANDROGENS-ANABOLIC
Fluoxymesterone Tab 10 MG
Methyltestosterone Oral Tab 10 MG
Testosterone TD Patch 24HR 2 MG/24HR
Testosterone TD Patch 24HR 4 MG/24HR
Testosterone Cypionate IM in Oil 200 MG/ML
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Non-Preferred Brand
Equivalent(s)
MILLIPRED
PRELONE
ORAPRED
Generic
PEDIAPRED
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Max Qty=240/claim
VERIPRED 20
Max Qty=150/claim
PREDNISONE
INTENSOL
STERAPRED
STERAPRED DS
Brand
Brand
Brand
Brand
Generic
CORTEF
CORTEF
CORTEF
MEDROL
MEDROL
MEDROL
Generic
Brand
Generic
Generic
Generic
Generic
Covered Brand
Product
ANDROXY
METHITEST
ANDRODERM
ANDRODERM
DEPOTESTOSTERONE
Daily Dosage=1
Daily Dosage=1
Max Qty=4/30 days
ESTROGENS
Estrogens, Conjugated Tab 0.3 MG
Brand
PREMARIN
Brand
PREMARIN
Brand
PREMARIN
Brand
PREMARIN
Estradiol Tab 0.5 MG
Estradiol Tab 1 MG
Estradiol Tab 2 MG
Brand
Generic
Generic
Generic
PREMARIN
ESTRACE
ESTRACE
ESTRACE
11
Limited to Female; Daily
Dosage=1
Dosage=1
Dosage=1
Dosage=1
Dosage=1
Limited to Female
Limited to Female
Limited to Female
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Limited to Female; Max
DS/DU=Lesser Of Max Days
Sply=28/Max Qty=8
Estradiol TD Patch Biweekly 0.025 MG/24HR
Brand
Brand
ALORA, VIVELLEDOT
MINIVELLE,
VIVELLE-DOT
Brand
ALORA,
ESTRADERM,
MINIVELLE,
VIVELLE-DOT
Brand
Sply=28/Max Qty=8
ALORA, MINIVELLE, DS/DU=Lesser Of Max Days
VIVELLE-DOT
Sply=28/Max Qty=8
Brand
ALORA,
ESTRADERM,
MINIVELLE,
VIVELLE-DOT
Estradiol TD Patch Weekly 0.025 MG/24HR
Generic
CLIMARA
Estradiol TD Patch Weekly 0.0375 MG/24HR (37.5
MCG/24HR)
Generic
CLIMARA
Generic
CLIMARA
Generic
CLIMARA
Generic
CLIMARA
Generic
CLIMARA
Estropipate Tab 0.75 MG
Generic
OGEN
Estropipate Tab 1.5 MG
Generic
OGEN
Estropipate Tab 3 MG
Esterified Estrogens & Methyltestosterone Tab 0.625-1.25
MG
Esterified Estrogens & Methyltestosterone Tab 1.25-2.5
MG
Conjugated Estrogen-Medroxyprogest Acetate Tab 0.3-1.5
MG
Conjugated Estrogen-Medroxyprogest Acetate Tab 0.45-1.5
MG
Conjugated Estrogen-Medroxyprogest Acetate Tab 0.6252.5 MG
Conjugated Estrogen-Medroxyprogest Acetate Tab 0.625-5
MG
Estradiol & Norethindrone Acetate Tab 1-0.5 MG
Estradiol-Norethindrone Ace TD PTTW 0.050.14MG/DAY
Estradiol-Norethindrone Ace TD PTTW 0.050.25MG/DAY
Generic
Sply=28/Max Qty=8
Sply=28/Max Qty=4
Sply=28/Max Qty=4
Sply=28/Max Qty=4
Sply=28/Max Qty=4
Sply=28/Max Qty=4
Sply=28/Max Qty=4
Dosage=1
Dosage=1
Dosage=2
Generic
Daily Dosage=1
Generic
Daily Dosage=1
Brand
PREMPRO
Brand
PREMPRO
Brand
PREMPRO
Brand
Generic
PREMPRO
ACTIVELLA
Limited to Female
Daily Dosage=1
Brand
COMBIPATCH
Max Qty=8/28 days
Brand
COMBIPATCH
Max Qty=8/28 days
CONTRACEPTIVES
Norethindrone Tab 0.35 MG
Medroxyprogesterone Acetate IM Susp 150 MG/ML
Medroxyprogesterone Acetate Subcutaneous Susp 104
MG/0.65ML
Generic
Generic
NOR-QD, ORTHO
MICRONOR
DEPO-PROVERA
Brand
DEPO-SQ PROV
12
Qty=1/claim; Min DS=84
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Levonorgestrel Tab 0.75 MG
Generic
PLAN B
Levonorgestrel Tab 1.5 MG
Ulipristal Acetate Tab 30 MG
Norelgestromin-Ethinyl Estradiol TD PTWK 150-20
MCG/24HR
Etonogestrel-Ethinyl Estradiol VA Ring 0.120-0.015
MG/24HR
Generic
Brand
PLAN B ONE-STEP
Covered Brand
Product
Limited to Ages 10-50; Limited
to Female; Max Qty=4/365 days
ELLA
Brand
ORTHO EVRA
Brand
NUVARING
Desogestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG
Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG
Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG35MCG
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG50MCG
Generic
Generic
Generic
Levonorgestrel & Ethinyl Estradiol Tab 0.10 MG-20MCG
Generic
Levonorgestrel & Ethinyl Estradiol Tab 0.15 MG-30MCG
Generic
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35MCG
Generic
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35MCG
Generic
Norethindrone & Ethinyl Estradiol Tab 1 MG-35MCG
Generic
DESOGEN,
DESOGEN-28,
ORTHO-CEPT
YAZ
YASMIN 28
Brand
Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30MCG
Norgestrel & Ethinyl Estradiol Tab 0.5 MG-50MCG
Generic
Brand
Norgestimate & Ethinyl Estradiol Tab 0.25MG-35MCG
Generic
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG20MCG
Generic
Norethindrone Ace-Ethinyl Estradiol-FE Tab 1 MG-20
MCG (24
Brand
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG30MCG
Generic
Desogest-Eth Estrad & Eth Estrad Tab 0.15-0.02/0.01
MG(21/5)
Generic
Norethindrone-Eth Estradiol Tab 0.5-35/1-35 MG-MCG
(10/11)
Brand
Desogest-Ethinyl Estrad Tab .1-.025/.125-.025/.15-.025
MG-MG
Generic
Levonorgestrel-Eth Estrad Tab .05-30/0.075-40/0.12530MG-MCG
Generic
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MGMCG
Generic
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MGMCG
Generic
Norgestimate-Eth Estrad Tab 0.18-25/0.215-25/0.25-25
MG-MCG
Brand
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35
MG-MCG
Generic
Levonorgestrel & Ethinyl Estradiol (91-Day) Tab 0.15-0.03
MG
Generic
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab
0.01MG(7)
Generic
Max Qty=3/claim; Min DS=28
Limited to Female
Brand
Norethindrone & Mestranol Tab 1 MG-50MCG
Max Qty=4/365 days
Max Qty=4/365 days
Limited to Female
Limited to Female
Limited to Female
Generic
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20MCG Generic
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG30MCG
Generic
ZOVIA 1/50E
Limited to female
Limited to female
NORDETTE,
NORDETTE-28
Limited to female
OVCON-35
BREVICON,
MODICON
NORINYL, ORTHONOVUM
Limited to female
Limited to female
LOESTRIN 21 1-20
Limited to female
LOESTRIN 21 1.5-30
Limited to female
Limited to female
NECON, NORINYL
LO/OVRAL-21,
LO/OVRAL-28
OGESTREL
Limited to female
Dosage=2
Limited to female
ORTHO-CYCLEN
Limited to female
LOESTRIN FE 1-20
Limited to female
LOESTRIN 24
LOESTRIN FE 1.5-30
Limited to female
MIRCETTE
Limited to female
NECON
CYCLESSA
Limited to female
Limited to female
ORTHO-NOVUM
TRI-NORINYL
ORTHO TRICYCLEN LO
PA
ORTHO TRICYCLEN
SEASONALE
SEASONIQUE
13
Product Description
PROGESTINS
Medroxyprogesterone Acetate Tab 2.5 MG
Medroxyprogesterone Acetate Tab 5 MG
Medroxyprogesterone Acetate Tab 10 MG
Norethindrone Acetate Tab 5 MG
Progesterone Micronized Cap 100 MG
Progesterone Micronized Cap 200 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
PROVERA
PROVERA
PROVERA
AYGESTIN
PROMETRIUM
PROMETRIUM
Max Qty=30/30 days
Max Qty=20/30 days
ANTIDIABETICS
Insulin Aspart Inj 100 U/ML
Brand
Insulin Glargine Inj 100 U/ML
Brand
NOVOLOG
LANTUS, LANTUS
FOR
Insulin Glulisine Inj 100 Unit/ML
Brand
APIDRA
Insulin Lispro (Human) Inj 100 U/ML
Brand
Insulin Regular (Human) Inj 100 U/ML
Brand
HUMALOG
HUMULIN R,
NOVOLIN R
HUMULIN N,
NOVOLIN N
NOVOLOG MIX
70/30
HUMALOG MIX
75/25
HUMALOG MIX
50/50
HUMULIN 70/30,
NOVOLIN 70/30
Insulin Isophane (Human) Inj 100 U/ML
Brand
Insulin Aspart & Aspart Prot (Human) Inj 100 U/ML (3070)
Brand
Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (752
Brand
Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (505
Brand
Insulin Isophane & Regular (Human) Inj 100 U/ML (70-30) Brand
Max Qty=40/30 days
Max Qty=40/30 days
PA-Pen Devices; Max
Qty=40/30 days
PA-Pen Devices; Max
Qty=40/30 days
PA-Pen Devices; Max
Qty=40/30 days
PA-Pen Devices; Max
Qty=40/30 days
Insulin Isophane & Regular (Human) Inj 100 U/ML (50-50)
Glimepiride Tab 1 MG
Glipizide Tab 5 MG
Glipizide Tab 10 MG
Glipizide Tab SR 24HR 2.5 MG
Glipizide Tab SR 24HR 5 MG
Glipizide Tab SR 24HR 10 MG
Glyburide Tab 1.25 MG
Glyburide Tab 2.5 MG
Glyburide Tab 5 MG
Glyburide Micronized Tab 1.5 MG
Glyburide Micronized Tab 3 MG
Glyburide Micronized Tab 6 MG
Metformin HCl Tab 500 MG
Metformin HCl Tab SR 24HR 500 MG
Metformin HCl Tab SR 24HR 750 MG
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Glucagon (rDNA) For Inj Kit 1 MG
Brand
GLUCAGON
Glucagon HCl (rDNA) For Inj 1 MG (Base Equiv)
Glucose Chew Tab 4 GM
Glucose Chew Tab 5 GM
Brand
Generic
Brand
GLUCAGEN
Linagliptin Tab 5 MG
Saxagliptin HCl Tab 2.5 MG (Base Equiv)
Saxagliptin HCl Tab 5 MG (Base Equiv)
Pioglitazone HCl Tab 15 MG (Base Equiv)
Brand
TRADJENTA
Daily Dosage=4
Daily Dosage=3
Max Fills=1/30 days; Package
Limit=1/claim
Max Fills=1/30 days; Package
Limit=1/claim
Max Qty=50/30 days
Max Qty=50/30 days
Daily Dosage=1
Linagliptin-Metformin HCl Tab 2.5-500 MG
Brand
Brand
JENTADUETO
JENTADUETO
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Generic
Generic
Generic
HUMULIN
PA-Pen Devices; Max
Qty=40/30 days
PA-Pen Devices; Max
Qty=30/30 days
PA-Pen Devices; Max
Qty=40/30 days
PA-Pen Devices; Max
Qty=40/30 days
AMARY
AMARY
AMARY
GLUCOTROL
GLUCOTROL
GLUCOTROL XL
GLUCOTROL XL
GLUCOTROL XL
DIABETA
DIABETA
DIABETA
GLYNASE
GLYNASE
GLYNASE
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE
Daily Dosage=5
BD GLUCOSE
ACTOS
ACTOS
ACTOS
14
Max Qty=40/30 days
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Brand
JENTADUETO
Saxagliptin-Metformin HCl Tab SR 24HR 2.5-1000 MG
Saxagliptin-Metformin HCl Tab SR 24HR 5-500 MG
Brand
Brand
KOMBIGLYZE
KOMBIGLYZE
Saxagliptin-Metformin HCl Tab SR 24HR 5-1000 MG
Glipizide-Metformin HCl Tab 2.5-250 MG
Glipizide-Metformin HCl Tab 2.5-500 MG
Glipizide-Metformin HCl Tab 5-500 MG
Glyburide-Metformin Tab 1.25-250 MG
Glyburide-Metformin Tab 2.5-500 MG
Glyburide-Metformin Tab 5-500 MG
Pioglitazone HCl-Metformin HCl Tab 15-500 MG
Pioglitazone HCl-Metformin HCl Tab 15-850 MG
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
KOMBIGLYZE
THYROID AGENTS
Levothyroxine Sodium Tab 0.025 MG
Liothyronine Sodium Tab 5 MCG
Liotrix Tab 15 MG
Liotrix Tab 30 MG
Liotrix Tab 60 MG
Liotrix Tab 120 MG
Liotrix Tab 180 MG
Thyroid Tab 15 MG (1/4 Grain)
METAGLIP
METAGLIP
METAGLIP
GLUCOVANCE
GLUCOVANCE
GLUCOVANCE
ACTOPLUS MET
ACTOPLUS MET
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
CYTOMEL
CYTOMEL
CYTOMEL
Thyroid Tab 30 MG (1/2 Grain)
Generic
ARMOUR THYROID
Thyroid Tab 60 MG (1 Grain)
Generic
ARMOUR THYROID
Thyroid Tab 90 MG (1 1/2 Grain)
Generic
ARMOUR THYROID
Methimazole Tab 5 MG
Methimazole Tab 10 MG
Propylthiouracil Tab 50 MG
Generic
Brand
Brand
Brand
Generic
Generic
Generic
ARMOUR THYROID
OXYTOCICS
Methylergonovine Maleate Tab 0.2 MG
Generic
METHERGINE
ENDOCRINE AND METABOLIC AGENTS - MISC.
Alendronate Sodium Tab 5 MG
Alendronate Sodium Oral Soln 70 MG/75ML
Etidronate Disodium Tab 200 MG
Etidronate Disodium Tab 400 MG
Risedronate Sodium Tab 5 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
FOSAMAX
FOSAMAX
FOSAMAX
FOSAMAX
FOSAMAX
FOSAMAX
DIDRONEL
DIDRONEL
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
THYROLAR-1/4
THYROLAR-1/2
THYROLAR-1
THYROLAR-2
THYROLAR-3
ARMOUR THYRO
ARMOUR THYRO
ARMOUR THYRO
ARMOUR THYRO
TAPAZOLE
TAPAZOLE
ACTONEL
ACTONEL
15
Daily Dosage=1
Daily Dosage=1
Daily Dosage=.15
Daily Dosage=1
Daily Dosage=.15
Daily Dosage=10.8
PA
PA
PA; Daily Dosage=1
PA; Daily Dosage=1
Product Description
Brand/
Generic
Calcitonin (Salmon) Inj 200 IU/ML
Brand
Brand
Calcitonin (Salmon) Nasal Soln 200 IU/ACT
Raloxifene HCl Tab 60 MG
Desmopressin Acetate Tab 0.1 MG
Desmopressin Acetate Tab 0.2 MG
Generic
Brand
Generic
Generic
Desmopressin Acetate Nasal Soln 0.01% (Refrigerated)
Desmopressin Acetate Nasal Spray Soln 0.01%
(Refrigerated)
Desmopressin Acetate Nasal Spray Soln 0.01%
Levocarnitine Tab 330 MG
Generic
Levocarnitine Oral Soln 1 GM/10ML (10%)
Calcitriol Cap 0.25 MCG
Calcitriol Cap 0.5 MCG
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
ACTONEL
MIACALCIN
MIACALCIN;
FORTICAL
EVISTA
DDAVP
DDAVP
DDAVP
Generic
Generic
Generic
LANOXIN
LANOXIN
ANTIANGINAL AGENTS
Isosorbide Dinitrate Tab 5 MG
Generic
Generic
Generic
Generic
ISORDIL
BETA BLOCKERS
Nadolol Tab 20 MG
Nadolol Tab 40 MG
Nadolol Tab 80 MG
Pindolol Tab 5 MG
Pindolol Tab 10 MG
Propranolol HCl Tab 10 MG
Propranolol HCl Oral Soln 20 MG/5ML
Propranolol HCl Oral Soln 40 MG/5ML
Propranolol HCl Cap SR 24HR 60 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA; Max DS/DU=Lesser Of
Max Days Sply=28/Max Qty=4
Max Qty=2/claim
Min DS=30; Package
Limit=1/claim
Daily Dosage=1
Daily Dosage=1
Daily Dosage=3
PA; Max Qty=5/claim
PA; Max Qty=5/claim
PA; Max Qty=5/claim
Daily Dosage=3
DDAVP
CARNITOR
CARNITOR,
CARNITOR SF
ROCALTROL
ROCALTROL
CARDIOTONICS
Digoxin Tab 0.125 MG
Digoxin Tab 0.25 MG
Digoxin Oral Soln 0.05 MG/ML
Isosorbide Dinitrate Tab CR 40 MG
Isosorbide Dinitrate SL Tab 2.5 MG
Isosorbide Dinitrate SL Tab 5 MG
Isosorbide Mononitrate Tab 10 MG
Isosorbide Mononitrate Tab 20 MG
Isosorbide Mononitrate Tab SR 24HR 30 MG
Nitroglycerin Cap CR 2.5 MG
Nitroglycerin Cap CR 6.5 MG
Nitroglycerin Cap CR 9 MG
Nitroglycerin SL Tab 0.3 MG
Nitroglycerin Oint 2%
Nitroglycerin TD Patch 24HR 0.1 MG/HR
Covered Brand
Product
Daily Dosage=30
ISOCHRON,
ISORDIL
PA
MONOKET
ISMO, MONOKET
IMDUR
IMDUR
IMDUR
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
NITROSTAT
NITROSTAT
NITROSTAT
NITRO-BID
NITRO-DUR
NITRO-DUR
NITRO-DUR
NITRO-DUR
CORGARD
CORGARD
CORGARD
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
INDERAL LA
INDERAL LA
INDERAL LA
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
16
Product Description
Sotalol HCl Tab 80 MG
Sotalol HCl (AFIB/AFL) Tab 80 MG
Timolol Maleate Tab 5 MG
Acebutolol HCl Cap 200 MG
Acebutolol HCl Cap 400 MG
Atenolol Tab 25 MG
Atenolol Tab 50 MG
Atenolol Tab 100 MG
Bisoprolol Fumarate Tab 5 MG
Bisoprolol Fumarate Tab 10 MG
Metoprolol Succinate Tab SR 24HR 25 MG
Metoprolol Tartrate Tab 25 MG
Carvedilol Tab 3.125 MG
Carvedilol Tab 25 MG
Carvedilol Phosphate Cap SR 24HR 10 MG
Labetalol HCl Tab 100 MG
CALCIUM CHANNEL BLOCKERS
Amlodipine Besylate Tab 2.5 MG
Amlodipine Besylate Tab 5 MG
Amlodipine Besylate Tab 10 MG
Diltiazem HCl Tab 30 MG
Diltiazem HCl Cap SR 12HR 60 MG
Diltiazem HCl Extended Release Beads Cap SR 24HR 120
MG
MG
MG
MG
MG
MG
Diltiazem HCl Coated Beads Cap SR 24HR 120 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
INDERAL LA
BETAPACE
BETAPACE
BETAPACE
BETAPACE
BETAPACE AF
BETAPACE AF
BETAPACE AF
Covered Brand
Product
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
NORVASC
NORVASC
NORVASC
CARDIZEM
CARDIZEM
CARDIZEM
CARDIZEM
DILACOR XR
DILACOR XR
DILACOR XR
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Generic
TIAZAC
Daily Dosage=1
Generic
TIAZAC
Daily Dosage=1
Generic
TIAZAC
Daily Dosage=2
Generic
TIAZAC
Daily Dosage=1
Generic
TIAZAC
Daily Dosage=1
Generic
Generic
Generic
Generic
Generic
TIAZAC
CARDIZEM CD
CARDIZEM CD
CARDIZEM CD
CARDIZEM CD
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
SECTRAL
SECTRAL
TENORMIN
TENORMIN
TENORMIN
ZEBETA
ZEBETA
TOPROL XL
TOPROL XL
TOPROL XL
TOPROL XL
LOPRESSOR
LOPRESSOR
COREG
COREG
COREG
COREG
COREG CR
COREG CR
COREG CR
COREG CR
TRANDATE
TRANDATE
TRANDATE
17
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Daily Dosage=3
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=4
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=3
Daily Dosage=6
Daily Dosage=8
Felodipine Tab SR 24HR 2.5 MG
Felodipine Tab SR 24HR 5 MG
Felodipine Tab SR 24HR 10 MG
Nicardipine HCl Cap 20 MG
Nicardipine HCl Cap 30 MG
Nifedipine Cap 10 MG
Nifedipine Cap 20 MG
Nifedipine Tab SR 24HR 30 MG
Nifedipine Tab SR 24HR Osmotic 30 MG
Verapamil HCl Tab 40 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Verapamil HCl Tab CR 120 MG
Generic
Generic
Verapamil HCl Cap SR 24HR 120 MG
Generic
Generic
Generic
Generic
Generic
ANTIARRHYTHMICS
Disopyramide Phosphate Cap 100 MG
Disopyramide Phosphate Cap 150 MG
Disopyramide Phosphate Cap SR 12HR 150 MG
Procainamide HCl Tab CR 750 MG
Quinidine Gluconate Tab CR 324 MG
Quinidine Sulfate Tab 200 MG
Quinidine Sulfate Tab 300 MG
Quinidine Sulfate Tab CR 300 MG
Mexiletine HCl Cap 150 MG
Flecainide Acetate Tab 50 MG
Propafenone HCl Tab 150 MG
Amiodarone HCl Tab 200 MG
Dofetilide Cap 125 MCG (0.125 MG)
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
NORPACE
NORPACE
NORPACE
ANTIHYPERTENSIVES
Benazepril HCl Tab 5 MG
Captopril Tab 12.5 MG
Captopril Tab 25 MG
Captopril Tab 50 MG
Captopril Tab 100 MG
Enalapril Maleate Tab 2.5 MG
Enalapril Maleate Tab 5 MG
Fosinopril Sodium Tab 10 MG
Lisinopril Tab 2.5 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LOTENSIN
LOTENSIN
LOTENSIN
LOTENSIN
Product Description
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
PROCARDIA
Daily Dosage=4
Daily Dosage=4
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
ADALAT CC
ADALAT CC
ADALAT CC
PROCARDIA XL
PROCARDIA XL
PROCARDIA XL
CALAN
CALAN
CALAN SR, ISOPTIN
SR
CALAN SR, ISOPTIN
SR
CALAN SR, ISOPTIN
SR
VERELAN
VERELAN
VERELAN
VERELAN
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
PROCAINAMIDE
TAMBOCOR
TAMBOCOR
TAMBOCOR
RYTHMOL
RYTHMOL
RYTHMOL
CORDARONE
TIKOSYN
TIKOSYN
TIKOSYN
VASOTEC
VASOTEC
VASOTEC
VASOTEC
MONOPRIL
MONOPRIL
ZESTRIL
18
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Lisinopril Tab 5 MG
Generic
PRINIVIL, ZESTRIL
Daily Dosage=2
Lisinopril Tab 10 MG
Generic
PRINIVIL, ZESTRIL
Daily Dosage=2
Quinapril HCl Tab 5 MG
Ramipril Cap 1.25 MG
Ramipril Cap 2.5 MG
Ramipril Cap 5 MG
Ramipril Cap 10 MG
Trandolapril Tab 1 MG
Irbesartan Tab 150MG
Irbesartan Tab 300MG
Irbesartan Tab 75MG
Losartan Potassium Tab 25 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PRINIVIL, ZESTRIL
ZESTRIL
ZESTRIL
ACCUPRIL
ACCUPRIL
ACCUPRIL
ACCUPRIL
ALTACE
ALTACE
ALTACE
ALTACE
MAVIK
MAVIK
MAVIK
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Valsartan Tab 40 MG
Brand
DIOVAN
Step Therapy; Daily Dosage=1
Valsartan Tab 80 MG
Brand
DIOVAN
Valsartan Tab 160 MG
Brand
DIOVAN
Valsartan Tab 320 MG
Clonidine HCl Tab 0.1 MG
Guanabenz Acetate Tab 4 MG
Guanabenz Acetate Tab 8 MG
Guanfacine HCl Tab 1 MG
Guanfacine HCl Tab 2 MG
Methyldopa Tab 250 MG
Methyldopa Tab 500 MG
Doxazosin Mesylate Tab 1 MG
Prazosin HCl Cap 1 MG
Terazosin HCl Cap 1 MG
Reserpine Tab 0.1 MG
Reserpine Tab 0.25 MG
Hydralazine HCl Tab 10 MG
Minoxidil Tab 2.5 MG
Minoxidil Tab 10 MG
Benazepril HCl-Amlodipine Besylate Cap 10-2.5 MG
Benazepril HCl-Amlodipine Besylate Cap 10-5 MG
Benazepril HCl-Amlodipine Besylate Cap 20-5 MG
Amlodipine Besylate-Benazepril HCl Cap 10-20 MG
Benazepril & Hydrochlorothiazide Tab 5-6.25 MG
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
DIOVAN
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
COZAAR
COZAAR
COZAAR
CATAPRES
CATAPRES
CATAPRES
TENEX
TENEX
CARDURA
CARDURA
CARDURA
CARDURA
MINIPRESS
MINIPRESS
MINIPRESS
APRESOLINE
LOTREL
LOTREL
LOTREL
LOTREL
LOTENSIN HCT
LOTENSIN HCT
19
Daily Dosage=3
Daily Dosage=10
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Benazepril & Hydrochlorothiazide Tab 20-25 MG
Captopril & Hydrochlorothiazide Tab 25-15 MG
Generic
Equivalent(s)
Generic
LOTENSIN HCT
Generic
LOTENSIN HCT
Generic
Generic
Generic
Generic
Enalapril Maleate & Hydrochlorothiazide Tab 5-12.5 MG
Generic
Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG
Generic
Product Description
Covered Brand
Product
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=3
Daily Dosage=2
VASERETIC
Daily Dosage=2
Fosinopril Sodium & Hydrochlorothiazide Tab 10-12.5 MG Generic
Daily Dosage=1
Fosinopril Sodium & Hydrochlorothiazide Tab 20-12.5 MG Generic
Daily Dosage=1
PRINZIDE,
ZESTORETIC
PRINZIDE,
ZESTORETIC
ZESTORECTIC
TENORETIC
TENORETIC
ZIAC
ZIAC
LOPRESSOR HCT
LOPRESSOR HCT
Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG
Generic
Daily Dosage=2
Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG
Lisinopril & Hydrochlorothiazide Tab 20-25 MG
Atenolol & Chlorthalidone Tab 50-25 MG
Atenolol & Chlorthalidone Tab 100-25 MG
Bisoprolol & Hydrochlorothiazide Tab 5-6.25 MG
Bisoprolol & Hydrochlorothiazide Tab 10-6.25 MG
Metoprolol & Hydrochlorothiazide Tab 50-25 MG
Metoprolol & Hydrochlorothiazide Tab SR 24HR 25-12.5
MG
MG
MG
Propranolol & Hydrochlorothiazide Tab 40-25 MG
Propranolol & Hydrochlorothiazide Tab 80-25 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Irbesartan-Hydrochlorothiazide Tab 150MG/12.5MG
Generic
Daily Dosage=1
Irbesartan-Hydrochlorothiazide Tab 300MG/12.5MG
Losartan Potassium & Hydrochlorothiazide Tab 50-12.5
MG
Losartan Potassium & Hydrochlorothiazide Tab 100-12.5
MG
Losartan Potassium & Hydrochlorothiazide Tab 100-25
MG
Generic
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Brand
DUTOPROL
Daily Dosage=1
Brand
DUTOPROL
Daily Dosage=1
Brand
Generic
Generic
DUTOPROL
Daily Dosage=1
Generic
HYZAAR
Daily Dosage=1
Generic
HYZAAR
Daily Dosage=1
Generic
HYZAAR
Daily Dosage=1
Valsartan-Hydrochlorothiazide Tab 80-12.5 MG
Generic
DIOVAN HCT
Generic
DIOVAN HCT
Valsartan-Hydrochlorothiazide Tab 160-25 MG
Generic
DIOVAN HCT
Generic
DIOVAN HCT
Valsartan-Hydrochlorothiazide Tab 320-25 MG
Generic
DIOVAN HCT
DIURETICS
Acetazolamide Tab 125 MG
Acetazolamide Tab 250 MG
Acetazolamide Cap SR 12HR 500 MG
Methazolamide Tab 25 MG
Methazolamide Tab 50 MG
Bumetanide Tab 0.5 MG
Bumetanide Tab 1 MG
Bumetanide Tab 2 MG
Furosemide Tab 20 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
DIAMOX SEQUELS
NEPTAZANE
NEPTAZANE
LASIX
LASIX
20
Furosemide Oral Soln 8 MG/ML
Furosemide Oral Soln 10 MG/ML
Torsemide Tab 5 MG
Torsemide Tab 10 MG
Torsemide Tab 20 MG
Torsemide Tab 100 MG
Amiloride HCl Tab 5 MG
Spironolactone Tab 25 MG
Chlorothiazide Tab 250 MG
Chlorothiazide Tab 500 MG
Chlorthalidone Tab 25 MG
Hydrochlorothiazide Cap 12.5 MG
Hydrochlorothiazide Tab 25 MG
Hydrochlorothiazide Tab 50 MG
Indapamide Tab 1.25 MG
Indapamide Tab 2.5 MG
Metolazone Tab 2.5 MG
Metolazone Tab 5 MG
Metolazone Tab 10 MG
Amiloride & Hydrochlorothiazide Tab 5-50 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
LASIX
Spironolactone & Hydrochlorothiazide Tab 25-25 MG
Triamterene & Hydrochlorothiazide Cap 37.5-25 MG
Triamterene & Hydrochlorothiazide Cap 50-25 MG
Triamterene & Hydrochlorothiazide Tab 37.5-25 MG
Triamterene & Hydrochlorothiazide Tab 75-50 MG
Generic
Generic
Generic
Generic
Generic
ALDACTAZIDE
DYAZIDE
Generic
Generic
Generic
Brand
PROAMATINE
PROAMATINE
PROAMATINE
Product Description
VASOPRESSORS
Midodrine HCl Tab 2.5 MG
Midodrine HCl Tab 5 MG
Midodrine HCl Tab 10 MG
Epinephrine Inj Device 0.15 MG/0.3ML (1:2000)
Epinephrine Inj Device 0.3 MG/0.3ML (1:1000)
ANTIHYPERLIPIDEMICS
Cholestyramine Powder 4 GM
Cholestyramine Powder Packets 4 GM
Cholestyramine Light Powder 4 GM/DOSE
Cholestyramine Light Powder Packets 4 GM
Colestipol HCl Tab 1 GM
Generic
Generic
Generic
Generic
Generic
Generic
Covered Brand
Product
DEMADEX
DEMADEX
DEMADEX
DEMADEX
MIDAMOR
ALDACTONE
ALDACTONE
ALDACTONE
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=4
Daily Dosage=2
Daily Dosage=4
MICROZIDE
ZAROXOLYN
ZAROXOLYN
Daily Dosage=1
MAXZIDE-25
MAXZIDE
EPIPEN-JR
Max Qty=1-2/30 days
ADRENACLICK,
AUVI-Q,
EPINEPHRINE,
EPINEPHRINE,
EPIPEN...
Max Qty=1-2/30 days
PA Daily Dosage=3
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Colestipol HCl Granules 5 GM
Fenofibrate Tab 54 MG
Fenofibrate Tab 160 MG
Fenofibrate Micronized Cap 67 MG
Gemfibrozil Tab 600 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QUESTRAN
QUESTRAN
QUESTRAN
QUESTRAN
COLESTID
COLESTID,
COLESTID FLA
LOFIBRA
LOFIBRA
LOFIBRA
LOFIBRA
LOFIBRA
LOPID
Atorvastatin Calcium Tab 10 MG (Base Equivalent)
Generic
LIPITOR
Daily Dosage=1; Step Therapy
Lovastatin Tab 10 MG
Pravastatin Sodium Tab 10 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LIPITOR
LIPITOR
LIPITOR
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
MEVACOR
MEVACOR
PRAVACHOL
21
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Non-Preferred Brand
Equivalent(s)
PRAVACHOL
PRAVACHOL
PRAVACHOL
ZOCOR
ZOCOR
ZOCOR
ZOCOR
Generic
PARA-TIME
Chlorpheniramine Maleate Tab 4 MG
Generic
CHLOR-TRIMETON
Chlorpheniramine Maleate Syrup 2 MG/5ML
Dexchlorpheniramine Maleate Tab CR 4 MG
Dexchlorpheniramine Maleate Syrup 2 MG/5ML
Clemastine Fumarate Tab 1.34 MG
Diphenhydramine HCl Cap 25 MG
Diphenhydramine HCl Cap 50 MG
Generic
Generic
Generic
Generic
Generic
Generic
CHLOR-TRIMETON
Diphenhydramine HCl Tab 25 MG
Diphenhydramine HCl Tab 50 MG
Generic
Generic
Product Description
Simvastatin Tab 5 MG
Niacin (Antihyperlipidemic) Tab 500 MG
Ezetimibe-Simvastatin Tab 10-10 MG
CARDIOVASCULAR AGENTS - MISC.
Papaverine HCl Cap CR 150 MG
Covered Brand
Product
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
NIACOR
VYTORIN
VYTORIN
VYTORIN
VYTORIN
PA; Daily Dosage=1
PA; Daily Dosage=1
PA; Daily Dosage=1
PA; Daily Dosage=1
ANTIHISTAMINES
Diphenhydramine HCl Liquid 12.5 MG/5ML
Diphenhydramine HCl Elixir 12.5 MG/5ML
Diphenhydramine HCl Syrup 12.5 MG/5ML
Promethazine HCl Tab 12.5 MG
Promethazine HCl Tab 25 MG
Promethazine HCl Tab 50 MG
Promethazine HCl Syrup 6.25 MG/5ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Promethazine HCl Suppos 12.5 MG
Generic
Promethazine HCl Suppos 25 MG
Generic
Promethazine HCl Suppos 50 MG
Cyproheptadine HCl Tab 4 MG
Cyproheptadine HCl Syrup 2 MG/5ML
Cetirizine HCl Tab 5 MG
Generic
Generic
Generic
Generic
Cetirizine HCl Tab 10 MG
Cetirizine HCl Chew Tab 5 MG
Generic
Generic
Cetirizine HCl Chew Tab 10 MG
Generic
Cetirizine HCl Syrup 5 MG/5ML
Generic
Fexofenadine HCl Tab 30 MG
Generic
Generic
Loratadine Tab 10 MG
Loratadine Syrup 5 MG/5ML
Generic
Generic
Generic
Loratadine Rapidly-Disintegrating Tab 10 MG
Generic
TAVIST, TAVIST-1
BENADRYL
BENADRYL,
BENADRYL ALG
BENADRYL
ALLERGY
Max Qty=120/claim
Daily Dosage=2
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Limited to Ages 2 and Older
Max Qty=12/claim
Max Qty=12/claim
Max Qty=12/claim
Daily Dosage=1
ZYRTEC, ZYRTEC
ALLGY, ZYRTEC
HIVES
ZYRTEC CHILD
ZYRTEC, ZYRTEC
CHILD
ZYRTEC CHILD,
ZYRTEC HIVES
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Max Qty=240/claim
ALLEGRA,
ALLEGRA ALRG
ALLEGRA,
ALLEGRA ALRG
CLARITIN
CLARITIN
CLARITIN,
CLARITIN RDT
NASAL AGENTS - SYSTEMIC AND TOPICAL
22
Daily Dosage=1
Max Qty=240/claim
Daily Dosage=1
Product Description
Brand/
Generic
Pseudoephedrine HCl Tab 30 MG
Pseudoephedrine HCl Tab 60 MG
Pseudoephedrine HCl Liq 15 MG/5ML
Pseudoephedrine HCl Liq 30 MG/5ML
Pseudoephedrine HCl Syrup 30 MG/5ML
Pseudoephedrine HCl Soln 7.5 MG/0.8ML
Pseudoephedrine HCl Tab SR 12HR 120 MG
Phenylephrine HCl Tab 10 MG
Phenylephrine HCl Soln 2.5 MG/5ML
Epinephrine HCl Nasal Soln 0.1%
Budesonide Nasal Susp 32 MCG/ACT
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Flunisolide Nasal Soln 0.025%
Flunisolide Nasal Soln 29 MCG/ACT
Generic
Generic
Fluticasone Propionate Nasal Susp 50 MCG/ACT
Generic
Mometasone Furoate Nasal Susp 50 MCG/ACT
Brand
Triamcinolone Acetonide Nasal Inhal 55 MCG/ACT
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
SUDAFD NASAL,
SUDAFED,
SUDAFED CONG
SUDAFED CHLD
PEDIACARE
Max Qty=62/31 days
Max Qty=24/claim
Max Qty=120/claim
SUDAFED PE
PEDIACARE
ADRENALIN
RHINOCORT
FLUNISOLIDE,
NASALIDE
Max Qty=9/30 days
Max Qty=25/30 days
FLONASE
NASONEX
NASACORT AQ
Min DS=12; Package
Limit=1/claim
Max Qty=17/30 days; Age 4 and
Older=Step Therapy
Max Qty=17/30 days; Age 4 and
Older=Step Therapy
Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY) Generic
ATROVENT NASAL
Max Qty=31/30 days
Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) Generic
ATROVENT NASAL
Max Qty=15/30 days
Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)
Saline Nasal Spray 0.65%
NASALCROM
OCEAN NASAL
Max Qty=26/30 days
Generic
Generic
COUGH/COLD/ALLERGY
Hydrocodone w/ Homatropine Syrup 5-1.5 MG/5ML
Generic
Benzonatate Cap 100 MG
Generic
TESSALON PERLES
Benzonatate Cap 200 MG
Dextromethorphan HBr Liquid 7.5 MG/5ML
Generic
Generic
TESSALON
TRIAMINIC
Dextromethorphan Polistirex Liquid CR 30 MG/5ML
Guaifenesin Syrup 100 MG/5ML
Generic
Generic
DELSYM
ROBITUSSIN)
Fills=1/30 days
Max Qty=240/6 days
Max Qty=240/6 days
Max Qty=240/6 days
Guaifenesin Tab SR 12HR 600 MG
Guaifenesin Tab SR 12HR 1200 MG
Acetylcysteine Inhal Soln 10%
Acetylcysteine Inhal Soln 20%
Sodium Chloride Soln Nebu 0.45%
Sodium Chloride Soln Nebu 0.9%
Sodium Chloride Soln Nebu 3%
Sodium Chloride Soln Nebu 10%
Sodium Chloride Aero Soln 0.9%
Pseudoephedrine w/ Acetaminophen Liquid 15-160
MG/5ML
Generic
Brand
Generic
Generic
Brand
Generic
Generic
Generic
Generic
HUMIBID, MUCINEX
DURATUSS G
MUCINEX
Brand
CEPACOL CHLD
Pseudoephedrine-Ibuprofen Tab 30-200 MG
Pseudoephedrine-Ibuprofen Susp 15-100 MG/5ML
Phenylephrine-APAP-Caffeine Tab 5-500-75 MG
Pseudoephedrine-Methscopolamine Tab SR 12HR 120-2.5
MG
Generic
Generic
Brand
ADVIL COLD/SINUS
CHILD MOTRIN
Generic
ALLERX-D
Brompheniramine & Phenylephrine Liqd 2-5 MG/ML
Brand
Brompheniramine & Phenylephrine Elixir 1-2.5 MG/5ML
Generic
Fills=1/30 days; Daily Dosage=2
Daily Dosage=2
SODIUM CHLOR
Max Qty=240/claim
TYLENOL CHLD
MEDI-GRAINE
Max Qty=120/30 days
DECON-A
DIMETAPP CLD
23
Fills=1/30 days
Product Description
Brand/
Generic
Brompheniramine & Phenylephrine Elixir 2-5 MG/5ML
Brand
Brompheniramine & Pseudoephedrine Cap CR 6-60 MG
Generic
Brompheniramine & Pseudoephedrine Cap CR 12-120 MG
Brompheniramine & Pseudoephedrine Elixir 1-15
MG/5ML
Brompheniramine & Pseudoephedrine Syrup 4-45
MG/5ML
Brompheniramine & Pseudoephedrine Tab SR 12HR 6-45
MG
Cetirizine-Pseudoephedrine Tab SR 12HR 5-120 MG
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
DECON-A
Daily Dosage=4
BROMFED
Daily Dosage=4
Fills=1/30 days
Generic
SILDEC
Generic
Generic
LODRANE 12D
ZYRTEC-D
Max Qty=240/claim
Fills=1/30 days
Daily Dosage=2
Chlorpheniramine & Phenylephrine Liquid 1-2 MG/ML
Generic
DALLERGY
Chlorpheniramine & Phenylephrine Liquid 1-3.5 MG/ML
Generic
Generic
Daily Dosage=1
Max Qty=30/claim
Chlorpheniramine & Phenylephrine Syrup 4-12.5 MG/5ML Generic
Max Qty=240/claim
Chlorpheniramine & Pseudoephedrine Cap CR 8-120 MG
Chlorpheniramine & Pseudoephedrine Liquid 2-30
MG/5ML
Chlorpheniramine & Pseudoephedrine Syrup 2-30
MG/5ML
Daily Dosage=2
Generic
Brand
LOHIST-D, HISTEX
Max Qty=240/claim
Brand
CPM/PSE
Max Qty=240/claim
Chlorpheniramine & Pseudoephedrine Soln 2-30 MG/5ML Generic
Chlorpheniramine Tan-Phenylephrine Tan Susp 4.5-5
MG/5ML
Generic
Daily Dosage=10-20
RYNATAN PED
Diphenhydramine & Pseudoephedrine Cap CR 25-60 MG
Brand
BENAPHEN
Diphenhydramine & Pseudoephedrine Tab 25-60 MG
Generic
Loratadine & Pseudoephedrine Tab SR 12HR 5-120 MG
Generic
CLARITIN-D
Loratadine & Pseudoephedrine Tab SR 24HR 10-240 MG
Generic
CLARITIN-D
Promethazine & Phenylephrine Syrup 6.25-5 MG/5ML
Chlorphen Tan-Pyrilamine Tan-PE Tan Susp 2-12.5-5
MG/5ML
Chlorpheniramine-PE-Methscopolamine Chew Tab 2-101.25 MG
Chlorphen-PE-Methscopolamine Syrup 2-10-0.625
MG/5ML
Chlorpheniramine-PE-Methscopolamine Syrup 2-10-1.25
MG/5ML
Chlorphen-PE-Methscopolamine Tab SR 12HR 8-20-1.25
MG
Chlorphen-PE-Methscopolamine Tab SR 12HR 8-20-2.5
MG
Generic
Daily Dosage=1
Max Qty=240/6 days
Generic
NALEX-A 12
Generic
DALLERGY
Daily Dosage=20
Limited to Ages 3-7; Max
Qty=60/claim
Chlorphen-Pseudoephedrine w/ APAP Cap 2-30-325 MG
Phenir-PE w/ Sod Salicyl & Caff Cit Liq 13-4-83-25
MG/5ML
Generic
Promethazine w/ Codeine Syrup 6.25-10 MG/5ML
Phenylephrine-Promethazine w/ Codeine Syrup 5-6.25-10
MG/5ML
Phenyleph-Chlorphen w/ Hydrocodone Syrup 5-2-1.67
MG/5ML
Phenyleph-Chlorphen w/ Hydrocodone Syrup 5-2-2.5
MG/5ML
Phenyleph-Pyrilamine w/ Hydrocodone Syrup 5-8.33-1.66
MG/5ML
Acetaminophen w/ DM Liq 160-5 MG/5ML
Phenylephrine-DM Syrup 2.5-5 MG/5ML
Generic
Generic
Generic
Max Qty=248/31 days
DEHISTINE
Generic
Generic
Brand
Brand; Daily Dosage=2
Max Qty=240/6 days
Max Qty=62/31 days
DALLERGY PE
Max Qty=62/31 days
SCOT-TUSSIN
Max Qty=240/claim
Max Qty=240/claim
Generic
Generic
Max Qty=240/claim
Generic
Max Qty=240/claim
Generic
Generic
Generic
Max Qty=240/claim
TRIAMINIC
24
Max Qty=240/claim
Phenylephrine-DM Syrup 2.5-5 MG/5ML
Pseudoephedrine-DM Liqd 15-7.5 MG/5ML
Pseudoephedrine-DM Elixir 20-10 MG/5ML
Brand/
Generic
Generic
Generic
Brand
Pseudoephedrine-DM Soln 7.5-2.5 MG/0.8ML
Chlorpheniramine-DM Liquid 2-15 MG/5ML
Chlorpheniramine-DM Syrup 1-7.5 MG/5ML
Generic
Generic
Brand
Product Description
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
DEXATREX D
DIMETAPP
Promethazine-DM Syrup 6.25-15 MG/5ML
Generic
Phenylephrine-Chlorphen-DM Chew Tab SR 12HR 30-4-30
MG
Brand
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Qty=30/6 days
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
ED DM
Phenylephrine-Chlorphen-DM Liquid 1.5-1-3 MG/ML
Generic
DONATUSSIN
Phenylephrine-Chlorphen-DM Liquid 10-2-15 MG/5ML
Generic
Phenylephrine-Chlorphen-DM Liquid 10-4-15 MG/5ML
Generic
Phenylephrine-Chlorphen-DM Liquid 3.5-1-3 MG/ML
Generic
Phenylephrine-Chlorphen-DM Syrup 5-2-15 MG/5ML
Generic
Generic
Max Qty=240/claim
Generic
Max Qty=240/claim
Phenylephrine-Chlorphen-DM Syrup 12.5-4-15 MG/5ML
Generic
Max Qty=240/claim
Phenylephrine-Chlorphen-DM Tab SR 12HR 20-8-30 MG
Generic
PHENABID DM
Phenylephrine-Pyrilamine-DM Syrup 5-8.33-10 MG/5ML
Pseudoephed-Chlorphen-DM Liq 15-1-5 MG/5ML
Generic
Generic
CODITUSS DM
Max Qty=240/claim
Max Qty=240/claim
Pseudoephed-Chlorphen-DM Liq 15-1-7.5 MG/5ML
Generic
TRIAMINIC
Max Qty=240/claim
Pseudoephed-Bromphen-DM Liquid 30-1-20 MG/5ML
Brand
Pseudoephed-Bromphen-DM Elixir 15-1-5 MG/5ML
Generic
Max Qty=240/claim
Pseudoephed-Bromphen-DM Syrup 30-2-10 MG/5ML
Generic
Max Qty=240/claim
Pseudoephed-Bromphen-DM Syrup 45-4-15 MG/5ML
Pseudoeph-Chlorphen-DM w/ APAP Syrup 60-4-30-500
MG/20ML
Pseudoeph-Doxylamine-DM w/ APAP Cap 30-6.25-15-325
MG
Pseudoeph-Doxylamine-DM w/ APAP Liq 60-7.5-301000MG/30ML
Pseudoeph-Doxylamine-DM w/APAP Liquid 60-12.5-301000MG/30ML
Phenylephrine-Guaifenesin Liqd 5-100 MG/5ML
Phenylephrine-Potassium Guaiacolsulfonate Liqd 5-75
MG/5ML
Generic
Max Qty=240/claim
Pseudoephedrine-Guaifenesin Syrup 30-100 MG/5ML
Generic
Pseudoephedrine-Guaifenesin Tab SR 12HR 60-600 MG
Generic
Pseudoephedrine-Guaifenesin Tab SR 12HR 120-600 MG
Generic
Max Qty=240/claim
Max Qty=240/claim
Max Qty=30/6 days; Package
Limit=2/31 days
POLY-TUSSIN
Max Qty=240/claim
DELTUSS DMX
Brand
MULTIDEXOL M
Generic
Generic
NYQUIL
Generic
Generic
RESCON-GG
Brand
Max Qty=240/claim
MUCINEX D
Max Qty=210/claim
Max Qty=210/claim
MUCINEX D
Generic
Generic
Generic
Max Qty=240/6 days
KGS-PE
Pseudoephedrine-Guaifenesin Tab SR 12HR 120-1200 MG Brand
Phenylephrine-Chlorphen-GG Soln 2-1-20 MG/ML
Dextromethorphan-Phenylephrine-APAP Cap 10-5-325
MG
Pseudoephedrine w/ APAP-DM Cap 30-325-15 MG
Max Qty=60/6 days
DAY TIME
25
Daily Dosage=2
Qty=30/6 days
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Pseudoephedrine w/ APAP-DM Liq 60-650-20 MG/30ML Generic
DIABETIC TUS,
TUSSO-C
Guaifenesin-Codeine Liquid 200-10 MG/5ML
Guaifenesin-Codeine Liquid 300-10 MG/5ML
Guaifenesin-Codeine Soln 100-10 MG/5ML
Dextromethorphan-Pot Guaiacolsulfonate Liqd 15-300
MG/5ML
Generic
Generic
Generic
TUSSI-ORGANI
Brand
PROLEX DM
Dextromethorphan-Guaifenesin Liquid 5-100 MG/5ML
Generic
Generic
Generic
Brand
Generic
Brand
Generic
Dextromethorphan-Guaifenesin Elixir 20-200 MG/5ML
Brand
Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML
Generic
Dextromethorphan-Guaifenesin Syrup 15-100 MG/5ML
Generic
Dextromethorphan-Guaifenesin Tab SR 12HR 30-600 MG Generic
Hydrocodone-Guaifenesin Syrup 5-100 MG/5ML
Generic
CHERACOL,
CHERACOL-D
ROBITUSSIN,
ROBITUSSN DM
Max Qty=240/claim
Max Qty=240/claim
BIOSPEC DMX,
TRISPEC DMX
NORTUSS-EX
HT-TUSS DM
ROBITUSSN DM
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Dosage=2
Max Qty=240/claim
CORICIDAN CO,
MUCINEX DM
Pseudoephedrine w/ COD-GG Soln 30-10-100 MG/5ML Generic
Max Qty=240/6 days
Pseudoephedrine w/ DM-GG Liquid 30-10-100 MG/5ML
Phenyleph-Chlorphen w/ DM-GG Syrup 10-2-7.5-100
MG/5ML
Phenyleph-Chlorphen w/ DM-GG Syrup 10-2-15-100
MG/5ML
Pseudoephedrine-DM-GG w/ APAP Liq 30-10-100-324
MG/15ML
Dextromethorphan-APAP-Chlorpheniramine Cap 15-325-4
MG
Generic
Max Qty=240/6 days
Generic
Max Qty=248/31 days
Dextromethorphan-Doxylamine-APAP Liquid 30-12.51000 MG/30ML
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Ipratropium Bromide Inhal Soln 0.02%
Generic
DONATUSSIN
Max Qty=240/claim
Generic
Brand
Generic
DIABETIC
CLEAR COUGH,
TYLENOL CGH,
TYLENOL WARM
Generic
Max Qty=375/25 days
Ipratropium Bromide HFA Inhal Aerosol 17 MCG/ACT
Tiotropium Bromide Monohydrate Inhal Cap 18 MCG
(Base Equiv)
Cromolyn Sodium Soln Nebu 20 MG/2ML
Cromolyn Sodium Inhal Aerosol Soln 800 MCG/ACT (1
MG/Valve)
Albuterol Sulfate Tab 2 MG
Albuterol Sulfate Tab 4 MG
Albuterol Sulfate Syrup 2 MG/5ML
Albuterol Sulfate Soln Nebu 0.083%
Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML)
Brand
ATROVENT HFA
Brand
Generic
SPIRIVA
Albuterol Sulfate Soln Nebu 0.63 MG/3ML (Base Equiv)
Generic
ACCUNEB
Max Qty=375/30 days
Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv)
Albuterol Sulfate Inhal Aero 120 MCG/ACT (100MCG
Base Equiv)
Generic
ACCUNEB
Max Qty=375/30 days
Generic
PROVENTIL HFA
Brand
Generic
Generic
Generic
Generic
Generic
INTAL 112, INTAL
200, INTAL INH
Package Limit=2/month
Min DS=25; Package
Limit=1/claim
Daily Dosage=8
Min DS=25; Package
Limit=1/claim
VENTOLIN
Daily Dosage=12.5
26
PROAIR, VENTOLIN
HFA
Product Description
Albuterol Sulfate Tab SR 12HR 4 MG
Albuterol Sulfate Tab SR 12HR 8 MG
Generic
Equivalent(s)
Generic
VOSPIRE ER
Generic
VOSPIRE ER
Covered Brand
Product
Formoterol Fumarate Inhal Cap 12 MCG
Metaproterenol Sulfate Tab 10 MG
Metaproterenol Sulfate Tab 20 MG
Metaproterenol Sulfate Syrup 10 MG/5ML
Salmeterol Xinafoate Aer Pow BA 50 MCG/DOSE (Base
Equiv)
Terbutaline Sulfate Tab 2.5 MG
Terbutaline Sulfate Tab 5 MG
Brand
Generic
Generic
Generic
FORADIL
Min DS=30; Package
Limit=1/claim
Brand
Generic
Generic
SEREVENT DIS
Daily Dosage=30
Min DS=30; Package
Limit=1/claim
BRETHINE
BRETHINE
Ipratropium-Albuterol Nebu Soln 0.5-2.5(3) MG/3ML
Ipratropium-Albuterol Aerosol 18-103 MCG/ACT (20120MCG/ACT)
Ipratropium-Albuterol Inhal Aerosol Soln 20-100
MCG/ACT
Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5
MCG/ACT
Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5
MCG/ACT
Generic
DUONEB
Daily Dosage=12
Brand
COMBIVENT
Daily Dosage=1
Brand
COMBIVENT
Max Qty=8/30 days
Brand
SYMBICORT
Max Qty=11/claim
Brand
SYMBICORT
Max Qty=11/claim
Fluticasone-Salmeterol Inhal Aerosol 45-21 MCG/ACT
Brand
ADVAIR HFA
Max Qty=12/claim
Brand
ADVAIR HFA
Max Qty=12/claim
Fluticasone-Salmeterol Aer Powder BA 100-50
MCG/DOSE
MCG/DOSE
MCG/DOSE
Mometasone Furoate-Formoterol Fumarate Aerosol 100-5
MCG/ACT
Mometasone Furoate-Formoterol Fumarate Aerosol 200-5
MCG/ACT
Aminophylline Tab 100 MG
Aminophylline Tab 200 MG
Dyphylline Tab 400 MG
Theophylline Elixir 80 MG/15ML
Theophylline Solution 80 MG/15ML
Theophylline Cap SR 12HR 125 MG
Theophylline Tab SR 12HR 100 MG
Brand
ADVAIR HFA
Max Qty=12/claim
Brand
ADVAIR DISKU
Brand
ADVAIR DISKU
Min DS=30; Package
Limit=60/claim
Brand
ADVAIR DISKU
Brand
DULERA
Max Qty=13/claim
Brand
Generic
Generic
Brand
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Generic
Generic
DULERA
Max Qty=13/claim
Beclomethasone Dipropionate Inhal Aero Soln 40
MCG/ACT
Beclomethasone Dipropionate Inhal Aero Soln 80
MCG/ACT
Generic
Generic
Generic
Generic
Budesonide Inhalation Susp 0.25 MG/2ML
Generic
PULMICORT
Budesonide Inhalation Susp 0.5 MG/2ML
Generic
PULMICORT
Budesonide Inhalation Susp 1 MG/2ML
Budesonide Inhal Aero Powd 90 MCG/ACT (Breath
Activated)
Brand
PULMICORT
Brand
PULMICORT
LUFYLLIN
Max Qty=475/claim
THEO-24
THEO-24
THEO-24
THEO-24
THEO-DUR
QUIBRON-T SR,
THEO-DUR
UNIPHYL
UNIPHYL
Brand
QVAR
Brand
QVAR
27
Max Qty=120/claim
Max Qty=120/claim
Max Qty=60/30 days
Min DS=25; Package
Limit=1/claim
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Budesonide Inhal Aero Powd 180 MCG/ACT (Breath
Activated)
Brand
PULMICORT
Fluticasone Propionate Aer Pow BA 50 MCG/BLISTER
Brand
FLOVENT DISK
Daily Dosage=2
Brand
FLOVENT DISK
Daily Dosage=2
Brand
FLOVENT DISK
Daily Dosage=2
Fluticasone Propionate HFA Inhal Aerosol 44 MCG/ACT Brand
FLOVENT HFA
Max Qty=11/25 days
Fluticasone Propionate HFA Inhal Aerosol 110 MCG/ACT Brand
FLOVENT HFA
Max Qty=12/25 days
FLOVENT HFA
Fluticasone Propionate HFA Inhal Aerosol 220 MCG/ACT
Montelukast Sodium Tab 10 MG (Base Equiv)
Montelukast Sodium Chew Tab 4 MG (Base Equiv)
Montelukast Sodium Chew Tab 5 MG (Base Equiv)
Montelukast Sodium Oral Granules Packet 4 MG (Base
Equiv)
LAXATIVES
Magnesium Hydroxide Susp 400 MG/5ML
Magnesium Citrate Soln
*Sodium Phosphates - Enema***
Bisacodyl Tab Delayed Release 5 MG
Bisacodyl Suppos 10 MG
Senna Tab 187 MG
Senna Powder
Sennosides Tab 8.6 MG
Calcium Polycarbophil Tab 625 MG
Psyllium Cap 0.52 GM
Psyllium Powder 28%
Psyllium Powder 28.3%
Psyllium Powder 30%
Psyllium Powder 33%
Psyllium Powder 50%
Psyllium Powder 68%
Psyllium Powder 100%
Docusate Sodium Cap 50 MG
Docusate Sodium Tab 100 MG
Docusate Sodium Liquid 150 MG/15ML
Docusate Sodium Syrup 60 MG/15ML
Glycerin Suppos 1.5 GM
Glycerin Suppos 2 GM
Glycerin Suppos 3 GM
Lactulose Solution 10 GM/15ML
Polyethylene Glycol 3350 Oral Powder
Sorbitol Oral Solution 70%
Phenolphthalein-DSS Tab 65-100 MG
Sennosides-Docusate Sodium Tab 8.6-50 MG
PEG 3350-KCl-Sod Bicarb-NaCl For Soln 420 GM
Bisacodyl Tab & PEG 3350-KCl-Sod Bicarb-NaCl For Soln
Kit
PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236
GM
PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 240
GM
ANTIDIARRHEALS
Diphenoxylate w/ Atropine Tab 2.5-0.025 MG
Diphenoxylate w/ Atropine Liq 2.5-0.025 MG/5ML
Min DS=25; Package
Limit=1/claim
Brand
Generic
Generic
Generic
SINGULAIR
SINGULAIR
SINGULAIR
Max Qty=12/25 days
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Generic
SINGULAIR
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Max Qty=992/31 days
FLEET
DULCOLAX
DULCOLAX
GENTLAX
SENOKOT,
SENOKOT 2GO
FIBERCON
METAMUCIL
Daily Dosage=1
Max Qty=12/claim
Daily Dosage=10
METAMUCIL
EVAC, KONSYL
COLACE
COLACE
Daily Dosage=3
Daily Dosage=3
COLACE
COLACE
Max Qty=12/claim
GLYCERIN
Max Qty=24/claim
MIRALAX
Daily Dosage=34
SENOKOT S
NULYTELY
Daily Dosage=4
Generic
HALFLYTELY
Generic
Generic
GOLYTELY
COLYTE,
COLYTE/FLAVOR
Generic
Generic
LOMOTIL
LOMOTIL
28
Product Description
Loperamide HCl Cap 2 MG
Loperamide HCl Tab 2 MG
Loperamide HCl Liq 1 MG/5ML
Attapulgite Liq 750 MG/15ML
Attapulgite Susp 750 MG/15ML
Bismuth Subsalicylate Chew Tab 262 MG
Bismuth Subsalicylate Susp 527 MG/30ML
ANTACIDS
Aluminum Hydroxide Gel Susp 320 MG/5ML
Aluminum Hydroxide Gel Susp 600 MG/5ML
Sodium Bicarbonate Tab 325 MG
Sodium Bicarbonate Tab 650 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
IMODIUM A-D
Daily Dosage=2
KAOPECTATE
PEPTO-BISMOL
PEPTO-BISMOL
Generic
Generic
Generic
Generic
Max Qty=496/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Generic
Generic
TUMS, TUMS
LASTING
MAG-OX 400
Generic
MAALOX SUS
Max Qty=744/31 days
Generic
MYLANTA
Max Qty=720/30 days
Generic
Generic
Generic
Generic
Generic
LEVSIN
LEVSIN/SL
Hyoscyamine Sulfate Orally Disintegrating Tab 0.125 MG
Hyoscyamine Sulfate Tab SR 12HR 0.375 MG
Glycopyrrolate Tab 1 MG
Glycopyrrolate Tab 2 MG
Dicyclomine HCl Cap 10 MG
Dicyclomine HCl Tab 20 MG
Dicyclomine HCl Oral Soln 10 MG/5ML
Belladonna Alkaloids-Phenobarbital Tab 16.2 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ANASPAZ
LEVBID
ROBINUL
ROBINUL FORTE
BENTYL
BENTYL
BENTYL
DONNATAL
Belladonna Alkaloids-Phenobarbital Elixir 16.2 MG/5ML
Generic
Calcium Carbonate (Antacid) Chew Tab 500 MG
Magnesium Oxide Tab 400 MG
Aluminum & Magnesium Hydroxides Susp 225-200
MG/5ML
Alum & Mag Hydroxide-Simethicone Susp 200-200-20
MG/5ML
ULCER DRUGS
Hyoscyamine Sulfate Tab 0.125 MG
Hyoscyamine Sulfate Tab SL 0.125 MG
Hyoscyamine Sulfate Elixir 0.125 MG/5ML
Hyoscyamine Sulfate Soln 0.125 MG/ML
Hyoscyamine Sulfate Cap SR 12HR 0.375 MG
LEVSINEX
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Max Qty=496/31 days
TAGAMET,
TAGAMET HB
Cimetidine Tab 200 MG
Cimetidine HCl Soln 300 MG/5ML
Ranitidine HCl Cap 150 MG
Ranitidine HCl Cap 300 MG
Ranitidine HCl Tab 75 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Ranitidine HCl Syrup 75 MG/5ML
Famotidine Tab 10 MG
Generic
Generic
ZANTAC
PEPCID AC
Nizatidine Tab 75 MG
Misoprostol Tab 100 MCG
Misoprostol Tab 200 MCG
Generic
Generic
Brand
Generic
Generic
PEPCID, PEPCID AC
PEPCID
Lansoprazole Cap Delayed Release 15 MG
Lansoprazole Tab Delayed Release Orally Disintegrating 15
MG
Lansoprazole Tab Delayed Release Orally Disintegrating 30
MG
Omeprazole Delayed Release Tab 20 MG
Omeprazole Cap Delayed Release 20 MG
Omeprazole Cap Delayed Release 40 MG
Generic
Daily Dosage=2
Daily Dosage=1
Daily Dosage=2
ZANTAC
ZANTAC
ZANTAC
ZANTAC
Daily Dosage=20
AXID AR
CYTOTEC)
CYTOTEC
PREVACID,
PREVACID 24H
Generic
PREVACID
Generic
Generic
Generic
Generic
PREVACID
PRILOSEC
PRILOSEC
29
Daily Dosage=4
Daily Dosage=1
Daily Dosage=1
Daily Dosage=4
Daily Dosage=4
Daily Dosage=2
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Omeprazole Magnesium Delayed Release Tab 20 MG (Base
Equiv)
Brand
PRILOSEC OTC
Omeprazole Suspension Compounding Kit 2MG/ML
Sucralfate Tab 1 GM
Brand
Generic
CARAFATE
Sucralfate Susp 1GM/10ML
Generic
CARAFATE
Generic
Brand
Generic
Generic
Generic
DRAMAMINE
Ondansetron Orally Disintegrating Tab 4 MG
Generic
ZOFRAN
Ondansetron Orally Disintegrating Tab 8 MG
Generic
ZOFRAN
Ondansetron HCl Tab 4 MG
Generic
ZOFRAN
Ondansetron HCl Inj 2 MG/ML
Ondansetron HCl Inj 4 MG/2ML (2 MG/ML)
Ondansetron HCl Inj 40 MG/20ML (2 MG/ML)
Ondansetron HCl Oral Soln 4 MG/5ML
Generic
Generic
Brand
Generic
Generic
Generic
ZOFRAN
ANTIEMETICS
Dimenhydrinate Tab 50 MG
Dimenhydrinate Chew Tab 50 MG
Meclizine HCl Tab 12.5 MG
Meclizine HCl Tab 25 MG
Meclizine HCl Chew Tab 25 MG
DIGESTIVE AIDS
Pancrelipase (Lip-Prot-Amyl) DR Cap 3000-10000-16000
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Unit
Amylase-Lipase-Protease Cap 20000-4000-25000 U
GASTROINTESTINAL AGENTS - MISC.
Ursodiol Cap 300 MG
Ursodiol Tab 250 MG
Simethicone Chew Tab 80 MG
Simethicone Liquid 40 MG/0.6ML
Simethicone Susp 40 MG/0.6ML
Metoclopramide HCl Tab 5 MG
Metoclopramide HCl Tab 10 MG
Covered Brand
Product
Daily Dosage=4
Max Qty= 300/claim
Daily Dosage=4
Max Qty=420/claim
DRAMAMINE
Max Qty=24/claim
Max Qty=24/claim
ANTIVERT
ANTIVERT
BONINE
Max DS=90/365 days; Daily
Dosage=1
Dosage=1
Dosage=2
Dosage=2
Max Qty=1/14 days
ZOFRAN
ZOFRAN
ZOFRAN
ZOFRAN
Max Qty=50/31 days
Brand
ZENPEP
Brand
PANCREAZE
Generic
Brand
CREON
Brand
ZENPEP
Brand
PANCREAZE
Brand
CREON
Brand
ZENPEP
Brand
PANCREAZE
Brand
ZENPEP
Brand
PANCREAZE
Brand
CREON
Brand
Generic
ZENPEP
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ACTIGALL
URSO 250
GAS-X
Daily Dosage=7
Max Qty=31/31 days
MYLICON,
MYLICON INFANT
REGLAN
REGLAN
30
Max Qty=31/31 days
Product Description
Metoclopramide HCl Soln 5 MG/5ML
Lactulose (Encephalopathy) Solution 10 GM/15ML
Balsalazide Disodium Cap 750 MG
Mesalamine Cap CR 250 MG
Mesalamine Cap CR 500 MG
Mesalamine Tab Delayed Release 400 MG
Mesalamine Enema 4 GM
Mesalamine Sulfite-Free (SF) Enema 4 GM/60ML
Mesalamine Cap DR 400 MG
Sulfasalazine Tab 500 MG
Sulfasalazine Tab Delayed Release 500 MG
Calcium Acetate (Phosphate Binder) Cap 667 MG
URINARY ANTI-INFECTIVES
Methenamine Mandelate Tab 0.5 GM
Methenamine Mandelate Tab 1 GM
Nitrofurantoin Susp 25 MG/5ML
Nitrofurantoin Macrocrystalline Cap 50 MG
Nitrofurantoin Macrocrystalline Cap 100 MG
Brand/
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Generic
Brand
Brand
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
COLAZAL
PENTASA
PENTASA
ASACOL
SFROWASA
DELZICOL
Daily Dosage=9
Daily Dosage=8
Daily Dosage=8
Daily Dosage=12
Daily Dosage=60
Daily Dosage=6
AZULFIDINE
AZULFIDINE
PHOSLO
Generic
Generic
Generic
Generic
Generic
Nitrofurantoin Monohydrate Macrocrystalline Cap 100 MG Generic
*Methenamine-Hyos-Meth Blue-Sod Phos-Phen Sal Tab
81.6 MG***
Generic
MACROBID
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
URECHOLINE
URECHOLINE
URECHOLINE
URECHOLINE
VAGINAL PRODUCTS
Clindamycin Phosphate Vaginal Cream 2%
Generic
CLEOCIN
Metronidazole Vaginal Gel 0.75%
Butoconazole Nitrate (One Dose) Vaginal Cream 2%
Generic
Brand
METROGEL-VAG
Clotrimazole Vaginal Cream 1%
Clotrimazole Vaginal Cream 2%
Miconazole Nitrate Vaginal Cream 2%
Generic
Generic
Generic
Miconazole Nitrate Vaginal Cream 4% (200 MG/5GM)
Miconazole Nitrate Vaginal Suppos 100 MG
Miconazole Nitrate Vaginal Suppos 200 MG
Miconazole Nitrate Vaginal Supp 200 MG & 2% Cream 9
GM Kit
Terconazole Vaginal Cream 0.4%
Terconazole Vaginal Cream 0.8%
Terconazole Vaginal Suppos 80 MG
Generic
Generic
Brand
MONISTAT 3
MONISTAT 7
Generic
Generic
Generic
Generic
Tioconazole Vaginal Oint 6.5%
Generic
MONISTAT 3
TERAZOL 7
TERAZOL 3
TERAZOL 3
MONISTAT 1,
VAGISTAT-1
Brand
Brand
Generic
Brand
Brand
Daily Dosage=40
FURADANTIN
MACRODANTIN
MACRODANTIN
URINARY ANTISPASMODICS
Bethanechol Chloride Tab 5 MG
Flavoxate HCl Tab 100 MG
Oxybutynin Chloride Tab 5 MG
Oxybutynin Chloride Syrup 5 MG/5ML
Oxybutynin Chloride Tab SR 24HR 5 MG
Tolterodine Tartrate Tab 1 MG
Tolterodine Tartrate Tab 2 MG
Tolterodine Tartrate Cap SR 24HR 2 MG
Tolterodine Tartrate Cap SR 24HR 4 MG
Nonoxynol-9 Gel 2%
Nonoxynol-9 Gel 3%
Nonoxynol-9 Gel 4%
Nonoxynol-9 Vaginal Suppos 100 MG
Nonoxynol-9 Film 28%
Covered Brand
Product
DITROPAN
DITROPAN XL
DITROPAN XL
DITROPAN XL
DETROL
DETROL
DETROL LA
DETROL LA
Max Qty=93/31 days
Max Qty=496/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Daily Dosage=1
Max Qty=31/31 days
Min DS=30; Package
Limit=1/claim
GYNAZOLE-1
GYNE-LOTRIMIN,
MYCELEX-7
GYNE-LOTRIMIN
MONISTAT 7
Max Qty=45/31 days
Max Qty=31/31 days
Max Qty=45/31 days
MICONAZOLE 3
GYNOL II, SHURSEAL
GYNOL II
CONCEPTROL
ENCARE
VCF VAGINAL
31
Max Qty=45/31 days
Max Qty=7/31 days
Max Qty=3/31 days
Product Description
Nonoxynol-9 Vaginal Insert 150 MG
Estradiol Vaginal Cream 0.1 MG/GM
Estrogens, Conjugated Vaginal Cream 0.625 MG/GM
GENITOURINARY AGENTS - MISCELLANEOUS
Potassium Citrate Tab CR 540 MG (5 MEQ)
Potassium Citrate Tab CR 1080 MG (10 MEQ)
Sodium Citrate & Citric Acid Soln 500-334 MG/5ML
Phenazopyridine HCl Tab 100 MG
Phenazopyridine HCl Tab 200 MG
Pentosan Polysulfate Sodium Caps 100 MG
Sodium Chloride Irrigation Soln 0.9%
Finasteride Tab 5 MG
Tamsulosin HCl Cap 0.4 MG
Brand/
Generic
Brand
Brand
Non-Preferred Brand
Equivalent(s)
Brand
Covered Brand
Product
CONCEPTROL
ESTRACE VAG
PREMARIN VAG
Generic
Generic
UROCIT-K 5
UROCIT-K 10
Generic
Generic
Generic
Brand
Generic
Generic
Generic
CITRA-2
PYRIDIUM
PYRIDIUM
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
XANAX
XANAX
XANAX
XANAX
Max Qty=43/31 days
Limited to Female; Age 40 and
Older: Max Qty=43/30 days; Age
0-40: Max Qty=43/365 days
Max Qty=500/30 days
ELMIRON
PROSCAR
FLOMAX
Daily Dosage=3
Daily Dosage=1
Daily Dosage=2
ANTIANXIETY AGENTS
Alprazolam Tab 0.25 MG
Alprazolam Tab 0.5 MG
Alprazolam Tab 1 MG
Alprazolam Tab 2 MG
Chlordiazepoxide HCl Cap 5 MG
Clorazepate Dipotassium Tab 3.75 MG
Clorazepate Dipotassium Tab 7.5 MG
Clorazepate Dipotassium Tab 15 MG
Diazepam Tab 2 MG
Diazepam Tab 5 MG
Diazepam Tab 10 MG
Diazepam Soln 1 MG/ML
Lorazepam Tab 0.5 MG
Lorazepam Tab 1 MG
Lorazepam Tab 2 MG
Oxazepam Cap 10 MG
Oxazepam Cap 15 MG
Oxazepam Cap 30 MG
Buspirone HCl Tab 5 MG
Buspirone HCl Tab 7.5 MG
Hydroxyzine HCl Tab 10 MG
Hydroxyzine HCl Syrup 10 MG/5ML
Hydroxyzine Pamoate Cap 25 MG
Meprobamate Tab 200 MG
Meprobamate Tab 400 MG
ANTIDEPRESSANTS
Mirtazapine Tab 7.5 MG
Mirtazapine Tab 15 MG
Mirtazapine Orally Disintegrating Tab 15 MG
Phenelzine Sulfate Tab 15 MG
Tranylcypromine Sulfate Tab 10 MG
Nefazodone HCl Tab 50 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LIBRIUM
TRANXENE T
TRANXENE T
TRANXENE T
VALIUM
VALIUM
VALIUM
ATIVAN
ATIVAN
ATIVAN
BUSPAR
Package Limit=1/claim; Daily
Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=3
Daily Dosage=4
Daily Dosage=3
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
VISTARIL
VISTARIL
REMERON
REMERON
REMERON
REMERON SLTB
REMERON SLTB
REMERON SLTB
NARDIL
PARNATE
32
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Max Qty=31/31 days
Max Qty=31/31 days
Max Qty=31/31 days
Product Description
Trazodone HCl Tab 50 MG
Vilazodone HCl Tab 10 MG
Vilazodone HCl Tab Starter Kit 10 (7) & 20 (7) & 40 (16)
MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
VIIBRYD
VIIBRYD
VIIBRYD
Brand
VIIBRYD
Citalopram Hydrobromide Tab 10 MG (Base Equiv)
Generic
CELEXA
Generic
CELEXA
Citalopram Hydrobromide Oral Soln 10 MG/5ML
Generic
Generic
CELEXA
Fluoxetine HCl Cap 10 MG
Generic
PROZAC
Generic
Generic
PROZAC
PROZAC
Fluoxetine HCl Tab 10 MG
Generic
Fluoxetine HCl Solution 20 MG/5ML
Fluvoxamine Maleate Tab 25 MG
Generic
Generic
Generic
Generic
Paroxetine HCl Tab 10 MG
Generic
PAXIL
Generic
PAXIL
Generic
PAXIL
Generic
PAXIL
Paroxetine HCl Oral Susp 10 MG/5ML (Base Equiv)
Generic
PAXIL
Paroxetine HCl Tab SR 24HR 12.5 MG
Generic
PAXIL CR
Paroxetine HCl Tab SR 24HR 25 MG
Generic
PAXIL CR
Paroxetine HCl Tab SR 24HR 37.5 MG
Generic
PAXIL CR
Sertraline HCl Tab 25 MG
Generic
ZOLOFT
Generic
ZOLOFT
Generic
ZOLOFT
Sertraline HCl Oral Conc 20 MG/ML
Venlafaxine HCl Tab 25 MG
Venlafaxine HCl Tab 37.5 MG
Venlafaxine HCl Cap SR 24HR 37.5 MG
Venlafaxine HCl Cap SR 24HR 75 MG
Venlafaxine HCl Cap SR 24HR 150 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ZOLOFT
Daily Dosage=2
PA; Daily Dosage=1
PA; Daily Dosage=1
PA; Daily Dosage=1
PA; Max Qty=30/365 days
Max Fills=1/30 days; Daily
Dosage=1.5
Dosage=1.5
Dosage=1
Max Fills=1/30 days
Max Fills=1/30 days; Max
Qty=124/31 days
Qty=124/31 days
Max Fills=1/30 days; PA
Max Fills=1/30 days; Limited to
Ages 12 and Under; Daily
Dosage=1
Max Fills=1/30 days; Limited to
Ages 6 and Under; Max
Qty=120/claim
Max Qty=62/31 days
Max Qty=62/31 days
Daily Dosage=3
Qty=62/31 days
Dosage=2
Qty=62/31 days
Qty=62/31 days
Max Fills=1/30 days; PA; Daily
Dosage=40
Qty=31/31 days
Qty=31/31 days
Qty=31/31 days
Dosage=1
Dosage=1.5
Dosage=2
Qty=186/31 days
EFFEXOR
EFFEXOR
EFFEXOR XR
EFFEXOR XR
EFFEXOR XR
33
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Venlafaxine HCl Tab SR 24HR 37.5 MG (Base Equivalent) Generic
VENLAFAXINE
Daily Dosage=1
Venlafaxine HCl Tab SR 24HR 75 MG (Base Equivalent)
Generic
VENLAFAXINE
Daily Dosage=1
Venlafaxine HCl Tab SR 24HR 150 MG (Base Equivalent) Generic
VENLAFAXINE
Daily Dosage=2
Venlafaxine HCl Tab SR 24HR 225 MG (Base Equivalent)
Amitriptyline HCl Tab 10 MG
Amoxapine Tab 25 MG
Amoxapine Tab 50 MG
Amoxapine Tab 100 MG
Amoxapine Tab 150 MG
Clomipramine HCl Cap 25 MG
Desipramine HCl Tab 10 MG
Doxepin HCl Cap 10 MG
Doxepin HCl Conc 10 MG/ML
Imipramine HCl Tab 10 MG
Nortriptyline HCl Cap 10 MG
Nortriptyline HCl Soln 10 MG/5ML
Maprotiline HCl Tab 25 MG
Bupropion HCl Tab 75 MG
Bupropion HCl Tab 100 MG
Bupropion HCl Tab SR 12HR 100 MG
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Daily Dosage=1
ANAFRANIL
ANAFRANIL
ANAFRANIL
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
Daily Dosage=2
TOFRANIL
TOFRANIL
TOFRANIL
PAMELOR
PAMELOR
PAMELOR
PAMELOR
PAMELOR
Daily Dosage=20
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
WELLBUTRIN
Daily Dosage=3
Daily Dosage=3
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
PA
Daily Dosage=1
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Risperidone Tab 0.25 MG
Generic
RISPERDAL
Risperidone Tab 0.5 MG
Generic
RISPERDAL
Risperidone Tab 1 MG
Generic
RISPERDAL
Generic
RISPERDAL
Generic
RISPERDAL
Generic
RISPERDAL
34
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Risperidone Soln 1 MG/ML
Generic
RISPERDAL
Risperidone Orally Disintegrating Tab 0.25 MG
Generic
Risperidone Orally Disintegrating Tab 0.5 MG
Generic
RISPERDAL M
Risperidone Orally Disintegrating Tab 1 MG
Generic
RISPERDAL M
Generic
RISPERDAL M
Generic
RISPERDAL M
Haloperidol Tab 0.5 MG
Haloperidol Tab 1 MG
Haloperidol Lactate Oral Conc 2 MG/ML
Haloperidol Decanoate IM Soln 50 MG/ML
Haloperidol Decanoate IM Soln 100 MG/ML
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
RISPERDAL M
Clozapine Tab 25 MG
Generic
CLOZARIL
Clozapine Tab 50 MG
Generic
Clozapine Tab 100 MG
Generic
Clozapine Tab 200 MG
Generic
Quetiapine Fumarate Tab 25 MG
Generic
SEROQUEL
Generic
SEROQUEL
Covered Brand
Product
Daily Dosage=4
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
HALDOL DECAN
HALDOL DECAN
CLOZARIL
Generic
SEROQUEL
Generic
SEROQUEL
Generic
SEROQUEL
Loxapine Succinate Cap 5 MG
Generic
Generic
Generic
Generic
Generic
SEROQUEL
LOXITANE
LOXITANE
LOXITANE
LOXITANE
Olanzapine Tab 2.5 MG
Generic
ZYPREXA
Olanzapine Tab 5 MG
Generic
ZYPREXA
Olanzapine Tab 7.5 MG
Generic
ZYPREXA
Olanzapine Tab 10 MG
Generic
ZYPREXA
35
Max Qty=93/31 days
Max Qty=93/31 days
Daily Dosage=9
Daily Dosage=3
Step Therapy; Limited to Ages
10 and Older; Ages 18-64: Max
Fills=1/year
10 and Older; Ages 18-64: Max
Fills=1/year
10 and Older; Max Qty=62/31
days; Daily Dosage=2
days
days; Daily Dosage=2
days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Fills=1/30 days; Step
Therapy; Limited to Ages 13 and
Older; Daily Dosage=1
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Generic
ZYPREXA
Molindone HCl Tab 5 MG
Chlorpromazine HCl Tab 10 MG
Fluphenazine HCl Tab 1 MG
Fluphenazine HCl Tab 2.5 MG
Fluphenazine Decanoate Inj 25 MG/ML
Perphenazine Tab 2 MG
Prochlorperazine Suppos 25 MG
Prochlorperazine Maleate Tab 5 MG
Prochlorperazine Maleate Tab 10 MG
Thioridazine HCl Tab 10 MG
Trifluoperazine HCl Tab 1 MG
Generic
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ZYPREXA
Aripiprazole Tab 2 MG
Brand
ABILIFY
Brand
ABILIFY
Brand
ABILIFY
Brand
ABILIFY
Brand
ABILIFY
Brand
ABILIFY
MOBAN
MOBAN
MOBAN
MOBAN
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Daily Dosage=10
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
COMPAZINE
Aripiprazole Oral Solution 1 MG/ML
Brand
ABILIFY
Aripiprazole Orally Disintegrating Tab 10 MG
Brand
ABILIFY DISC
Aripiprazole Orally Disintegrating Tab 15 MG
Thiothixene Cap 1 MG
Brand
Generic
Generic
Generic
Generic
ABILIFY DISC
NAVANE
NAVANE
NAVANE
36
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Older; Max Qty=150/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Max Qty=93/31 days
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Ziprasidone HCl Cap 20 MG
Generic
GEODON
18 and Older; Daily Dosage=2
Generic
GEODON
Generic
GEODON
GEODON
Lithium Carbonate Cap 150 MG
Lithium Carbonate Tab 300 MG
Lithium Carbonate Tab CR 300 MG
Lithium Carbonate Tab CR 450 MG
Lithium Citrate Oral Soln 8 mEq/5ML
HYPNOTICS
Phenobarbital Tab 15 MG
Phenobarbital Tab 16.2 MG
Phenobarbital Elixir 20 MG/5ML
Flurazepam HCl Cap 15 MG
Flurazepam HCl Cap 30 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LITHOBID
Max Qty=310/31 days
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Temazepam Cap 15 MG
Generic
RESTORIL
Temazepam Cap 30 MG
Triazolam Tab 0.125 MG
Triazolam Tab 0.25 MG
Generic
Generic
Generic
RESTORIL
Zaleplon Cap 5 MG
Generic
SONATA
Zaleplon Cap 10 MG
Zolpidem Tartrate Tab 5 MG
Zolpidem Tartrate Tab 10 MG
Doxylamine Succinate (Sleep) Tab 25 MG
Diphenhydramine HCl (Sleep) Cap 50 MG
Diphenhydramine HCl (Sleep) Tab 25 MG
Diphenhydramine HCl (Sleep) Tab 50 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SONATA
AMBIEN
AMBIEN
UNISOM
UNISOM SLEEP
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
HALCION
Step Therapy; Limited to Ages 18
and Older; Daily Dosage=1
Step Therapy; Limited to Ages 18
and Older; Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
NYTOL MX-STR
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Dextroamphetamine Sulfate Tab 5 MG
Generic
Dextroamphetamine Sulfate Tab 10 MG
Generic
Dextroamphetamine Sulfate Cap SR 24HR 5 MG
Generic
DEXEDRINE
Generic
DEXEDRINE
Generic
DEXEDRINE
Amphetamine-Dextroamphetamine Tab 5 MG
Generic
ADDERALL
Amphetamine-Dextroamphetamine Tab 7.5 MG
Generic
ADDERALL
37
Qty=62/31 days
Qty=62/31 days
Qty=31/31 days
Limited to Ages 6-21; Daily
Dosage=2
Dosage=2
Dosage=2
Qty=62/31 days
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Generic
ADDERALL
Amphetamine-Dextroamphetamine Tab 12.5 MG
Generic
ADDERALL
Generic
ADDERALL
Generic
ADDERALL
Generic
ADDERALL
Amphetamine-Dextroamphetamine Cap SR 24HR 5 MG
Generic
ADDERALL XR
Generic
ADDERALL XR
Generic
ADDERALL XR
Generic
ADDERALL XR
Generic
ADDERALL XR
Amphetamine-Dextroamphetamine Cap SR 24HR 30 MG Generic
Caffeine Citrate Oral Soln 60 MG/3ML (10 MG/ML Base
Equiv)
Generic
Caffeine Citrate Powder
Generic
ADDERALL XR
CAFCIT
Dexmethylphenidate HCl Tab 2.5 MG
Generic
FOCALIN
Dexmethylphenidate HCl Tab 5 MG
Generic
FOCALIN
Dexmethylphenidate HCl Tab 10 MG
Generic
FOCALIN
Methylphenidate HCl Cap CR 10 MG
Generic
METADATE CD
Generic
METADATE CD
Generic
METADATE CD
Generic
METADATE CD
Generic
METADATE CD
Generic
METADATE CD
Methylphenidate HCl Tab 5 MG
Generic
RITALIN
Generic
RITALIN
Generic
RITALIN
Methylphenidate HCl Tab CR 10 MG
Generic
Methylphenidate HCl Tab CR 20 MG
Generic
RITALIN, RITALIN
SR
Methylphenidate HCl Tab SA OSM 18 MG
Generic
CONCERTA
Generic
CONCERTA
Generic
CONCERTA
Generic
CONCERTA
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Donepezil Hydrochloride Tab 5 MG
Generic
Donepezil Hydrochloride Tab 10 MG
Generic
Galantamine Hydrobromide Tab 4 MG
Generic
Generic
ARICEPT
ARICEPT
RAZADYNE
RAZADYNE
38
Covered Brand
Product
Qty=62/31 days
Qty=62/31 days
Qty=62/31 days
Dosage=2
Qty=62/31 days
Qty=31/31 days
Qty=31/31 days
Qty=31/31 days
Dosage=2
Qty=31/31 days
Qty=31/31 days
Fills=2/lifetime
Dosage=2
Dosage=2
Dosage=2
Dosage=1
Dosage=1
Qty=31/31 days
Qty=31/31 days
Qty=31/31 days
Limited to Ages 6-21r; Max
Qty=31/31 days
Dosage=3
Qty=93/31 days
Dosage=3
Qty=62/31 days
Qty=62/31 days
PA, Brand; Limited to Ages 6-21;
Max Qty=31/31 days
Max Qty=31/31 days
Max Qty=62/31 days
Max Qty=31/31 days
Max Qty=31/31 days
Max Qty=31/31 days
Daily Dosage=2
Daily Dosage=2
Product Description
Galantamine Hydrobromide Oral Soln 4 MG/ML
Galantamine Hydrobromide Cap SR 24HR 8 MG
Rivastigmine TD Patch 24HR 4.6 MG/24HR
Rivastigmine TD Patch 24HR 9.5 MG/24HR
Rivastigmine Tartrate Cap 1.5 MG
Rivastigmine Tartrate Cap 3 MG
Rivastigmine Tartrate Cap 4.5 MG
Rivastigmine Tartrate Cap 6 MG
Rivastigmine Tartrate Soln 2 MG/ML
Memantine HCl Tab 5 MG
Memantine HCl Tab 10 MG
Memantine HCl Tab 5 MG (28) & 10 MG (21) Titration
Pak
Memantine HCl Oral Solution 2 MG/ML
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Brand
Brand
Brand
Generic
Nicotine TD Patch 24HR 7 MG/24HR
Generic
Generic
Generic
Nicotine Polacrilex Gum 2 MG
Generic
Nicotine Polacrilex Gum 4 MG
Fluoxetine HCl (PMDD) Cap 10 MG
Fluoxetine HCl (PMDD) Cap 20 MG
Milnacipran HCl Tab 12.5 MG
Milnacipran HCl Tab 25 MG
Milnacipran HCl Tab 12.5 MG (5) & 25 MG (8) & 50 MG
(42) Pak
Disulfiram Tab 250 MG
Perphenazine-Amitriptyline Tab 2-10 MG
Generic
Generic
Generic
Brand
Brand
Brand
Brand
Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG
Aspirin Buffered Tab 325 MG
Acetaminophen Tab 325 MG
Acetaminophen Tab 500 MG
Acetaminophen Chew Tab 80 MG
Acetaminophen Chew Tab 160 MG
Acetaminophen Liquid 160 MG/5ML
Acetaminophen Elixir 160 MG/5ML
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Covered Brand
Product
EXELON
NAMENDA
NAMENDA
NAMENDA
NAMENDA
PA; Package Limit=1/28 days
PA; Daily Dosage=10
EXELON
EXELON
EXELON
EXELON
ZYBAN
NICODERM 21,
NICODERM CQ
NICODERM CQ
NICODERM CQ
NICORETTE,
NICORETTE ST
NICORETTE,
NICORETTE ST
PROZAC
ANTABUSE
DUO-VIL
DUO-VIL
Daily Dosage=2
Daily Dosage=6
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
PA; Daily Dosage=1
PA; Daily Dosage=1
PA; Daily Dosage=2
PA; Daily Dosage=2
PA; Daily Dosage=2
PA; Daily Dosage=2
PA; Daily Dosage=6
PA; Daily Dosage=2
PA; Daily Dosage=2
EXELON
EXELON
Brand
Brand
Bupropion HCl (Smoking Deterrent) Tab SR 150 MG
ANALGESICS - NonNarcotic
Aspirin Tab 81 MG
Aspirin Tab 325 MG
Aspirin Chew Tab 75 MG
Aspirin Chew Tab 81 MG
Aspirin Tab Delayed Release 81 MG
Aspirin Suppos 60 MG
Diflunisal Tab 500 MG
Salsalate Tab 500 MG
Salsalate Tab 750 MG
Non-Preferred Brand
Equivalent(s)
RAZADYNE
RAZADYNE
RAZADYNE ER)
RAZADYNE ER
RAZADYNE ER
Max DS=84/365 days
Max DS=84/365 days
SAVELLA
SAVELLA
SAVELLA
SAVELLA
Max DS=84/365 days
Max Qty=124/31 days
Max Qty=124/31 days
PA; Daily Dosage=2
PA; Daily Dosage=2
PA; Daily Dosage=2
PA; Daily Dosage=2
SAVELLA
PA; Max Qty=55/365 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
Max Qty=124/31 days
ST JOSEPH
ECOTRIN
ECOTRIN M/S
Max Qty=12/31 days
Max Qty=12/31 days
Max Qty=12/31 days
Max Qty=12/31 days
Max Qty=12/31 days
BUFFERIN
TYLENOL
TYLENOL
39
Product Description
Brand/
Generic
Acetaminophen Susp 80 MG/0.8ML
Generic
Acetaminophen Susp 160 MG/5ML
Acetaminophen Soln 100 MG/5ML
Acetaminophen Soln 160 MG/5ML
Acetaminophen Suppos 120 MG
Butalbital-Acetaminophen Cap 50-650 MG
Butalbital-Acetaminophen Tab 50-325 MG
Butalbital-Acetaminophen Tab 50-650 MG
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
TYLENOL INFANT
TYLENOL CHLD,
TYLENOL INFANT
Max Qty=30/claim
Max Qty=12/31 days
Max Qty=12/31 days
Max Qty=12/31 days
PHRENILIN
PHRENILIN
SEDAPAP
Max Qty=124/31 days
Generic
ESGIC
Max Qty=124/31 days
Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG
Generic
ESGIC, FIORICET
Daily Dosage=4
Butalbital-Acetaminophen-Caffeine Tab 50-500-40 MG
Butalbital-Aspirin-Caffeine Cap 50-325-40 MG
Butalbital-Aspirin-Caffeine Tab 50-325-40 MG
Generic
Generic
Generic
ESGIC-PLUS
FIORINAL
Max Qty=124/31 days
Max Qty=124/31 days
Daily Dosage=4
DURAGESIC
DURAGESIC
DURAGESIC
DURAGESIC
DURAGESIC
DILAUDID
DILAUDID
DILAUDID
Daily Dosage=.33
Daily Dosage=.33
Daily Dosage=.33
Daily Dosage=.33
Daily Dosage=.33
Daily Dosage=8
ANALGESICS - OPIOID
Codeine Sulfate Tab 15 MG
Fentanyl TD Patch 72HR 12.5 MCG/HR
Fentanyl TD Patch 72HR 25 MCG/HR
Hydromorphone HCl Tab 2 MG
Hydromorphone HCl Suppos 3 MG
Meperidine HCl Tab 50 MG
Meperidine HCl Tab 100 MG
Meperidine HCl Oral Soln 50 MG/5ML
Methadone HCl Tab 5 MG
Methadone HCl Tab 10 MG
Morphine Sulfate Tab 15 MG
Morphine Sulfate Tab 30 MG
Morphine Sulfate Tab CR 15 MG
Morphine Sulfate Oral Soln 10 MG/5ML
Morphine Sulfate Oral Soln 20 MG/5ML
Morphine Sulfate Oral Soln 20 MG/ML
Morphine Sulfate Suppos 5 MG
Oxycodone HCl Cap 5 MG
Oxycodone HCl Tab 5 MG
Oxycodone HCl Conc 20 MG/ML
Tramadol HCl Tab 50 MG
Oxycodone w/ Acetaminophen Cap 5-500 MG
Oxycodone w/ Acetaminophen Tab 5-325 MG
Oxycodone w/ Acetaminophen Tab 7.5-325 MG
Oxycodone w/ Acetaminophen Tab 7.5-500 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Daily Dosage=4
Max Qty=62/31 days
Daily Dosage=6
Daily Dosage=6
DEMEROL
DEMEROL
DOLOPHINE
DOLOPHINE
MS CONTIN
MS CONTIN
MS CONTIN
MS CONTIN
MS CONTIN
ROXANOL
OXYIR
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ULTRAM
TYLOX
PERCOCET
ROXICET
PERCOCET
PERCOCET
PERCOCET
PERCOCET
40
Max Qty=124/31 days
Daily Dosage=10
Daily Dosage=6
Daily Dosage=6
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Max Qty=500/31 days
Max Qty=500/31 days
Max Qty=240/claim
Max Qty=24/31 days
Max Qty=24/31 days
Max Qty=24/31 days
Max Qty=24/31 days
Daily Dosage=6
Max Qty=186/31 days
Daily Dosage=6
Daily Dosage=6
Max Qty=120/claim
Daily Dosage=8
Max Qty=186/31 days
Max Qty=186/31 days
Max Qty=124/31 days
Max Qty=186/31 days
Max Qty=186/31 days
Max Qty=186/31 days
Max Qty=186/31 days
Product Description
Brand/
Generic
Oxycodone w/ Acetaminophen Soln 5-325 MG/5ML
Oxycodone w/ Aspirin Tab Full Strength
Oxycodone-Aspirin Tab 4.8355-325 MG
Acetaminophen w/ Codeine Tab 300-15 MG
Brand
Generic
Generic
Generic
Generic
Acetaminophen w/ Codeine Soln 120-12 MG/5ML
Aspirin w/ Codeine Tab 325-60 MG
Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30
MG
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
ROXICET
PERCODAN
TYLENOL/CODEIN
E
TYLENOL/CODEIN
E
Hydrocodone-Acetaminophen Tab 5-500 MG
Hydrocodone-Acetaminiphen Tab 7.5-500 MG
Generic
Generic
Generic
Hydrocodone-Acetaminophen Tab 7.5-650 MG
Generic
Generic
Generic
Generic
Generic
Generic
FIORICET/CODEIN
E
FIORINAL/CODEIN
E
NORCO
LORTAB, LORTAB 5,
VICODIN
LORTAB
LORTAB
ANEXSIA, LORCET
PLUS
LORCET
ANEXSIA
VICODIN ES
NORCO
NORCO
Hydrocodone-Acetaminophen Soln 7.5-500 MG/15ML
Tramadol-Acetaminophen Tab 37.5-325 MG
Generic
Generic
LORTAB
ULTRACET
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
CATAFLAM
Generic
Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG Generic
Generic
ANALGESICS - ANTI-INFLAMMATORY
Diclofenac Potassium Tab 50 MG
Diclofenac Sodium Tab Delayed Release 25 MG
Etodolac Cap 200 MG
Etodolac Cap 300 MG
Etodolac Tab 400 MG
Etodolac Tab 500 MG
Fenoprofen Calcium Cap 400mg
Flurbiprofen Tab 50 MG
Flurbiprofen Tab 100 MG
Ibuprofen Tab 400 MG
Ibuprofen Susp 100 MG/5ML
Ibuprofen Lysine IV Soln 10 MG/ML
Indomethacin Cap 25 MG
Indomethacin Cap 50 MG
Indomethacin Susp 25 MG/5ML
Indomethacin Sup 50 MG
Indomethacin Inj 1 MG
Ketorolac Tromethamine Tab 10 MG
Ketorolac Tromethamine Inj 15 MG/ML
Ketorolac Tromethamine Inj 30 MG/ML
Ketorolac Tromethamine Inj 60 MG/2ML
Meloxicam Tab 7.5 MG
Meloxicam Tab 15 MG
Nabumetone Tab 500 MG
Nabumetone Tab 750 MG
Naproxen Tab 250 MG
Naproxen Tab 375 MG
Generic
Brand
Generic
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Covered Brand
Product
Max Qty=500/31 days
Max Qty=186/31 days
Max Qty=186/31 days
Max Qty=186/31 days
Max Qty=186/31 days
Max Qty=186/31 days
Daily Dosage=30
Max Qty=124/31 days
Max Qty=124/31 days
Daily Dosage=6
Daily Dosage=8
Daily Dosage=8
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=5
Daily Dosage=6
Daily Dosage=8
Daily Dosage=120
Max Qty=124/31 days
VOLTAREN
NALFON
ADVIL CHILD,
CHILD MOTRIN,
MOTRIN, MOTRIN
CHILD
NEOPROFEN
INDOCIN
INDOCIN
TORADOL ORAL
MOBIC
MOBIC
NAPROSYN
NAPROSYN
41
Max Qty=20/30 days
Product Description
Naproxen Tab 500 MG
Naproxen Susp 125 MG/5ML
Naproxen Sodium Tab 220 MG
Piroxicam Cap 10 MG
Piroxicam Cap 20 MG
Sulindac Tab 150 MG
Sulindac Tab 200 MG
Methotrexate Sodium Tab 2.5 MG (Antirheumatic)
Leflunomide Tab 10 MG
Leflunomide Tab 20 MG
MIGRAINE PRODUCTS
Dihydroergotamine Mesylate Inj 1 MG/ML
Dihydroergotamine Mesylate Nasal Spray 4 MG/ML
Almotriptan Malate Tab 6.25 MG
Almotriptan Malate Tab 12.5 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Non-Preferred Brand
Equivalent(s)
NAPROSYN
NAPROSYN
ALEVE
ANAPROX
ANAPROX DS
FELDENE
FELDENE
Generic
Generic
Brand
Brand
D.H.E. 45
MIGRANAL
Covered Brand
Product
Max Qty=62/31 days
CLINORIL
RHEUMATREX
ARAVA
ARAVA
Daily Dosage=1
Daily Dosage=1
AXERT
AXERT
Max Qty=6/30 days
Max Qty=6/30 days
Max Qty=6/30 days
Eletriptan Hydrobromide Tab 20 MG (Base Equivalent)
Brand
RELPAX
Eletriptan Hydrobromide Tab 40 MG (Base Equivalent)
Brand
RELPAX
Sumatriptan Nasal Spray 5 MG/ACT
Generic
IMITREX
Sumatriptan Nasal Spray 20 MG/ACT
Generic
IMITREX
Sumatriptan Succinate Tab 25 MG
Generic
IMITREX
Generic
IMITREX
Generic
IMITREX
Sumatriptan Succinate Inj 6 MG/0.5ML
Zolmitriptan Tab 2.5 MG
Zolmitriptan Tab 5 MG
Zolmitriptan Nasal Spray 5 MG/Spray Unit
Zolmitriptan Orally Disintegrating Tab 2.5 MG
Zolmitriptan Orally Disintegrating Tab 5 MG
Acetaminophen-Isometheptene-Dichloral Cap 325-65-100
MG
Ergotamine w/ Caffeine Tab 1-100 MG
Generic
Generic
Generic
Brand
Generic
Generic
IMITREX
ZOMIG
ZOMIG
ZOMIG
ZOMIG ZMT
ZOMIG ZMT
Generic
Generic
CAFERGOT
Generic
Generic
ZYLOPRIM
ZYLOPRIM
Generic
Generic
Generic
COLCRYS
Generic
Generic
Generic
KLONOPIN
KLONOPIN
KLONOPIN
Diazepam Rectal Gel Delivery System 2.5 MG
Generic
DIASTAT PED
Diazepam Rectal Gel Delivery System 10 MG
Generic
DIASTAT ACDL
Diazepam Rectal Gel Delivery System 20 MG
Felbamate Tab 400 MG
Felbamate Tab 600 MG
Felbamate Susp 600 MG/5ML
Tiagabine HCl Tab 2 MG
Generic
Generic
Generic
Generic
Generic
Generic
Brand
DIASTAT ACDL
FELBATOL
FELBATOL
FELBATOL
GABITRIL
GABITRIL
GOUT AGENTS
Allopurinol Tab 100 MG
Allopurinol Tab 300 MG
Colchicine Tab 0.6 MG
Probenecid Tab 500 MG
Colchicine w/ Probenecid Tab 0.5-500 MG
ANTICONVULSANTS
Clonazepam Tab 0.5 MG
Clonazepam Tab 1 MG
Clonazepam Tab 2 MG
Fills=1/30 days
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Max Qty=1/claim
Max Qty=1/claim
Max Qty=1/claim
GABITRIL
42
Max Qty=6/30 days
Max Qty=6/30 days
Max Qty=6/30 days
Max Qty=9/30 days
Max Qty=9/30 days
Max Qty=9/30 days
Max Qty=2/30 days
Max Qty=6/30 days
Max Qty=6/30 days
Max Qty=6/30 days
Max Qty=6/30 days
Max Qty=6/30 days
Phenytoin Chew Tab 50 MG
Phenytoin Susp 125 MG/5ML
Phenytoin Sodium Extended Cap 30 MG
Phenytoin Sodium Extended Cap 100 MG
Ethosuximide Cap 250 MG
Ethosuximide Soln 250 MG/5ML
Divalproex Sodium Tab Delayed Release 125 MG
Brand/
Generic
Brand
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Divalproex Sodium Cap Sprinkle 125 MG
Divalproex Sodium Tab SR 24 HR 250 MG
Divalproex Sodium Tab SR 24 HR 500 MG
Valproate Sodium Syrup 250 MG/5ML
Valproic Acid Cap 250 MG
Carbamazepine Tab 200 MG
Carbamazepine Chew Tab 100 MG
Carbamazepine Susp 100 MG/5ML
Carbamazepine Tab SR 12HR 100 MG
Gabapentin Cap 100 MG
Gabapentin Tab 600 MG
Gabapentin Tab 800 MG
Gabapentin Oral Soln 250 MG/5ML
Lamotrigine Tab 25 MG
Lamotrigine Tab Chewable Dispersible 5 MG
Lamotrigine Tab Chewable Dispersible 25 MG
Levetiracetam Tab 250 MG
Levetiracetam Soln 100 MG/ML
Oxcarbazepine Tab 150 MG
Oxcarbazepine Susp 300 MG/5ML (60 MG/ML)
Primidone Tab 50 MG
Primidone Tab 250 MG
Topiramate Tab 25 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Topiramate Sprinkle Cap 15 MG
Generic
Topiramate Sprinkle Cap 25 MG
Zonisamide Cap 25 MG
Generic
Generic
Generic
Generic
Product Description
ANTIPARKINSON AGENTS
Benztropine Mesylate Tab 0.5 MG
Benztropine Mesylate Tab 1 MG
Benztropine Mesylate Tab 2 MG
Trihexyphenidyl HCl Tab 2 MG
Trihexyphenidyl HCl Tab 5 MG
Trihexyphenidyl HCl Elixir 0.4 MG/ML
Amantadine HCl Cap 100 MG
Amantadine HCl Syrup 50 MG/5ML
Bromocriptine Mesylate Cap 5 MG
Bromocriptine Mesylate Tab 2.5 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
DILANTIN
DILANTIN-125
Covered Brand
Product
GABITRIL
DILANTIN
DILANTIN
DILANTIN
ZARONTIN
ZARONTIN
DEPAKOTE
DEPAKOTE
DEPAKOTE
DEPAKOTE
SPRINKLES
DEPAKOTE ER
DEPAKOTE ER
DEPAKENE
DEPAKENE
TEGRETOL
TEGRETOL
TEGRETOL
Daily Dosage=2
Daily Dosage=3
Daily Dosage=7
Daily Dosage=8
Max Qty=93/31 days
Daily Dosage=7
TEGRETOL-XR
TEGRETOL-XR
TEGRETOL-XR
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
LAMICTAL
LAMICTAL
LAMICTAL
LAMICTAL
LAMICTAL
LAMICTAL
KEPPRA
KEPPRA
KEPPRA
KEPPRA
TRILEPTAL
TRILEPTAL
TRILEPTAL
TRILEPTAL
MYSOLINE
MYSOLINE
TOPAMAX
TOPAMAO
TOPAMAX
TOPAMAX
TOPAMAX
SPRINKLES
TOPAMAX
SPRINKLES
ZONEGRAN
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=16
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=6
Daily Dosage=8
ZONEGRAN
ARTANE
Max Qty=500/31 days
PARLODEL
PARLODEL
43
Product Description
Ropinirole Hydrochloride Tab 0.25 MG
Ropinirole Hydrochloride Tab 0.5 MG
Ropinirole Hydrochloride Tab 1 MG
Carbidopa & Levodopa Tab 10-100 MG
Carbidopa & Levodopa Tab CR 25-100 MG
Carbidopa & Levodopa Tab CR 50-200 MG
Selegiline HCl Cap 5 MG
Selegiline HCl Tab 5 MG
Carbidopa Tab 25 MG
MUSCULOSKELETAL THERAPY AGENTS
Baclofen Tab 10 MG
Baclofen Tab 20 MG
Chlorzoxazone Tab 500 MG
Cyclobenzaprine HCl Tab 5 MG
Cyclobenzaprine HCl Tab 10 MG
Methocarbamol Tab 500 MG
Methocarbamol Tab 750 MG
Tizanidine HCl Tab 2 MG
Tizanidine HCl Tab 4 MG
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
SINEMET
SINEMET
SINEMET
SINEMET CR
SINEMET CR
ELDEPRYL
Covered Brand
Product
Daily Dosage=6
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=6
Daily Dosage=6
Daily Dosage=3
LODOSYN
PARAFON FORT
FLEXERIL
Generic
Generic
Generic
Generic
Generic
FLEXERIL
ROBAXIN
ROBAXIN-750
ANTIMYASTHENIC AGENTS
Pyridostigmine Bromide Tab 60 MG
Pyridostigmine Bromide Tab CR 180 MG
Generic
Brand
MESTINON
VITAMINS
Thiamine HCl Tab 50 MG
Thiamine Mononitrate Tab 100 MG
Riboflavin Tab 25 MG
Niacin Cap CR 250 MG
Niacin Cap CR 500 MG
Niacin Tab 500 MG
Niacin Tab CR 250 MG
Pyridoxine HCl Tab 25 MG
Ascorbic Acid Tab 250 MG
Ergocalciferol Cap 50000 IU
Cholecalciferol Cap 1000 Unit
Cholecalciferol Cap 2000 Unit
Vitamin E Cap 100 IU
Vitamin E Chew Tab 400 IU
Phytonadione Tab 5 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
MULTIVITAMINS
*B-Complex Vitamin Cap**
*B-Complex Vitamin Tab**
*B-Complex w/ C Cap**
Generic
Generic
Generic
Max Qty=93/31 days
Dosage=3
ZANAFLEX
MESTINON
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
VITAMIN B-1
SLO-NIACIN
SLO-NIACIN
NIACIN TR
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
DRISDOL
Max Qty=100/claim
Max Qty=100/claim
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
MEPHYTON
Max Qty=31/31 days
Max Qty=31/31 days
Max Qty=31/31 days
44
Product Description
*B-Complex w/ C & Folic Acid Cap 1 MG***
*B-Complex w/ C & Folic Acid Tab 1 MG***
Generic
Equivalent(s)
Generic
NEPHROCAPS
Generic
NEPHRO-VITE
Covered Brand
Product
Daily Dosage=1
Daily Dosage=1
Generic
Generic
CARDENZ,
LYSIPLEX, ONE-ADAY, THERAGRAN
GERITOL EXT
Max Qty=31/31 days
Max Qty=31/31 days
Generic
CAROMEGA,
CENTRUM,
CENTRUM SILV,
FEMTABS, FOSFREE
Max Qty=31/31 days
Generic
Generic
Generic
TRI-VI-SOL
POLY-VI-SOL
VITACRAVES
Max Qty=50/claim
Max Qty=50/claim
Daily Dosage=1
*Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML** Generic
POLY-VI-SOL
Max Qty=60/claim
*Pediatric Vitamins ACD w/ Iron Drops 10 MG/ML***
TRI-VI-SOL/IRON
Max Qty=50/claim
*Multiple Vitamin Tab**
*Multiple Vitamins w/ Iron Tab**
*Multiple Vitamins w/ Minerals Tab**
*Pediatric Vitamins ADC Drops 1500IU-400IU-35
MG/ML***
*Pediatric Multiple Vitamin w/ C Soln 35 MG/ML**
*Pediatric Multiple Vitamin w/ C & FA Chew Tab**
Generic
*Pediatric Vitamins ACD w/ Fluoride Chew Tab 1 MG*** Generic
*Pediatric Vitamins ACD w/ Fluoride Soln 0.25
MG/ML***
Generic
Limited to Ages 21 and Under,
Max Qty=50/claim
Max Qty=50/claim
*Pediatric Vitamins ACD w/ Fluoride Soln 0.5 MG/ML***
*Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.25
MG***
*Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.5
MG***
*Pediatric Multiple Vitamins w/ Fluoride Chew Tab 1
MG***
*Pediatric Multiple Vitamins w/ Fluoride Soln 0.25
MG/ML***
*Pediatric Multiple Vitamins w/ Fluoride Soln 0.5
MG/ML***
*Pediatric Multiple Vitamins w/ Fl-Fe Chew Tab 1-12
MG**
*Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.25-10
MG/ML**
*Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.5-10
MG/ML**
*Pediatric Vitamins ACD Fluoride & Fe Drops 0.25-10
MG/ML***
Generic
*Prenatal Vitamin Fast Dissolving Tab**
*Prenatal Multivitamins & Minerals w/ Iron & FA Cap
0.1MG***
Brand
CALNA
Brand
TYLER PRENAT
Brand
Brand
MYNATAL
KPN, KPN
PRENATAL
Brand
NUTRICION
*Prenatal Multivitamins & Minerals w/ Iron & FA Cap 1
MG***
*Prenatal Multivitamins & Minerals w/ Iron & FA Tab
0.1MG***
*Prenatal Multivitamins & Minerals w/ Fe & FA Tab 0.25
MG***
*Prenatal Multivitamins & Minerals w/ Iron & FA Tab
0.8MG***
Generic
Daily Dosage=1
Generic
Generic
Max Qty=50/claim
Max Qty=50/claim
Generic
Generic
Generic
Max Qty=50/claim
Max Qty=50/claim
Generic
Generic
POLY-VI-FLOR/FE
Generic
TRI-VI-FLOR/FE
Generic
*Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***
Brand
*Prenatal Vit w/ Fe Fumarate-FA Cap 13.5-0.4 MG***
Brand
*Prenatal Vit w/ Fe Fumarate-FA Tab 15-1 MG***
Brand
Limited to female
Limited to female
Limited to female
Limited to female
Limited to female
Limited to female
NATAL-V RX,
PRENATABS RX,
PRENATAL,
PRENATAL+FE, RE- Limited to Ages 50 and Under;
NATA 29...
Limited to Female
PERRY PRENAT
Limited to female
Limited to female
O-CAL
45
Product Description
Brand/
Generic
Brand
*Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***
Generic
Generic
*Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
PRENAFIRST
CO-NATAL FA,
PRENATABS FA,
VENATAL-FA
Dosage=1
Limited to female
Limited to Female
Limited to female
Limited to Female; Limited to
Female
Daily Dosage=1
Limited to female
Limited to female
Brand
Generic
Generic
Brand
NATALVIT
*Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***
Brand
COMPLETENATE,
NATACHEW,
PRENATAL 19, RE
PRENATAL, SENATAL 19
*Prenatal Vit w/ Fe Gluconate-FA Tab 30-0.4 MG***
Brand
MISSION PREN
*Prenatal Vit w/ Fe Gluconate-FA Tab 30-0.8 MG***
Brand
MISSION PREN
*Prenatal Vit w/ Fe Sulfate-FA Tab 27-0.8 MG***
*Prenatal Vit w/ Iron Carbonyl-Fe Gluc-FA Tab 271MG***
*Prenatal w/o A Vit w/ Fe Fumarate-FA Cap 106.5-1
MG***
Brand
PRENATAL
VINATE CAL,
CITRANATAL
PRENATAL-U,
TRIVEEN-U
CAVAN,
GESTICARE, TARON- Limited to Ages 49 and Under;
EC CAL
Limited to Female
*Prenatal w/o A Vit w/ Fe Fumarate-FA Tab DR 30-1
MG***
Prenatal Z, Prenatal 1
Brand
Brand
Brand
PRENATABS, RELimited to Ages 49 and Under;
NATA 29, VITASPIRE Limited to Female
Limited to Female
COMPLETE-RF
Limited to Female
VINATE M
Dosage=1
*Prenatal w/o A Vit w/ Fe Carbonyl-FA Tab 29-1 MG*** Brand
*Prenatal without A w/ Fe Carbonyl-Docusate-FA Tab 901MG***
Brand
*Prenatal Vit w/ Sel-Fe Fumarate-FA Tab 27-1 MG***
Brand
*Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***
Generic
*Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG***
*Prenatal Vit w/ DSS-Fe Fumarate-FA Tab CR 90-1
MG***
*Prenatal w/FE Polys Cmplx-FA-Ca Tab & Omega 3 Cap
Pack***
*Vitamins w/ Lipotropics Cap**
Generic
MINERALS & ELECTROLYTES
Calcium Carbonate Susp 1250 MG/5ML
Oyster Shell Calcium Tab 500 MG
Calcium 500 MG w/ Vitamin D Tab
Calcium w/ Vitamin D Tab 500 MG-125 Unit
Calcium-Cholecalciferol Tab 500 MG-200 Unit
Calcium-Ergocalciferol Tab 500 MG-200 Unit
Calcium Carbonate-Vitamin D Tab 250MG-125IU
Calcium Carbonate-Vitamin D Tab 600 MG-400 Unit
Limited to Female
Limited to female
Limited to female
Limited to female
Limited to Female
Limited to Female
MYNATE 90, SENATAL 90
Brand
Brand
Generic
MARNATAL-F
Generic
Generic
Generic
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Limited to female
Limited to female
Max Qty=31/31 days
Max Qty=500/30 days
CA HI-CAL/D
CA HI-CAL/D
PARVA-CAL
Max Qty=62/31 days
Generic
Max Qty=62/31 days
46
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Calcium Carbonate-Cholecalciferol Tab 500 MG-200 Unit
Generic
Calcium Carbonate-Ergocalciferol Tab 500MG-200 Unit
Sodium Fluoride Chew Tab 0.25MG F (from 0.55 MG
NaF)
Generic
Generic
LURIDE
Limited to Ages 15 and Under
Sodium Fluoride Chew Tab 0.5MG F (from 1.1 MG NaF)
Generic
LURIDE
Sodium Fluoride Chew Tab 1 MG F (from 2.2 MG NaF)
Sodium Fluoride Soln 0.125 MG/DROP F (0.275
MG/DROP NaF)
Sodium Fluoride Soln 0.5 MG/ML F (from 1.1 MG/ML
NaF)
Potassium Iodide Soln 1 GM/ML
Potassium & Sodium Phosphates For Soln 278-164-250
MG/75ML
Pot Phos Monobasic w/Sod Phos Di & Monobas Tab 155852-130MG
Potassium Bicarbonate Effer Tab 25 mEq
Potassium Chloride Cap CR 8 mEq
Potassium Chloride Cap CR 10 mEq
Potassium Chloride Tab CR 8 mEq
Potassium Chloride Tab CR 10 mEq
Potassium Chloride Oral Liq 10%
Potassium Chloride Oral Liq 20%
Generic
LURIDE
Potassium Chloride Powder Packet 20 mEq
Potassium Chloride Powder Packet 25 mEq
Potassium Chloride Microencapsulated CRYS CR Tab 10
mEq
Potassium Chloride Microencapsulated Crys CR Tab 15
mEq
Potassium Chloride Microencapsulated CRYS CR Tab 20
mEq
Zinc Sulfate Cap 220 MG (50 MG Elemental Zn)
Generic
Generic
Brand
LURIDE
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
SSKI
NEUTRA-PHOS
Max Qty=68/31 days
K-PHOS
Daily Dosage=8
MICRO-K
MICRO-K
Daily Dosage=1
K-TABS
Generic
Generic
K-LOR
KLOR-CON-25
Generic
K-TABS
Brand
PA, NDC 00456066270 KAY
CIEL POW 20MEQ; PA,
NDC 00456066271 KAY CIEL
POW 20MEQ
KLOR-CON M15
Generic
Generic
*Oral Electrolyte Solution***
Generic
NUTRIENTS
Glucose Polymers Liqd
Glucose Polymers Powder 94%
*Omega-3 Fatty Acids Cap 1000 MG**
*Omega-3 Fatty Acids Cap 1200 MG**
Brand
Brand
Generic
Generic
HEMATOPOIETIC AGENTS
Cyanocobalamin Inj 1000 MCG/ML
Folic Acid Tab 400 MCG
Folic Acid Tab 800 MCG
Folic Acid Tab 1 MG
Carbonyl Iron Chew Tab 15 MG (Elemental Iron)
Generic
Generic
Generic
Generic
Generic
EQUALYTE,
PEDIALYTE,
PEDIALYTE ST
POLYCOSE
POLYCOSE
Daily Dosage=6
Daily Dosage=6
Max Qty=10/270 days
Daily Dosage=1
Daily Dosage=1
ICAR)
Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe)
Ferrous Sulfate Tab 28 MG (Elemental Fe)
Generic
Generic
Ferrous Sulfate Tab EC 324 MG (65 MG Fe Equivalent)
Generic
Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent)
Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML
Elemental Fe)
Ferrous Sulfate Soln 75 MG/ML (15 MG/ML Elemental
Fe)
Generic
Generic
FEOSOL
Generic
FER-IN-SOL
Daily Dosage=3.4
47
Ferrous Sulfate Soln 75 MG/0.6ML
Brand/
Generic
Generic
Ferrous Gluconate Tab 324 MG (38 MG Elemental Iron)
Generic
Daily Dosage=3.4
Max Qty=100/31 days
Generic
Generic
Ferrous Gluconate Tab 325 MG (37.5 MG Elemental Fe)
Generic
Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe)
Polysaccharide Iron Complex Cap 150 MG
*Ferrous Fumarate-FA-B Complex-C-Zn-Mg-Mn-Cu Tab
106-1 MG***
Generic
Generic
Brand
Brand
Brand
Product Description
Ferrous Gluconate Tab 325 MG
Ferrous Gluconate Tab 325 MG (36 MG Elemental Fe)
Non-Preferred Brand
Equivalent(s)
HEMOCYTE
Daily Dosage=1
Generic
Generic
Generic
Generic
Generic
Enoxaparin Sodium Inj 30 MG/0.3ML
Generic
LOVENOX
Generic
LOVENOX
Generic
LOVENOX
Generic
LOVENOX
Enoxaparin Sodium Inj 100 MG/ML
Generic
LOVENOX
Generic
LOVENOX
Enoxaparin Sodium Inj 150 MG/ML
Generic
LOVENOX
Enoxaparin Sodium Inj 300 MG/3ML
Warfarin Sodium Tab 1 MG
Warfarin Sodium Tab 2.5 MG
Warfarin Sodium Tab 7.5 MG
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
LOVENOX
COUMADIN)
COUMADIN)
COUMADIN)
COUMADIN)
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
Rivaroxaban Tab 10 MG
Brand
Tranexamic Acid Tab 650 MG
Daily Dosage=2
Daily Dosage=1
Generic
Generic
Generic
DROXIA
DROXIA
DROXIA
ANTICOAGULANTS
Heparin Sodium (Porcine) Inj 1000 U/ML
Heparin Sodium (Porcine) PF Inj 5000 Unit/0.5ML
HEMOSTATICS
Aminocaproic Acid Tab 500 MG
Aminocaproic Acid Syrup 25%
Covered Brand
Product
Max DS=7; Max Fills=3/180
days
days
days
days
days
days
days
days
XARELTO
AMICAR
AMICAR
Generic
Max Qty=24/claim
Max Qty=60/claim
LYSTEDA
48
Dosage=1
Qty=30/5 days; Max
Fills=1/month
Product Description
HEMATOLOGICAL AGENTS - MISC.
Dipyridamole Tab 25 MG
Cilostazol Tab 50 MG
Cilostazol Tab 100 MG
Clopidogrel Bisulfate Tab 75 MG (Base Equiv)
Prasugrel HCl Tab 5 MG (Base Equiv)
Prasugrel HCl Tab 10 MG (Base Equiv)
Pentoxifylline Tab CR 400 MG
Ecallantide Inj 10 MG/ML
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Brand
Generic
Brand
OPHTHALMIC AGENTS
Bacitracin Ophth Oint 500 U/GM
Generic
Ciprofloxacin HCl Ophth Soln 0.3%
Generic
Ciprofloxacin HCl Ophth Oint 0.3%
Brand
Erythromycin Ophth Oint 5 MG/GM
Generic
Gentamicin Sulfate Ophth Soln 0.3%
Generic
Generic
Gentamicin Sulfate Ophth Oint 0.3%
Moxifloxacin HCl Ophth Soln 0.5%
Brand
Ofloxacin Ophth Soln 0.3%
Generic
Tobramycin Sulfate Ophth Soln 0.3%
Generic
Tobramycin Sulfate Ophth Oint 0.3%
Brand
Sulfacetamide Sodium Ophth Soln 10%
Generic
Sulfacetamide Sodium Ophth Oint 10%
Generic
Trifluridine Ophth Soln 1%
Generic
Bacitracin-Polymyxin B Ophth Oint
Generic
Polymyxin B-Trimethoprim Ophth Soln 10000 UNITS/ML0.1%
Generic
Neomycin-Bacitracin Zn-Polymyx 3.5(5)MG-400U-10000U
Op Oint
Generic
Neomycin-Polymyxin B-Gramicidin Ophth Soln
Generic
Hydroxypropyl Methylcellulose Ophth Soln 0.4%
Generic
Polyvinyl Alcohol Ophth Soln 1.4%
Generic
*Artificial Tear Ophth Ointment***
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
PERSANTINE
PERSANTINE
PERSANTINE
PLETAL
PLETAL
PLAVIX
EFFIENT
EFFIENT
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
KALBITOR
PA
CILOXAN
Max Qty=4/31 days
TRENTAL
CILOXAN
GARAMYCIN
GARAMYCIN
VIGAMOX
OCUFLOX
TOBREX
Max Qty=4/31 days
Max Qty=3/claim
Max Qty=10/31 days
Max Qty=5/31 days
TOBREX
BLEPH-10
Max Qty=15/31 days
Max Qty=4/31 days
Max Qty=8/31 days
Max Qty=4/31 days
Limit=1/claim
VIROPTIC
POLYSPORIN)
POLYTRIM
NEOSPORIN
TEARGEN II
PREMIER VALUE
REFRESH P.M.
Max Qty=4/31 days
Max Qty=15/claim
Max Qty=31/31 days
Max Qty=4/claim
Polyethylene Glycol-Polyvinyl Alcohol Ophth Soln 1-1%
Generic
HYPOTEARS
Max Qty=31/31 days
*White Petrolatum-Mineral Oil Ophth Ointment***
Betaxolol HCl Ophth Soln 0.5%
Carteolol HCl Ophth Soln 1%
Levobunolol HCl Ophth Soln 0.25%
Levobunolol HCl Ophth Soln 0.5%
Timolol Maleate Ophth Soln 0.25%
Timolol Maleate Preservative Free Ophth Soln 0.25%
Timolol Maleate Ophth Soln 0.5%
Timolol Maleate Preservative Free Ophth Soln 0.5%
Dorzolamide HCl-Timolol Maleate Ophth Soln 22.3-6.8
MG/ML
Dexamethasone Sodium Phosphate Ophth Soln 0.1%
Fluorometholone Ophth Susp 0.1%
Fluorometholone Ophth Oint 0.1%
Prednisolone Acetate Ophth Susp 0.12%
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Brand
TEARS NATURALE
Max Fills=1/30 days
Max Qty=15/31 days
Max Qty=15/31 days
Max Qty=15/31 days
Max Qty=15/31 days
Max Qty=15/31 days
Generic
Generic
Generic
Brand
Brand
COSOPT
Prednisolone Acetate Ophth Susp 1%
Prednisolone Sodium Phosphate Ophth Soln 1%
Rimexolone Ophth Susp 1%
Gentamicin-Prednisolone Ace Ophth Susp 0.3-1%
Generic
Generic
Brand
Brand
Sulfacetamide Sodium-Prednisolone Ophth Susp 10-0.2%
Brand
Sulfacetamide Sodium-Prednisolone Ophth Soln 10-0.25%
Generic
Sulfacetamide Sodium-Prednisolone Ophth Oint 10-0.2%
Tobramycin-Dexamethasone Ophth Susp 0.3-0.1%
Tobramycin-Dexamethasone Ophth Oint 0.3-0.1%
Brand
Generic
Brand
BETAGAN
BETAGAN
TIMOPTIC
TIMOPTIC OCU
TIMOPTIC
TIMOPTIC OCU
Max Qty=10/31 days
FML LIQUIFLM
FML, FML S.O.P.
PRED MILD
OMNIPRED, PRED
FORTE
Max Qty=4/31 days
Max Qty=10/31 days
VEXOL
PRED-G
BLEPHAMIDE
Max Qty=10/31 days
BLEPHAMIDE
TOBRADEX
TOBRADEX
49
Max Qty=4/31 days
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Neomycin-Polymyxin-Dexamethasone Ophth Susp 0.1%
Generic
MAXITROL
Max Qty=10/31 days
Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1%
Neomycin-Polymyxin-HC Ophth Susp
Neomycin-Polymyxin-Prednisolone Ace Ophth Susp 0.5%
(new)
Latanoprost Ophth Soln 0.005%
Generic
Generic
MAXITROL
Max Qty=4/31 days
Max Qty=15/31 days
Atropine Sulfate Ophth Soln 1%
Atropine Sulfate Ophth Oint 1%
Cyclopentolate HCl Ophth Soln 0.5%
Cyclopentolate HCl Ophth Soln 1%
Cyclopentolate HCl Ophth Soln 2%
Generic
Generic
Brand
Generic
Generic
Homatropine HBr Ophth Soln 2%
Brand
Homatropine HBr Ophth Soln 5%
Tropicamide Ophth Soln 0.5%
Tropicamide Ophth Soln 1%
Naphazoline HCl Ophth Soln 0.1%
Generic
Generic
Generic
Generic
Phenylephrine HCl Ophth Soln 2.5%
Generic
Tetrahydrozoline HCl Ophth Soln 0.05%
Generic
MYDFRIN
SUSTAINED DR,
VISINE, VISINE
EXTRA
Naphazoline w/ Pheniramine Ophth Soln 0.025-0.3%
Generic
NAPHCON-A
Naphazoline w/ Pheniramine Ophth Soln 0.027-0.315%
Carbachol Ophth Soln 1.5%
Carbachol Ophth Soln 3%
Pilocarpine HCl Ophth Soln 0.5%
Pilocarpine HCl Ophth Soln 1%
Generic
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Generic
OPCON-A
Apraclonidine HCl Ophth Soln 0.5% (Base Equivalent)
Apraclonidine HCl Ophth Soln 1% (Base Equivalent)
Brimonidine Tartrate Ophth Soln 0.2%
Generic
Brand
Generic
IOPIDINE
Azelastine HCl Ophth Soln 0.05%
Generic
OPTIVAR
Cromolyn Sodium Ophth Soln 4%
Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)
Generic
Generic
CROLOM
ZADITOR
Lodoxamide Tromethamine Ophth Soln 0.1%
Brand
ALOMIDE
Nedocromil Sodium Ophth Soln 2%
Brinzolamide Ophth Susp 1%
Dorzolamide HCl Ophth Soln 2%
Diclofenac Sodium Ophth Soln 0.1%
Flurbiprofen Sodium Ophth Soln 0.03%
Ketorolac Tromethamine Ophth Soln 0.4%
Ketorolac Tromethamine Ophth Soln 0.5%
Nepafenac Ophth Susp 0.1%
Brand
Brand
Generic
Generic
Generic
Generic
Generic
Brand
ALOCRIL
AZOPT
OTIC AGENTS
Ofloxacin Otic Soln 0.3%
Fluocinolone Acetonide (Otic) Oil 0.01%
Hydrocortisone w/ Acetic Acid Otic Soln 1-2%
Acetic Acid Otic Soln 2%
Carbamide Peroxide 6.5% Otic Soln
Ciprofloxacin-Dexamethasone Otic Susp 0.3-0.1%
Brand
Generic
Generic
Generic
Generic
Generic
Generic
POLY-PRED
XALATAN
Max Qty=5/31 days
ISOPTO ATROPINE
CYCLOGYL
CYCLOGYL
CYCLOGYL
Max Qty=15/31 days
ISOPTO
HOMATROPINE
Max Qty=15/31 days
ISOPTO
HOMATROPINE
MYDRIACYL
NAPHCON FORTE
Qty=5/31 days
Pkg Size 15: Package Limit=1/30
days
Max Qty=15/30 days
ISO CARBACHO
ISO CARBACHO
ISOPTO CARPINE
ISOPTO CARPINE
ISOPTO CARPINE
ISOPTO CARPINE
ISOPTO CARPINE
IOPIDINE
NEVANAC
Max Qty=6/31 days; Step
Therapy
Limit=1/claim
Therapy
Therapy
Max Qty=10/31 days
Max Qty=3/31 days
Max Qty=5/31 days
Max Fills=1/30 days
PA; Max Qty=3/claim
CIPRODEX
Max Qty=20/31 days
Max Qty=15/31 days
Max Qty=15/31 days
Limit=1/claim
TRUSOPT
VOLTAREN
OCUFEN
ACULAR LS
ACULAR
FLOXIN OTIC
DERMOTIC
VOSOL HC
VOSOL
DEBROX
Brand
50
Product Description
Brand/
Generic
Neomycin-Polymyxin-HC Otic Susp 3.5 MG/ML-10000
U/ML-1%
Generic
Neomycin-Polymyxin-HC Otic Soln 1%
Generic
Antipyrine-Benzocaine Otic Soln 54-14 MG/ML (5.4-1.4%) Generic
Generic
Pramoxine-Chloroxylenol Otic Liquid 1-0.1%
Pramoxine-HC-Chloroxylenol Otic Soln 10-10-1 MG/ML
Pramoxine-HC-Chloroxylenol Aqueous Otic Soln 10-101MG/ML
MOUTH/THROAT/DENTAL AGENTS
Nystatin Susp 100000 U/ML
Chlorhexidine Gluconate Soln 0.12%
Zinc Lozenge 15 MG
Triamcinolone Acetonide Dental Paste 0.1%
Lidocaine HCl Viscous Soln 2%
Sodium Fluoride Cream 1.1%
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
Qty=10/claim
CORTISPORIN
Generic
OTILAM NR
PRAMOTIC
CORTANE-B,
OTICIN HC
Generic
CORTANE-B
Generic
Generic
Generic
Generic
Generic
Generic
Sodium Fluoride Gel 1.1%
Generic
Sodium Fluoride Paste 1.1%
*Artificial Saliva - Solution***
Pilocarpine HCl Tab 5 MG
Generic
Generic
Generic
ANORECTAL AGENTS
Hydrocortisone Rectal Cream 2.5%
Hydrocortisone Acetate Suppos 25 MG
Hydrocortisone Enema 100 MG/60ML
Generic
Generic
Generic
Hydrocortisone Acetate w/ Pramoxine Rectal Cream 1-1% Generic
Hydrocortisone Acetate w/ Pramoxine Rectal Cream 2.51%
Generic
Hydrocortisone Acetate w/ Pramoxine Rectal Lotn 2.5-1% Brand
Phenyleph-Shark Liver Oil-Cocoa Butter Suppos 0.25-385.5%
Generic
Phenylephrine-Shark Liver Oil-MO-Pet Oint 0.25-3-1471.9%
Generic
Max Fills=1/30 days
PERIDEX
Max Qty=100/claim
Max Qty=60/month
PREVIDENT
PREVIDENT, THERAFLUR-N
PREVDNT 5000,
PREVIDENT
Max Qty=60/month
Max Qty=60/month
Max Qty=900/claim
Daily Dosage=6
SALAGEN
ANUSOL-HC
ANUSOL-HC
CORTENEMA
ANALPRAM-HC
Max Qty=62/31 days
ANALPRAM-HC
Max Qty=30/claim
ANALPRAM-HC
Max Qty=62/31 days
PREPARATION
Max Qty=12/31 days
PREPARATION
Max Qty=31/31 days
DERMATOLOGICALS
BENZAC AC,
BENZAC W,
DESQUAM-X
BENZAC AC,
BENZAC W,
DESQUAM-X
Benzoyl Peroxide Liq 5%
Generic
Benzoyl Peroxide Liq 10%
Benzoyl Peroxide Gel 2.5%
Benzoyl Peroxide Gel 5%
Benzoyl Peroxide Gel 10%
Benzoyl Peroxide Lotion 5%
Benzoyl Peroxide Lotion 10%
Generic
Generic
Generic
Generic
Generic
Generic
Isotretinoin Cap 10 MG
Generic
ABSORICA
Generic
ABSORICA
Generic
ABSORICA
Tretinoin Cream 0.025%
Generic
RETIN-A
Generic
RETIN-A
Generic
RETIN-A
Tretinoin Gel 0.01%
Generic
RETIN-A
BENZAC AC
BENZAC AC
CLEAN&CLEAR
51
PA; Limited to Ages 21 and
Under; Daily Dosage=2
Max Qty=20/claim
Max Qty=20/claim
Max Qty=20/claim
Max Qty=15/claim
Product Description
Tretinoin Gel 0.025%
Clindamycin Phosphate Soln 1%
Clindamycin Phosphate Gel 1%
Clindamycin Phosphate Lotion 1%
Erythromycin Soln 2%
Erythromycin Gel 2%
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Sulfacetamide Sodium Lotion 10% (Acne)
Clindamycin Phosphate-Benzoyl Peroxide Gel 1-5%
Generic
Generic
Sulfacetamide Sodium w/ Sulfur Susp 10-5%
Sulfacetamide Sodium w/ Sulfur Lotion 10-5%
Generic
Generic
Metronidazole Cream 0.75%
Generic
Metronidazole Gel 0.75%
Metronidazole Lotion 0.75%
Generic
Generic
Bacitracin Oint 500 U/GM
Bacitracin Zinc Oint 500 U/GM
Gentamicin Sulfate Cream 0.1%
Gentamicin Sulfate Oint 0.1%
Mupirocin Oint 2%
Mupirocin Calcium Cream 2%
*Bacitracin-Polymyxin B Powder***
*Neomycin-Bacitracin-Polymyxin Oint***
Generic
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
RETIN-A
CLEOCIN-T
CLEOCIN-T
CLEOCIN-T
Limited to Ages 21 and Under,
KLARON
BENZACLIN
Max Qty=124/31 days; Pkg Size
118: Package Limit=1/claim; Pkg
Size 59: Package Limit=2/claim
NOVACET
30: Package Limit=1/claim
METROCREAM
METROLOTION
Pkg Size 30: Package
Limit=1/claim; Pkg Size 28:
Max Qty=30/claim
BACIGUENT
Generic
Generic
Generic
Generic
Brand
Generic
Neomycin-Polymyxin w/ Pramoxine Cream 1%
*Nystatin Topical Powder**
Nystatin Cream 100000 U/GM
Generic
Generic
Generic
Nystatin Oint 100000 U/GM
Tolnaftate Cream 1%
Generic
Generic
Terbinafine HCl Cream 1%
Clotrimazole Soln 1%
Generic
Generic
Clotrimazole Cream 1%
Econazole Nitrate Cream 1%
Generic
Generic
Ketoconazole Cream 2%
Ketoconazole Shampoo 1%
Generic
Brand
BACTROBAN
BACTROBAN
POLYSPORIN
Size 15: Package Limit=2/claim;
Pkg Size 28.35: Package
Limit=1/claim; Pkg Size 14.2:
NEOSPORIN,
TRIPLE ANTIBIOTIC
14.2: Package Limit=1/claim; Pkg
Size 15: Package Limit=1/claim;
Pkg Size 14: Package
Limit=1/claim
Package Limit=1/31 days;
Max Qty=30/claim
NEOSPORIN
TINACTIN
LAMISIL AT,
LAMISIL ATC
LOTRIMIN AF,
MYCELEX OTC
Max Qty=30/claim
Fill Limit=1/31 days; Package
Limit=1/claim
NIZORAL A-D
52
Product Description
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
120: Package Limit=1/claim
PA, Legend
Max Qty=45/31 days
Max Qty=31/31 days
Ketoconazole Shampoo 2%
Miconazole Nitrate Cream 2%
Clotrimazole w/ Betamethasone Cream 1-0.05%
Clotrimazole w/ Betamethasone Lotion 1-0.05%
Generic
Generic
Generic
Generic
NIZORAL
MICATIN
LOTRISONE
LOTRISONE
Nystatin-Triamcinolone Cream 100000-0.1 U/GM-%
Generic
Nystatin-Triamcinolone Oint 100000-0.1 U/GM-%
Diphenhydramine HCl Cream 2%
Camphor & Menthol Lotion 0.5-0.5%
Generic
Generic
Generic
Calcipotriene Soln 0.005% (50 MCG/ML)
Generic
BENADRYL M-S
SARNA
DOVONEX,
DOVONX SCALP
Calcipotriene Cream 0.005%
Generic
DOVONEX
Tazarotene Cream 0.05%
Brand
TAZORAC
Tazarotene Cream 0.1%
Brand
TAZORAC
Tazarotene Gel 0.05%
Brand
TAZORAC
Tazarotene Gel 0.1%
Brand
DOVONEX
TAZORAC
SELSUN BLUE,
DENOREX
Limit=1/claim
Limit=1/claim
Limit=1-4/claim
Limit=1-2/claim
Limit=2/claim
Limit=2/claim
Selenium Sulfide Lotion 1%
Generic
Limit=1/claim
Selenium Sulfide Lotion 2.5%
Generic
Sulfacetamide Sodium Liquid 10%
Sulfacetamide Sodium-Urea Lotion 10-10%
Acyclovir Cream 5%
Generic
Brand
Brand
Acyclovir Oint 5%
Fluorouracil Soln 2%
Fluorouracil Soln 5%
Fluorouracil Cream 0.5%
Fluorouracil Cream 5%
Silver Sulfadiazine Cream 1%
Generic
Generic
Generic
Brand
Generic
Generic
Coal Tar Shampoo 0.5%
Betamethasone Dipropionate Cream 0.05%
Betamethasone Dipropionate Lotion 0.05%
Betamethasone Dipropionate Oint 0.05%
Generic
Generic
Generic
Generic
Betamethasone Dipropionate Augmented Cream 0.05%
Betamethasone Dipropionate Augmented Gel 0.05%
Generic
Generic
DIPROLENE AF
Betamethasone Dipropionate Augmented Lotion 0.05%
Betamethasone Dipropionate Augmented Oint 0.05%
Betamethasone Valerate Cream 0.1%
Betamethasone Valerate Lotion 0.1%
Betamethasone Valerate Oint 0.1%
Clobetasol Propionate Soln 0.05%
Clobetasol Propionate Cream 0.05%
Clobetasol Propionate Gel 0.05%
Clobetasol Propionate Oint 0.05%
Clobetasol Propionate Emollient Base Cream 0.05%
Desonide Cream 0.05%
Desonide Lotion 0.05%
Desonide Oint 0.05%
Desoximetasone Cream 0.05%
Desoximetasone Cream 0.25%
Desoximetasone Gel 0.05%
Desoximetasone Oint 0.25%
Fluocinolone Acetonide Soln 0.01%
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
DIPROLENE
DIPROLENE
SELSUN
OVACE PLUS,
OVACE WASH
CARMOL SCALP
ZOVIRAX
ZOVIRAX
EFUDEX
Limit=1/claim
Max Qty=10/31 days
Max Qty=10/31 days
CARAC
EFUDEX
SILVADENE
DHS TAR, DHS TAR
GEL, NEUTRO
T/GEL
Max Qty=40/31 days
TEMOVATE
TEMOVATE
TEMOVATE
TEMOVATE
TEMOVATE E
DESOWEN
DESOWEN
DESOWEN
TOPICORT
TOPICORT
TOPICORT
TOPICORT
SYNALAR
53
Fluocinolone Acetonide Cream 0.01%
Fluocinolone Acetonide Cream 0.025%
Fluocinolone Acetonide Oint 0.025%
Fluocinonide Soln 0.05%
Fluocinonide Cream 0.05%
Fluocinonide Gel 0.05%
Fluocinonide Oint 0.05%
Fluocinonide Emulsified Base Cream 0.05%
Fluticasone Propionate Cream 0.05%
Fluticasone Propionate Oint 0.005%
Halobetasol Propionate Cream 0.05%
Halobetasol Propionate Oint 0.05%
Hydrocortisone Cream 0.5%
Hydrocortisone Cream 1%
Brand/
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Hydrocortisone Cream 2.5%
Hydrocortisone Lotion 1%
Generic
Generic
Product Description
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
SYNALAR
SYNALAR
CUTIVATE
CUTIVATE
ULTRAVATE
ULTRAVATE
JAR Max Qty=120/30 days;
TUBE Package Limit=1/claim
Hydrocortisone Lotion 2.5%
Generic
LACTICARE HC,
ALOCORT,
CETACORT
Hydrocortisone Oint 1%
Hydrocortisone Oint 2.5%
Hydrocortisone Valerate Cream 0.2%
Hydrocortisone Valerate Oint 0.2%
Hydrocortisone Butyrate Soln 0.1%
Hydrocortisone Butyrate Cream 0.1%
Hydrocortisone Butyrate Oint 0.1%
Mometasone Furoate Solution 0.1% (Lotion)
Mometasone Furoate Cream 0.1%
Mometasone Furoate Oint 0.1%
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
WESTCORT
WESTCORT
LOCOID
LOCOID
LOCOID
ELOCON
ELOCON
ELOCON
Triamcinolone Acetonide Cream 0.025%
Triamcinolone Acetonide Lotion 0.025%
Triamcinolone Acetonide Lotion 0.1%
Triamcinolone Acetonide Oint 0.025%
Pramoxine-HC Aerosol Foam 1-1%
Hydrocortisone-Aloe Vera Cream 1%
*Emollient - Lotion**
Lactic Acid (Ammonium Lactate) Cream 12%
Lactic Acid (Ammonium Lactate) Lotion 12%
Urea Cream 40%
Urea Lotion 40%
Podofilox Soln 0.5%
Salicylic Acid Gel 6%
Salicylic Acid Gel 3%
Imiquimod Cream 5%
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
Generic
Pimecrolimus Cream 1%
Brand
ELIDEL
Tacrolimus Oint 0.03%
Brand
PROTOPIC
Tacrolimus Oint 0.1%
Brand
PROTOPIC
Max Qty=48/180 days
Capsaicin Cream 0.025%
Generic
Brand
CAPZASIN-P
Limit=1/claim
Capsaicin Gel 0.025%
Generic
Generic
Brand
Limit=1/30 days
JAR Max Qty=120/30 days;
TUBE Package Limit=1/claim
EPIFOAM
PA
PA
LAC-HYDRIN
LAC-HYDRIN
CARMOL 40
CONDYLOX
KERALYT
KERALYT
ALDARA
ZOSTRIX, ZOSTRIX
ARTHRITIS
ZOSTRIX, ZOSTRIX
HP, ZOSTRIX SPRT,
ZOSTRX FOOT
CAPZASIN-HP
CAPSAGEL
54
Capsaicin Gel 0.05%
Capsaicin Gel 0.075%
Capsaicin Lotion 0.035%
Brand/
Generic
Brand
Brand
Brand
Dibucaine Oint 1%
Generic
Lidocaine Oint 5%
Lidocaine HCl Cream 3%
Generic
Generic
LIDAMANTLE
Lidocaine HCl Gel 2%
Generic
XYLOCAINE
Lidocaine-Prilocaine Cream 2.5-2.5%
Generic
EMLA
Crotamiton Cream 10%
Crotamiton Lotion 10%
Brand
Brand
Malathion Lotion 0.5%
Generic
OVIDE
Permethrin Creme Rinse 1%
Generic
NIX COMPLETE,
NIX CREME RINSE
Permethrin Cream 5%
Generic
ELIMITE
Permethrin Lotion 1%
Generic
Product Description
*Nit Remover - Shampoo***
Pyrethrins-Piperonyl Butoxide Liq 0.18-2.2%
Pyrethrins-Piperonyl Butoxide Liq 0.2-2%
Brand
Brand
Generic
Generic
Pyrethrins-Piperonyl Butoxide Foam 0.33-4%
Pyrethrins-Piperonyl Butoxide Gel 0.33-4%
Pyrethrins-Piperonyl Butoxide Shampoo 0.3-3%
Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
Pyrethrins-Piperonyl Butoxide Shampoo Kit
Generic
Brand
Brand
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
EURAX
EURAX
ANTISEPTICS & DISINFECTANTS
Formaldehyde Solution 10%
Chlorhexidine Gluconate Liquid 4%
Limit=1/claim
Package Limit=1/claim Fill
limit=1/31 days
Limit=1-2/claim
Max Qty=30/claim; Package
Limit=1/claim
Limit=1/claim
Fills=2/30 days
Limit=1-6/claim
Limit=1-2/claim
KLOUT,
SCHOOLTIME
BARC
Max Qty=1/14 days
RID
RID, NIX LICE
TREATMENT
RID LICE KIL
A-200
TEGRIN-LT
PRONTO
PRONTO
Pyrethrins Spray & Pyrethins-Piperonyl Butoxide Shamp Kit Brand
Pyreth-Piper But Spray & Pyreth-Piper But Shamp Kit
Permethrin Spray & Pyrethins-Piperonyl Butoxide Shamp
Kit
Pyreth-Piperonyl Butox Sham-Permeth Aero-Nit Remover
Gel Kit
Aluminum Chloride Soln 20%
Zinc Oxide Oint 20%
*Skin Protectants Misc - Cream***
Covered Brand
Product
CAPSAGEL XS
CAPSAGEL MS
CASTIVA
LICE TRTMNT
LICIDE TREAT,
TEGRIN-LT
Brand
Generic
A-200
Generic
Generic
Generic
Generic
RID COMPLETE
DRYSOL
ZINC OXIDE O
EUCERIN
Generic
Max Qty=90/claim
ANTIDOTES
Ipecac Syrup
Succimer Cap 100 MG
Naltrexone HCl Tab 50 MG
Generic
Brand
Generic
IPECAC, RA IPECAC,
SM IPECAC
CHEMET
REVIA
DIAGNOSTIC PRODUCTS
Acetone (Urine) Test Strip
Brand
Glucose Blood Test Strip
Generic
CHEK-STIX,
CHEMSTRIP K,
KETOCARE,
KETOSTIX, RELION
KETON
TRUETRACK,
TRUETEST
55
Daily Dosage=5
Product Description
Ketone Blood Test Strip
Brand/
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
NOVA MAX PLS,
PRECISN XTRA, PTS
PANELS
Brand
Max Qty=30/30 days
ALTERNATIVE MEDICINES
Ginger (Zingiber officinalis) Cap 250 MG
Melatonin Tab 3 MG
Melatonin Tab 5 MG
Generic
Generic
Generic
CHEMICALS
Omeprazole (Bulk) Powder
Promethazine HCl (Bulk) Powder
Generic
Generic
PA
MEDICAL DEVICES
Insulin Syringe (Disp) U-100 1 ML
Insulin Syringe/Needle U-100 0.3 ML 28 x 1/2"
Insulin Syringe/Needle U-100 1/2 ML 27 x 1/2"
Insulin Syringe/Needle U-100 1 ML 25 x 5/8"
Insulin Syringe/Needle U-100 1 ML 25 x 1"
Insulin Syringe/Needle U-100 2 ML 27.5 x 5/8"
Insulin Syringe/Needle U-100 0.3 ML 29 x 1"
Insulin Pen Needle 29 G X 8 MM (5/16")
Generic
Brand
Generic
Brand
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Brand
Generic
Brand
Generic
Brand
Brand
Generic
Generic
Brand
Brand
Brand
Brand
Brand
Brand
Daily Dosage=5
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Daily Dosage=5
Daily Dosage=5
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Daily Dosage=5
Insulin Pen Needle 29 G X 12 MM
Insulin Pen Needle 29 G X 12.7 MM
Generic
Daily Dosage=4
Daily Dosage=1
Daily Dosage=1
MELATONIN 3
AUTOSHIELD
1ST TIER UNI,
AUTOSHIELD, EASY
TOUCH,
INCONTROL,
INSULIN PEN...
Daily Dosage=5
Brand
BD PEN NEEDL,
LITETOUCH, PEN
NEEDLE, SURE
COMFORT, SUREFINE
Daily Dosage=5
Brand
INSUPEN ULTR,
NOVOFINE,
NOVOFINE AUT,
NOVOTWIST, PEN
NEEDLES
Daily Dosage=5
56
Product Description
Brand/
Generic
Generic
1ST TIER UNI,
CLICKFINE,
COMFORT EZ, EASY
TOUCH, IN
CONTROL...
Brand
Brand
Generic
Daily Dosage=5
Daily Dosage=5
1ST TIER UNI, BD
PEN NEEDL,
CLICKFINE,
COMFORT EZ, EASY
COMFORT...
Generic
Brand
Covered Brand
Product
1ST TIER UNI, BD
PEN NEEDL,
COMFORT EZ, EASY
COMFORT, EASY
TOUCH...
Brand
*Respiratory Therapy Supplies - Misc**
Non-Preferred Brand
Equivalent(s)
1ST TIER UNI, BD
PEN NEEDL,
CLICKFINE,
COMFORT EZ,
INSUPEN...
EASY TOUCH,
NOVOTWIST
EASY TOUCH,
INSUPEN SENS,
NOVOFINE
ACE AERO CLD,
ACTIVITY PCH,
ADULT MASK,
AEROSOL MASK,
AEROTRC PLUS...
Daily Dosage=5
Daily Dosage=5
Daily Dosage=5
Daily Dosage=5
Max Qty=1/360 days
Generic
ADULT DISPOS, ALL
FLOW,
EXPIRATORY,
KOKO PEAK PR,
MICROSPACER...
PA Mouthpiece
*Spacer/Aerosol-Holding Chambers - Device***
Brand
AERCHMBR PLS,
AERCHMBR Z-,
AEROCHAMBER,
ARIAL,
BREATHERITE...
Max Qty=2/360 days
*Spacer/Aerosol-Holding Chamber Supplies - Bags***
*Blood Glucose Calibration - Liquid***
*Blood Glucose Calibration - Liquid - High***
*Blood Glucose Calibration - Liquid - Normal***
*Blood Glucose Calibration - Liquid - Low***
*Blood Glucose Monitoring Devices****
*Blood Glucose Monitoring Kit****
*Blood Glucose Monitoring Kit w/ Device****
Brand
Generic
Brand
Generic
Brand
Brand
Brand
Generic
INSPIREASE
ALL BRANDS
ALL BRANDS
ALL BRANDS
ALL BRANDS
TRUETRACK
TRUETRACK
TRUETRACK
Max Qty=3/180 days
Max Qty=1/90 days
Max Qty=1/90 days
Max Qty=1/90 days
Max Qty=1/90 days
Max Qty=1/730 days
Max Qty=1/730 days
Max Qty=1/730 days
*Respiratory Therapy Supplies - Mouthpieces**
*Lancets****
*Lancet Devices****
*Gauze Pads & Dressings - Pads 2" X 2"***
Generic
1ST CHOICE, ACCUCHEK, ACTI-LANCE,
ADV TRAVEL,
ADVOCATE...
Max Qty=200/30 days
Generic
ADJ LANCING, ADV
LANCING,
ADVOCATE,
ALTRNATE SIT,
AQUA LANCE...
Max Qty=1/180 days
Generic
AMD FOAM, CUREX
SPONGE, CURITY
AMD, CURITY
GAUZE, CURITY
SPONG...
57
Product Description
Condoms Latex Lubricated
Condoms Latex Non-Lubricated
Diaphragm Arc-Spring 65 MM
Diaphragm Coil Spring Kit 50 MM
Diaphragm Flat Spring Kit 55 MM
*Alcohol Swabs***
Brand/
Generic
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
Covered Brand
Product
CURITY COVER,
CURITY GAUZE,
CURITY SPONG,
CURITY STRIP,
DERMACEA...
ADH DRESSING,
ALL PURPOSE, AMD
FOAM, BIATAIN,
BIATAIN FOAM...
Max Qty=36/30 days
ATLAS CONDOM,
KIMONO MICRO,
MENTOR, TROJAN,
TROJAN PLUS...
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO COIL
ORTHO COIL
ORTHO COIL
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Generic
Package Limit=1-4/30 days
Max Qty=1/365 days
Max Qty=1/365 days
Max Qty=1/365 days
Max Qty=1/365 days
Max Qty=1/365 days
Max Qty=400/claim
PHARMACEUTICAL ADJUVANTS
Xanthan Gum Oral Thickening Gel
Brand
Lanolin
Generic
ASSORTED CLASSES
Penicillamine Cap 250 MG
Cyclosporine Cap 25 MG
Cyclosporine Cap 100 MG
Cyclosporine Oral Soln 100 MG/ML
Cyclosporine Modified Cap 25 MG
Cyclosporine Modified Oral Soln 100 MG/ML
Mycophenolate Mofetil Cap 250 MG
Mycophenolate Mofetil Tab 500 MG
Mycophenolate Mofetil For Oral Susp 200 MG/ML
Mycophenolate Sodium Tab DR 180 MG (Mycophenolic
Acid Equiv)
Mycophenolate Sodium Tab DR 360 MG (Mycophenolic
Acid Equiv)
Sirolimus Tab 0.5 MG
Sirolimus Tab 1 MG
Sirolimus Tab 2 MG
Sirolimus Oral Soln 1 MG/ML
Tacrolimus Cap 0.5 MG
Tacrolimus Cap 1 MG
Tacrolimus Cap 5 MG
Azathioprine Tab 50 MG
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Brand
SIMPLYTHICK
LANSINOH, LAN-OSOOTHE
Max Qty=1816/claim; Limited
to Ages 1 and Older
PA
CUPRIMINE
SANDIMMUNE
SANDIMMUNE
SANDIMMUNE
NEORAL
PA
PA
PA
NEORAL
NEORAL
CELLCEPT
CELLCEPT
CELLCEPT
Brand
MYFORTIC
Brand
Brand
Brand
Brand
Brand
Generic
Generic
Generic
Generic
Brand
Brand
MYFORTIC
RAPAMUNE
RAPAMUNE
RAPAMUNE
RAPAMUNE
PROGRAF
PROGRAF
PROGRAF
IMURAN
AZASAN
AZASAN
58
Product Description
Sodium Polystyrene Sulfonate Oral Susp 15 GM/60ML
*Sodium Polystyrene Sulfonate Powder**
Brand/
Generic
Generic
Generic
Non-Preferred Brand
Equivalent(s)
SPS
KAYEXALATE
59
Covered Brand
Product
Preferred Specialty Drug List
Peach State provides coverage of a number of specialty drugs. All specialty drugs, such as biopharmaceuticals
and injectables, require PA to be approved for payment by Peach State. PA requirements are programmed
specific to the drug. The following products are the Peach State preferred agents within the specified
therapeutic class.
Product Description
Brand/
Generic
Limitations/
Restrictions
Covered Brand Product
TUMOR NECROSIS FACTOR MODIFIERS
Adalimumab
Brand
HUMIRA
PA
Etanercept
Brand
ENBREL
PA
BIOLOGIC RESPONSE MODIFIERS
Glatiramer
Brand
COPAXONE
PA
Interferon Beta-1b
Brand
EXTAVIA
PA
HUMAN GROWTH HORMONE
Somatropin, rh-GH
Brand
TEV-TROPIN
PA
Somatropin, rh-GH
Brand
NORDITROPIN
PA
Peginterferon Alfa-2a
Brand
PEGASYS
PA
Peginterferon Alfa-2b
Brand
PEG-INTRON
PA
Telaprevir
Brand
INCIVEK
PA
Boceprevir
Brand
VICTRELIS
PA
ALPHA INTERFERONS
ANTI-HEPATITIS AGENTS
60

Peach State Health Plan Preferred Drug List

Transcription

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