Buckeye Community Health Plan Preferred Drug List

Transcription

Buckeye Community Health Plan
Preferred Drug List
Approved September 5, 2013
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
BCHP-MM-090711-01rev10-2013
Buckeye Community Health Plan Pharmacy Program
Buckeye Community Health Plan, Inc. (Buckeye) is committed to providing appropriate, high quality, and
cost effective drug therapy to all Buckeye members. Buckeye works with providers and pharmacists to
ensure that medications used to treat a variety of conditions and diseases are covered. Buckeye covers
prescription medications and certain over- the-counter (OTC) medications when ordered by a
physician/clinician. The pharmacy program does not cover all medications. Some medications require
prior authorization (PA) or have limitations on age, dosage, and maximum quantities. This section
provides an overview of the Buckeye pharmacy program. For more detailed information, please visit our
website at www.bchpohio.com. The following program covers both the Covered Families & Children
(CFC) and Aged, Blind or Disabled (ABD) Ohio Medicaid consumers who are enrolled in Buckeye.
Plan Preferred Drug List and Prior Authorization List
The Buckeye Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy
providers will be reimbursed for medications dispensed to members covered under the program. All
drugs covered under the Ohio Medicaid program are available for Buckeye members. The PDL includes
all drugs available without PA and those agents that have the restrictions of Step Therapy (ST). The PA
list includes those drugs that require PA for coverage. The PDL applies to drugs you receive at retail
pharmacies. The PDL is continually evaluated by the Buckeye Pharmacy and Therapeutics (P&T)
Committee to promote the appropriate and cost-effective use of medications. The Committee is
composed of the Buckeye Medical Director, Buckeye Pharmacy Director, and several Ohio primary care
physicians, pharmacists, and specialists. The PDL does not:

Require or prohibit the prescribing or dispensing of any medication

Substitute for the independent professional judgment of the physician/clinician or pharmacist, or

Relieve the physician/clinician or pharmacist of any obligation to the patient or others
US Script
With the exceptions of biopharmaceuticals and specialty drugs, Buckeye works with US Script to process
all pharmacy claims for prescribed drugs. Some drugs on the Buckeye PDL and PA list require a PA and
US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager.
Follow these guidelines for efficient processing of your authorization requests:
1. Complete the Buckeye Community Health Plan/US Script form: Medication Prior Authorization
Request Form.
2. Fax to US Script at 1-866-399-0929.
3. Once approved, US Script notifies the prescriber by fax.
4. If the clinical information provided does not explain the medical necessity for the requested PA
medication, US Script will deny the request and offer PDL alternatives to the prescriber by fax.
5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour emergency supply of
medication by calling 1-800-460-8988.
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Prior Authorization Process
The Buckeye PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged
to prescribe from the Buckeye PDL for their patients who are members of Buckeye. Some drugs will
require PA and are listed on the PA list. In addition, all name brand drugs not listed on either the PDL or
PA list will require prior authorization. If a request for authorization is needed the information should be
submitted by your physician/clinician to US Script on the Buckeye Community Health Plan/US Script
form: Medication Prior Authorization Request Form. This form should be faxed to US Script at 1-866399-0929. This document is located on the Buckeye website at www.bchpohio.com.
Buckeye will cover the medication if it is determined that:
1. There is a medical reason you need the specific medication.
2. Depending on the medication, other medications on the PDL have not worked.
All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye
P&T Committee. Once approved, US Script notifies the physician/clinician by fax. If the clinical
information provided does not meet the coverage criteria for the requested medication Buckeye we will
notify you and your physician/clinician of alternatives and provide information regarding the appeal
process.
The P&T committee has reviewed and approved, with input from its members and in consideration of
medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate
and cost-effective drug therapy to all members covered under the Buckeye pharmacy program. If a patient
requires a brand name medication that does not appear on the PDL, the physician/clinician can make a
PA request for the brand name medication. It is anticipated that such exceptions will be rare and that PDL
medications will be appropriate to treat the vast majority of medical conditions.
A phone or fax-in process is available for PA requests.
US Script Contact Information: Prior Authorization Fax
1-866-399-0929
Prior Authorization Phone 1-866-399-0928
Mailing Address:
2425 W Shaw Ave, Fresno, CA 93711
When calling, please have patient information, including Medicaid number, complete diagnosis, medication
history and current medications readily available. US Script will provide a decision to the request by fax or
phone within 24 hours. When incomplete information is received to support medical necessity of a drug
requiring PA, the request will be denied. If the request is approved, information in the on-line pharmacy
claims processing system will be changed to allow the specific member to receive this specific drug. If the
request is denied, information about the denial will be provided to the clinician.
Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the
Buckeye pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the
pharmacist should attempt to contact the clinician to request a change to a product included in the PDL.
Phone Numbers for Buckeye Community Health Plan Member Services
The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians
requesting PA medication items only. Members can not be assisted if they call the PA toll-free number.
Buckeye Member Services may be reached at 1-866-246-4358 (TTY 1-800-750-0750).
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Transition Period
Buckeye members new to managed care will be able to receive their prescription drugs with no new PA
requirements than traditional Fee-for-Service (FFS) Medicaid for 30 days they are enrolled in our plan if
the prescription drug does not require PA by traditional FFS Medicaid. This means that if you needed a
PA under traditional FFS Medicaid to get your prescriptions you will most likely still need a PA to get the
same medication. If you have not needed PA under traditional FFS Medicaid to get your prescription you
will not need PA from Buckeye to get the same medication for the first 30 days you are enrolled. This will
allow you and your doctor time to consider other medications that do not require PA and to learn the
steps to getting PA. Buckeye’s PDL and PA List identify the drugs that will require PA once you have
been a managed care member for 30 days. If you are not sure when you will need to have your
medications prior authorized or you have other questions about continuing to get your medications, call
member services at 1-866-246-4358 (TTY 1-800-750-0750).
72-Hour Emergency Supply Policy
State and federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any
patient awaiting a 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 the
US Script Pharmacy Help Desk at 1-800-460-8988 for a prescription override to submit the 72-hour
medication supply for payment.
Step Therapy
Some medications listed on the Buckeye PDL may require specific medications to be used before you can
receive the step therapy medication. If Buckeye has a record that the required medication was tried first
the ST medications are automatically covered. If Buckeye does not have a record that the required
medication was tried, you or your physician/clinician may be required to provide additional information. If
Buckeye does not grant PA we will notify you and your physician/clinician and provide information
regarding the appeal process.
Dispensing Limits, Quantity Limits, and Age Limits
Drugs may be dispensed up to a maximum 31 day supply for each new or refill non-controlled substance.
A total of 80 percent (80%) of the days supplied must have elapsed before the prescription can be refilled.
A prescription can be filled after 26 days. Dispensing outside the quantity limit (QL) or age limits (AL)
requires PA. Buckeye may limit how much of a medication you can get at one time. If the
physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA.
If Buckeye does not grant PA we will notify you and your physician/clinician and provide information
regarding the appeal process. Some medications on the Buckeye PDL may have AL. These are set for
certain drugs based on Food and Drug Administration (FDA) approved labeling and for safety concerns
and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of
pharmaceuticals.
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Gender Limits
Some medications on the Buckeye PDL may be limited to one gender. These medications have a GL after
them on the PDL. 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 you require a medication that does not appear on the PDL, you or your physician/clinician can make a
medical necessity request for the medication. It is anticipated that such exceptions will be rare and that
PDL medications will be appropriate to treat the vast majority of medical conditions. Buckeye 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.
All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye
P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested
medication Buckeye will notify you and your physician/clinician of alternatives and provide information
regarding the appeal process.
Appropriate Use and Safety Edits
Your health and safety is a priority for Buckeye. One of the ways we address your safety is through Pointof-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. Additional information about the
drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and
Safety Edits document located on the Buckeye website at www.bchpohio.com.
DUR (Drug Utilization Review) programs
Buckeye will monitor ongoing prescribing of medications for clinical appropriateness. Buckeye reviews
prescribing retrospectively to review for both safety and efficacy. Buckeye will work with US Script to
review for such things as disease management, fraud and abuse (i.e. Coordinated Services Program), and
prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns.
Buckeye will continue to monitor for issues going forward and take action as needed.
Mandatory Generic Substitution
When generic drugs are available, the brand name drug will not be covered without Buckeye PA. Generic
drugs have the same active ingredient and work the same as brand name drugs. If you or your
physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA.
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We will cover the brand name drug according to our clinical guidelines if there is a medical reason you
need the particular brand name drug. If Buckeye does not grant PA we will notify you and your
physician/clinician 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, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin,
Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin, Procainamide, Propafenone,
Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin.
Over-The-Counter Medications
The pharmacy program covers a large selection of OTC medications. All covered OTC medications
appear in the PDL. All OTC medications must be written on a valid prescription by a licensed
physician/clinician in order to be reimbursed.
Filling a Prescription
You can have prescriptions filled at a Buckeye network pharmacy. If you decide to have a prescription
filled at a network pharmacy you can locate a pharmacy near you by contacting a Buckeye Member
Services Representative. At the pharmacy you will need to provide the pharmacist with your prescription
and your Buckeye ID card.
Please visit the Buckeye website at www.bchpohio.com to access the Buckeye PDL, Buckeye PA lists,
important forms, and provider/member information 24 hours a day, seven days a week.
Mail Order Program
Buckeye Community Health Plan offers a 90 day supply (3 month supply) of maintenance medications by
mail. These drugs are used to treat long-term conditions or illnesses. You can find a list of covered
maintenance medications in the Maintenance Drug Pharmacy Program document located on the Buckeye
website at www.bchpohio.com.
Please contact a Buckeye Member Service Representative if you have any questions. To transfer a current
prescription or to have you doctor phone a prescription directly to our mail order pharmacy they may call
RxDirect at 1-800-785-4197.
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Buckeye Community Health Plan Pharmacy Program - Additional Information
Working with Our Pharmacy Benefit Managers
Buckeye works with two Pharmacy Benefit Managers (PBMs). CVS Caremark the preferred provider of
biopharmaceuticals and injectables for Buckeye. US Script administers all other prescribed drugs. Certain
drugs require PA to be approved for payment by Buckeye. These include:

Some Buckeye drugs listed on the PA list

Most injectables including Procrit, Neulasta and Neupogen.
CVS Caremark – Biopharmaceuticals and Injectables
CVS Caremark is the provider of biopharmaceuticals and injectables for Buckeye. Most injectables require
PA to be approved for payment. Our Medical Director oversees the clinical review. Buckeye provides a
number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals
and injectables require a PA to be approved for payment by Buckeye; however, PA requirements are
programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program
document located on the Buckeye website at www.bchpohio.com. Follow these guidelines for the most
efficient processing of your authorization requests.
Providers can request that CVS Caremark deliver the specialty drug to the office/member. If you want
CVS Caremark to deliver the specialty drug to the office/member:
1. Fax the CVS Caremark Enrollment form to Buckeye 1-866-704-3066 for PA.
2. If approved, CVS Caremark will contact the provider or member for delivery confirmation.
Pharmacy and Therapeutics Committee
The Buckeye Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes
included in the PDL. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacist,
and several community based primary care physicians and specialists. The primary purpose of the
Committee is to assist in developing and monitoring the Buckeye PDL and to establish programs and
procedures that promote the appropriate and cost-effective use of medications. The P&T Committee
schedules meetings at least twice yearly, and coordinates reviews with a national P&T Committee which
meets at least 4 times a year. Changes to the Buckeye PDL are done in conjunction with the approval of
the State of Ohio. Buckeye will meet with the State quarterly to review any proposed changes and update
the PDL and PA lists accordingly based on the results of both the Buckeye P&T Committee and the
requirements from the State of Ohio. Buckeye will follow all State policies regarding member notification
when changes are made to the PA list.
Unapproved Use of Preferred Medication
Medication coverage under this program is limited to non-experimental indications as approved by the
FDA. Other indications may also be covered if they are accepted as safe and effective using current
medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for
specific non-approved indications will be made by Buckeye. Experimental drugs and investigational drugs
are not eligible for coverage.
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Benefit Exclusions
The following drug categories are not part of the Buckeye PDL and are not covered by the 72-hour
emergency supply policy:

Fertility enhancing drugs

Anorexia, weight loss, or weight gain drugs

Immunizations and vaccines (except flu vaccine)

Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that
are classified as ineffective

Infusion therapy and supplies

Drugs and other agents used for cosmetic purposes or for hair growth

Erectile dysfunction drugs prescribed to treat impotence
DESI drugs products and known related drug products are defined as less than effective by the FDA
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. State programs may allow
coverage of certain DESI drugs. Any DESI drugs that are covered are listed in the PDL.
Newly Approved Products
We review new drugs for safety and effectiveness for the first 12 months before adding them to the
Buckeye Community PDL. During this period, access to these medications will be considered through the
PA review process. If Buckeye does not grant PA we will notify you and your physician/clinician and
provide information regarding the appeal process.
Medical Benefits
The following drugs and medical services are a part of the Buckeye medical benefit and are not available at
the retail pharmacy:
1. Members will receive vaccines as a medical benefit under physician reimbursement if listed the
vaccine covered under the vaccine for children program.
2. Cosmetic-botox is a medical benefit that is covered for non-cosmetic purposes only- it requires a
PA from Buckeye.
3. Blood and blood products.
4. Those specialty injectable drugs available as a medical benefit. Most injectables require PA from
Buckeye.
Prescribers who request medical prior authorizations at US Script will be redirected to contact Buckeye
Community Health Plan as applicable.
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DME/Home Health Benefits
The following medical services are a part of the Buckeye medical benefit and are not available at the retail
pharmacy:
1. Enteral products
2. Nebulizers
3. Medical supplies
Injectable Drugs
Injections that are self-administered by the member and/or a family member and appear on the PDL are
covered by the Buckeye pharmacy program. Insulin vials, Glucagon Kit, Epi-pen, Ana-Kit, Imitrex, and
Depo-Provera IM are covered by Buckeye and do not require a PA. Pre-filled insulin cartridges and
syringes require PA. All other injectables require PA.
Coordinated Services Program
Consumers eligible for Ohio Medicaid may be selected for enrollment in the Coordinated Services
Program, or CSP. CSP enrollees must get medications filled at one pharmacy and coordinate medical
services through their primary care provider.
After being enrolled in CSP, the member will still be able to get all medically necessary Medicaid- covered
health care services. However, the member must select one pharmacy to fill their prescriptions. If they go
to a different pharmacy without approval, their medication will not be covered. The member also has a
primary care provider (PCP) to coordinate their health care services with other providers. Except in an
emergency, the member should contact their PCP before seeing other providers. By knowing the complete
medical history, the PCP and pharmacy can take better care of the patient. A care manager will also
contact the member to discuss care management services.
We help keep you informed
The Buckeye Pharmacy Director, a registered pharmacist, compiles current pharmacological policy and
information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The
information is consistent with published guidelines and is mailed to network providers as a service. The
most current Buckeye PDL and PA List can be downloaded from our website at www.bchpohio.com.
Contacts for Pharmacy Appeals/Grievances
Members: In the event that a member disagrees with the decision regarding coverage of a medication, the
member may file an appeal with Buckeye by calling Buckeye Member Services at 1-866-246-4358 (TTY 1800-750-0750).
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Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a
medication, the clinician may request an appeal by submitting additional information to Buckeye in writing
to the Appeals Department at the following address:
Buckeye Community Health Plan
4349 Easton Way, Suite 200
Columbus, Ohio 43219
A decision will be rendered and the clinician will be notified with a mailed response. An expedited appeal
may be requested at any time the provider believes the adverse determination might seriously jeopardize
the life or health of a member by calling Buckeye at 1-866-246-4356 ext. 24084 (TTY 1-800-750-0750). A
response will be rendered the same day as receipt of complete information. In circumstances that require
research, a same day response may not be possible.
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Over-the-Counter Pharmacy Program
T
he Buckeye Community Health Plan pharmacy program covers a variety of OTC products. The
products listed below are covered when a valid prescription from a licensed clinician that meets all
the legal requirements for a prescription is presented to be filled at a Buckeye network pharmacy.
Covered products are available in quantities up to a 30-day supply. Refer to the Buckeye Community
Health Plan PDL for a complete listing of available OTC items. Please note that generic products must be
prescribed when available.
ANALGESICS & ANTIPYRETICS
Acetaminophen – generic tablets, elixir, drops,
suppositories
Aspirin – generic tablets
ANTACIDS
Maalox – generic tablets, liquid
Mylanta DS – generic liquid
ANTHELMINTICS
Pin-X – Pyrantel pamoate tablets/chewable/suspension
ANTI-DIARRHEALS
Imodium A-D – generic (loperamide) capsules
Kaopectate – (attapulgite) suspension
Pepto-Bismol – generic (pink bismuth) chewable/liquid
ANTI-EMETIC
Antivert – generic (meclizine)
ANTI-FLATULENTS
Gas-X chewables – generic simethicone 80mg
Mylicon drops** – generic simethicone 40 mg/0.6ml
ANTI-HISTAMINES
Benadryl – generic (diphenhydramine) capsules, liquid
Chlor-Trimeton – generic (chlorpheniramine) tablets, liquid
Claritin – generic (loratadine) tablets, syrup
Claritin-D – generic (loratadine/ pseudoephedrine) tablets
Zyrtec – generic (cetirizxine) tablets/chewables/liquid
CONTRACEPTIVES
Condoms lubricated
COUGH/EXPECTORANT/DECONGESTANT
Dallergy drops (chlorpheniramine & phenylephrine liquid)
1-2 mg/ml
Decon A drops (brompheniramine & phenylephrine liquid)
2-5 mg/ml
Delsym – DM Polistirex Liquid CR
Dimetapp – generic (brompheniramine & phenylephrine
elixir) 1-2.5 mg/5ml
Mucinex – generic (guaifenesin) tablets
Robitussin – generic (guaifenesin) syrup
Robitussin DM – generic (guaifenesin DM) syrup
Sudafed – generic (pseudoephedrine) tablets, liquid
Triaminic – generic AM, Night, soft chewable tablets
DILUENTS
Sodium chloride – generic aerosol solution
DME PRODUCTS
Diabetic testing supplies (TRUEtest preferred)
Gauze pad – 2”x2”, 3”x3”, 4”x4”
Peak Flow Meters
Spacers
OTIC PREPARATIONS
Debrox drops – generic (carbamide peroxide 6.5%)
ELECTROLYTES
Electrolyte solutions – generic
H2-RECEPTOR ANTAGONISTS
Pepcid – generic (famotidine) 10mg tablets
Tagamet – generic (cimetidine) 200mg tablets
Zantac – generic (ranitidine) 75mg tablets
IRON PREPERATIONS
Ferrous fumarate – generic tablets
Ferrous gluconate – generic tablets
Ferrous sulfate – generic tablets, elixir, drops
Polysaccharide Iron Complex – generic capsules 150mg
LAXATIVES
Citrate of magnesium – generic
Colace – generic (docusate sodium) capsules
Dulcolax – generic (bisacodyl) tablets, suppositories
Fleet enema – generic
Metamucil – generic (psyllium)
Milk Of Magnesium – generic MOM
Miralax OTC
Pediatric glycerin suppositories – generic
Senokot – generic (senna) tablets
Sorbitol oral solution 70%
MINERALS
Citracal – generic (calcium citrate) - tablets
Citracal+D – generic (calcium citrate+D) tablets
Magnesium oxide – generic
Neutra-phos/K powder – generic
Oscal 500+Vit D – generic (calcium carbonate+D) tablets
Tums Chew Tabs – generic (calcium carbonate)
Zinc sulfate – generic capsules 220mg
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NASAL
Nasalcrom spray – generic
Saline nasal spray/gel/solution
NSAIDS
Ibuprofen – generic tablets, chewable, liquid, drops
Naproxen – generic tablets
NUTRITIONAL SUPPLEMENTS
Omega-3 fatty acid capsules 1000mg, 1200mg
OPHTHALMIC PREPARATIONS
Alaway (ketotifen 0.025%)
Artificial tears – generic polyvinyl alcohol drops
Lacri-lube – generic (artificial tears) ointment
Naphcon-A – generic (naphazoline/pheniramine 0.025/0.3)
Zaditor-OTC (ketotifen 0.025%)
PEDICULICIDES
NIX – generic (permethrin)
RID – generic (pyrethrins/piperonyl butoxide)
PROTON PUMP INHIBITORS (PPIS)
Prevacid 24 HR capsules
Prilosec OTC tablets
SLEEPING AIDS
Nytol – generic (diphenhydramine sleep) tablets/capsules
Unisom – generic (doxylamine sleep) tablets
SMOKING DETERRENTS
Commit Lozenges
NicoDerm CQ transdermal patch – generic
Nicorette DS gum – generic
Nicorette gum – generic
Nicotrol transdermal patch – generic
TOPICALS
AmLactin – generic
Bacitracin ointment – generic
Benzoyl peroxide – generic liquid/gel/lotion
Calamine – generic
Capsaicin cream/gel/lotion – generic
Clotrimazole – generic cream, vaginal cream/inserts
Hibiclens – generic (chlorhexidine gluconate liquid) 4%
Hydrocortisone – generic cream, lotion, ointment, solution
Miconazole – generic cream, vaginal cream/inserts
Polysporin – generic ointment
Nupercainal – generic (dibucaine rectal ointment) 1%
Selsun Blue – generic (selenium shampoo) 1%
Tolnaftate – generic cream
Triple antibiotic ointment
Vagistat – generic (tioconazole vaginal ointment) 6.5%
Xylocaine generic (lidocaine) gel 2%
Zinc oxide ointment – generic
VITAMINS
Folic acid – generic
Multi-vitamins with iron – generic tablets, liquid, chewable
Multi-vitamins – generic tablets, liquid, chewable
Niacin – generic
Prenatal vitamins – generic tablets
Pyridoxine – generic tablets
Slo-Niacin CR tablets
Thiamine – generic tablets
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MEDICATION PRIOR AUTHORIZATION REQUEST FORM
Buckeye Community Health Plan, Ohio
Do Not Use This Form for Biopharmaceutical Products
FAX this completed form to 866-399-0929
OR Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA 93711
Call 800-460-8988 to request a 72-hour supply of medication.
I. Provider Information
II. Member Information
Prescriber name (print):
Member name:
Prescriber Specialty:
Identification number:
Fax:
Phone:
Date of Birth:
Office Contact Name:
Medication allergies:
III. Drug Information (One drug request per form)
Drug name and strength:
Dosage form:
Dosage interval (sig):
Qty per Day:
Diagnosis relevant to this request:
Expected length of therapy:
Medication History for this Diagnosis
A. Is member currently treated on this medication?
yes; How Long?_______________
[go to item B]
no [skip items B & C; go to item D]
B. Is this request for continuation of a previous approval?
yes [go to item C]
no [skip item C; go to item D]
C. Has strength, dosage, or quantity required per day increased or decreased?
yes [go to item D]
no [skip item D; indicate rationale for continuation in Section IV and submit form]
D. Please indicate previous treatment and outcomes below.
Drug Name
(include strength and dosage)
Dates of Therapy
Reason for Discontinuation
1
2
3
4
NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Buckeye
Community Health Plan Preferred Drug List (PDL) is available on the Buckeye Community Health Plan website at www.bchpohio.com.
IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)
Appropriate clinical information to support the request on
the basis of medical necessity must be submitted.
Provider Signature:
Date:
US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior
authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when
appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)
*Contact Buckeye Community Health Plan at 1-866-246-4356 for Biopharmaceutical Products*
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PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
PENICILLINS
Additional
Information
Product Description
Limitations/
Restrictions
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
AMOXIL
Amoxicillin (Trihydrate) Chew Tab
125 MG
250 MG
400 MG
Amoxicillin (Trihydrate) For Susp 50
MG/ML
Amoxicillin (Trihydrate) For Susp
125 MG/5ML
125 MG/5ML
250 MG/5ML
400 MG/5ML
Ampicillin Cap 250 MG
Ampicillin Cap 500 MG
Ampicillin For Susp 125 MG/5ML
Ampicillin For Susp 250 MG/5ML
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN XR
CEPHALOSPORINS
Dicloxacillin Sodium Cap 250 MG
Dicloxacillin Sodium Cap 500 MG
Amoxicillin & K Clavulanate Tab 250
MG
MG
MG
Amoxicillin & K Clavulanate Chew
Tab 200 MG
Tab 250 MG
Tab 400 MG
Amoxicillin & K Clavulanate For
Susp 125 MG/5ML
Susp 200 MG/5ML
Susp 250 MG/5ML
Susp 400 MG/5ML
Susp 600 MG/5ML
Amoxicillin & K Clavulanate Tab SR
12HR 1000-62.5 MG
13
Max Qty=30/claim
Max Qty=30/claim
Max Qty=20/claim
Max Qty=20/claim
Max Qty=30/claim
Max Qty=20/claim
Package Limit=1/claim
Max Qty=40/30 days
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
DURICEF
KEFLEX
KEFLEX
Additional
Information
Product Description
Cefadroxil Cap 500 MG
CEFADROXIL 1 GM TABLET
CEFADROXIL 250 MG/5 ML
SUSP
CEFADROXIL 500 MG/5 ML
SUSP
Cephalexin Cap 250 MG
Cephalexin Cap 500 MG
Limitations/
Restrictions
Max Qty=20/claim
Max Qty=10/claim
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
Max Qty=20/claim
Max Qty=20/claim
Limit=2/claim; Pkg Size
100: Package
Limit=2/claim
Pkg Size 50: Package
Limit=1/claim
Max Qty=20/claim
Max Qty=20/claim
Cefprozil For Susp 125 MG/5ML
Cefprozil For Susp 250 MG/5ML
CEFTIN
CEFTIN
CEFTIN
Cefuroxime Axetil Tab 250 MG
Cefuroxime Axetil Tab 500 MG
Cefuroxime Axetil For Susp 125
MG/5ML
CEFTIN Susp 250 MG/5ML
OMNI-PAC, OMNICEF Cefdinir Cap 300 MG
Max Qty=20/claim
OMNICEF
Cefdinir For Susp 125 MG/5ML
OMNICEF
Cefdinir For Susp 250 MG/5ML
MACROLIDES
ERYC
Erythromycin Tab 250 MG
Erythromycin Tab 500 MG
Erythromycin Tab Delayed Release
250 MG
333 MG
500 MG
Erythromycin w/ Enteric Coated
Particles Cap 250 MG
Particles Tab 333 MG
Particles Tab 500 MG
Erythromycin Stearate Tab 250 MG
Erythromycin Stearate Tab 500 MG
Erythromycin Ethylsuccinate Tab
400 MG
Erythromycin Ethylsuccinate Susp
200 MG/5ML
Erythromycin Ethylsuccinate Susp
400 MG/5ML
Erythromycin Ethylsuccinate For
Susp 100 MG/2.5ML
ERYTHROMYCIN
ERYTHROMYCIN
E-MYCIN, ERY-TAB
ERY-TAB,
ERYTHROMYCIN
ERY-TAB
ERYTHROMYCIN
PCE
PCE
ERYTHROCIN,
ERYTHROM ST
ERYTHROCIN,
ERYTHROM ST
ERYPED
14
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
BIAXIN
BIAXIN
BIAXIN
BIAXIN
BIAXIN XL
TETRACYCLINES
VIBRAMYCIN
PERIOSTAT
VIBRATAB
MINOCIN
MINOCIN
FLUOROQUINOLONES
CIPRO
CIPRO
CIPRO
Product Description
Susp 200 MG/5ML
Susp 400 MG/5ML
Azithromycin Tab 250 MG
Azithromycin For Susp 100
MG/5ML
Max Qty=6/claim
Max Qty=3/claim
Max Qty=8/28 days
30: Package
22.5: Package
Limit=2/claim
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
Max Qty=2/claim
Max Qty=28/claim
Max Qty=28/claim
Max Qty=14/claim
Doxycycline Hyclate Cap 50 MG
Doxycycline Hyclate Cap 100 MG
DOXYCYCLINE HYCLATE 20
MG T
Doxycycline Hyclate Tab 100 MG
Minocycline HCl Cap 50 MG
Tetracycline HCl Cap 250 MG
Tetracycline HCl Cap 500 MG
Ciprofloxacin HCl Tab 100 MG
(Base Equiv)
(Base Equiv)
(Base Equiv)
(Base Equiv)
Levofloxacin Tab 250 MG
LEVAQUIN
LEVAQUIN
SULFONAMIDES
Limitations/
Restrictions
ERYPED 400
Azithromycin For Susp 200
MG/5ML
LEVAQUIN
AMINOGLYCOSIDES
Additional
Information
E.E.S. GRAN,
ERYPED 200
Max Qty=6/claim
Max Qty=14/claim;
Daily Dosage=1
Max Qty=14/claim;
Daily Dosage=1
Max Qty=14/claim;
Daily Dosage=1
Max Qty=56/claim
Max Qty=56/claim
Max Qty=56/claim
Ofloxacin Tab 200 MG
Neomycin Sulfate Tab 500 MG
Sulfisoxazole Acetyl Susp 500
MG/5ML
ANTIMYCOBACTERIAL AGENTS
MYAMBUTOL
Ethambutol HCl Tab 100 MG
MYAMBUTOL
Ethambutol HCl Tab 400 MG
TRECATOR Tab 250mg
GANTRIS PED
15
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Isoniazid Tab 100 MG
Isoniazid Tab 300 MG
Isoniazid Syrup 50 MG/5ML
Pyrazinamide Tab 500 MG
Limitations/
Restrictions
Step Therapy
MYCOBUTIN 150 MG CAPSULE
RIFADIN
RIFADIN
ANTIFUNGALS
GRIFULVIN V
LAMISIL
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
ANTIVIRALS
Rifampin Cap 150 MG
Rifampin Cap 300 MG
GRIFULVIN V Tab 500 MG
Griseofulvin Microsize Susp 125
MG/5ML
GRIS-PEG Tab 125 MG
GRIS-PEG, GRISEOFULVIN Tab
250 MG
Nystatin Tab 500000 U
Daily Dosage=6
Max Qty=90/120 days;
Daily Dosage=1
Daily Dosage=1
Max Qty=3/14 days
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
Max Qty=2/claim
Max Qty=70/claim
Max Qty=70/claim
SELZENTRY Tab 150 MG
Daily Dosage=2
SELZENTRY Tab 300 MG
Daily Dosage=4
ISENTRESS Tab 400 MG (Base
Equiv)
ISENTRESS 100 MG TABLET CHE
AGENERASE Cap 50 MG
AGENERASE Soln 15 MG/ML
REYATAZ Cap 100 MG (Base
Equiv)
Equiv)
Equiv)
Equiv)
PREZISTA Tab 75 MG (Base Equiv)
PREZISTA Tab 150 MG (Base
Equiv)
Equiv)
Equiv)
Equiv)
PREZISTA 800 MG TABLET
PREZISTA 100 MG/ML SUSPENSI
LEXIVA Tab 700 MG (Base Equiv)
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=3
Daily Dosage=4
Daily Dosage=2
Daily Dosage=2
Daily Dosage=4
LEXIVA Susp 50 MG/ML (Base
Equiv)
CRIXIVAN Cap 100 MG
CRIXIVAN Cap 200 MG
CRIXIVAN Cap 333 MG
CRIXIVAN Cap 400 MG
VIRACEPT Tab 250 MG
Daily Dosage=56
Daily Dosage=6
Daily Dosage=9
Daily Dosage=6
Daily Dosage=9
16
Biopharmacy benefit
via Acaria
Biopharmacy benefit
via Acaria
Biopharmacy benefit
via Acaria
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ZIAGEN
Additional
Information
Product Description
VIRACEPT Tab 625 MG
VIRACEPT Oral Powder 50
MG/GM
NORVIR Cap 100 MG
NORVIR Tab 100 MG
NORVIR Oral Soln 80 MG/ML
INVIRASE Cap 200 MG
INVIRASE Tab 500 MG
APTIVUS Cap 250 MG
APTIVUS Oral Soln 100 MG/ML
Limitations/
Restrictions
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
ZIAGEN Tab 300 MG (Base Equiv)
Daily Dosage=2
ZERIT
ZERIT
ZERIT
ZERIT
ZIAGEN Soln 20 MG/ML (Base
Equiv)
VIDEX For Soln 2 GM
VIDEX For Soln 4 GM
Didanosine Delayed Release Capsule
125 MG
200 MG
250 MG
400 MG
EMTRIVA Caps 200 MG
EMTRIVA Soln 10 MG/ML
EPIVIR Tab 150 MG
EPIVIR Tab 300 MG
EPIVIR Oral Soln 10 MG/ML
Stavudine Cap 15 MG
Stavudine Cap 20 MG
Stavudine Cap 30 MG
Stavudine Cap 40 MG
Daily Dosage=2
Daily Dosage=1
Daily Dosage=30
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
ZERIT
Stavudine For Oral Soln 1 MG/ML
Daily Dosage=80
RETROVIR
RETROVIR
RETROVIR
Zidovudine Cap 100 MG
Zidovudine Tab 300 MG
Zidovudine Syrup 10 MG/ML
VIREAD Tab 150 MG
VIREAD Tab 200 MG
VIREAD Tab 250 MG
VIREAD Tab 300 MG
Daily Dosage=6
Daily Dosage=2
Daily Dosage=60
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
VIREAD POWDER
Max dose= 240/30 days
RESCRIPTOR Tab 100 MG
RESCRIPTOR Tab 200 MG
SUSTIVA Cap 50 MG
SUSTIVA Cap 100 MG
SUSTIVA Cap 200 MG
SUSTIVA Tab 600 MG
INTELENCE Tab 25 MG
INTELENCE Tab 100 MG
INTELENCE 200 MG TABLET
VIRAMUNE Tab 200 MG
VIRAMUNE Susp 50 MG/5ML
VIRAMUNE XR 100 MG TABLET
EDURANT HCl Tab 25 MG
EPZICOM Tab 600-300 MG
TRUVADA Tab 200-300 MG
COMBIVIR Tab 150-300 MG
KALETRA Cap 133.3-33.3 MG
KALETRA Tab 100-25 MG
KALETRA Tab 200-50 MG
Daily Dosage=12
Daily Dosage=6
Daily Dosage=2
VIDEX EC
VIDEX EC
VIDEX EC
VIDEX EC
EPIVIR
EPIVIR
VIRAMUNE
COMBIVIR
Daily Dosage=30
Daily Dosage=20
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=4
Daily Dosage=4
Daily Dosage=2
Daily Dosage=40
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=6
Daily Dosage=4
Daily Dosage=4
17
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Product Description
KALETRA Soln 400-100 MG/5ML
(80-20 MG/ML)
TRIZIVIR Tab 300-150-300 MG
ATRIPLA Tab 600-200-300 MG
Additional
Information
Limitations/
Restrictions
Max Qty=480/30 days
Daily Dosage=2
COMPLERA TABLET
COMPLERA 200-25-300 MG
ZOVIRAX
ZOVIRAX
ZOVIRAX
Ganciclovir Cap 250 MG
Ganciclovir Cap 500 MG
VALCYTE Tab 450 MG
Acyclovir Cap 200 MG
Acyclovir Tab 400 MG
Acyclovir Tab 800 MG
Daily Dosage=6
Daily Dosage=6
Daily Dosage=2
Max Qty=50/30 days
Daily Dosage=2
Max Qty=50/30 days
ZOVIRAX
Acyclovir Susp 200 MG/5ML
Max Qty=400/30 days
VALTREX
VALTREX
Valacyclovir HCl Tab 500 MG
Valacyclovir HCl Tab 1 GM
FLUMADINE
Rimantadine Hydrochloride Tab 100
MG
Max Qty=42/31 days
Max Qty=21/31 days
Max DS/DU=Lesser Of
Max Days Sply=10/Max
Qty=20
Max Qty=20/30 days;
Max fill=1/180 days
Max Qty=10/30 days;
Max fill=1/180 days
Max Qty=10/30 days;
Max fill=1/180 days
Max Qty=75/30 days;
Max fill=1/180 days
Limited to Ages 5 and
Older ; Package
Limit=1/30 days
TAMIFLU Cap 30 MG (Base Equiv)
TAMIFLU Susp 12 MG/ML (Base
Equiv)
RELENZA 5 MG/BLISTER
ANTIMALARIALS
Chloroquine Phosphate Tab 250 MG
ARALEN
PLAQUENIL
LARIAM
Chloroquine Phosphate Tab 500 MG
Daily Dosage=1
Hydroxychloroquine Sulfate Tab 200
MG
Mefloquine HCl Tab 250 MG
PRIMAQUINE Tab 26.3 MG
QUALAQUIN 324 MG CAPSULE
ANTHELMINTICS
VERMOX
COARTEM Tab 20-120 MG
Max Qty=24/claim
Mebendazole Chew Tab 100 MG
Pyrantel Pamoate Susp 250
MG/5ML (50 MG/ML Base Equiv)
Max Qty=120/claim
ANTI-INFECTIVE AGENTS - MISCELLANEOUS
FLAGYL
Metronidazole Tab 250 MG
FLAGYL
Metronidazole Tab 500 MG
TRIMPEX
Trimethoprim Tab 100 MG
Vancomycin HCl For Inj 500 MG
CLEOCIN
Clindamycin HCl Cap 150 MG
CLEOCIN
Clindamycin HCl Cap 300 MG
Clindamycin Palmitate HCl For Soln
CLEOCIN PED
75 MG/5ML (Base Equiv)
Dapsone Tab 25 MG
Dapsone Tab 100 MG
MEPRON 750 MG/5 ML
SUSPENSI
Erythromycin & Sulfisoxazole For
PEDIAZOLE
Susp 200-600 MG/5ML
Sulfamethoxazole-Trimethoprim Tab
BACTRIM, SEPTRA
400-80 MG
18
Max Qty=14/30 days
Max Qty=300/claim
Step Therapy
PREFERRED DRUG LIST
Common Brand
Product Description
Name(s)
Column1
BACTRIM DS, SEPTRA Sulfamethoxazole-Trimethoprim Tab
DS
800-160 MG
Sulfamethoxazole-Trimethoprim
Susp 200-40 MG/5ML
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
MYLERAN Tab 2 MG
LEUKERAN Tab 2 MG
Cyclophosphamide Tab 25 MG
Cyclophosphamide Tab 50 MG
ALKERAN Tab 2 MG
CEENU Cap 10 MG
CEENU Cap 40 MG
CEENU Cap 100 MG
Mercaptopurine Tab 50 MG
PURINETHOL
Methotrexate Sodium Tab 2.5 MG
(Base Equiv)
Methotrexate Sodium Tab 5 MG
(Base Equiv)
Additional
Information
Limitations/
Restrictions
Step Therapy
TREXALL Tab 7.5 MG (Base Equiv)
TREXALL Tab 10 MG (Base Equiv)
TREXALL Tab 15 MG (Base Equiv)
Methotrexate Sodium Inj 25 MG/ML
ARIMIDEX
Methotrexate Sodium Inj PF 25
MG/ML
TESLAC Tab 50 MG
LYSODREN Tab 500 MG
Bicalutamide Tab 50 MG
Flutamide Cap 125 MG
Tamoxifen Citrate Tab 10 MG (Base
Equivalent)
Tamoxifen Citrate Tab 20 MG (Base
Equivalent)
Anastrozole Tab 1 MG
AROMASIN
AROMASIN Tab 25 MG
Step Therapy
FEMARA
Letrozole Tab 2.5 MG
Step Therapy
CASODEX
Megestrol Acetate Tab 20 MG
Megestrol Acetate Tab 40 MG
MEGACE ORAL
HYDREA
CORTICOSTEROIDS
Megestrol Acetate Susp 40 MG/ML
Etoposide Cap 50 MG
Hydroxyurea Cap 500 MG
Leucovorin Calcium Tab 5 MG
Cortisone Acetate Tab 25 MG
Dexamethasone Tab 0.5 MG
Dexamethasone Tab 1 MG
Dexamethasone Elixir 0.5 MG/5ML
Dexamethasone Conc 1 MG/ML
19
Prior use of
Anastrozole
Prior use of
Anastrozole
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Limitations/
Restrictions
Dexamethasone Soln 0.5 MG/5ML
CORTEF
CORTEF
CORTEF
MEDROL
MEDROL
MEDROL
MEDROL
MEDROL
PRELONE
ORAPRED
PEDIAPRED
Dexamethasone sodium phosphate
4mg/mL Inj
Hydrocortisone Tab 5 MG
Methylprednisolone Tab 4 MG
Methylprednisolone Tab 8 MG
METHYLPREDNISOLONE 16
MG TA
METHYLPREDNISOLONE 32
MG TA
Methylprednisolone Tab 4 MG Dose
Pack
MILLIPRED Tab 5 MG
Prednisolone Syrup 5 MG/5ML
Prednisolone Syrup 15 MG/5ML
Prednisolone Sod Phosphate Oral
Soln 15 MG/5ML (Base Equiv)
QL = 1 dispense/month
Prednisolone Sod Phosph Oral Soln
6.7 MG/5ML (5 MG/5ML Base)
STERAPRED
VERIPRED 20 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
STERAPRED DS
Prednisone Tab 10 MG Dose Pack
Max Qty=150/claim
Fludrocortisone Acetate Tab 0.1 MG
ANDROGENS-ANABOLIC
DEPO-TESTOST
ESTROGENS
DANAZOL 50 MG CAPSULE
ANDRODERM Patch 24HR 2
MG/24HR
ANDRODERM Patch 24HR 2.5
MG/24HR
MG/24HR
MG/24HR
Testosterone Cypionate IM in Oil
200 MG/ML
Daily Dosage=1
Daily Dosage=1
Max Qty=4/30 days
Limited to Female ;
Daily Dosage=1
Limited to Female ;
Daily Dosage=1
Limited to Female ;
Daily Dosage=1
Limited to Female ;
Daily Dosage=1
Limited to Female ;
Daily Dosage=1
Limited to Female
PREMARIN Tab 0.3 MG
PREMARIN Tab 0.45 MG
PREMARIN Tab 0.9 MG
ESTRACE
Estradiol Tab 0.5 MG
20
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
ESTRACE
ESTRACE
Additional
Information
Product Description
Estradiol Tab 1 MG
Estradiol Tab 2 MG
ALORA Patch Biweekly 0.025
MG/24HR
MG/24HR
Estradiol TD Patch Biweekly 0.05
MG/24HR
MG/24HR
MG/24HR
Estradiol TD Patch Biweekly 0.1
MG/24HR
Limitations/
Restrictions
Limited to Female
Limited to Female
Limited to Female; Max
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=8
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=8
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=8
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=8
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=8
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=8
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=4
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=4
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=4
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=4
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=4
DS/DU=Lesser Of Max
Days Sply=28/Max
Qty=4
Limited to Female; Daily
Dosage=1
Dosage=1
Dosage=2
CLIMARA
Estradiol TD Patch Weekly 0.025
MG/24HR
CLIMARA
MG/24HR (37.5 MCG/24HR)
CLIMARA
MG/24HR
CLIMARA
MG/24HR
CLIMARA
MG/24HR
CLIMARA
MG/24HR
OGEN
Estropipate Tab 0.75 MG
OGEN
Estropipate Tab 1.5 MG
OGEN
Estropipate Tab 3 MG
ESTRATEST HS
Esterified Estrogens &
Methyltestosterone Tab 0.625-1.25
MG
Daily Dosage=1
ESTRATEST
Esterified Estrogens &
Methyltestosterone Tab 1.25-2.5 MG
Daily Dosage=1
PREMPRO Tab 0.3-1.5 MG
Limited to Female
21
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
PREMPRO Tab 0.625-5 MG
Limitations/
Restrictions
ACTIVELLA 0.5-0.1 MG TABLET
CONTRACEPTIVES
NOR-QD, ORTHO
MICRON
DEPO-PROVERA
COMBIPATCH TD PTTW 0.050.14MG/DAY
COMBIPATCH TD PTTW 0.050.25MG/DAY
Norethindrone Tab 0.35 MG
Qty=1/claim; Min
DS=84
Qty=1/claim; Min
DS=84
Qty=4/365 days
Max Qty=4/365 days;
1/21 days
Max Qty=4/365 days
Max Qty=3/claim; Min
DS=28
Qty=1/claim
Medroxyprogesterone Acetate IM
Susp 150 MG/ML
DEPO-SQ PROV Subcutaneous
Susp 104 MG/0.65ML
PLAN B
Levonorgestrel Tab 0.75 MG
PLAN B
PLAN B Tab 1.5 MG
ELLA Tab 30 MG
ORTHO EVRA TD PTWK 150-20
MCG/24HR
NUVARING VA Ring 0.120-0.015
MG/24HR
DESOGEN, DESOGEN- Desogestrel & Ethinyl Estradiol Tab
28, ORTHO-CEPT
0.15 MG-30 MCG
Limited to Female
Desogest-Eth Estrad & Eth Estrad
Tab .15-.02/.01 MG (21/5)
YAZ
YASMIN 28
Limited to Female
Drospirenone-Ethinyl Estradiol Tab
3-0.02 MG
Drospirenone-Ethinyl Estradiol Tab
3-0.03 MG
Ethynodiol Diacetate & Ethinyl
Estradiol Tab 1 MG-35MCG
Limited to Female
Limited to Female
Limited to Female
ZOVIA 1/50E Tab 1 MG-50MCG
NORDETTE,
NORDETTE-28
OVCON-35
BREVICON,
MODICON
NORINYL, ORTHONOVUM
LOESTRIN
LOESTRIN 21
LO/OVRAL,
LO/OVRAL-28
ORTHO-CYCLEN
Levonorgestrel & Ethinyl Estradiol
Tab 0.10 MG-20MCG
Tab 0.15 MG-30MCG
Norethindrone & Ethinyl Estradiol
Tab 0.4 MG-35MCG
Tab 0.5 MG-35MCG
Tab 1 MG-35MCG
OVCON-50 28 TABLET
Norethindrone Ace & Ethinyl
Estradiol Tab 1 MG-20MCG
Estradiol Tab 1.5 MG-30MCG
Norethindrone & Mestranol Tab 1
MG-50MCG
Norgestrel & Ethinyl Estradiol Tab
0.3 MG-30MCG
Limited to Female
Limited to Female
Limited to Female
Limited to Female
Limited to Female
Limited to Female
Limited to Female
Limited to Female
Limited to Female
NECON, NORINYL
Limited to Female
Dosage=2
OGESTREL Tab 0.5 MG-50MCG
Limited to Female
Norgestimate & Ethinyl Estradiol
Tab 0.25MG-35MCG
Limited to Female
22
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
LOESTRIN FE
Additional
Information
Product Description
Estradiol-FE Tab 1 MG-20MCG
LOESTRIN 24-FE Tab 1 MG-20
MCG (24
Limitations/
Restrictions
Limited to Female
LOESTRIN FE
Estradiol-FE Tab 1.5 MG-30MCG
Limited to Female
MIRCETTE 28 DAY
TABLET
MIRCETTE 28 DAY TABLET
Limited to Female
CYCLESSA
NECON Tab 0.5-35/1-35 MG-MCG
(10/11)
Desogest-Ethinyl Estrad Tab .1.025/.125-.025/.15-.025 MG-MG
Limited to Female
Limited to Female
Levonorgestrel-Eth Estrad Tab .0530/0.075-40/0.125-30MG-MCG
ORTHO-NOVUM
TRI-NORINYL
ORTHO-NOVUM Tab 0.5-35/0.7535/1-35 MG-MCG
Norethindrone-Eth Estradiol Tab 0.535/1-35/0.5-35 MG-MCG
Norgestimate-Eth Estrad Tab 0.1825/0.215-25/0.25-25 MG-MCG
ORTHO TRI-
Norgestimate-Eth Estrad Tab 0.1835/0.215-35/0.25-35 MG-MCG
SEASONALE
(91-Day) Tab 0.15-0.03 MG
SEASONIQUE
SEASONIQUE Tab 0.150.03MG(84) & Eth Est Tab
0.01MG(7)
PROGESTINS
ORTHO TRI-,
ORTHO TRI-CY
Qty=91/claim; Min
DS=91
Qty=91/claim; Min
DS=91
AYGESTIN
Medroxyprogesterone Acetate Tab
2.5 MG
Medroxyprogesterone Acetate Tab 5
MG
Medroxyprogesterone Acetate Tab 10
MG
Norethindrone Acetate Tab 5 MG
PROMETRIUM
PROMETRIUM 100 MG CAPSULE
Max Qty=30/30 days
PROMETRIUM
PROMETRIUM 200 MG CAPSULE
Max Qty=30/30 days
PROVERA
PROVERA
PROVERA
ANTIDIABETICS
Insulin Aspart Inj 100 U/ML
Insulin Glargine Inj 100 U/ML
APIDRA 100 UNITS/ML VIAL
Insulin Lispro (Human) Inj 100
U/ML
Insulin Regular (Human) Inj 100
U/ML
Insulin Regular (Human) Inj 100
U/ML
NOVOLOG VIALS
LANTUS VIALS
Max Qty=40/30 days
Max Qty=30/30 days
Max Qty=40/30 days
HUMALOG VIALS
Max Qty=40/30 days
HUMULIN R,
HUMULIN R,
NOVOLIN R,
RELION R VIALS
HUMULIN R,
HUMULIN R,
NOVOLIN R,
RELION R VIALS
HUMULIN R 500 UNITS/ML
VIAL
23
Max Qty=40/30 days
Max Qty=40/30 days
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Insulin Aspart & Aspart Prot
(Human) Inj 100 U/ML (30-70)
Additional
Information
HUMULIN N,
HUMULIN N PN,
HUMULIN N PN,
NOVOLIN N,
RELION N VIALS
HUMULIN N,
HUMULIN N PN,
HUMULIN N PN,
NOVOLIN N,
RELION N VIALS
NOVOLOG MIX
VIALS
Insulin Lispro Prot & Lispro
(Human) Inj 100 Unit/ML (75-25)
HUMALOG MIX 75-25
Max Qty=40/30 days
VIALS
Insulin Lispro Prot & Lispro
(Human) Inj 100 Unit/ML (50-50)
HUMALOG MIX 5050 VIALS
Product Description
Insulin Isophane (Human) Inj 100
U/ML
Insulin Isophane (Human) Inj 100
U/ML
Limitations/
Restrictions
Max Qty=40/30 days
Max Qty=40/30 days
Max Qty=40/30 days
Max Qty=40/30 days
HUMULIN,
Insulin Isophane & Regular (Human) NOVOLIN,
Max Qty=40/30 days
Inj 100 U/ML (70-30)
NOVOLIN 70/,
RELION 70/30 VIALS
HUMULIN,
Insulin Isophane & Regular (Human) NOVOLIN,
Max Qty=40/30 days
Inj 100 U/ML (70-30)
NOVOLIN 70/,
RELION 70/30 VIALS
MICRONASE
MICRONASE
CHLORPROPAMIDE 100 MG
TABLE
CHLORPROPAMIDE 250 MG
TABLE
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
GLYNASE
Glyburide Micronized Tab 1.5 MG
GLYNASE
GLYNASE
Glyburide Micronized Tab 3 MG
Glyburide Micronized Tab 6 MG
DIABINESE
AMARYL
AMARYL
AMARYL
GLUCOTROL
GLUCOTROL
GLUCOTROL XL
GLUCOTROL XL
GLUCOTROL XL
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
TOLAZAMIDE 250 MG TABLET
TOLAZAMIDE 500 MG TABLET
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE
TOLBUTAMIDE 500 MG
TABLET
Metformin HCl Tab 500 MG
Metformin HCl Tab SR 24HR 500
MG
Metformin HCl Tab SR 24HR 750
MG
Daily Dosage=4
Daily Dosage=4
Daily Dosage=3
STARLIX
NATEGLINIDE 60 MG TABLET
STARLIX
NATEGLINIDE 120 MG TABLET
24
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
PRECOSE
PRECOSE
PRECOSE
METAGLIP
METAGLIP
METAGLIP
GLUCOVANCE
GLUCOVANCE
GLUCOVANCE
THYROID AGENTS
Max Fills=1/30 days;
GLUCAGEN Inj 1 MG (Base
Equiv)
Max Fills=1/30 days;
Glucose Chew Tab 4 GM
Glucose Chew Tab 5 GM
GLUTOSE 15 GEL
ACARBOSE 25 MG TABLET
TRADJENTA TAB 5MG
ONGLYZA 2.5 MG TABLET
ONGLYZA 5 MG TABLET
ACTOS Tab 15 MG (Base Equiv)
JENTADUETO 2.5-500 MG
Max Qty=50/30 days
Max Qty=50/30 days
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
KOMBIGLYZE XR 2.5-1,000 MG
Daily Dosage=1
KOMBIGLYZE XR 5-500 MG
TABL
KOMBIGLYZE XR 5-1,000 MG
TA
Glipizide-Metformin HCl Tab 2.5250 MG
Glipizide-Metformin HCl Tab 2.5500 MG
Glipizide-Metformin HCl Tab 5-500
MG
Glyburide-Metformin Tab 1.25-250
MG
Glyburide-Metformin Tab 2.5-500
MG
Daily Dosage=2
ACTOPLUS MET Tab 15-850 MG
Daily Dosage=2
Levothyroxine Sodium Tab 0.05 MG
SYNTHROID
SYNTHROID
SYNTHROID
Daily Dosage=1
ACTOPLUS MET Tab 15-500 MG
SYNTHROID
SYNTHROID
Daily Dosage=1
Glyburide-Metformin Tab 5-500 MG
Levothyroxine Sodium Tab 0.025
MG
SYNTHROID
Limitations/
Restrictions
Glucagon (rDNA) For Inj Kit 1 MG
SYNTHROID
SYNTHROID
Additional
Information
Product Description
MG
MG
MG
MG
MG
SYNTHROID
SYNTHROID
MG
25
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
SYNTHROID
SYNTHROID
CYTOMEL
Liothyronine Sodium Tab 5 MCG
CYTOMEL
CYTOMEL
ARMOUR THYRO
Additional
Information
Product Description
THYROLAR-1/4 Tab 15 MG
THYROLAR-1/2 Tab 30 MG
THYROLAR-1 Tab 60 MG
ARMOUR Thyroid Tab 15 MG (1/4
Grain)
ARMOUR Thyroid Tab 30 MG (1/2
Grain)
NATURE-THROI,
WESTHROID
Thyroid Tab 32.5 MG
ARMOUR THYRO
ARMOUR Thyroid Tab 60 MG (1
Grain)
NATURE-THROI,
WESTHROID
Thyroid Tab 65 MG
ARMOUR THYRO
Limitations/
Restrictions
Thyroid Tab 90 MG (1 1/2 Grain)
Grain)
NATURE-THROI,
WESTHROID
Thyroid Tab 130 MG
Grain)
NATURE-THROI,
WESTHROID
Thyroid Tab 195 MG
TAPAZOLE
TAPAZOLE
Grain)
Grain)
Methimazole Tab 5 MG
Methimazole Tab 10 MG
Propylthiouracil Tab 50 MG
OXYTOCICS
METHERGINE
METHERGINE Tab 0.2 MG
ENDOCRINE AND METABOLIC AGENTS - MISCELLANEOUS
FOSAMAX
Alendronate Sodium Tab 5 MG
FOSAMAX
FOSAMAX
FOSAMAX
FOSAMAX
Daily Dosage=1
Daily Dosage=1
Daily Dosage=.15
Daily Dosage=1
Daily Dosage=.15
FOSAMAX Oral Soln 70 MG/75ML
Daily Dosage=10.8
MIACALCIN
MIACALCIN Inj 200 IU/ML
Calcitonin (Salmon) Nasal Soln 200
IU/ACT
EVISTA HCl Tab 60 MG
Max Qty=2/claim
Min DS=30; Package
Limit=1/claim
Daily Dosage=1
DDAVP
Desmopressin Acetate Tab 0.1 MG
Daily Dosage=1
DDAVP
Desmopressin Acetate Tab 0.2 MG
Daily Dosage=1
DDAVP
DDAVP
Desmopressin Acetate Nasal Soln
0.01% (Refrigerated)
Desmopressin Acetate Nasal Spray
Soln 0.01% (Refrigerated)
Desmopressin Acetate Nasal Spray
Soln 0.01%
Max Qty=5/claim
Max Qty=5/claim
Max Qty=5/claim
26
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
CARNITOR
CARNITOR,
CARNITOR SF
CARNITOR,
CARNITOR SF
ROCALTROL
ROCALTROL
ROCALTROL
CARDIOTONICS
LANOXIN
LANOXIN
ANTIANGINAL AGENTS
ISORDIL
Additional
Information
Product Description
Levocarnitine Tab 330 MG
Levocarnitine Oral Soln 1
GM/10ML (10%)
Levocarnitine Oral Soln 1
GM/10ML (10%)
Calcitriol Cap 0.25 MCG
Calcitriol Cap 0.5 MCG
CALCITRIOL 1 MCG/ML
SOLUTIO
Limitations/
Restrictions
Daily Dosage=3
Daily Dosage=30
Daily Dosage=30
Digoxin Tab 0.125 MG
Digoxin Tab 0.25 MG
Digoxin Oral Soln 0.05 MG/ML
Isosorbide Dinitrate Tab 5 MG
ISORDIL 40 MG TABLET
Isosorbide Dinitrate Tab CR 40 MG
Isosorbide Dinitrate SL Tab 2.5 MG
Isosorbide Dinitrate SL Tab 5 MG
MONOKET
Isosorbide Mononitrate Tab 10 MG
Daily Dosage=2
ISMO, MONOKET
Isosorbide Mononitrate Tab 20 MG
Daily Dosage=2
IMDUR
IMDUR
IMDUR
NITRO-DUR
NITRO-DUR
NITRO-DUR
NITRO-DUR
BETA BLOCKERS
CORGARD
CORGARD
CORGARD
Isosorbide Mononitrate Tab SR
24HR 30 MG
24HR 60 MG
24HR 120 MG
Nitroglycerin Cap CR 2.5 MG
Nitroglycerin Cap CR 6.5 MG
Nitroglycerin Cap CR 9 MG
NITROSTAT SL Tab 0.3 MG
NITRO-BID Oint 2%
Nitroglycerin TD Patch 24HR 0.1
MG/HR
MG/HR
MG/HR
MG/HR
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Nadolol Tab 20 MG
Nadolol Tab 40 MG
Nadolol Tab 80 MG
Nadolol Tab 160 MG
Pindolol Tab 5 MG
Pindolol Tab 10 MG
Propranolol HCl Tab 10 MG
Propranolol HCl Oral Soln 20
MG/5ML
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
27
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
BETAPACE
BETAPACE
BETAPACE
BETAPACE
Propranolol HCl Oral Soln 40
MG/5ML
Propranolol HCl Cap SR 24HR 60
MG
MG
MG
MG
Sotalol HCl Tab 80 MG
BETAPACE AF
Sotalol HCl (AFIB/AFL) Tab 80 MG
INDERAL LA
INDERAL LA
INDERAL LA
INDERAL LA
Limitations/
Restrictions
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Sotalol HCl (AFIB/AFL) Tab 120
MG
Sotalol HCl (AFIB/AFL) Tab 160
BETAPACE AF
MG
Timolol Maleate Tab 5 MG
SECTRAL
Acebutolol HCl Cap 200 MG
SECTRAL
Acebutolol HCl Cap 400 MG
TENORMIN
Atenolol Tab 25 MG
TENORMIN
Atenolol Tab 50 MG
TENORMIN
Atenolol Tab 100 MG
KERLONE
BETAXOLOL 10 MG TABLET
KERLONE
BETAXOLOL 20 MG TABLET
ZEBETA
Bisoprolol Fumarate Tab 5 MG
ZEBETA
Bisoprolol Fumarate Tab 10 MG
Metoprolol Succinate Tab SR 24HR
TOPROL XL
25 MG
TOPROL XL
50 MG
TOPROL XL
100 MG
TOPROL XL
200 MG
Metoprolol Tartrate Tab 25 MG
LOPRESSOR
LOPRESSOR
COREG
Carvedilol Tab 3.125 MG
COREG
COREG
COREG
Carvedilol Tab 25 MG
TRANDATE
Labetalol HCl Tab 100 MG
TRANDATE
TRANDATE
CALCIUM CHANNEL BLOCKERS
NORVASC
Amlodipine Besylate Tab 2.5 MG
NORVASC
Amlodipine Besylate Tab 5 MG
NORVASC
Amlodipine Besylate Tab 10 MG
CARDIZEM
Diltiazem HCl Tab 30 MG
CARDIZEM
CARDIZEM
CARDIZEM
Daily Dosage=2
Daily Dosage=2
BETAPACE AF
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=2
Daily Dosage=2
Daily Dosage=3
Daily Dosage=2
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=4
Daily Dosage=3
Daily Dosage=6
Daily Dosage=8
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Diltiazem HCl Cap SR 12HR 60 MG
Daily Dosage=2
Diltiazem HCl Cap SR 12HR 90 MG
Daily Dosage=2
Diltiazem HCl Cap SR 12HR 120
MG
Daily Dosage=2
28
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
DILACOR XR
DILACOR XR
DILACOR XR
TIAZAC
TIAZAC
TIAZAC
TIAZAC
TIAZAC
TIAZAC
CARDIZEM CD
CARDIZEM CD
CARDIZEM CD
CARDIZEM CD
CARDIZEM CD
Additional
Information
Product Description
MG
MG
MG
Diltiazem HCl Extended Release
Beads Cap SR 24HR 120 MG
Diltiazem HCl Coated Beads Cap SR
24HR 120 MG
24HR 180 MG
24HR 240 MG
24HR 300 MG
CARDIZEM CD 360 MG
CAPSULE
Limitations/
Restrictions
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
CARDIZEM LA 120 MG TABLET
CARDIZEM LA
CARDIZEM LA
CARDIZEM LA
CARDIZEM LA
CARDIZEM LA
PLENDIL
PLENDIL
PLENDIL
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
60 MG
90 MG
Verapamil HCl Tab 40 MG
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=3
Daily Dosage=3
Daily Dosage=4
Daily Dosage=4
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Verapamil HCl Tab CR 120 MG
Daily Dosage=2
Daily Dosage=2
PROCARDIA
ADALAT CC
ADALAT CC
ADALAT CC
PROCARDIA XL
PROCARDIA XL
PROCARDIA XL
CALAN
CALAN
CALAN
CALAN SR, ISOPTIN
SR
CALAN SR, ISOPTIN
SR
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
29
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
CALAN SR, ISOPTIN
SR
VERELAN
VERELAN
VERELAN
VERELAN
ANTIARRHYTHMICS
NORPACE
NORPACE
Additional
Information
Product Description
Limitations/
Restrictions
Step Therapy
Daily Dosage=2
Verapamil HCl Cap SR 24HR 120
MG
MG
MG
MG
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Disopyramide Phosphate Cap 100
MG
Disopyramide Phosphate Cap 150
MG
NORPACE CR 100 MG CAPSULE
PRONESTYL
NORPACE SR 12HR 150 MG
Procainamide HCl Cap 250 MG
Procainamide HCl Cap 500 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
TAMBOCOR
TAMBOCOR
TAMBOCOR
RYTHMOL
RYTHMOL
RYTHMOL
CORDARONE
PACERONE
Mexiletine HCl Cap 150 MG
Flecainide Acetate Tab 50 MG
Propafenone HCl Tab 150 MG
Amiodarone HCl Tab 200 MG
AMIODARONE HCL 400 MG
TABLE
TIKOSYN Cap 125 MCG (0.125
MG)
Biopharmacy benefit
via Acaria
Biopharmacy benefit
via Acaria
Biopharmacy benefit
via Acaria
TIKOSYN Cap 250 MCG (0.25 MG)
TIKOSYN Cap 500 MCG (0.5 MG)
ANTIHYPERTENSIVES
LOTENSIN
LOTENSIN
LOTENSIN
LOTENSIN
CAPOTEN
CAPOTEN
CAPOTEN
CAPOTEN
VASOTEC
VASOTEC
VASOTEC
VASOTEC
MONOPRIL
MONOPRIL
MONOPRIL
ZESTRIL
PRINIVIL, ZESTRIL
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
Lisinopril Tab 5 MG
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
Daily Dosage=2
30
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
PRINIVIL, ZESTRIL
PRINIVIL, ZESTRIL
ZESTRIL
ZESTRIL
UNIVASC
UNIVASC
ACEON
ACEON
ACEON
ACCUPRIL
ACCUPRIL
ACCUPRIL
ACCUPRIL
ALTACE
ALTACE
ALTACE
ALTACE
MAVIK
MAVIK
MAVIK
COZAAR
COZAAR
COZAAR
CATAPRES
CATAPRES
CATAPRES
TENEX
TENEX
CARDURA
CARDURA
CARDURA
CARDURA
MINIPRESS
MINIPRESS
MINIPRESS
HYTRIN
Additional
Information
Product Description
Lisinopril Tab 10 MG
MOEXIPRIL HCL 7.5 MG
TABLET
MOEXIPRIL HCL 15 MG
TABLET
PERINDOPRIL ERBUMINE 2
MG T
MG T
MG T
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 75 MG TABLET
Losartan Potassium Tab 25 MG
Limitations/
Restrictions
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Step Therapy
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
DIOVAN Tab 40 MG
Daily Dosage=1; Step
Therapy
Prior use of Lisinopril,
Enalapril, Fosinopril,
Ramipril, Losartan
DIOVAN Tab 80 MG
Therapy
Ramipril, Losartan
DIOVAN Tab 160 MG
Therapy
Ramipril, Losartan
DIOVAN Tab 320 MG
Therapy
Ramipril, Losartan
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
31
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
HYTRIN
HYTRIN
HYTRIN
APRESOLINE
LOTREL
LOTREL
LOTREL
LOTREL
LOTREL
LOTREL
LOTENSIN HCT
LOTENSIN HCT
LOTENSIN HCT
LOTENSIN HCT
CAPOZIDE
CAPOZIDE
CAPOZIDE
CAPOZIDE
VASERETIC
Product Description
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
Cap 10-5 MG
Cap 20-5 MG
AMLODIPINE-BENAZEPRIL 540
Amlodipine Besylate-Benazepril HCl
Cap 10-20 MG
AMLODIPINE-BENAZEPRIL 1040
Benazepril & Hydrochlorothiazide
Tab 5-6.25 MG
Tab 10-12.5 MG
Tab 20-12.5 MG
Tab 20-25 MG
Captopril & Hydrochlorothiazide Tab
25-15 MG
25-25 MG
50-15 MG
50-25 MG
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
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=3
Daily Dosage=2
MOEXIPRIL-HCTZ 7.5-12.5 MG
UNIRETIC
Daily Dosage=1
Enalapril Maleate &
Hydrochlorothiazide Tab 10-25 MG
UNIRETIC
UNIRETIC
Daily Dosage=3
Daily Dosage=10
Daily Dosage=2
PRINZIDE,
ZESTORETIC
PRINZIDE,
ZESTORETIC
PRINZIDE,
ZESTORETIC
MONOPRIL HCT
Limitations/
Restrictions
Enalapril Maleate &
Hydrochlorothiazide Tab 5-12.5 MG
Fosinopril Sodium &
Hydrochlorothiazide Tab 10-12.5
MG
Fosinopril Sodium &
MG
Lisinopril & Hydrochlorothiazide
Tab 10-12.5 MG
Tab 20-12.5 MG
Tab 20-25 MG
MONOPRIL HCT
Additional
Information
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=2
MOEXIPRIL-HCTZ 15-12.5 MG
TAB
MOEXIPRIL-HCTZ 15-25 MG
TAB
Daily Dosage=2
Daily Dosage=2
32
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ACCURETIC
ACCURETIC
ACCURETIC
TENORETIC
TENORETIC
ZIAC
ZIAC
ZIAC
Product Description
QUINAPRIL-HCTZ 10-12.5 MG
TAB
QUINAPRIL-HCTZ 20-12.5 MG
TAB
QUINAPRIL-HCTZ 20-25 MG
TAB
Atenolol & Chlorthalidone Tab 50-25
MG
Atenolol & Chlorthalidone Tab 10025 MG
Bisoprolol & Hydrochlorothiazide
Tab 2.5-6.25 MG
Tab 5-6.25 MG
Tab 10-6.25 MG
Additional
Information
Limitations/
Restrictions
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
LOPRESS HCT
Metoprolol & Hydrochlorothiazide
Tab 50-25 MG
Daily Dosage=2
LOPRESS HCT
Tab 100-25 MG
Daily Dosage=2
LOPRESS HCT
Tab 100-50 MG
Daily Dosage=1
CORZIDE
CORZIDE
DUTOPROL 25-12.5 TABLET
NADOLOL-BENDROFLU 40-5
MG T
NADOLOL-BENDROFLU 80-5
MG T
Step Therapy
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Propranolol & Hydrochlorothiazide
Tab 40-25 MG
Propranolol & Hydrochlorothiazide
Tab 80-25 MG
AVALIDE
AVALIDE
HYZAAR
HYZAAR
HYZAAR
Irbesartan-Hydrochlorothiazide 15012.5 MG
Irbesartan-Hydrochlorothiazide 30012.5 MG
Losartan Potassium &
MG
MG
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
DIOVAN HCT Tab 80-12.5 MG
Therapy
Therapy
DIOVAN HCT Tab 160-25 MG
Therapy
33
Ramipril, LosartanHCT
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Limitations/
Restrictions
Therapy
DIOVAN HCT Tab 320-25 MG
Therapy
METHYLDOPA-HCTZ 250-15 MG
T
METHYLDOPA-HCTZ 250-25 MG
T
Hydralazine & HCTZ Cap 25-25 MG
Hydralazine & HCTZ Cap 50-50 MG
DIURETICS
DEMADEX
DEMADEX
DEMADEX
DEMADEX
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
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
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
MIDAMOR
AMILORIDE HCL 5 MG TABLET
Daily Dosage=4
ALDACTONE
ALDACTONE
ALDACTONE
Spironolactone Tab 25 MG
CHLOROTHIAZIDE 250 MG
TABLE
CHLOROTHIAZIDE 500 MG
TABLE
Chlorthalidone Tab 25 MG
MICROZIDE
Hydrochlorothiazide Cap 12.5 MG
ZAROXOLYN
ZAROXOLYN
ZAROXOLYN
HYDROCHLOROTHIAZIDE 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
DIAMOX SEQUE
NEPTAZANE
NEPTAZANE
LASIX
LASIX
LASIX
AMILORIDE HCL-HCTZ 5-50 MG
ALDACTAZIDE
Spironolactone &
34
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
DYAZIDE
Additional
Information
Product Description
Limitations/
Restrictions
Triamterene & Hydrochlorothiazide
Cap 37.5-25 MG
Cap 50-25 MG
MAXZIDE-25
Tab 37.5-25 MG
MAXZIDE
Tab 75-50 MG
VASOPRESSORS
PROAMATINE
PROAMATINE
PROAMATINE
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)
EPIPEN-JR
ADRENACLICK,
EPINEPHRINE,
EPIPEN, EPIPEN 2PAK, TWINJECT...
ADRENACLICK,
EPINEPHRINE,
ADRENACLICK,
EPINEPHRINE,
MG/0.3ML (1:1000)
MG/0.3ML (1:1000)
MG/0.3ML (1:1000)
ANTIHYPERLIPIDEMICS
QUESTRAN
Max Qty=2/30 days
Max Qty=2/30 days
Max Qty=2/30 days
Max Qty=2/30 days
COLESTID
LOFIBRA
LOFIBRA
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
Fenofibrate Tab 54 MG
Fenofibrate Tab 160 MG
Daily Dosage=3
Daily Dosage=1
LOFIBRA
Fenofibrate Micronized Cap 67 MG
Daily Dosage=2
LOFIBRA
Daily Dosage=1
LOFIBRA
Daily Dosage=1
LOPID
Gemfibrozil Tab 600 MG
Atorvastatin Calcium Tab 10 MG
(Base Equivalent)
(Base Equivalent)
(Base Equivalent)
(Base Equivalent)
Lovastatin Tab 10 MG
Pravastatin Sodium Tab 10 MG
Simvastatin Tab 5 MG
Daily Dosage=2
QUESTRAN
QUESTRAN
QUESTRAN
MEVACOR
MEVACOR
MEVACOR
PRAVACHOL
PRAVACHOL
PRAVACHOL
PRAVACHOL
ZOCOR
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
35
Step Therapy
PREFERRED DRUG LIST
Common Brand
Product Description
Name(s)
Column1
ZOCOR
ZOCOR
ZOCOR
CARDIOVASCULAR AGENTS - MISCELLANEOUS
NIACIN FLUSH FREE 500 MG
NIACINOL
CA
Papaverine HCl Cap CR 150 MG
ANTIHISTAMINES
Chlorpheniramine Maleate Cap CR 8
MG
Chlorpheniramine Maleate Cap CR
12 MG
CHLOR-TRIMET
CHLOR-TRIMET
CHLOR-TRIMET
TAVIST, TAVIST-1
BENADRYL,
BENADRYL DF
BENADRYL,
BENADRYL ALG
BENADRYL,
BENADRYL ALG
BENADRYL ALL
Additional
Information
Limitations/
Restrictions
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=2
Chlorpheniramine Maleate Tab 4 MG
Max Qty= 120/claim
CHLORPHENIRAMINE ER 12
MG T
ED CHLORPED DROPS
Chlorpheniramine Maleate Syrup 2
MG/5ML
Dexchlorpheniramine Maleate Tab
CR 4 MG
Dexchlorpheniramine Maleate Syrup
2 MG/5ML
Clemastine Fumarate Tab 1.34 MG
CLEMASTINE FUM 2.68 MG TAB
Daily Dosage=2
Diphenhydramine HCl Cap 25 MG
Daily Dosage=4
Diphenhydramine HCl Cap 50 MG
Daily Dosage=4
Diphenhydramine HCl Tab 25 MG
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Diphenhydramine HCl Liquid 12.5
MG/5ML
Diphenhydramine HCl Elixir 12.5
MG/5ML
Diphenhydramine HCl Syrup 12.5
MG/5ML
Max Qty= 240/claim
Max Qty= 240/claim
Max Qty= 240/claim
Older
Older
Older
Older
Older; Max
Qty=12/claim
Older; Max
Qty=12/claim
Older; Max
Qty=12/claim
Promethazine HCl Tab 12.5 MG
Promethazine HCl Tab 25 MG
Promethazine HCl Tab 50 MG
Promethazine HCl Syrup 6.25
MG/5ML
Promethazine HCl Suppos 12.5 MG
Promethazine HCl Suppos 25 MG
Promethazine HCl Suppos 50 MG
Cyproheptadine HCl Tab 4 MG
Cyproheptadine HCl Syrup 2
MG/5ML
Cetirizine HCl Tab 5 MG
Daily Dosage=1
36
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
ZYRTEC, ZYRTEC
ALLGY, ZYRTEC
HIVES
ZYRTEC CHILD
ZYRTEC, ZYRTEC
CHILD
ZYRTEC CHILD,
ZYRTEC HIVES
CLARITIN
Additional
Information
Product Description
Limitations/
Restrictions
Cetirizine HCl Tab 10 MG
Daily Dosage=1
Cetirizine HCl Chew Tab 5 MG
Daily Dosage=1
Cetirizine HCl Chew Tab 10 MG
Daily Dosage=1
Cetirizine HCl Syrup 5 MG/5ML
Max Qty= 240/claim
Loratadine Tab 10 MG
Daily Dosage=1
Step Therapy
CHILD'S CLARITIN 5 MG TAB C
CLARITIN
Loratadine Syrup 5 MG/5ML
CLARITIN, CLARITIN Loratadine Rapidly-Disintegrating
RDT
Tab 10 MG
NASAL AGENTS - SYSTEMIC AND TOPICAL
SUDAFD NASAL,
SUDAFED, SUDAFED Pseudoephedrine HCl Tab 30 MG
CONG
Pseudoephedrine HCl Tab 60 MG
Pseudoephedrine HCl Liq 15
SUDAFED CHLD
MG/5ML
Pseudoephedrine HCl Liq 30
MG/5ML
Pseudoephedrine HCl Syrup 30
MG/5ML
Pseudoephedrine HCl Soln 7.5
PEDIACARE
MG/0.8ML
Pseudoephedrine HCl Tab SR 12HR
120 MG
NASAL DECONGESTANT PE 10
SUDAFED PE
MG
Phenylephrine HCl Soln 2.5
PEDIACARE
MG/5ML
Max Qty= 240/claim
Branded/MS; Max
Qty=31/31 days
Max Qty=62/31 days
Max Qty=24/claim
ADRENALIN HCl Nasal Soln 0.1%
AFRIN, AFRIN 12 HR,
AFRIN NODRIP,
AFRIN SINUS,
DRISTAN...
AFRIN, AFRIN 12 HR,
AFRIN NODRIP,
AFRIN SINUS,
DRISTAN...
NEO-SYNEPHRI
NASALIDE
NASAREL
FLONASE
AFRIN 0.05% NOSE SPRAY
MUCINEX FULL FORCE NASAL
SP
NOSE DROPS
Flunisolide Nasal Soln 0.025%
Flunisolide Nasal Soln 29
MCG/ACT
Fluticasone Propionate Nasal Susp 50
MCG/ACT
ATROVENT NAS
ATROVENT NAS
NASALCROM
Max Qty=16/30 days
Older ; Max Qty=17/30
days; Step Therapy Flonase
days; Step Therapy Flonase
NASONEX Nasal Susp 50
MCG/ACT
NASACORT AQ
Max Qty=25/30 days
NASACORT AQ Nasal Inhal 55
MCG/ACT
BACTROBAN Nasal Oint 2%
Ipratropium Bromide Nasal Soln
0.03% (21 MCG/SPRAY)
Ipratropium Bromide Nasal Soln
0.06% (42 MCG/SPRAY)
Cromolyn Sodium Nasal Aerosol
Soln 5.2 MG/ACT (4%)
Max Qty=31/30 days
Max Qty=15/30 days
Max Qty=26/30 days
37
Step Therapy Flonase
Step Therapy Flonase
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
OCEAN NASAL
Additional
Information
Product Description
Saline Nasal Spray 0.65%
Limitations/
Restrictions
TESSALON PER
AYR NASAL Soln 0.65%
Saline Nasal Gel
Hydrocodone w/ Homatropine
Syrup 5-1.5 MG/5ML
Benzonatate Cap 100 MG
TESSALON
Benzonatate Cap 200 MG
Max Qty=30/30 days;
Max Fills=1/30 days
TRIAMINIC
Dextromethorphan HBr Liquid 7.5
MG/5ML
Max Qty=240/6 days
VICKS DAYQUI,
VICKS NATURE
DAY TIME COUGH LIQUID
HYCODAN
DELSYM
COUGH/COLD/ALLERGY
COUGH RELIEF LIQUID
ROBITUSSIN PEDIATRIC
COUGH
Dextromethorphan Polistirex Liquid
DELSYM
CR 30 MG/5ML
Max Qty=240/6 days
GUAIFENESIN 200 MG TABLET
ALLFEN
MUCUS RELIEF 400 MG TABLET
ORGANIDIN NR
ROBITUSSIN
Guaifenesin Liquid 100 MG/5ML
Guaifenesin Syrup 100 MG/5ML
Max Qty=240/6 days
HUMIBID, MUCINEX
MUCINEX Tab SR 12HR 600 MG
Daily Dosage=2
DURATUSS G
MUCINEX Tab SR 12HR 1200 MG
Daily Dosage=2
Acetylcysteine Inhal Soln 10%
Acetylcysteine Inhal Soln 20%
Sodium Chloride Soln Nebu 0.45%
EXCEDRIN SIN
CEPACOL CHLD
ADVIL COLD/
CHILD MOTRIN
ALLERX-D
BROVEX PEB
DIMETAPP CLD
Sodium Chloride Soln Nebu 0.9%
Sodium Chloride Soln Nebu 3%
Sodium Chloride Soln Nebu 10%
Sodium Chloride Aero Soln 0.9%
SINUS CONGESTION-PAIN
CAPLE
Max Qty=240/claim
Pseudoephedrine w/ Acetaminophen
Liquid (TYLENOL CHLD) 15-160
MG/5ML
Pseudoephedrine-Ibuprofen Tab 30200 MG
Pseudoephedrine-Ibuprofen Susp 15100 MG/5ML
Phenylephrine-APAP-Caffeine Tab 5500-75 MG
Max Qty=120/30 days
Pseudoephedrine-Methscopolamine
Tab SR 12HR 120-2.5 MG
LOHIST-PEB LIQUID
DECON-A (Brompheniramine &
Phenylephrine) Liqd 2-5 MG/ML
DIMETAPP COLD & ALLERGY
ELI
DECON-A (Brompheniramine &
Phenylephrine) Elixir 2-5 MG/5ML
Brompheniramine &
Pseudoephedrine Cap CR 6-60 MG
Daily Dosage=4
38
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
BROMFED
BROVEX PSB
ZYRTEC-D ALG
ED-A-HIST
ED A-HIST
Additional
Information
Product Description
Brompheniramine &
Pseudoephedrine Cap CR 12-120
MG
LOHIST-PSB LIQUID
Brompheniramine &
Pseudoephedrine Elixir 1-15
MG/5ML
Brompheniramine &
Pseudoephedrine Syrup 4-45
MG/5ML
Brompheniramine &
Pseudoephedrine Cap SR 12HR 10120 MG
Brompheniramine &
Pseudoephedrine Tab SR 12HR 10120 MG
Cetirizine-Pseudoephedrine Tab SR
12HR 5-120 MG
ED-A-HIST TABLET
COLD & ALLERGY TABLET
ED A-HIST LIQUID
Limitations/
Restrictions
Daily Dosage=4
Max Qty=240/claim
Max Qty=240/claim
Legend; Daily Dosage=2
Chlorpheniramine & Phenylephrine
Liquid 1-2 MG/ML
Daily Dosage=1
Liquid 1-3.5 MG/ML
Max Qty=30/claim
RONDEC
Syrup 4-12.5 MG/5ML
Max Qty=240/claim
DECONAMINE
Chlorpheniramine &
Daily Dosage=2
DALLERGY
DECONAMINE
HISTEX
DECONAMINE
RYNATAN PED
SUDOGEST COLD & ALLERGY
TAB
LOHIST-D (Chlorpheniramine &
Pseudoephedrine) Liquid 2-30
MG/5ML
Chlorpheniramine &
Pseudoephedrine Syrup 2-30
MG/5ML
Chlorpheniramine &
Pseudoephedrine Soln 2-30
MG/5ML
Max Qty=240/claim
Max Qty=240/claim
Older ; > 6 Daily
Dosage=20; From age 3
through 5: Daily
Dosage=10
Chlorpheniramine TanPhenylephrine Tan Susp 4.5-5
MG/5ML
Diphenhydramine &
CLARITIN-D
CLARITIN-D
Diphenhydramine &
Pseudoephedrine Tab 25-60 MG
Diphenhydramine &
Pseudoephedrine Liquid 12.5-30
MG/5ML
Loratadine & Pseudoephedrine Tab
SR 12HR 5-120 MG
Loratadine & Pseudoephedrine Tab
SR 24HR 10-240 MG
Max Qty=240/claim
Brand; Daily Dosage=2
Daily Dosage=1
Promethazine & Phenylephrine Syrup
6.25-5 MG/5ML
39
days
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
ACTIFED
ALLERFRIM SYRUP
TRIAMINIC NT
NALEX-A
EXTENDRYL
DURAHIST PE
SCOT-TUSSIN
NOTUSS-DC
Additional
Information
Product Description
APRODINE TABLET
Triprolidine & Pseudoephedrine
Syrup 1.25-30 MG/5ML
DIMETAPP COLD & CONGEST
LIQ
CHILD DELSYM COUGH-COLD
NIG
Chlorphen-Ptolox-Phenyleph Liquid
2.5-7.5-5 MG/5ML
Chlorphen Tan-Pyrilamine Tan-PE
Tan Susp 2-12.5-5 MG/5ML
DALLERGY (Chlorphen-PEMethscopolamine) Tab 4-10-1.25
MG
Limitations/
Restrictions
Daily Dosage=20
DALLERGY (Chlorpheniramine-PEMethscopolamine) Chew Tab 2-101.25 MG
Chlorphen-PE-Methscopolamine
Syrup 2-10-0.625 MG/5ML
DEHISTINE (Chlorpheniramine-PEMethscopolamine) Syrup 2-10-1.25
MG/5ML
Chlorphen-PE-Methscopolamine
Tab SR 12HR 8-20-1.25 MG
DALLERGY PE (Chlorphen-PEMethscopolamine) Tab SR 12HR 820-2.5 MG
ALLERGY MULTI-SYMPTOM
CAPLE
Chlorphen-Pseudoephedrine w/
APAP Cap 2-30-325 MG
FLU RELIEF THERAPY NIGHT
LI
ADT ROBITUSSIN COUGHCOLD-FLU
Phenir-PE w/ Sod Salicyl & Caff Cit
Liq 13-4-83-25 MG/5ML
ENDACOF-DC LIQUID
Promethazine w/ Codeine Syrup 6.2510 MG/5ML
Older; Limited to Ages 7
and Under; Max
Qty=60/claim
Max Qty=248/31 days
Max Qty=240/6 days
Max Qty=62/31 days
Max Qty=62/31 days
Older ; Max
Qty=240/claim
PRO-CLEAR AC SYRUP
Older ; Max
Qty=240/claim
Phenylephrine-Promethazine w/
Codeine Syrup 5-6.25-10 MG/5ML
PRO-RED AC SYRUP
PHENYLHISTINE DH LIQUID
Phenyleph-Chlorphen w/
Hydrocodone Syrup 5-2-1.67
MG/5ML
Phenyleph-Chlorphen w/
Hydrocodone Syrup 5-2-2.5
MG/5ML
Max Qty=240/claim
Max Qty=240/claim
Phenyleph-Pyrilamine w/
Hydrocodone Syrup 5-5-5 MG/5ML
Max Qty=240/claim
Phenyleph-Pyrilamine w/
Hydrocodone Syrup 5-8.33-1.66
MG/5ML
*PE-Pheniramine-COD-Sod
Salicylate-Sod Cit-Caff Liquid***
Acetaminophen w/ DM Liq 160-5
MG/5ML
Max Qty=240/claim
40
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
NYQUIL COUGH,
VICKS NYQUIL
Additional
Information
Product Description
TRIACTING COLD & COUGH
LIQU
Pseudoephedrine-DM Liqd 15-7.5
MG/5ML
Pseudoephedrine-DM Elixir 20-10
MG/5ML
Pseudoephedrine-DM Soln 7.5-2.5
MG/0.8ML
Chlorpheniramine-DM Liquid 2-15
MG/5ML
DIMETAPP (ChlorpheniramineDM) Syrup 1-7.5 MG/5ML
TRICODENE SF
(Chlorpheniramine-DM) Syrup 2-10
MG/5ML
Max Qty=240/claim
Max Qty=240/claim
Max Qty=31/claim; Max
Qty=30/6 days
Max Qty=240/claim
Max Qty=240/claim
NITE TIME COUGH LIQUID
Older ; Max
Qty=240/claim
Promethazine-DM Syrup 6.25-15
MG/5ML
DIMETAPP DM
PHENABID DM
CODIMAL DM
TRIAMINIC
COMTREX COLD,
THERAFLU SEV
TYLENOL CHLD
TYLENOL COLD,
TYLENOL WARM
Limitations/
Restrictions
DIMETAPP DM COLD &
COUGH EL
Phenylephrine-Chlorphen-DM Chew
Tab SR 12HR 30-4-30 MG
Phenylephrine-Chlorphen-DM Tab
SR 12HR 20-8-30 MG
Phenylephrine-Pyrilamine-DM Syrup
5-8.33-10 MG/5ML
Pseudoephed-Chlorphen-DM Liq 151-5 MG/5ML
Pseudoephed-Chlorphen-DM Liq 151-7.5 MG/5ML
RESCON-DM LIQUID
Pseudoephed-Bromphen-DM Liquid
30-1-20 MG/5ML
Pseudoephed-Bromphen-DM Elixir
15-1-5 MG/5ML
Pseudoephed-Bromphen-DM Syrup
30-2-10 MG/5ML
Pseudoephed-Bromphen-DM Syrup
45-4-15 MG/5ML
COLD HEAD CONGESTION
CAPLET
ADLT ROBITUSSIN COUGHCOLDDELSYM MULTI-SYMPTOM
NIGHT
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Pseudoeph-Chlorphen-DM w/
APAP Syrup 60-4-30-500 MG/20ML
Pseudoeph-Doxylamine-DM w/
APAP Cap 30-6.25-10-250 MG
APAP Cap 30-6.25-15-325 MG
NYQUIL
MUCINEX COLD
RESCON-GG
APAP Liq 60-7.5-30-1000MG/30ML
Pseudoeph-Doxylamine-DM
w/APAP Liquid 60-12.5-301000MG/30ML
Phenylephrine-Guaifenesin Liqd 2.5100 MG/5ML
Phenylephrine-Guaifenesin Liqd 5100 MG/5ML
Max Qty=240/6 days
41
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Product Description
COLD MULTISYMPTOM CAPLET
Phenylephrine-Potassium
Guaiacolsulfonate Liqd 5-75
MG/5ML
RESPAIRE-30 CAPSULE
Pseudoephedrine-Guaifenesin Syrup
30-100 MG/5ML
MUCINEX D (PseudoephedrineGuaifenesin) Tab SR 12HR 60-600
MG
GUAIMAX-D (PseudoephedrineGuaifenesin) Tab SR 12HR 120-600
MG
MUCINEX D (PseudoephedrineGuaifenesin) Tab SR 12HR 120-1200
MG
Phenylephrine-Chlorphen-GG Soln 21-20 MG/ML
CHEST CONGEST-PAIN RLF PE
T
LUSONEX PLUS (PhenylephrineAPAP-GG) Tab SR 12HR 30-2501100 MG
Dextromethorphan-PhenylephrineAPAP Cap 10-5-325 MG
Dextromethorphan-Phenyl-APAP
Tab 10-5-325 MG
TYLENOL COLD
DAY TIME COLD & FLU RELIEF
NUMONYL NR
DAY TIME
Additional
Information
Limitations/
Restrictions
Max Qty=240/claim
Max Qty=210/claim
Max Qty=210/claim
Daily Dosage=2
Qty=30/6 days
LITTLE COLDS
(Dextromethorphan-PhenylephrineAPAP) Liqd 2.5-1.25-80 MG/ML
PRO-CLEAR
TUSSI-ORGANI
PROLEX DM
GNP DAY TIME
CHERACOL,
CHERACOL-D
ROBITUSSIN,
ROBITUSSN DM
Pseudoephedrine w/ APAP-DM
Caps 30-250-10 MG
Pseudoephedrine w/ APAP-DM Cap
30-325-15 MG
Pseudoephedrine w/ APAP-DM Liq
60-650-20 MG/30ML
PRO-CLEAR CAPS
DIABETIC, DIABETIC TUS,
TUSSO, 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
CORICIDIN (DextromethorphanGuaifenesin) Cap 10-200 MG
MUCUS RELIEF DM TABLET
DAYTIME MUCUS RELIEF DM
LIQ
Dextromethorphan-Guaifenesin
Liquid 5-100 MG/5ML
Liquid 10-100 MG/5ML
BIOSPEC DMX, TRISPEC DMX
(Dextromethorphan-Guaifenesin)
Liquid 15-25 MG/5ML
42
Max Qty=240/claim
Max Qty=240/claim
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Product Description
SCOT-TUSSIN (DextromethorphanGuaifenesin) Liquid 15-200
MG/5ML
NORTUSS-EX (DextromethorphanGuaifenesin) Liquid 20-200
MG/5ML
HT-TUSS DM (DextromethorphanGuaifenesin) Elixir 20-200 MG/5ML
ROBITUSSN DM
ROBITUSSN DM
SCOT-TUSSIN
MUCINEX CGH
CORICIDAN CO
ROBITUSSIN
DONATUSSIN
Syrup 10-100 MG/5ML
Syrup 10-100 MG/5ML
Syrup 15-100 MG/5ML
MUCINEX CGH
(Dextromethorphan-Guaifenesin)
Granules Packet 5-100 MG
MUCINEX DM (DextromethorphanGuaifenesin) Tab SR 12HR 30-600
MG
Dextromethorphan-Guaifenesin Tab
SR 12HR 60-1200 MG
Hydrocodone-Guaifenesin Tab 2.5300 MG
Hydrocodone-Guaifenesin Liquid 5100 MG/5ML
Hydrocodone-Guaifenesin Syrup 390 MG/5ML
Hydrocodone-Guaifenesin Syrup 5100 MG/5ML
Hydrocodone-Guaifenesin Tab SR
12HR 5-575 MG
Hydrocodone-Guaifenesin Tab SR
12HR 5-600 MG
ROBITUSSIN COUGH-COLD CF
SY
CHILD MUCINEX MULTISYMPTOM
Phenylephrine w/ Hydrocodone-GG
Syrup 10-2-100 MG/5ML
Pseudoephedrine w/ COD-GG Soln
30-10-100 MG/5ML
CAPMIST DM TABLET
TUSNEL PEDIATRIC LIQUID
Pseudoephedrine w/ DM-GG Liquid
30-10-100 MG/5ML
ADT ROBITUSSIN COUGHCOLD D
DONATUSSIN DM SYRUP
Additional
Information
Limitations/
Restrictions
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Max Qty=240/claim
Max Qty=210/claim;
Daily Dosage=2
Max Qty=240/claim
Max Qty=240/6 days
Max Qty=240/6 days
Pseudoephedrine w/ HydrocodoneGG Liqd 15-2.5-100 MG/5ML
Pseudoephedrine w/ HydrocodoneGG Liqd 15-3-100 MG/5ML
Pseudoephedrine w/ HydrocodoneGG Elixir 30-2.5-100 MG/5ML
Max Qty=240/6 days
Phenyleph-Chlorphen w/ DM-GG
Syrup 10-2-7.5-100 MG/5ML
Max Qty=248/31 days
43
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
TYLENOL COLD
TYLENOL COLD
TYLENOL COLD,
TYLENOL WARM
Additional
Information
Product Description
DONATUSSIN (PhenylephChlorphen w/ DM-GG) Syrup 10-215-100 MG/5ML
COLD MULTI-SYMPTOM
CAPLET
COLD HEAD CONGESTION
CAPLET
COLD MULTI-SYMPTOM
DAYTIME
Limitations/
Restrictions
Max Qty=240/claim
Pseudoephedrine-DM-GG w/ APAP
Liq 30-10-100-324 MG/15ML
Dextromethorphan-APAPDIABETIC
Chlorpheniramine Cap 15-325-4 MG
TRIAMINIC FLU COUGHFEVER S
CHILD'S MAPAP COUGH-SINUS
CHLD TYLENOL
S
CLEAR COUGH,
Dextromethorphan-DoxylamineAPAP Liquid 30-12.5-1000
TYLENOL CGH,
MG/30ML
TYLENOL WARM
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Ipratropium Bromide Inhal Soln
0.02%
ATROVENT HFA Inhal Aerosol 17
MCG/ACT
SPIRIVA Inhal Cap 18 MCG (Base
Equiv)
Cromolyn Sodium Soln Nebu 20
INTAL
MG/2ML
Albuterol Inhal Aerosol 90
PROVENTIL
MCG/ACT
Albuterol Sulfate Tab 2 MG
Albuterol Sulfate Tab 4 MG
VENTOLIN
Max Qty=375/25 days
Package Limit=2/month
Min DS=25; Package
Limit=1/claim
Daily Dosage=8
Albuterol Sulfate Syrup 2 MG/5ML
Albuterol Sulfate Soln Nebu 0.083%
ACCUNEB
ACCUNEB
VOSPIRE ER
VOSPIRE ER
Daily Dosage=12.5
Albuterol Sulfate Soln Nebu 0.5% (5
MG/ML)
Albuterol Sulfate Soln Nebu 0.5% (5
MG/ML)
Albuterol Sulfate Soln Nebu 0.63
MG/3ML (Base Equiv)
Albuterol Sulfate Soln Nebu 1.25
MG/3ML (Base Equiv)
PROAIR HFA, VENTOLIN HFA
PROAIR HFA,
Inhal Aero 120 MCG/ACT
VENTOLIN HFA
(100MCG Base Equiv)
Albuterol Sulfate Tab SR 12HR 4
MG
Albuterol Sulfate Tab SR 12HR 8
MG
Max Qty=375/30 days
Max Qty=375/30 days
Min DS=30; Package
Limit=1/claim
FORADIL Inhal Cap 12 MCG
Metaproterenol Sulfate Tab 10 MG
Metaproterenol Sulfate Tab 20 MG
Metaproterenol Sulfate Syrup 10
MG/5ML
Metaproterenol Sulfate Soln Nebu
0.4%
Daily Dosage=30
44
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
BRETHINE
BRETHINE
DUONEB
Product Description
Metaproterenol Sulfate Soln Nebu
0.6%
SEREVENT DIS Aer Pow BA 50
MCG/DOSE (Base Equiv)
Terbutaline Sulfate Tab 2.5 MG
Terbutaline Sulfate Tab 5 MG
EPHEDRINE SU 25 MG
CAPSULE
Ipratropium-Albuterol Nebu Soln 0.52.5(MG/3ML
COMBIVENT Aerosol 18-103
MCG/ACT (20-120MCG/ACT)
COMBIVENT RESPIMAT 20 mcg100 mcg/actuation
SYMBICORT 80-4.5 MCG
INHALE
Additional
Information
Limitations/
Restrictions
Min DS=30; Package
Limit=1/claim
Daily Dosage=12
Daily Dosage=1
SYMBICORT 160-4.5 MCG INHAL
ADVAIR HFA Inhal Aerosol 45-21
MCG/ACT
MCG/ACT
MCG/ACT
ADVAIR HFA Aer Powder BA 10050 MCG/DOSE
DULERA 100 MCG/5 MCG
INHALE
DULERA 200 MCG/5 MCG
INHALE
Aminophylline Tab 100 MG
Aminophylline Tab 200 MG
LUFYLLIN Tab 200 MG
LUFYLLIN Tab 400 MG
Theophylline Elixir 80 MG/15ML
Theophylline solution 80MG/15ML
Max Qty=12/claim
Max Qty=12/claim
Max Qty=12/claim
Max Qty=60/claim
Max Qty=60/claim
Max Qty=60/claim
Max Qty =
475/dispense
Theophylline Cap SR 12HR 125 MG
THEO-24 Cap SR 24HR 100 MG
Theophylline Tab SR 12HR 100 MG
THEO-DUR
QUIBRON-T SR, THEOTheophylline Tab SR 12HR 300 MG
DUR
UNIPHYL
UNIPHYL
QVAR Inhal Aero Soln 40
MCG/ACT
QVAR Inhal Aero Soln 80
MCG/ACT
45
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Limitations/
Restrictions
PULMICORT
PULMICORT Susp 0.25 MG/2ML
Max Qty=120/claim
PULMICORT
PULMICORT Susp 0.5 MG/2ML
PULMICORT Susp 1 MG/2ML
FLOVENT DISK Aer Pow BA 50
MCG/BLISTER
MCG/BLISTER
MCG/BLISTER
FLOVENT HFA Inhal Aerosol 44
MCG/ACT
MCG/ACT
MCG/ACT
SINGULAIR Tab 10 MG (Base
Equiv)
SINGULAIR Chew Tab 4 MG (Base
Equiv)
SINGULAIR Chew Tab 5 MG (Base
Equiv)
Max Qty=120/claim
Max Qty=60/30 days
SINGULAIR Oral Granules Packet 4
MG (Base Equiv)
LAXATIVES
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Therapy
QUIBRON-300 Cap 300-180 MG
FLEET
FLEET
Magnesium Hydroxide Susp 400
MG/5ML
MILK OF MAGNESIA
CONCENTRAT
Magnesium Citrate Soln
ORAL SALINE LAXATIVE
LIQUID
*Sodium Phosphates - Enema***
*Sodium Phosphates - Enema***
DULCOLAX
Bisacodyl Tab Delayed Release 5 MG
Daily Dosage=1
DULCOLAX
FLEET BISACODYL 10 MG
ENEMA
Bisacodyl Suppos 10 MG
Senna Tab 187 MG
Senna Powder
Max Qty=12/claim
MILK OF MAGN
Max Qty=992/31 days
SENOKOT, SENOKOT
SENNA Tab 8.6 MG
2GO
SENNA SYRUP
FIBER THERAPY 500 MG
CITRUCEL
CAPLET
FIBER LAXATIVE 625 MG
FIBERCON
CAPLE
METAMUCIL
Psyllium Cap 0.52 GM
NATURAL VEG Psyllium Powder
28%
28.3%
30%
30.9%
30.9%
Daily Dose=10
46
Step Therapy
Allergic rhinitis: prior
use of Loratidine
OTC, Zyrtec OTC,
Fluticasone spray
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
METAMUCIL
EVAC, KONSYL
FLEET MINERL,
FLEET OIL
Additional
Information
Product Description
33%
48.57%
50%
KONSYL-D POWDER
Psyllium Powder 58.6%
KONSYL-ORANGE POWDER
Psyllium Powder 68%
KONSYL EASY MIX FORMULA
POW
Psyllium Powder 100%
Limitations/
Restrictions
FLEET MINERAL OIL ENEMA
ENEMEEZ PLUS MINI ENEMA
COLACE
COLACE
COLACE
COLACE
MIRALAX
MIRALAX
SENOKOT S
NULYTELY
DOCUSATE CAL 240 MG
CAPSULE
Docusate Sodium Cap 50 MG
Docusate Sodium Tab 100 MG
Docusate Sodium Liquid 150
MG/15ML
Docusate Sodium Syrup 60
MG/15ML
ENEMEEZ MINI ENEMA
Glycerin Suppos 1.5 GM
Glycerin Suppos 3 GM
Lactulose Solution 10 GM/15ML
Polyethylene Glycol 3350 Oral
Powder
Daily Dosage=3
Daily Dosage=3
Max Qty=12/claim
Max Qty=24/claim
Daily Dosage=36
Polyethylene Glycol 3350 Oral Packet
Sorbitol Oral Solution 70%
Phenolphthalein-DSS Tab 65-100
MG
SENNA S (Sennosides-Docusate
Sodium Tab 8.6-50 MG)
FLEET PREP (Bisacodyl-Sod
Biphos/Sod Phos) Prep Kit
PEG 3350-KCl-Sod Bicarb-NaCl
For Soln 420 GM
HALFLYTELY Bisacodyl Tab &
PEG 3350-KCl-Sod Bicarb-NaCl For
Soln Kit
PEG 3350-KCl-Na Bicarb-NaCl-Na
Sulfate Soln 6 GM/100ML
Daily Dosage=4
COLYTE WITH FLAVOR PACKS
GOLYTELY
COLYTE,
COLYTE/FLAVR
ANTIDIARRHEALS
LOMOTIL
LOMOTIL
IMODIUM A-D
Sulfate For Soln 236 GM
Sulfate For Soln 240 GM
GOLYTELY PACKET
Diphenoxylate w/ Atropine Tab 2.50.025 MG
Diphenoxylate w/ Atropine Liq 2.50.025 MG/5ML
Loperamide HCl Cap 2 MG
ANTI-DIARRHEAL 2 MG
CAPLET
47
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
KAOPECTATE
PEPTO-BISMOL
PEPTO-BISMOL
PEPTO-BISMOL
PEPTO-BISMOL
ANTACIDS
Additional
Information
Product Description
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
Bismuth Subsalicylate Susp 527
MG/30ML
Limitations/
Restrictions
PINK BISMUTH MAX-STR SUSP
ACIDOPHILUS X-STR CAPTAB
ACIDOPHILUS CAPLET
Aluminum Hydroxide Gel Susp 320
MG/5ML
Aluminum Hydroxide Gel Susp 600
MG/5ML
Max Qty=496/31 days
Sodium Bicarbonate Tab 325 MG
Max Qty=100/31 days
Sodium Bicarbonate Tab 650 MG
Max Qty=100/31 days
CALCIUM CARBONATE 648 MG
TA
Calcium Carbonate (Antacid) Chew
TUMS, TUMS LASTING
Tab 500 MG
MAG-OX 400
Magnesium Oxide Tab 400 MG
MAALOX SUS
GAVISCON
GAVISCON
MYLANTA
Aluminum & Magnesium Hydroxides
Susp 225-200 MG/5ML
Max Qty=744/31 days
FOAMING ANTACID LIQUID
FOAMING ANTACID TABLET
CHEW
Alum & Mag Hydroxide-Simethicone
Susp 200-200-20 MG/5ML
Max Qty=744/31 days
MYLANTA, MYLANTA
ANTACID PLUS SUSPENSION
DS
MYLANTA, MYLANTA MAALOX MAXIMUM
DS
STRENGTH SUS
ULCER DRUGS
LEVSIN
SYMAX DUOTAB
LEVSIN/SL
LEVSIN
LEVSIN
LEVSINEX
ANASPAZ
LEVBID
ROBINUL
Hyoscyamine Sulfate Tab 0.125 MG
Hyoscyamine Sulfate Tab CR 0.375
MG
LEVSIN Tab SL 0.125 MG
Hyoscyamine Sulfate Elixir 0.125
MG/5ML
LEVSIN Inj 0.5 MG/ML
Hyoscyamine Sulfate Soln 0.031
MG/ML
Hyoscyamine Sulfate Soln 0.125
MG/ML
Hyoscyamine Sulfate Powder
Hyoscyamine Sulfate Cap SR 12HR
0.375 MG
Hyoscyamine Sulfate Orally
Disintegrating Tab 0.125 MG
Hyoscyamine Sulfate Tab Disp 0.25
MG
Hyoscyamine Sulfate Tab SR 12HR
0.375 MG
GLYCOPYRROLATE 1 MG
TABLET
Daily Dosage=4
Daily Dosage=4
48
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ROBINUL FORT
BENTYL
BENTYL
BENTYL
DONNATAL
DONNATAL
Additional
Information
Product Description
GLYCOPYRROLATE 2 MG
TABLET
PROPANTHELINE 15 MG
TABLET
Dicyclomine HCl Cap 10 MG
Dicyclomine HCl Tab 20 MG
Dicyclomine HCl Oral Soln 10
MG/5ML
Belladonna Alkaloids-Phenobarbital
Tab 16.2 MG
Belladonna Alkaloids-Phenobarbital
Elixir 16 MG/5ML
Limitations/
Restrictions
Daily Dosage=4
Daily Dosage=4
Max Qty=496/31 days
TAGAMET, TAGAMET
Cimetidine Tab 200 MG
HB
Cimetidine HCl Soln 300 MG/5ML
TALADINE, ZANTAC
TALADINE, ZANTAC
ZANTAC
ZANTAC
ZANTAC
Ranitidine HCl Cap 150 MG
Ranitidine HCl Cap 300 MG
Ranitidine HCl Tab 75 MG
Daily Dosage=2
Daily Dosage=1
Daily Dosage=2
ZANTAC
Ranitidine HCl Syrup 75 MG/5ML
Daily Dosage=20
PEPCID AC
PEPCID, PEPCID AC
PEPCID
PEPCID
Famotidine Tab 10 MG
PEPCID Susp 40 MG/5ML
AXID AR Tab 75 MG
CYTOTEC
Misoprostol Tab 100 MCG
CYTOTEC
Misoprostol Tab 200 MCG
PREVACID, PREVACID Lansoprazole Cap Delayed Release
24H
15 MG
LANSOPRAZOLE DR 30 MG
PREVACID
CAPSU
PRILOSEC
PRILOSEC
PRILOSEC
PROTONIX
PROTONIX
CARAFATE
PA, Legend; OTC: Daily
Dosage=4
Daily Dosage=2
Lansoprazole Tab Delayed Release
Orally Disintegrating 15 MG
Daily Dosage=1
Lansoprazole Tab Delayed Release
Orally Disintegrating 30 MG
Daily Dosage=1
OMEPRAZOLE DR 20 MG
TABLET
Omeprazole suspension
compounding kit 2MG/Ml
OMEPRAZOLE DR 10 MG
CAPSULE
Omeprazole Cap Delayed Release 20
MG
Omeprazole Cap Delayed Release 40
MG
PRILOSEC OTC (Omeprazole
Magnesium Delayed Release Tab 20
MG Base Equiv)
OMEPRAZOLE MAG DR 20.6
MG C
PANTOPRAZOLE SOD DR 20
MG T
PANTOPRAZOLE SOD DR 40
MG T
Sucralfate Tab 1 GM
Max Qty=300
Daily Dosage=2
Daily Dosage=4
Daily Dosage=2
Daily Dosage=4
Daily Dosage=2
Daily Dosage=2
49
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Limitations/
Restrictions
SUCRALFATE 1 GM/10 ML SUSP
ZEGERID
ANTIEMETICS
DRAMAMINE
ANTIVERT
ANTIVERT
BONINE
TIGAN
ZOFRAN ODT
ZOFRAN ODT
ZEGERID OTC (OmeprazoleSodium Bicarbonate Cap 20-1100
MG)
ZEGERID (Omeprazole-Sodium
Bicarbonate Powd Pack for Susp 201680 MG)
ZEGERID (Omeprazole-Sodium
Bicarbonate Powd Pack for Susp 401680 MG)
DIMENHYDRINATE 50 MG
TABLET
Meclizine HCl Tab 12.5 MG
Meclizine HCl Tab 25 MG
MECLIZINE 25 MG TABLET
CHEW
TRIMETHOBENZAMIDE 300
MG CA
Ondansetron Orally Disintegrating
Tab 4 MG
Ondansetron Orally Disintegrating
Tab 8 MG
ZOFRAN
Ondansetron HCl Tab 4 MG
ZOFRAN
ZOFRAN
ZOFRAN
ZOFRAN
ZOFRAN
EMETROL
DIGESTIVE AIDS
Daily Dosage=2
Max DS=90/365 days;
Daily Dosage=1
Max DS=90/365 days;
Daily Dosage=1
Max DS=90/365 days;
Daily Dosage=2
Max DS=90/365 days;
Daily Dosage=2
Max Qty=1/14 days
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
ANTI-NAUSEA LIQUID
Max Qty=50/31 days
LACTRASE 250 MG CAPSULE
CREON (Pancrelipase (Lip-ProtAmyl) DR Cap 3000-9500-15000
Unit)
ZENPEP (Pancrelipase (Lip-ProtAmyl) DR Cap 3000-10000-16000
Unit)
PANCREAZE (Pancrelipase (LipProt-Amyl) DR Cap 4200-1000017500 Unit)
Unit)
Unit)
Unit)
Unit)
50
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Product Description
Unit)
Unit)
Unit)
Unit)
Amylase-Lipase-Protease Cap 200004000-25000 U
GASTROINTESTINAL AGENTS - MISCELLANEOUS
ACTIGALL
Ursodiol Cap 300 MG
URSO 250
Ursodiol Tab 250 MG
URSO FORTE
URSODIOL 500 MG TABLET
GAS-X
Simethicone Chew Tab 80 MG
GAS-X EX-STR,
GAS-X EX-STR 125 MG TAB CHE
MYLANTA GAS
MYLICON, MYLICON
INFA
REGLAN
REGLAN
COLAZAL
ROWASA
AZULFIDINE
AZULFIDINE
PHOSLO
ELIPHOS
URINARY ANTI-INFECTIVES
Additional
Information
Limitations/
Restrictions
Daily Dosage=7
Simethicone Liquid 40 MG/0.6ML
Max Qty=31/31 days
Simethicone Susp 40 MG/0.6ML
Max Qty=31/31 days
Metoclopramide HCl Tab 5 MG
Metoclopramide HCl Tab 10 MG
Metoclopramide HCl Soln 5
MG/5ML
Lactulose (Encephalopathy) Solution
10 GM/15ML
BALSALAZIDE DISODIUM 750
MG
PENTASA Cap CR 250 MG
PENTASA Cap CR 500 MG
ASACOL Tab Delayed Release 400
MG
MESALAMINE 4 GM/60 ML
ENEMA
SFROWASA (Mesalamine SulfiteFree (SF)) Enema 4 GM/60ML
DELZICOL DR 400 MG CAPSULE
Sulfasalazine Tab 500 MG
Sulfasalazine Tab Delayed Release
500 MG
Calcium Acetate (Phosphate Binder)
Cap 667 MG
ELIPHOS 667 MG TABLET
Daily Dosage=9
Daily Dosage=8
Daily Dosage=8
Daily Dosage=12
Daily Dose= 1 unit
Daily Dosage=6
Methenamine Mandelate Tab 0.5 GM
Methenamine Mandelate Tab 1 GM
FURADANTIN
FURADANTIN Susp 25 MG/5ML
Daily Dosage=40
MACRODANTIN 25 MG
CAPSULE
51
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
MACRODANTIN
MACRODANTIN
MACROBID
Additional
Information
Product Description
Nitrofurantoin Macrocrystalline Cap
50 MG
Nitrofurantoin Macrocrystalline Cap
100 MG
Nitrofurantoin Monohydrate
Macrocrystalline Cap 100 MG
URELLE TABLET
Limitations/
Restrictions
*Methenamine-Hyos-Meth Blue-Sod
Phos-Phen Sal Tab 81.6 MG***
URINARY ANTISPASMODICS
URECHOLINE
URECHOLINE
URECHOLINE
URECHOLINE
URISPAS
DITROPAN
DITROPAN
DITROPAN XL
DITROPAN XL
DITROPAN XL
SANCTURA
VAGINAL PRODUCTS
CLEOCIN
METROGEL-VAG
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
Oxybutynin Chloride Tab SR 24HR
10 MG
Oxybutynin Chloride Tab SR 24HR
15 MG
TROSPIUM CHLORIDE 20MG
Tab
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
Daily Dosage=2
Clindamycin Phosphate Vaginal
Cream 2%
Clindamycin Phosphate (One Dose)
Vaginal Cream 2%
Min DS=30; Package
Limit=1/claim
Metronidazole Vaginal Gel 0.75%
NYSTATIN VAGINAL TABLET
GYNE-LOTRIM
GYNE-LOTRIM,
MYCELEX-7
GYNE-LOTRIMI
GYNAZOLE-1 (One Dose) Vaginal
Cream 2%
CLOTRIMAZOLE INSERT
Clotrimazole Vaginal Cream 1%
Max Qty=45/31 days
Max Qty=31/31 days
TERAZOL 7
TERAZOL 3
Clotrimazole Vaginal Cream 2%
Miconazole Nitrate Vaginal Cream
2%
Miconazole Nitrate Vaginal Cream
4% (200 MG/5GM)
Miconazole Nitrate Vaginal Suppos
100 MG
MICONAZOLE 3 Vaginal Suppos
200 MG
Miconazole Nitrate Vaginal Supp 200
MG & 2% Cream 9 GM Kit
MICONAZOLE 1
COMBINATION PA
Terconazole Vaginal Cream 0.4%
Terconazole Vaginal Cream 0.8%
TERAZOL 3
Terconazole Vaginal Suppos 80 MG
MONISTAT 1,
VAGISTAT-1
Tioconazole Vaginal Oint 6.5%
MONISTAT 7
MONISTAT 3
MONISTAT 7
MONISTAT 3
MONISTAT 1
VCF VAGINAL (Nonoxynol-9)
Foam 12.5%
GYNOL II, SHUR-SEAL
(Nonoxynol-9) Gel 2%
Max Qty=45/31 days
Max Qty=45/31 days
Max Qty=7/31 days
Max Qty=3/31 days
52
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
CONCEPTROL
Additional
Information
Product Description
KY PLUS (Nonoxynol-9) Gel 2.2%
GYNOL II (Nonoxynol-9) Gel 3%
Nonoxynol-9 Gel 4%
ENCARE (Nonoxynol-9) Vaginal
Suppos 100 MG
VCF VAGINAL (Nonoxynol-9) Film
28%
CONCEPTROL (Nonoxynol-9)
Vaginal Insert 150 MG
ESTRACE VAG Cream 0.1
MG/GM
PREMARIN VAG Cream 0.625
MG/GM
GENITOURINARY AGENTS - MISCELLANEOUS
Potassium Citrate Tab CR 540 MG (5
UROCIT-K 5
MEQ)
Potassium Citrate Tab CR 1080 MG
UROCIT-K 10
(10 MEQ)
Sodium Citrate & Citric Acid Soln
BICITRA, SHOHLS
500-334 MG/5ML
PYRIDIUM
Phenazopyridine HCl Tab 100 MG
PYRIDIUM
Phenazopyridine HCl Tab 200 MG
PROSCAR
FLOMAX
ANTIANXIETY AGENTS
XANAX
XANAX
XANAX
XANAX
Limitations/
Restrictions
SODIUM CHLORIDE 0.45%
IRRIG
Sodium Chloride Irrigation Soln
0.9%
Finasteride Tab 5 MG
Tamsulosin HCl Cap 0.4 MG
Max Qty=43/31 days
Max Qty=43/30 days
Max Qty=500/30 days
Daily Dosage=1
Daily Dosage=2
Alprazolam Tab 0.25 MG
Alprazolam Tab 0.5 MG
Alprazolam Tab 1 MG
Alprazolam Tab 2 MG
Alprazolam Conc 1 MG/ML
Chlordiazepoxide HCl Cap 5 MG
Clorazepate Dipotassium Tab 3.75
MG
Clorazepate Dipotassium Tab 7.5
MG
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
TRANXENE T
Clorazepate Dipotassium Tab 15 MG
Daily Dosage=3
VALIUM
VALIUM
VALIUM
Diazepam Tab 2 MG
Diazepam Tab 5 MG
Diazepam Tab 10 MG
Diazepam Conc 5 MG/ML
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
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
LIBRIUM
LIBRIUM
LIBRIUM
TRANXENE T
TRANXENE T
ATIVAN
ATIVAN
ATIVAN
BUSPAR
BUSPAR
BUSPAR
BUSPAR
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=3
Daily Dosage=3
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
53
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
VISTARIL
VISTARIL
Additional
Information
Product Description
Hydroxyzine HCl Tab 10 MG
Hydroxyzine HCl Syrup 10
MG/5ML
Hydroxyzine Pamoate Cap 25 MG
Limitations/
Restrictions
ANTIDEPRESSANTS
Meprobamate Tab 200 MG
Meprobamate Tab 400 MG
NARDIL
Mirtazapine Tab 7.5 MG
Mirtazapine Tab 15 MG
Mirtazapine Orally Disintegrating
Tab 15 MG
Tab 30 MG
Tab 45 MG
NARDIL Tab 15 MG
PARNATE
Tranylcypromine Sulfate Tab 10 MG
REMERON
REMERON
REMERON
REMERON SLTB
REMERON SLTB
REMERON SLTB
CELEXA
CELEXA
CELEXA
CELEXA
LEXAPRO
LEXAPRO
LEXAPRO
PROZAC
PROZAC
RAPIFLUX
PROZAC
PAXIL
PAXIL
PAXIL
PAXIL
PAXIL
ZOLOFT
ZOLOFT
ZOLOFT
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Nefazodone HCl Tab 50 MG
Trazodone HCl Tab 50 MG
Citalopram Hydrobromide Tab 10
MG (Base Equiv)
MG (Base Equiv)
MG (Base Equiv)
Citalopram Hydrobromide Oral Soln
10 MG/5ML
Escitalopram 5MG tab
Fluoxetine HCl Cap 10 MG
Fluoxetine HCl Cap 20 MG
Fluoxetine HCl Tab 10 MG
Fluoxetine HCl Tab 20 MG
Fluoxetine HCl Solution 20
MG/5ML
Fluvoxamine Maleate Tab 25 MG
Daily Dosage=2
Daily Dosage=1.5
Daily Dosage=1.5
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dose=4
Daily Dose=4
Daily Dose=4
Daily Dose=4
Daily Dose=2
Daily Dose=2
Daily Dose=3
Paroxetine HCl Tab 10 MG
Paroxetine HCl Oral Susp 10
MG/5ML (Base Equiv)
Sertraline HCl Tab 25 MG
Daily Dose=2
Daily Dose=2
Daily Dose=2
Daily Dose=2
Daily Dose=40
Daily Dosage=1.5
Daily Dosage=1.5
Daily Dosage=2
54
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
PAMELOR
PAMELOR
PAMELOR
PAMELOR
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
Venlafaxine HCl Tab SR 24HR 37.5
MG (Base Equivalent)
Venlafaxine HCl Tab SR 24HR 75
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
Imipramine Pamoate Cap 75 MG
Nortriptyline HCl Cap 10 MG
PAMELOR
Nortriptyline HCl Soln 10 MG/5ML
VIVACTIL
PROTRIPTYLINE HCL 10 MG
TAB
ZOLOFT
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR XR
EFFEXOR XR
EFFEXOR XR
VENLAFAXINE
VENLAFAXINE
VENLAFAXINE
ANAFRANIL
ANAFRANIL
ANAFRANIL
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
TOFRANIL
TOFRANIL
TOFRANIL
Additional
Information
Product Description
Limitations/
Restrictions
Daily Dose=2
Daily Dose=2
Daily Dose=2
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=2
Daily Dosage=1
Daily Dosage=3
Daily Dosage=2
Daily Dosage=2
Daily Dose=20
55
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Maprotiline HCl Tab 25 MG
WELLBUTRIN
WELLBUTRIN
Bupropion HCl Tab 75 MG
Bupropion HCl Tab 100 MG
Bupropion HCl Tab SR 12HR 100
WELLBUTRIN
MG
WELLBUTRIN
MG
WELLBUTRIN
MG
WELLBUTRIN
MG
WELLBUTRIN
MG
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Limitations/
Restrictions
Benefit Cls (81006)
Antidepressants: Max
Fills=2/30 days
Benefit Cls (81006)
Fills=2/30 days
Benefit Cls (81006)
Fills=2/30 days
Daily Dosage=3
Daily Dosage=3
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=1
Daily Dosage=1
RISPERDAL
Risperidone Tab 0.25 MG
Older ; Daily Dosage=2
RISPERDAL
Risperidone Tab 0.5 MG
RISPERDAL
Risperidone Tab 1 MG
RISPERDAL
RISPERDAL
RISPERDAL
Risperidone Soln 1 MG/ML
Older ; 2)Daily
Dosage=4
RISPERIDONE 0.25 MG ODT
RISPERDAL M
Risperidone Orally Disintegrating
Tab 0.5 MG
RISPERDAL M
Tab 1 MG
RISPERDAL M
Tab 2 MG
RISPERDAL M
Tab 3 MG
RISPERDAL M
Tab 4 MG
Haloperidol Tab 0.5 MG
Haloperidol Tab 1 MG
Daily Dosage=3
Daily Dosage=3
RISPERDAL
56
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
HALDOL DECAN
HALDOL DECAN
HALDOL DECAN
HALDOL DECAN
Additional
Information
Product Description
Haloperidol Lactate Oral Conc 2
MG/ML
Haloperidol Decanoate IM Soln 50
MG/ML
MG/ML
MG/ML
MG/ML
Limitations/
Restrictions
Daily Dosage=3
Clozapine Tab 25 MG
Older; Daily Dosage=3
Clozapine Tab 50 MG
Clozapine Tab 100 MG
Clozapine Tab 200 MG
SEROQUEL
Quetiapine Fumarate
(SEROQUEL)Tab 25 MG
SEROQUEL
Quetiapine Fumarate (SEROQUEL)
Tab 50 MG
SEROQUEL
Tab 100 MG
SEROQUEL
Tab 200 MG
Older
SEROQUEL
Tab 300 MG
SEROQUEL
Tab 400 MG
LOXITANE
LOXITANE
LOXITANE
LOXITANE
Loxapine Succinate Cap 5 MG
Older; Max Qty=62/31
days;
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
ZYPREXA
Olanzapine (ZYPREXA) Tab 2.5
MG
ZYPREXA
Olanzapine (ZYPREXA) Tab 5 MG
Older;Daily Dosage=1
ZYPREXA
Olanzapine (ZYPREXA)Tab 7.5 MG
ZYPREXA
Olanzapine (ZYPREXA)Tab 10 MG
ZYPREXA
Olanzapine (ZYPREXA) Tab 15
MG
ZYPREXA
Olanzapine (ZYPREXA) Tab 20
MG
CLOZARIL
CLOZARIL
57
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
COMPAZINE
Additional
Information
Product Description
Chlorpromazine HCl Tab 10 MG
Fluphenazine HCl Tab 1 MG
Fluphenazine HCl Tab 2.5 MG
FLUPHENAZINE 2.5 MG/5 ML
EL
FLUPHENAZINE 5 MG/ML
CONC
FLUPHENAZINE 2.5 MG/ML
VIAL
Fluphenazine Decanoate Inj 25
MG/ML
Perphenazine Tab 2 MG
Prochlorperazine Suppos 25 MG
Limitations/
Restrictions
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Prochlorperazine Maleate Tab 5 MG
Prochlorperazine Maleate Tab 10
MG
Thioridazine HCl Tab 10 MG
Trifluoperazine HCl Tab 1 MG
NAVANE
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
ABILIFY Tab 2 MG
Older ; Daily Dosage=1;
Step-Therapy
ABILIFY Tab 5 MG
Step-Therapy
ABILIFY Tab 10 MG
Step-Therapy
ABILIFY Tab 15 MG
Step-Therapy
ABILIFY Tab 20 MG
Step-Therapy
ABILIFY Tab 30 MG
Step-Therapy
ABILIFY Oral Solution 1 MG/ML
Step-Therapy
Thiothixene Cap 1 MG
Daily Dosage=3
Daily Dosage=3
58
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
NAVANE
NAVANE
Additional
Information
Product Description
Limitations/
Restrictions
Daily Dosage=3
Daily Dosage=3
GEODON
Ziprasidone (GEODON) HCl Cap
20 MG
GEODON
40 MG
GEODON
60 MG
GEODON
80 MG
Ziprasidone Mesylate (GEODON)
For Inj 20 MG (Base Equivalent)
Older; Step Therapy
Step Therapy
Lithium Carbonate Cap 150 MG
Lithium Carbonate Tab 300 MG
LITHOBID
Lithium Carbonate Tab CR 300 MG
Lithium Carbonate Tab CR 450 MG
HYPNOTICS
Lithium Citrate Oral Soln 8
mEq/5ML
Phenobarbital Tab 15 MG
Phenobarbital Tab 16.2 MG
Phenobarbital Elixir 20 MG/5ML
SOMNOTE (Chloral Hydrate) Cap
500 MG
Daily Dose=1
Chloral Hydrate Syrup 500 MG/5ML
Daily Dose= 240/claim
Daily Dosage=2
HALCION
Chloral Hydrate Suppos 500 MG
ESTAZOLAM 1 MG TABLET
ESTAZOLAM 2 MG TABLET
Flurazepam HCl Cap 15 MG
Flurazepam HCl Cap 30 MG
Temazepam Cap 15 MG
Temazepam Cap 30 MG
Triazolam Tab 0.125 MG
Triazolam Tab 0.25 MG
SONATA
Zaleplon Cap 5 MG
SONATA
Zaleplon Cap 10 MG
PROSOM
PROSOM
DALMANE
DALMANE
RESTORIL
RESTORIL
AMBIEN
AMBIEN
Zolpidem Tartrate Tab 5 MG
Zolpidem Tartrate Tab 10 MG
Doxylamine Succinate (Sleep) Tab 25
UNISOM
MG
Diphenhydramine (sleep)
Diphenhydramine HCl (Sleep) Tab
NYTOL MX-STR
50 MG
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
59
Daily Dose=1
Daily Dose=1
Daily Dose=1
Daily Dose=1
Daily Dose=1
Daily Dose=1
Daily Dose=1, StepTherapy
Daily Dose=1, StepTherapy
Daily Dose=1
Daily Dose=1
Prior use of Zolpidem
IR
Prior use of Zolpidem
IR
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Limitations/
Restrictions
Dextroamphetamine Sulfate Tab 5
MG
DEXTROSTAT
Dextroamphetamine Sulfate Tab 10
MG
DEXEDRINE
Dextroamphetamine Sulfate Cap SR
24HR 5 MG
DEXEDRINE
24HR 10 MG
DEXEDRINE
24HR 15 MG
ADDERALL
Amphetamine-Dextroamphetamine
Tab 5 MG
Under; Limited to Ages
3 and Older ; Daily
Dosage=2
ADDERALL
Tab 7.5 MG
ADDERALL
Tab 10 MG
ADDERALL
Tab 12.5 MG
ADDERALL
Tab 15 MG
ADDERALL
Tab 20 MG
ADDERALL
Tab 30 MG
ADDERALL XR
Cap (ADDERALL XR) SR 24HR 5
MG
ADDERALL XR
MG
ADDERALL XR
MG
ADDERALL XR
MG
ADDERALL XR
MG
ADDERALL XR
MG
CAFCIT
Caffeine Citrate Oral Soln 60
MG/3ML (10 MG/ML Base Equiv)
60
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Caffeine Citrate Powder
Limitations/
Restrictions
Fills=2/lifetime
FOCALIN
Dexmethylphenidate HCl Tab 2.5
MG
FOCALIN
Dexmethylphenidate HCl Tab 5 MG
FOCALIN
Dexmethylphenidate HCl Tab 10
MG
METADATE CD Cap CR 10 MG
RITALIN
Methylphenidate HCl Tab 5 MG
RITALIN
RITALIN
METADATE
Methylphenidate HCl Tab CR 10 MG
RITALIN, RITALIN SR Methylphenidate HCl Tab CR 20 MG
Methylphenidate HCl Tab SA OSM
(CONCERTA) 18 MG
(CONCERTA) 27 MG
(CONCERTA) 36 MG
(CONCERTA) 54 MG
METHYLPHENIDATE 5 MG/5
ML S
METHYLPHENIDATE 10 MG/5
METHYLIN
ML
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISCELLANEOUS
ORAP 1 MG TABLET
ORAP 2 MG TABLET
METHYLIN
61
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ARICEPT
ARICEPT
ARICEPT ODT
ARICEPT ODT
RAZADYNE
RAZADYNE
RAZADYNE
RAZADYNE
RAZADYNE ER
RAZADYNE ER
RAZADYNE ER
Additional
Information
Product Description
Donepezil Hydrochloride Tab 5 MG
Limitations/
Restrictions
Max Qty=31/31 days
Donepezil Hydrochloride Tab 10
MG
DONEPEZIL HCL ODT 5 MG
TABL
DONEPEZIL HCL ODT 10 MG
TAB
Galantamine Hydrobromide Tab 4
MG
MG
MG
Galantamine Hydrobromide Oral
Soln 4 MG/ML
Galantamine Hydrobromide Cap SR
24HR 8 MG
24HR 16 MG
24HR 24 MG
Max Qty=31/31 days
Max Qty=31/31 days
Max Qty=31/31 days
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
Daily Dosage=6
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
EXELON
Rivastigmine Tartrate Cap 1.5 MG
Daily Dosage=2
EXELON
Rivastigmine Tartrate Cap 3 MG
Daily Dosage=2
EXELON
Rivastigmine Tartrate Cap 4.5 MG
Daily Dosage=2
EXELON
Rivastigmine Tartrate Cap 6 MG
Daily Dosage=2
ZYBAN
Bupropion HCl (Smoking Deterrent)
Tab SR 150 MG
Max Day Supply=84 per
365 days, Daily dose = 2
NICODERM 21,
NICODERM CQ
NICODERM CQ
NICODERM CQ
NICORETTE,
NICORETTE ST
NICORETTE,
NICORETTE ST
Nicotine TD Patch 24HR 7
MG/24HR
MG/24HR
MG/24HR
Max Qty=84/365 days
Max Qty=84/365 days
Max Qty=84/365 days
365 days
365 days
365 days
365 days
Nicotine Polacrilex Gum 2 MG
Nicotine Polacrilex Gum 4 MG
COMMIT, NICORETTE Nicotine Polacrilex Lozenge 2 MG
COMMIT, NICORETTE Nicotine Polacrilex Lozenge 4 MG
PROZAC
ANTABUSE
ANTABUSE
LIMBITROL
LIMBITROL DS
Fluoxetine HCl (SARAFEM PMDD)
Cap 10 MG
Fluoxetine HCl (SARAFEM PMDD)
Cap 20 MG
ANTABUSE Tab 250 MG
ANTABUSE 500 MG TABLET
Chlordiazepoxide-Amitriptyline Tab
5-12.5 MG
Chlordiazepoxide-Amitriptyline Tab
10-25 MG
Perphenazine-Amitriptyline Tab 2-10
MG
MG
MG
MG
62
Max Qty=124/31 days
Max Qty=124/31 days
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ANALGESICS - NonNarcotic
ST JOSEPH
BAYER CHILD
Product Description
MG
Additional
Information
Limitations/
Restrictions
Aspirin Tab 81 MG
Aspirin Tab 325 MG
Aspirin Chew Tab 75 MG
Aspirin Chew Tab 81 MG
Aspirin Tab Delayed Release 81 MG
ECOTRIN, THERAP
BAYER
ECOTRIN M/S
BUFFERIN
TYLENOL
TYLENOL
TYLENOL 8 HR,
TYLENOL ARTH
Aspirin Suppos 60 MG
Diflunisal Tab 500 MG
Salsalate Tab 500 MG
Salsalate Tab 750 MG
Aspirin Buffered (Ca Carb-Mg CarbMg Ox) Tab 324 MG
Aspirin Buffered (Ca Carb-Mg CarbMg Ox) Tab 325 MG
Aspirin Buffered (Mg Carbonate-Al
Aminoace) Tab 325 MG
Aspirin Buffered Tab 325 MG
Choline & Magnesium Salicylates Tab
1000 MG
Acetaminophen Cap 500 MG
Acetaminophen Tab 160 MG
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
Acetaminophen Tab CR 650 MG
Acetaminophen Chew Tab 80 MG
Acetaminophen Chew Tab 160 MG
Acetaminophen Liquid 160
MG/5ML
Acetaminophen Elixir 160 MG/5ML
TYLENOL INF
Acetaminophen Susp 80 MG/0.8ML
TYLENOL CHLD,
TYLENOL INF
Acetaminophen Susp 160 MG/5ML
Acetaminophen Soln 100 MG/ML
Acetaminophen Soln 160 MG/5ML
Acetaminophen Suppos 120 MG
Max Qty=12/31 days
Max Qty=12/31 days
Max Qty=12/31 days
Aspirin-APAP-Salicylamide-Caffeine
Tab 500-250-150-32.5 MG
PHRENILIN
SEDAPAP
PHRENILIN (ButalbitalAcetaminophen) Cap 50-650 MG
Butalbital-Acetaminophen Tab 50325 MG
Butalbital-Acetaminophen Tab 50650 MG
63
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ESGIC
ESGIC-PLUS
ESGIC, FIORICET
ESGIC-PLUS
FIORINAL
ANALGESICS - OPIOID
Additional
Information
Product Description
Butalbital-Acetaminophen-Caffeine
Cap 50-325-40 MG
ESGIC PLUS CAPSULE
Tab 50-325-40 MG
Tab 50-500-40 MG
Butalbital-Aspirin-Caffeine Cap 50325-40 MG
Butalbital-Aspirin-Caffeine Tab 50325-40 MG
Limitations/
Restrictions
DILAUDID
DILAUDID
DILAUDID
Codeine Sulfate Tab 15 MG
Fentanyl TD Patch 72HR 12.5
MCG/HR
Fentanyl TD Patch 72HR 25
MCG/HR
MCG/HR
MCG/HR
MCG/HR
Hydromorphone HCl Tab 2 MG
Daily Dosage=8
Daily Dosage=8
Daily Dosage=8
DILAUDID-5
DILAUDID-5 1 MG/ML LIQUID
Daily Dosage=80
Hydromorphone HCl Suppos 3 MG
Max= 12/claim
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
METHADONE 10 MG/ML ORAL
CON
METHADONE 5 MG/5 ML
SOLUTIO
METHADONE 10 MG/5 ML
SOLUTI
Morphine Sulfate Tab 15 MG
Morphine Sulfate Tab 30 MG
Morphine Sulfate Oral Soln 10
MG/5ML
MG/5ML
MG/5ML
MG/ML
Morphine Sulfate Suppos 5 MG
Morphine Sulfate Tab SR 12HR 15
MG
MG
MG
Daily Dosage=4
Daily Dosage=4
DURAGESIC
DURAGESIC
DURAGESIC
DURAGESIC
DURAGESIC
DEMEROL
DEMEROL
DOLOPHINE
DOLOPHINE
METHADONE
ROXANOL
MS CONTIN
MS CONTIN
MS CONTIN
Daily Dosage=2
Daily Dosage=2
Daily Dosage=2
QL=0.33/day
QL=0.33/day
QL=0.33/day
QL=0.33/day
QL=0.33/day
Daily Dosage=4
Daily Dosage=10
Daily Dosage=10
Daily Dosage=30
Daily Dosage=60
Daily Dosage=6
Daily Dosage=6
Max Qty=500/31 days
Max Qty=500/31 days
Max Qty=500/31 days
Max Qty=240/claim
Max Qty=24/claim
Max Qty=24/claim
Max Qty=24/claim
Max Qty=24/claim
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
64
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
MS CONTIN
MS CONTIN
Additional
Information
Product Description
MG
MG
Limitations/
Restrictions
Daily Dosage=3
Daily Dosage=3
OXYCODONE, OXYIR Oxycodone HCl Cap 5 MG
Daily Dose=2
ROXICODONE
Daily Dose=2
ROXICODONE
Oxycodone HCl Tab 5 MG
OXYCODONE HCL 10 MG
TABLET
OXYCODONE HCL 20 MG
TABLET
ROXICODONE
Oxycodone HCl Conc 20 MG/ML
Daily Dosage=6
OXYCODONE HCL 5 MG/5 ML
SOL
Tramadol HCl Tab 50 MG
Oxycodone w/ Acetaminophen Cap
5-500 MG
Daily Dosage=8
ROXICODONE
ROXICODONE
ULTRAM
TYLOX
PERCOCET
PERCOCET
PERCOCET
PERCOCET
PERCOCET
PERCOCET
TYLENOL/COD
TYLENOL/COD
FIORICET/COD
FIORINAL/COD
NORCO
LORTAB, LORTAB 5,
VICODIN
LORTAB
Daily Dose=2
Daily Dose=2
Daily Dose=2
Daily Dose=2
Daily Dosage=6
PERCOCET 2.5-325 MG TABLET
Oxycodone w/ Acetaminophen Tab
5-325 MG
ROXICET Tab 5-500 MG
7.5-325 MG
7.5-500 MG
10-325 MG
10-650 MG
ROXICET (Oxycodone w/
Acetaminophen) Soln 5-325
MG/5ML
Oxycodone w/ Aspirin Tab Full
Strength
Oxycodone w/ Aspirin Tab Full
Strength
Acetaminophen w/ Codeine Tab 30015 MG
Acetaminophen w/ Codeine Soln
120-12 MG/5ML
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=30
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=30
Aspirin w/ Codeine Tab 325-30 MG
Daily Dosage=6
Aspirin w/ Codeine Tab 325-60 MG
Daily Dosage=6
Butalbital-Acetaminophen-Caff w/
COD Cap 50-325-40-30 MG
Butalbital-Aspirin-Caff w/ Codeine
Cap 50-325-40-30 MG
Hydrocodone-Acetaminophen Tab
10-325 MG
HYDROCODONACETAMINOPH 2.5-500
Hydrocodone-Acetaminophen Tab 5500 MG
Hydrocodone-Acetaminiphen Tab
7.5-500 MG
65
Daily Dosage=6
Daily Dosage=4
Daily Dosage=6
Daily Dosage=8
Daily Dosage=6
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Product Description
10-500 MG
ANEXSIA, LORCET
PLUS
7.5-650 MG
LORCET
10-650 MG
ANEXSIA
10-660 MG
VICODIN ES
7.5-750 MG
Hydrocodone-Acetaminophen Tab 5NORCO
325 MG
NORCO
7.5-325 MG
7.5-325 MG/15 ML
Hydrocodone-Acetaminophen Soln
LORTAB
7.5-500 MG/15ML
ANALGESICS - ANTI-INFLAMMATORY
Diclofenac Potassium Tab 50 MG
CATAFLAM
Diclofenac Sodium Tab Delayed
Release 25 MG
Release 50 MG
VOLTAREN
Release 75 MG
Diclofenac Sodium Tab SR 24HR
VOLTAREN-XR
100 MG
Etodolac Cap 200 MG
Etodolac Cap 300 MG
Etodolac Tab 400 MG
Etodolac Tab 500 MG
Etodolac Tab SR 24HR 400 MG
LORTAB
FENOPROFEN 600 MG TABLET
ANSAID
ADVIL, NUPRIN
Flurbiprofen Tab 50 MG
Flurbiprofen Tab 100 MG
Ibuprofen Tab 200 MG
Ibuprofen (CHILD ADVIL, CHILD
MOTRIN) Chew Tab 50 MG
CHILD MOTRIN,
MOTRIN JR ST
CHILD ADVIL,
INFANT ADVIL,
MOTRIN, MOTRIN
INFAN
Ibuprofen Chew (CHILD ADVIL,
CHILD MOTRIN)Tab 100 MG
Ibuprofen Susp 40 MG/ML
ADVIL CHILD, CHILD
MOTRIN, MOTRIN,
Ibuprofen Susp 100 MG/5ML
MOTRIN CHILD
INDOCIN SR
Indomethacin Cap 25 MG
Indomethacin Cap 50 MG
Indomethacin Cap CR 75 MG
INDOCIN 25 MG/5 ML
SUSPENSI
INDOCIN 50 MG SUPPOSITORY
Ketoprofen Cap 50 MG
66
Additional
Information
Limitations/
Restrictions
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=6
Daily Dosage=5
Daily Dosage=12
Daily Dosage=8
Daily Dosage=120
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Ketoprofen Cap 75 MG
Limitations/
Restrictions
Ketoprofen Cap SR 24HR 200 MG
TORADOL ORAL
MOBIC
MOBIC
Older; Max Qty=20/30
days
Ketorolac Tromethamine Tab 10
MG
MECLOFENAMATE 50 MG
CAPSULE
MECLOFENAMATE 100 MG
CAPSUL
Meloxicam Tab 7.5 MG
Meloxicam Tab 15 MG
MELOXICAM 7.5 MG/5 ML SUSP
NAPROSYN
NAPROSYN
NAPROSYN
EC-NAPROSYN
EC-NAPROSYN
NAPROSYN
ALEVE
ANAPROX
ANAPROX DS
DAYPRO
FELDENE
FELDENE
CLINORIL
Nabumetone Tab 500 MG
Nabumetone Tab 750 MG
Naproxen Tab 250 MG
Naproxen Tab 375 MG
Naproxen Tab 500 MG
Naproxen Tab EC 375 MG
Naproxen Tab EC 500 MG
Naproxen Susp 125 MG/5ML
Naproxen Sodium Tab 220 MG
Oxaprozin Tab 600 MG
Piroxicam Cap 10 MG
Piroxicam Cap 20 MG
Sulindac Tab 150 MG
Sulindac Tab 200 MG
RIDAURA 3 MG CAPSULE
Daily Dosage=2
Daily Dosage=2
Max Qty=62/31 days
RHEUMATREX (Methotrexate
Sodium) Tab 2.5 MG (Antirheumatic)
ARAVA
ARAVA
MIGRAINE PRODUCTS
D.H.E. 45
Leflunomide Tab 10 MG
Leflunomide Tab 20 MG
Daily Dosage=1
Daily Dosage=1
Dihydroergotamine Mesylate Inj 1
MG/ML
MIGRANAL Nasal Spray 4 MG/ML
Sumatriptan Nasal Spray 5 MG/ACT
Sumatriptan Nasal Spray 20
MG/ACT
IMITREX
Sumatriptan Succinate Tab 25 MG
IMITREX
IMITREX
IMITREX
Sumatriptan Succinate Inj 6
MG/0.5ML
IMITREX
Sumatriptan Succinate Inj 6
MG/0.5ML
67
days
days
days
days
days
days
days
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Sumatriptan Succinate Inj Kit 4
MG/0.5ML
Sumatriptan Succinate Inj Kit 4
MG/0.5ML
Sumatriptan Succinate Inj Kit
Sumatriptan Succinate Inj Kit
MIDRIN
CAFERGOT
GOUT AGENTS
ZYLOPRIM
ZYLOPRIM
ANTICONVULSANTS
KLONOPIN
KLONOPIN
KLONOPIN
FELBATOL
FELBATOL
FELBATOL
DILANTIN-125
DILANTIN
PHENYTEK
PHENYTEK
ZARONTIN
ZARONTIN
Limitations/
Restrictions
days
days
days
days
Acetaminophen-IsomethepteneDichloral Cap 325-65-100 MG
Ergotamine w/ Caffeine Tab 1-100
MG
Allopurinol Tab 100 MG
Allopurinol Tab 300 MG
Probenecid Tab 500 MG
Colchicine w/ Probenecid Tab 0.5500 MG
Clonazepam Tab 0.5 MG
Clonazepam Tab 1 MG
Clonazepam Tab 2 MG
DIASTAT PED Gel Delivery System
2.5 MG
DIASTAT ACDL Gel Delivery
System 10 MG
DIASTAT ACDL Gel Delivery
System 20 MG
FELBATOL Tab 400 MG
FELBATOL Tab 600 MG
FELBATOL Susp 600 MG/5ML
GABITRIL Tab 2 MG
GABITRIL Tab 4 MG
GABITRIL Tab 12 MG
GABITRIL Tab 16 MG
DILANTIN Chew Tab 50 MG
Phenytoin (Dilantin) Susp 125
MG/5ML
Dilantin Extended Cap 30 MG
Phenytoin Sodium (Dilantin)
Extended Cap 100 MG
PHENYTEK 200 MG CAPSULE
PHENYTEK 300 MG CAPSULE
Ethosuximide Cap 250 MG
Ethosuximide Soln 250 MG/5ML
DEPAKOTE
Divalproex Sodium (DEPAKOTE)
Tab Delayed Release 125 MG
DEPAKOTE
Tab Delayed Release 250 MG
DEPAKOTE
Divalproex Sodium
(DEPAKOTE)Tab Delayed Release
500 MG
DEPAKOTE SPR
Cap Sprinkle 125 MG
DEPAKOTE ER
Divalproex Sodium (DEPAKOTE
ER) Tab SR 24 HR 250 MG
68
Daily Dosage=4
Daily Dosage=4
Daily Dosage=4
Max Qty=1/claim
Max Qty=1/claim
Max Qty=1/claim
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
DEPAKOTE ER
Limitations/
Restrictions
Divalproex Sodium (DEPAKOTE
ER)Tab SR 24 HR 500 MG
DEPAKENE
TEGRETOL
Valproate Sodium Syrup 250
MG/5ML
Valproic Acid Cap 250 MG
Carbamazepine Tab 200 MG
TEGRETOL
Carbamazepine Chew Tab 100 MG
TEGRETOL
Carbamazepine Susp 100 MG/5ML
TEGRETOL
Carbamazepine Susp 100 MG/5ML
DEPAKENE
Additional
Information
Product Description
NEURONTIN
NEURONTIN
CARBATROL ER 100 MG
CAPSULE
CARBATROL ER 200 MG
CAPSULE
CARBATROL ER 300 MG
CAPSULE
Carbamazepine Tab SR 12HR 100
MG
MG
MG
Gabapentin Cap 100 MG
Gabapentin Tab 100 MG
NEURONTIN
Gabapentin Oral Soln 250 MG/5ML
LAMICTAL
LAMICTAL
LAMICTAL
LAMICTAL
MYSOLINE
MYSOLINE
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
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
TOPAMAX SPR
Topiramate Sprinkle Cap 15 MG
Max Qty=100/30 days
TOPAMAX SPR
Topiramate Sprinkle Cap 25 MG
Max Qty=100/30 days
ZONEGRAN
Zonisamide Cap 25 MG
CARBATROL
CARBATROL
CARBATROL
TEGRETOL XR
TEGRETOL XR
NEURONTIN
NEURONTIN
NEURONTIN
LAMICTAL
LAMICTAL
KEPPRA
KEPPRA
KEPPRA
KEPPRA
KEPPRA
TRILEPTAL
TRILEPTAL
TRILEPTAL
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=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
69
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ZONEGRAN
ANTIPARKINSON AGENTS
Additional
Information
Product Description
Limitations/
Restrictions
Benztropine Mesylate Tab 0.5 MG
ARTANE
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
COMTAN 200 MG TABLET
Amantadine HCl Cap 100 MG
Max Qty=500/31 days
Amantadine HCl Syrup 50 MG/5ML
PARLODEL
Bromocriptine Mesylate Cap 5 MG
PARLODEL
Bromocriptine Mesylate Tab 2.5 MG
MIRAPEX
MIRAPEX
MIRAPEX
PRAMIPEXOLE 0.125 MG
TABLET
PRAMIPEXOLE 0.25 MG
TABLET
Daily Dosage=3
Daily Dosage=3
PRAMIPEXOLE 0.5 MG TABLET
Daily Dosage=3
MIRAPEX
PRAMIPEXOLE 0.75 MG
TABLET
PRAMIPEXOLE 1 MG TABLET
Daily Dosage=3
MIRAPEX
PRAMIPEXOLE 1.5 MG TABLET
Daily Dosage=3
MIRAPEX
Daily Dosage=3
Ropinirole Hydrochloride (REQUIP)
Tab 0.25 MG
REQUIP
Tab 0.5 MG
Ropinirole Hydrochloride
REQUIP
(REQUIP) Tab 1 MG
REQUIP
(REQUIP) Tab 2 MG
REQUIP
Tab 3 MG
REQUIP
Tab 4 MG
REQUIP
(REQUIP) Tab 5 MG
Carbidopa & Levodopa Tab 10-100
SINEMET
MG
SINEMET
MG
SINEMET
MG
Carbidopa & Levodopa Tab CR 25SINEMET CR
100 MG
Carbidopa & Levodopa Tab CR 50SINEMET CR
200 MG
ELDEPRYL
Selegiline HCl Cap 5 MG
Selegiline HCl Tab 5 MG
MUSCULOSKELETAL THERAPY AGENTS
Baclofen Tab 10 MG
Baclofen Tab 20 MG
PARAFON FORT
Chlorzoxazone Tab 500 MG
FLEXERIL
Cyclobenzaprine HCl Tab 5 MG
FLEXERIL
Cyclobenzaprine HCl Tab 10 MG
ROBAXIN
Methocarbamol Tab 500 MG
ROBAXIN-750
Methocarbamol Tab 750 MG
REQUIP
70
Daily Dosage=6
Daily Dosage=3
Daily Dosage=3
Daily Dosage=3
Daily Dosage=6
Daily Dosage=6
Daily Dosage=3
Max Qty=93/31 days
Daily Dosage=3
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ZANAFLEX
DANTRIUM
DANTRIUM
DANTRIUM
ANTIMYASTHENIC AGENTS
MESTINON
Additional
Information
Product Description
Orphenadrine Citrate Tab SR 12HR
100 MG
Tizanidine HCl Tab 2 MG
Tizanidine HCl Tab 4 MG
Dantrolene Sodium Cap 25 MG
Limitations/
Restrictions
Pyridostigmine Bromide Tab 60 MG
Pyridostigmine Bromide
(MESTINON) Tab CR 180 MG
MESTINON
MESTINON 60 MG/5 ML SYRUP
VITAMINS
SLO-NIACIN
SLO-NIACIN
SLO-NIACIN
DRISDOL
DRISDOL
Thiamine HCl Tab 50 MG
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Thiamine Mononitrate Tab 100 MG
Max Qty=100/31 days
Riboflavin Tab 25 MG
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Niacin Cap CR 125 MG
Niacin Tab 500 MG
Niacin Tab CR 250 MG
Pyridoxine HCl Tab 25 MG
Ascorbic Acid Tab 250 MG
Max Qty=100/31 days
Max Qty=100/31 days
Max Qty=100/31 days
Ergocalciferol Cap 50000 IU
DRISDOL 8,000 UNITS/ML
DROP
VITAMIN D 1,000 UNITS
VITAMIN D 2,000 UNITS
VITAMIN D3 5,000 UNIT CAPSU
MAXIMUM D3 10,000 UNITS CAP
VITAMIN D 1,000 UNIT TABLET
VITAMIN D-3 2,000 UNIT TABL
VITAMIN D3 5,000 UNIT TABLE
71
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
D-VI-SOL
Additional
Information
Product Description
Limitations/
Restrictions
D-VI-SOL 400 UNITS/ML DROP
VITAMIN D3 5,000 UNIT/ML DR
AQUASOL E
MULTIVITAMINS
NEPHROCAPS
CEFOL, MILCO-BFORT, STROVITE
NEPHRO-VITE
NEPHRO-VITE
Vitamin E Cap 100 IU
Vitamin E Chew Tab 400 IU
AQUASOL E 50 UNIT/ML
DROPS
AQUA-E LIQUID
MEPHYTON Tab 5 MG
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
Max Qty=62/31 days
*B-Complex Vitamin Cap**
*B-Complex Vitamin Tab**
*B-Complex w/ C Cap**
VI-STRESS TABLET
*B-Complex w/ C & Folic Acid Cap
1 MG***
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
Daily Dosage=1
VITABEE WITH VIT C CAPLET
NEPHRO-VITE TABLET
*B-Complex w/ C & Folic Acid Tab
1 MG***
*B-Complex w/ C-Min-Fe & Folic
Acid Tab 106-1 MG***
GERI-TONIC LIQUID
Daily Dosage=1
Daily Dosage=1
CARDENZ, LYSIPLEX,
ONE-A-DAY,
*Multiple Vitamin Tab**
THERAGRAN
THERA-PLUS LIQUID
GERITOL EXT
*Multiple Vitamins w/ Iron Tab**
THERAMILL
OCUVITE SOFTGEL
PRESERVISION AREDS 2
THERAMILL
SOFTGE
THERAMILL
AQUADEKS SOFTGEL
Daily Dosage=1
Daily Dosage=1
CAROMEGA,
ADV DIABETIC, B-50
CENTRUM, FEMTABS,
FORMULA*Multiple Vitamins w/
FOSFREE, ONE-AMinerals Tab**
DAY...
CENTRUM,
SENETONIC
TRI-VI-SOL
POLY-VI-SOL
B-PLEX PLUS
Daily Dosage=1
CEROVITE LIQUID
*Pediatric Vitamins ADC Drops
1500IU-400IU-35 MG/ML***
MULTI-DELYN LIQUID
*Pediatric Multiple Vitamin w/ C
Soln 35 MG/ML**
*Pediatric Multiple Vitamin w/ C &
FA Chew Tab**
*Pediatric Multiple Vitamin w/ C &
FA Chew Tab**
ZOO FRIENDS TABLET
CHEWABLE
ZOO FRIENDS COMPLETE TAB
CH
VITAMAX *Pediatric Multiple
Vitamin w/ Minerals & C Chew Tab
60 MG**
AQUADEKS PEDIATRIC
LIQUID
*Pediatric Multiple Vitamins w/ Iron
Chew Tab 15 MG**
72
Max Qty=50/claim
Max Qty=50/claim
Daily Dosage=1
Daily Dosage=1
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
POLY-VI-SOL
Additional
Information
Product Description
Chew Tab 15 MG**
MULTI-DELYN WITH IRON
LIQUI
Drops 10 MG/ML**
MYKIDZ IRON SUSPENSION
Limitations/
Restrictions
TRI-VI-SOL *Pediatric Vitamins
ACD w/ Iron Drops 10 MG/ML***
*Pediatric Vitamins ACD w/
Fluoride Chew Tab 1 MG***
Fluoride Soln 0.25 MG/ML***
*Pediatric Multiple Vitamins w/
Fluoride Chew Tab 0.25 MG***
Fluoride Chew Tab 0.5 MG***
Fluoride Chew Tab 1 MG***
*Pediatric Multiple Vitamins w/ FlFe Chew Tab 0.5-12 MG**
*Pediatric Multiple Vitamins w/ FlFe Chew Tab 1-12 MG**
*Pediatric Multiple Vitamins w/ FlFe Drops 0.25-10 MG/ML**
*Pediatric Multiple Vitamins w/ FlPOLY-VIT/FE
Fe Drops 0.5-10 MG/ML**
*Pediatric Vitamins ACD Fluoride &
Fe Drops 0.25-10 MG/ML***
*Prenatal Vitamin Fast Dissolving
CALNA
Tab**
*Prenatal Multivitamins & Minerals
w/ Iron & FA Cap 0.1MG***
TYLER PRENAT
w/ Iron & FA Cap 1 MG***
MYNATAL
w/ Iron & FA Tab 0.1MG***
KPN
w/ Fe & FA Tab 0.25 MG***
NUTRICION
w/ Iron & FA Tab 0.8MG***
PRENATAL/FE
w/ Iron & FA Tab 1 MG***
*Prenatal Vit w/ Iron Carbonyl-FA
Tab 29-1 MG***
*Prenatal Vit w/ Iron Carbonyl-FA
Tab 50-1 MG***
*Prenatal Vit w/ Fe Fumarate-FA
Cap 13.5-0.4 MG***
Tab 15-1 MG***
PRENATABS RX
PERRY PRENAT
O-CAL
73
Max Qty=50/claim
Max Qty=50/claim
Daily Dosage=1
Max Qty=50/claim
Max Qty=50/claim
Max Qty=50/claim
Max Qty=50/claim
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
NOVASTART
Additional
Information
Product Description
Tab 17-1 MG***
NATELLE-EZ TABLET
Tab 27-0.5 MG***
Tab 27-0.8 MG***
PRENAFIRST
PRENATAL
PRENATAL,
TRICARE
PRENATAL, VOLPLUS
Tab 27-1 MG***
Tab 28-0.8 MG***
Tab 29-1 MG***
Tab 60-0.8 MG***
PRENATAL
PRENATABS FA
SE-NATAL ONE,
TRINATAL RX,
VINATE ONE
MYNATAL PLUS,
VITAFOL-OB
Tab 60-1 MG***
Tab 65-1 MG***
Tab 75-1 MG***
NATACHEW
CITRANATAL
NATALVIT
PRENATAL 19
Chew Tab 29-1 MG***
DAILY PRENATAL COMBO
PACK
*Prenatal Vit w/ Fe Gluconate-FA
MISSION PREN
Tab 30-0.4 MG***
*Prenatal Vit w/ Fe Gluconate-FA
MISSION PREN
Tab 30-0.8 MG***
*Prenatal Vit w/ Fe Sulfate-FA Tab
PRENATAL
27-0.8 MG***
*Prenatal Vit w/ Fe Polysac CmplxNIFEREX-PN
FA Tab 60-1 MG***
*Prenatal Vit w/ Iron Carbonyl-Fe
CAL-NATE, VINATE
Gluc-FA Tab 27-1MG***
CAL
*Prenatal w/o A Vit w/ Fe Fumarate- PRENATAL-U,
FA Cap 106.5-1 MG***
TRIVEEN-U
Limitations/
Restrictions
Daily Dosage=1
Dose=1
Dose=1
Limited to Female;
Daily Dose=1
Dose=1
Dose=1
Dose=1
Dose=1
Dose=1
Under; Limited to
Female; Daily Dose=1
Dose=1
Dose=1
Dose=1
Dose=1
Dose=1
Dose=1
Dose=1
CAVAN, GESTICARE,
*Prenatal w/o A Vit w/ Fe FumarateLimited to Female; Daily
TARON-EC CAL,
Dose=1
FA Tab DR 30-1 MG***
TRINATE
NOVANATAL
*Prenatal w/o A Vit w/ Fe Carbonyl- PRENATABS,
FA Tab 29-1 MG***
VITASPIRE
Dose=1
*Prenatal without A w/ Fe CarbonylCOMPLETE-RF
Docusate-FA Tab 90-1MG***
Dose=1
*Prenatal Vit w/ Sel-Fe Fumarate-FA
Tab 27-1 MG***
*Prenatal Vit w/ DSS-Iron CarbonylFA Tab 90-1 MG***
*Prenatal Vit w/ DSS-Iron CarbonylFA Tab 90-1 MG***
*Prenatal Vit w/ DSS-Fe FumarateFA Tab 29-1 MG***
Dose=1
Dose=1
Dose=1
*Prenatal Vit w/ DSS-Fe FumarateFA Tab CR 90-1 MG***
VINATE M
INATAL ADV
INATAL ADV
PRENATAL 19
MYNATE 90
*Prenatal w/FE Polys Cmplx-FA-Ca
MARNATAL-F
Tab & Omega 3 Cap Pack***
74
Dose=1
Dose=1
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
TARON EC CALCIUM DHA
COMB P
*Vitamins w/ Lipotropics Cap**
*Iron w/ Vitamin Tab**
GERITOL, VITAFOL
FEMIRON
IBERET-500, IBERET*Iron w/ Vitamin Tab CR**
FOLIC
MINERALS & ELECTROLYTES
CALCI-MIX 1.25 GM CAPSULE
ELEMENTAL CALCIUM 600 MG
TA
CALCIUM 500 MG TABLET
OS-CAL, OS-CAL 500
CALCI-CHEW TABLET
Calcium Carbonate Susp 1250
MG/5ML
Limitations/
Restrictions
Max Qty=500/30 days
CALCITRATE 950 MG TABLET
CALCIONATE 1.8 GM/5 ML
SYRU
CALCIUM GLUCONATE 650 MG
TA
CALCIUM LACTATE 648 MG
TABL
CALCIUM LACTATE 10GR
TABLET
Oyster Shell Calcium Tab 500 MG
CALCET TABLET
CALCIUM OYS SHELL 250 MG
TA
Calcium 500 MG w/ Vitamin D Tab
OS-CAL
MAGNEBIND 300 TABLET
Calcium Carbonate-Vitamin D Tab
250MG-125IU
500MG-125IU
500MG-200IU
OYSTER SHELL CALCIUM-VIT
D
600MG-200IU
600 MG-400 Unit
OYSCO 500+D TABLET
CHEWABLE
CITRACAL
CITRUS CALCIUM-VIT D 200-25
DICAL-D
CALVITE P&D TABLET
CALTRATE 600+D PLUS TAB
CHE
CALTRATE 600
Max Qty=62/31 days
Max Qty=62/31 days
SODIUM FLUORIDE 1 MG (2.2 M
LURIDE
LURIDE
LURIDE
Sodium Fluoride Chew Tab 0.25MG
F (from 0.55 MG NaF)
Sodium Fluoride Chew Tab 0.5MG F
(from 1.1 MG NaF)
Sodium Fluoride Chew Tab 1 MG F
(from 2.2 MG NaF)
FLURA-DROPS Sodium Fluoride
Soln 0.125 MG/DROP F (0.275
MG/DROP NaF)
75
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
LURIDE
SLOW-MAG
SLOW-MAG
K-PHOS
MICRO-K
Additional
Information
Product Description
Soln 0.25 MG/DROP F (from 0.55
MG/DROP NaF
Soln 0.5 MG/ML F (from 1.1
MG/ML NaF)
SSKI Soln 1 GM/ML
MAGNESIUM DR 64 MG
TABLET
MAG DELAY 64 MG TABLET
MAGONATE 27 MG TABLET
MAGTRATE 500 MG TABLET
MAGONATE 54 MG/5 ML
LIQUID
MAG-TAB SR 84 MG CAPLET
SLOW-MAG 71.5 MG TABLET
NEUTRA-PHOS Potassium &
Sodium Phosphates For Soln 278164-250 MG/75ML
PHOS-NAK PACKET
K-PHOS NEUTRAL TABLET
Potassium Bicarbonate Effer Tab 25
mEq
Max Qty=68/31 days
Potassium Chloride Cap CR 10 mEq
Potassium Chloride Tab CR 8 mEq
K-TABS
K-LOR
K-TABS
EQUALYTE,
PEDIALYTE,
PEDIALYTE ST
NUTRIENTS
Limitations/
Restrictions
Potassium Chloride Tab CR 10 mEq
Potassium Chloride Oral Liq 10%
Potassium Chloride Oral Liq 20%
Potassium Chloride Powder Packet
20 mEq
Potassium Chloride Powder Packet
25 mEq
Potassium Chloride
Microencapsulated CRYS CR Tab 10
mEq
KLOR-CON M15 Potassium
Chloride Microencapsulated Crys CR
Tab 15 mEq
Potassium Chloride
Microencapsulated CRYS CR Tab 20
mEq
ZINC 50 MG TABLET
Zinc Sulfate Cap 220 MG (50 MG
Elemental Zn)
CERALYTE 50, CERALYTE 70,
CERASPORT, ENFALYTE *Oral
Electrolyte Solution***
POLYCOSE Glucose Polymers Liqd
POLYCOSE Glucose Polymers
Powder 94%
ARGININE 500 MG TABLET
FISH OIL SOFTGEL
*Omega-3 Fatty Acids Cap 1000
MG**
MG**
MG**
76
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
MG**
Limitations/
Restrictions
FISH OIL 1,000 MG EC SOFTGE
HEMATOPOIETIC AGENTS
FISH OIL 1,200 MG SOFTGEL
SEA OMEGA + D SOFTGEL
SLOESTEROL POWDER
Cyanocobalamin Inj 1000 MCG/ML
ICAR
Max Qty=10/270 days
Folic Acid Tab 200 MCG
Folic Acid Tab 1 MG
Carbonyl Iron Chew Tab 15 MG
(Elemental Iron)
Daily Dosage=1
Daily Dosage=1
MYKIDZ IRON 10 SUSPENSION
Ferrous Sulfate Tab 83 MG
Ferrous Sulfate Tab 325 MG (65 MG
Elemental Fe)
Ferrous Sulfate Tab 28 MG
(Elemental Fe)
FERROUS SULFATE ER 140 MG
T
SLOW RELEASE IRON 160 GM
TA
Ferrous Sulfate Tab EC 325 MG (65
MG Fe Equivalent)
FEOSOL
Ferrous Sulfate Elixir 220 MG/5ML
(44 MG/5ML Elemental Fe)
FER-IN-SOL
Ferrous Sulfate Soln 75 MG/ML (15
MG/ML Elemental Fe)
Daily Dosage=3.4
Ferrous Sulfate Soln 75 MG/0.6ML
Daily Dosage=3.4
SLOW FE
FERGON
HEMOCYTE
NIFEREX-150
Ferrous Sulfate Dried Tab CR 160
MG (50 MG Fe Equivalent)
Ferrous Gluconate Tab 216 MG
Ferrous Gluconate Tab 324 MG (38
MG Elemental Iron)
MG Elemental Fe)
(37.5 MG Elemental Fe)
MG Fe Equivalent)
MG Elemental Fe)
Ferrous Fumarate Tab 325 MG (106
MG Elemental Fe)
Polysaccharide Iron Complex Cap
150 MG
PRO FE 180 MG CAPSULE
DROXIA 200 MG CAPSULE
BIFERA 28 MG TABLET
POLYSACCHARIDE IRON
FORTE
FERREX 150 PLUS CAPSULE
Daily Dosage=2
Daily Dosage=1
77
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
ANTICOAGULANTS
Additional
Information
Product Description
Limitations/
Restrictions
Heparin Sodium (Porcine) Inj 1000
U/ML
U/ML
U/ML
U/ML
LOVENOX
7 days supply per claim
and 3 claim max at retail
allowed - after that PA
with Specialty required
LOVENOX
LOVENOX
LOVENOX
Enoxaparin Sodium Inj 100 MG/ML LOVENOX
Enoxaparin Sodium Inj 120
MG/0.8ML
LOVENOX
Enoxaparin Sodium Inj 150 MG/ML LOVENOX
LOVENOX
MG/3ML
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
Warfarin Sodium Tab 1 MG
Warfarin Sodium Tab 2.5 MG
Warfarin Sodium Tab 7.5 MG
LOVENOX
LOVENOX
MG/0.3ML
MG/0.4ML
LOVENOX
MG/0.6ML
LOVENOX
MG/0.8ML
LOVENOX
LOVENOX
LOVENOX
XARELTO
LOVENOX
TAB 10MG
Max Qty=35/6 months
HEMOSTATICS
AMICAR
Aminocaproic Acid Tab 500 MG
AMICAR
Aminocaproic Acid Syrup 25%
HEMATOLOGICAL AGENTS - MISCELLANEOUS
Max Qty=24/claim
Max Qty=60/claim
78
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
HEMOFIL M 220-400 UNITS VIA
HEMOFIL M 401-800 UNITS VIA
HEMOFIL M 801-1,700 UNITS V
HEMOFIL M 1,701-2,000 UNITS
MONOCLATE-P 1,000 UNITS
KIT
MONOCLATE-P 1,500 UNITS
KIT
RECOMBINATE 220-400 UNIT VI
RECOMBINATE 401-800 UNIT VI
RECOMBINATE 801-1,240 UNIT
RECOMBINATE 1,241-1,800 UNI
RECOMBINATE 1,801-2,400 UNI
HELIXATE FS 250 UNIT VIAL
KOGENATE FS 250 UNIT VIAL
HELIXATE FS 500 UNIT VIAL
KOGENATE FS 500 UNIT VIAL
HELIXATE FS 1,000 UNIT VIAL
KOGENATE FS 1,000 UNITS VIA
HELIXATE FS 2,000 UNIT VIAL
KOGENATE FS 2,000 UNIT VIAL
HELIXATE FS 3,000 UNITS VIA
KOGENATE FS 3,000 UNITS VIA
ADVATE 200-400 UNITS VIAL
ADVATE 401-800 UNITS VIAL
ADVATE 801-1,200 UNITS VIAL
ADVATE 1,201-1,800 UNITS VI
XYNTHA 250 UNIT KIT
XYNTHA 500 UNIT KIT
XYNTHA 1,000 UNIT KIT
XYNTHA 2,000 UNIT KIT
XYNTHA 3,000 UNIT SYRINGE
K
79
Limitations/
Restrictions
Biopharmacy benefit via
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
HUMATE-P 600 UNIT VWF:RCO
HUMATE-P 1,200 UNIT
VWF:RCO
HUMATE-P 2,400 UNIT
VWF:RCO
ALPHANATE 250-100 UNIT VIAL
ALPHANATE 500-200 UNIT VIAL
ALPHANATE 1,000-400 UNIT VI
ALPHANATE 1,500-600 UNIT VI
FEIBA VH IMMU 1,750-3,250 U
FEIBA VH IMMUNO 400-650 UNI
FEIBA NF 400-650 UNIT VIAL
FEIBA NF 1,750-3,250 UNIT V
FEIBA VH IMMUNO 651-1,200 U
FEIBA NF 651-1,200 UNIT VIA
NOVOSEVEN RT 1,000 MCG
VIAL
NOVOSEVEN 1,200 MCG VIAL
VIAL
NOVOSEVEN 2,400 MCG VIAL
VIAL
VIAL
MONONINE 1,000 UNITS VIAL
BENEFIX 250 UNIT VIAL
BENEFIX 500 UNIT VIAL
BENEFIX 1,000 UNIT VIAL
BENEFIX 2,000 UNIT VIAL
PROFILNINE SD 500 UNITS VIA
PROFILNINE SD 1,000 UNITS V
PROFILNINE SD 1,500 UNITS V
BEBULIN VH INJ 200-1200
PERSANTINE
PERSANTINE
PERSANTINE
PLETAL
PLETAL
AGRYLIN
Dipyridamole Tab 25 MG
Cilostazol Tab 50 MG
Cilostazol Tab 100 MG
ANAGRELIDE HCL 0.5 MG
CAPSU
Limitations/
Restrictions
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Daily Dosage=2
Daily Dosage=2
80
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
PLAVIX
TRENTAL
OPHTHALMIC AGENTS
CILOXAN
Additional
Information
Product Description
ANAGRELIDE HCL 1 MG
CAPSULE
Clopidogrel Bisulfate (PLAVIX) Tab
75 MG (Base Equiv)
Pentoxifylline Tab CR 400 MG
Limitations/
Restrictions
Bacitracin Ophth Oint 500 U/GM
Max Qty=4/31 days
Ciprofloxacin HCl Ophth Soln 0.3%
Ciprofloxacin HCl Ophth Oint 0.3%
Erythromycin Ophth Oint 5
MG/GM
GARAMYCIN
Gentamicin Sulfate Ophth Soln 0.3%
Gentamicin Sulfate Ophth Oint 0.3%
Max Qty=4/31 days
Max Qty=3/claim
Max Qty=10/31 days
VIROPTIC
VIGAMOX Ophth Soln 0.5%
Ofloxacin Ophth Soln 0.3%
Tobramycin Sulfate Ophth Soln
0.3%
TOBREX Ophth Oint 0.3%
Sulfacetamide Sodium Ophth Soln
10%
Sulfacetamide Sodium Ophth Oint
10%
Trifluridine Ophth Soln 1%
POLYSPORIN
Bacitracin-Polymyxin B Ophth Oint
Max Qty=4/31 days
POLYTRIM
Polymyxin B-Trimethoprim Ophth
Soln 10000 UNITS/ML-0.1%
OCUFLOX
TOBREX
BLEPH-10
NEOSPORIN
REFRESH PLUS
GENTEAL
PREMIER VALU
AQUASITE
AQUASITE
AQUASITE
AQUASITE
Max Qty=5/31 days
Max Qty=15/31 days
Max Qty=4/31 days
Max Qty=8/31 days
Neomycin-Bacitracin Zn-Polymyx
3.5(5)MG-400U-10000U Op Oint
Neomycin-Polymyxin B-Gramicidin
Ophth Soln
REFRESH PLUS 0.5% EYE
DROPS
REFRESH CELLUVISC 1% EYE
DR
GENTEAL MILD 0.2% EYE
DROPS
GENTEAL MILD-MODERATE
EYE D
Hydroxypropyl Methylcellulose
Ophth Soln 0.4%
ISOPTO TEARS 0.5% EYE
DROPS
GENTEAL SEVERE 0.3% EYE
GEL
Max Qty=4/31 days
Max Qty=10/31 days
Polyvinyl Alcohol Ophth Soln 1.4%
Max Qty=31/31 days
SYSTANE BALANCE 0.6% EYE
DR
SM ARTIFICIAL TEARS
TEARS NATURALE FORTE
DROPS
TEARS NATURALE FREE
DROPS
TEARS NATURALE-II EYE
DROPS
81
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Limitations/
Restrictions
AKWA TEARS, LACRILUBE, REFRESH P.M., *Artificial Tear Ophth Ointment***
SOOTHE NIGHT
Max Qty=4/claim
AKWA TEARS, LACRILUBE, REFRESH P.M., *Artificial Tear Ophth Ointment***
SOOTHE NIGHT
Max Qty=4/claim
Polyethylene Glycol-Polyvinyl
Alcohol Ophth Soln 1-1%
SYSTANE, SYSTANE
PF, SYSTANE ULTR
TEARS NATURA
TEARS NATURA
Max Qty=31/31 days
SYSTANE 0.3-0.4% EYE DROPS
SYSTANE NIGHTTIME EYE
OINT
PURALUBE OPHTHALMIC
OINTMEN
CARTEOLOL HCL 1% EYE
DROPS
Package Limit=1/31
days
Package Limit=1/31
days
BETAGAN
Levobunolol HCl Ophth Soln 0.25%
BETAGAN
Levobunolol HCl Ophth Soln 0.5%
Max Qty=15/31 days
BETIMOL 0.25% EYE DROPS
BETIMOL 0.5% EYE DROPS
Max Qty=15/31 days
Max Qty=15/31 days
TIMOPTIC
Timolol Maleate Ophth Soln 0.25%
Max Qty=15/31 days
TIMOPTIC
Timolol Maleate Ophth Soln 0.5%
Max Qty=15/31 days
TIMOPTIC-XE
TIMOPTIC-XE 0.25% EYE SOLN
TIMOPTIC-XE
Timolol Maleate Ophth Gel Forming
Soln 0.5%
COSOPT
Dorzolamide HCl-Timolol Maleate
Ophth Soln 22.3-6.8 MG/ML
Betaxolol HCl Ophth Soln 0.5%
Package Limit=1/31
days
Package Limit=1/31
days
Max Qty=10/31 days
Dexamethasone Sodium Phosphate
Ophth Soln 0.1%
FML LIQUIFLM
Fluorometholone Ophth Susp 0.1%
OMNIPRED, PRED
FORTE
FML S.O.P. Ophth Oint 0.1%
Prednisolone Acetate (PRED MILD)
Ophth Susp 0.12%
Prednisolone Acetate Ophth Susp
1%
Prednisolone Sodium Phosphate
Ophth Soln 1%
VEXOL Ophth Susp 1%
TOBRADEX
MAXITROL
Package Limit=1/31
days
Max Qty=4/31 days
Max Qty=10/31 days
Package Limit=1/31
days
Package Limit=1/31
days
PRED-G Ophth Susp 0.3-1%
BLEPHAMIDE Ophth Susp 100.2%
Package Limit=1/31
days
Sulfacetamide Sodium-Prednisolone
Ophth Soln 10-0.25%
Max Qty=10/31 days
BLEPHAMIDE Ophth Oint 100.2%
Tobramycin-Dexamethasone Ophth
Susp 0.3-0.1%
Package Limit=1/31
days
TOBRADEX Ophth Oint 0.3-0.1%
Max Qty=4/31 days
Neomycin-PolymyxinDexamethasone Ophth Susp 0.1%
Max Qty=10/31 days
82
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
CYCLOGYL
Neomycin-PolymyxinDexamethasone Ophth Oint 0.1%
Neomycin-Polymyxin-HC Ophth
Susp
POLY-PRED Ophth Susp 0.5%
(new)
NEO-BACIT-POLY-HC EYE
OINT
Latanoprost Ophth Soln 0.005%
Atropine Sulfate Ophth Soln 1%
Atropine Sulfate Ophth Oint 1%
CYCLOGYL Ophth Soln 0.5%
CYCLOGYL Ophth Soln 1%
CYCLOGYL
CYCLOGYL Ophth Soln 2%
ISO HOMATROP
ISO HOMATROP (Homatropine
HBr) Ophth Soln 2%
ISO HOMATROP (Homatropine
HBr) Ophth Soln 5%
Tropicamide Ophth Soln 0.5%
Tropicamide Ophth Soln 1%
MAXITROL
CORTISPORIN
XALATAN
ISO ATROPINE
Additional
Information
Product Description
Limitations/
Restrictions
Step Therapy
Max Qty=4/31 days
Max Qty=15/31 days
Max Qty=5/31 days
Max Qty=15/31 days
Package Limit=1/31
days
Max Qty=15/31 days
MYDRIACYL
ALBALON, NAPHCON
Naphazoline HCl Ophth Soln 0.1%
FORT
MYDFRIN
Phenylephrine HCl Ophth Soln 2.5%
Max Qty=5/31 days;
Max Qty=5/31 days
SUSTAINED DR,
VISINE, VISINE
EXTRA
Tetrahydrozoline HCl Ophth Soln
0.05%
Max Qty= 1 package/30
days
ISO CARPINE
ISOPTO CARP
ISOPTO CARP
ISOPTO CARP
ISOPTO CARP
ISO CARBACHO (Carbachol Ophth
Soln) 1.5%
ISO CARBACHO (Carbachol Ophth
Soln) 3%
Pilocarpine HCl Ophth Soln 0.5%
Pilocarpine HCl Ophth Soln 1%
Dipivefrin HCl Ophth Soln 0.1%
IOPIDINE Ophth Soln 1% (Base
Equivalent)
Brimonidine Tartrate Ophth Soln
0.2%
Package Limit=1/31
days
Max Qty=6/31 days;
Step Therapy
OPTIVAR
OPTIVAR Ophth Soln 0.05%
CROLOM
Cromolyn Sodium Ophth Soln 4%
ZADITOR
Ketotifen Fumarate Ophth Soln
0.025% (Base Equiv)
Package Limit=1/31
days
Max Qty=10/31 days;
Step Therapy
Max Qty=5/31 days;
Step Therapy
Package Limit=1/31
days
Max Qty=10/31 days
Package Limit=1/31
days
Package Limit=1/31
days
Max Qty=3/31 days
ALOMIDE Ophth Soln 0.1%
ALOCRIL Ophth Soln 2%
AZOPT Ophth Susp 1%
TRUSOPT
Dorzolamide HCl Ophth Soln 2%
MURO 128
MURO-128 5% EYE DROPS
MURO 128
MURO-128 5% EYE OINTMENT
VOLTAREN
VOLTAREN Ophth Soln 0.1%
Flurbiprofen Sodium Ophth Soln
0.03%
OCUFEN
Max Qty=5/31 days
83
Prior use of Zaditor
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
ACULAR LS
ACULAR LS Ophth Soln 0.4%
ACULAR
ACULAR Ophth Soln 0.5%
NEVANAC 0.1% DROPTAINER
Max Qty=3/claim
OTIC AGENTS
FLOXIN OTIC
Ofloxacin Otic Soln 0.3%
DERMOTIC
DERMOTIC (Otic) Oil 0.01%
VOSOL HC
VOSOL
DEBROX
CORTISPORIN,
PEDIOTIC
CORTISPORIN
CORTANE-B, OTICIN
HC
CORTANE-B
Limitations/
Restrictions
Package Limit=1/30
days
Package Limit=1/31
days
Package Limit=1/31
days
Package Limit=1/30
days
Hydrocortisone w/ Acetic Acid Otic
Soln 1-2%
Acetic Acid Otic Soln 2%
Acetic Acid 2% in Aluminum Acetate
Otic Soln
REED DEBROX 6.5% Otic Soln
Max Qty=20/31 days
Max Qty=15/31 days
Max Qty=15/31 days
CIPRODEX Otic Susp 0.3-0.1%
Neomycin-Polymyxin-HC Otic Susp
3.5 MG/ML-10000 U/ML-1%
Max Qty=20/31 days
Neomycin-Polymyxin-HC Otic Soln
1%
OTILAM NR (BenzocaineAntipyrine) Otic Soln 1.4-5.4%
Pramoxine-HC-Chloroxylenol Otic
Soln 10-10-1 MG/ML
Max Qty=10/claim
Package Limit=1/30days
Pramoxine-HC-Chloroxylenol
Aqueous Otic Soln 10-10-1MG/ML
MOUTH/THROAT/DENTAL AGENTS
Nystatin Susp 100000 U/ML
CLOTRIMAZOLE 10 MG
MYCELEX
TROCHE
PERIDEX
Chlorhexidine Gluconate Soln 0.12%
Zinc Lozenge 15 MG
Triamcinolone Acetonide Dental
Paste 0.1%
Max Qty=100/claim;
Compound: Max
Qty=120/claim
Lidocaine HCl Viscous Soln 2%
PREVIDENT
PREVIDENT
Sodium Fluoride Rinse 0.2%
Sodium Fluoride Cream 1.1%
Sodium Fluoride Gel 1%
PREVIDENT, THERASodium Fluoride Gel 1.1%
FLUR-N
PREVIDENT
Sodium Fluoride Paste 1.1%
GEL-KAM
Stannous Fluoride Conc 0.63%
Artificial Saliva - Solution
PILOCARPINE HCL 5 MG
SALAGEN
TABLET
SALAGEN
SALAGEN 7.5 MG TABLET
ANORECTAL AGENTS
ANUSOL-HC
ANUSOL-HC
CORTENEMA
PROCTOFOAM
ANALPRAM-HC
Max Qty=60/month
Hydrocortisone Rectal Cream 2.5%
Hydrocortisone Acetate Suppos 25
MG
Hydrocortisone Enema 100
MG/60ML
Pramoxine HCl Rectal Foam 1%
Hydrocortisone Acetate w/
Pramoxine Rectal Cream 1-1%
Daily Dosage=2
Max Qty=62/31 days
84
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ANALPRAM-HC
PREPARATION
Additional
Information
Product Description
Hydrocortisone Acetate w/
Pramoxine Rectal Cream 2.5-1%
ANALPRAM-HC (Hydrocortisone
Acetate w/ Pramoxine) Rectal Lotn
2.5-1%
Phenyleph-Shark Liver Oil-Cocoa
Butter Suppos 0.25-3-85.5%
PREPARATION
DERMATOLOGICALS
Step Therapy
Max Qty=30/claim
Max Qty=62/31 days
Max Qty=12/31 days
HEMORRHOIDAL CREAM
PREPARATION
Limitations/
Restrictions
Phenylephrine-Shark Liver Oil-MOPet Oint 0.25-3-14-71.9%
Phenylephrine-Shark Liver Oil-MOPet Oint 0.25-3-14-71.9%
Max Qty=31/31 days
Max Qty=31/31 days
BENZAC AC, BENZAC
Benzoyl Peroxide Liq 2.5%
W, DESQUAM-X
LAVOCLEN-4 CREAMY WASH
BENZAC AC, BENZAC
Benzoyl Peroxide Liq 5%
W, DESQUAM-X
LAVOCLEN-8 CREAMY WASH
BENZAC AC, BENZAC
W, DESQUAM-X
BENZAC AC, BENZAC
W, DESQUAM-X
PANOXYL 10% FOAM Benzoyl Peroxide Foam 10%
BENZAC AC
BENZAC AC
BENZAC AC,
DESQUAM-X
BENZAC AC,
DESQUAM-X
TRIAZ CLEANS
Benzoyl Peroxide Gel 2.5%
Benzoyl Peroxide Gel 4%
TRIAZ 3% CLEANSER
BENZOYL PEROX 4%
CLEANSING
Benzoyl Peroxide Lotion 5%
TRIAZ CLEANS
TRIAZ 6% CLEANSER
TRIAZ CLEANS
TRIAZ 9% CLEANSER
Benzoyl Peroxide Lotion 10%
ACCUTANE
Benzoyl Peroxide-Sulfur Lotion 5-2%
Max Qty=62/31 days
Benzoyl Peroxide-Sulfur Lotion 105%
Max Qty=62/31 days
Isotretinoin Cap 10 MG
Prior use of topical
antibiotics,
antiinfectives,
Under ; Daily
retinoids + oral
Dosage=2; Step Therapy
antibiotics as 1st-line
therapy
85
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
ACCUTANE
Additional
Information
Product Description
Limitations/
Restrictions
antibiotics,
antiinfectives,
Under ; Daily
retinoids + oral
therapy
CLARAVIS 30 MG CAPSULE
antibiotics,
antiinfectives,
Under ; Daily
retinoids + oral
therapy
ACCUTANE
RETIN-A
RETIN-A
RETIN-A
RETIN-A
RETIN-A
CLEOCIN-T
CLEOCIN-T
Tretinoin Cream 0.025%
Tretinoin Gel 0.01%
Tretinoin Gel 0.025%
Clindamycin Phosphate Soln 1%
CLINDAGEL Gel 1%
CLEOCIN-T
Clindamycin Phosphate Lotion 1%
antibiotics,
antiinfectives,
Under ; Daily
retinoids + oral
therapy
Max Qty=20/claim
Max Qty=20/claim
Max Qty=20/claim
Max Qty=15/claim
Erythromycin Soln 2%
ERYGEL
Erythromycin Gel 2%
KLARON
Sulfacetamide Sodium Lotion 10%
(Acne)
BENZAMYCIN
BENZAMYCIN GEL
BENZACLIN
BENZACLIN GEL
PLEXION CLNS
CLENIA FOAMING WASH
NOVACET
Sulfacetamide Sodium w/ Sulfur
Susp 10-5%
Lotion 10-5%
Lotion 10-5%
Limit=1/claim
Package Limit=1/31
days
Package Limit=1/31
days
Max DS/DU=Lesser Of
Qty=45
Max DS/DU=Lesser Of
Qty=45
NOVACET
METROCREAM
Metronidazole Cream 0.75%
Metronidazole Gel 0.75%
METROLOTION
BACIGUENT
Metronidazole Lotion 0.75%
Bacitracin Oint 500 U/GM
Bacitracin Zinc Oint 500 U/GM
Bacitracin Zinc Oint 500 U/GM
Gentamicin Sulfate Cream 0.1%
Gentamicin Sulfate Oint 0.1%
BACTROBAN
Mupirocin Oint 2%
Max Qty=30/claim
Max Qty=30/claim
Package Limit=1/31
days
Package Limit=1/31
days
BACTROBAN Cream 2%
*Bacitracin-Polymyxin B Powder***
POLYSPORIN
Step Therapy
*Bacitracin-Polymyxin B Oint***
86
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
NEOSPORIN, TRIPLE
ANTIB
NEOSPORIN, TRIPLE
ANTIB
NEOSPORIN
Additional
Information
Product Description
*Neomycin-Bacitracin-Polymyxin
Oint***
*Neomycin-Bacitracin-Polymyxin
Oint***
Neomycin-Polymyxin w/ Pramoxine
Cream 1%
TRIPLE ANTIBIOTIC PLUS
OINT
Limitations/
Restrictions
PENLAC
PENLAC 8% SOLUTION
LOPROX
CICLOPIROX 0.77% GEL
LOPROX
CICLOPIROX 0.77% TOPICAL SU
LOPROX
CICLOPIROX 0.77% CREAM
Package Limit=1/31
days
Package Limit=1/31
days
*Nystatin Topical Powder**
Nystatin Cream 100000 U/GM
Nystatin Oint 100000 U/GM
TINACTIN
TOLNAFTATE 1% SOLUTION
TINACTIN
TOLNAFTATE 1% POWDER
TINACTIN, TINACTIN
JOCK ITCH 1% POWDER SPRAY
POW
TINACTIN
Tolnaftate Cream 1%
Max Qty=30/claim
LAMISIL AT 1% GEL
LAMISIL ANTIFUNGAL 1%
SPRAY
LAMISIL AT 1% SPRAY
LAMISIL AT, LAMISIL
AT C
Terbinafine HCl Cream 1%
LOTRIMIN AF,
MYCELEX OTC
Clotrimazole Cream 1%
Clotrimazole Soln 1%
Econazole Nitrate Cream 1%
Package Limit=1/31
days
Max Qty=30/claim
Ketoconazole Cream 2%
Ketoconazole Shampoo 1%
Ketoconazole Shampoo 2%
Limit=1/claim
FUNGOID 2% TINCTURE
ZEASORB-AF 2% POWDER
MICATIN
Miconazole Nitrate Cream 2%
PA, Legend
ALOE VESTA
ALOE VESTA 2% OINTMENT
NIZORAL
LOTRISONE
LOTRISONE
BENADRYL M-S
DERMAREST
Clotrimazole w/ Betamethasone
Cream 1-0.05%
Clotrimazole w/ Betamethasone
Lotion 1-0.05%
Nystatin-Triamcinolone Cream
100000-0.1 U/GM-%
Nystatin-Triamcinolone Oint 1000000.1 U/GM-%
Diphenhydramine HCl Cream 2%
Diphenhydramine HCl Gel 2%
87
Max Qty=45/31 days
Max Qty=31/31 days
Step Therapy
PREFERRED DRUG LIST
Common Brand
Name(s)
Column1
BENADRYL,
BENADRYL ITC
BENADRYL
Additional
Information
Product Description
Diphenhydramine-Zinc Acetate
Cream 1-0.1%
ANTI-ITCH 2% CREAM
Limitations/
Restrictions
DRITHO-CRÈME (Anthralin
Cream) 1%
DOVONEX, DOVONX Calcipotriene Soln 0.005% (50
SCALP
MCG/ML)
Limit=1/claim
Limit=1/claim
DOVONEX Cream 0.005%
CALCIPOTRIENE 0.005%
OINTME
TAZORAC Cream 0.05%
TAZORAC Cream 0.1%
Limit=2/claim
Limit=2/claim
TAZORAC Gel 0.05%
TAZORAC Gel 0.1%
SELSUN BLUE
Selenium Sulfide Lotion 1%
Selenium Sulfide Lotion 2.5%
SELSUN
OVACE PLUS, OVACE
Sulfacetamide Sodium Liquid 10%
WASH
SEBULEX MEDICATED
SEBULEX
SHAMPOO
Sulfacetamide Sodium-Urea Lotion
CARMOL SCALP
10-10%
ZOVIRAX Cream 5%
Package Limit=1/31
days
ZOVIRAX Oint 5%
Max Qty=10/31 days
Max Qty=10/31 days
SILVADENE
Fluorouracil Soln 2%
Fluorouracil Soln 5%
CARAC Cream 0.5%
Fluorouracil Cream 5%
SULFAMYLON 8.5% CREAM
Silver Sulfadiazine Cream 1%
THERAPLEX T
IONIL T SHAMPOO
DENOREX THER
BETATAR GEL SHAMPOO
AMCINONIDE 0.1% CREAM
EFUDEX
EFUDEX
EFUDEX
DIPROLENE
Max Qty=40/31 days
Betamethasone Dipropionate Cream
0.05%
Betamethasone Dipropionate Lotion
0.05%
Betamethasone Dipropionate Oint
0.05%
Betamethasone Dipropionate
Augmented Cream 0.05%
Augmented Gel 0.05%
Augmented Lotion 0.05%
Augmented Oint 0.05%
Betamethasone Valerate Cream 0.1%
Betamethasone Valerate Lotion 0.1%
Betamethasone Valerate Oint 0.1%
TEMOVATE
Clobetasol Propionate Soln 0.05%
88
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Limitations/
Restrictions
TEMOVATE
Clobetasol Propionate Cream 0.05%
TEMOVATE
Clobetasol Propionate Gel 0.05%
TEMOVATE
Clobetasol Propionate Oint 0.05%
TEMOVATE E
Clobetasol Propionate Emollient
Base Cream 0.05%
DESOWEN
Desonide Cream 0.05%
DESOWEN
Desonide Lotion 0.05%
DESOWEN
Desonide Oint 0.05%
Desoximetasone Cream 0.05%
TOPICORT
Desoximetasone Cream 0.25%
TOPICORT
Desoximetasone Gel 0.05%
TOPICORT
Desoximetasone Oint 0.25%
Diflorasone Diacetate Cream 0.05%
Diflorasone Diacetate Oint 0.05%
Fluocinolone Acetonide Soln 0.01%
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%
CUTIVATE
Fluticasone Propionate Cream 0.05%
Package Limit=1/30
days
CUTIVATE
Fluticasone Propionate Oint 0.005%
LIDEX
Hydrocortisone Cream 0.5%
HYTONE
Hydrocortisone Cream 1%
Hydrocortisone Cream 1%
Pkg JAR: Max
Qty=120/30 days; Pkg
TUBE: Package
Limit=1/claim
Hydrocortisone Lotion 1%
Hydrocortisone Lotion 2.5%
HYDROCORTISONE 0.5%
OINTMEN
89
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
Hydrocortisone Oint 1%
Limitations/
Restrictions
Max Qty=60/30 days;
Package Limit=1/30
days
Hydrocortisone Oint 2.5%
ANUSOL HC-1, TUCKS Hydrocortisone Acetate Oint 1%
WESTCORT
Hydrocortisone Valerate Cream 0.2%
LOCOID
Hydrocortisone Butyrate Soln 0.1%
LOCOID
Hydrocortisone Butyrate Cream 0.1%
LOCOID
Hydrocortisone Butyrate Oint 0.1%
ELOCON
Mometasone Furoate Cream 0.1%
ELOCON
Mometasone Furoate Oint 0.1%
Triamcinolone Acetonide Cream
0.025%
Pkg JAR: Max
Qty=120/30 days; Pkg
TUBE: Package
Limit=1/claim
0.1%
0.5%
Triamcinolone Acetonide Lotion
0.025%
Triamcinolone Acetonide Lotion
0.1%
Triamcinolone Acetonide Oint
0.025%
Triamcinolone Acetonide Oint 0.1%
Triamcinolone Acetonide Oint 0.5%
Pramoxine-HC Aerosol Foam 1-1%
Hydrocortisone-Aloe Vera Cream 1%
ALPHA GLOW *Emollient Lotion**
ALPHA GLOW *Emollient Lotion**
DERMAPHOR OINTMENT
Lactic Acid (Ammonium Lactate)
Cream 12%
Lactic Acid (Ammonium Lactate)
Lotion 12%
PETROLATUM BASE
OINTMENT
Package Limit=1/31
days
Package Limit=1/31
days
ATRAC-TAIN
ATRAC-TAIN CREAM
ATRAC-TAIN
NUTRAPLUS 10% CREAM
LAC-HYDRIN
LAC-HYDRIN
Urea Cream 40%
CARMOL 10
UREA 10% LOTION
CARMOL 40
CONDYLOX
Urea Lotion 40%
Podofilox Soln 0.5%
WART OFF
SALACTIC FILM SOLUTION
KERALYT
Salicylic Acid Gel 6%
90
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
COMPOUND W
Additional
Information
Product Description
SAL-PLANT 17% GEL
Limitations/
Restrictions
KERALYT (Salicylic Acid Gel) 3%
Salicylic Acid 6% Shampoo
Capsicum Oleoresin Cream 0.025%
Capsicum Oleoresin Cream 0.075%
ZIKS ARTHRITIS PAIN RELIEF
ZOSTRIX, ZOSTRIX
ARTH
Capsaicin Cream 0.025%
ZOSTRIX, ZOSTRIX
HP, ZOSTRIX SPRT,
ZOSTRX FOOT
CAPZASIN-HP
ARTHRITIS PAIN RELIEF 0.1%
Capsaicin Gel 0.025%
Capsaicin Gel 0.05%
Capsaicin Gel 0.075%
Capsaicin Lotion 0.035%
Dibucaine Oint 1%
LMX 4
LMX 4 4% CREAM
Lidocaine Oint 5%
LIDAMANTLE
Lidocaine HCl Cream 3%
XYLOCAINE
Lidocaine HCl Gel 2%
EMLA
Lidocaine-Prilocaine Cream 2.5-2.5%
LIDOCAINE-PRILOCAINE
CREAM
ELDOQUIN, LUSTRA Hydroquinone Cream 4%
SCABICIDES/PEDICULOCIDES
Max Qty=30/claim
EMLA
OVIDE
NIX COMPLETE, NIX
CREM RIN
RID
ELIMITE
EURAX Cream 10%
Limit=1/claim
EURAX Lotion 10%
OVIDE 0.5% LOTION
NIX LICE Spray 0.25%
Permethrin Creme Rinse 1%
Permethrin Aerosol 0.4%
Permethrin Aerosol 0.5%
Permethrin Cream 5%
Permethrin Lotion 1%
KLOUT *Nit Remover Shampoo***
KLOUT LICE *Nit Remover Kit***
Pyrethrins-Piperonyl Butoxide Liq
0.17-2%
0.18-2.2%
Pyrethrins-Piperonyl Butoxide Liq 0.22%
91
Max Qty=1/14 days
Max Qty=1/14 days
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
RID
RID
TEGRIN-LT
PRONTO
PRONTO
A-200
RID COMPLETE
DRYSOL
DERMAGRAN
DERMAGRAN
EUCERIN
EUCERIN
EUCERIN
ALOE VESTA
ALOE VESTA
ALOE VESTA
ALOE VESTA
ALOE VESTA
Product Description
Pyrethrins-Piperonyl Butoxide Liq 0.33%
0.33-4%
Pyrethrins-Piperonyl Butoxide Foam
0.33-4%
Pyrethrins-Piperonyl Butoxide Gel
0.3-3%
Pyrethrins-Piperonyl Butoxide Gel
0.33-4%
Pyrethrins-Piperonyl Butoxide
Shampoo 0.3-3%
Shampoo 0.33-4%
Shampoo Kit
Pyrethrins Spray & PyrethinsPiperonyl Butoxide Shamp Kit
Pyreth-Piper But Spray & PyrethPiper But Shamp Kit
Permethrin Spray & PyrethinsPiperonyl Butoxide Shamp Kit
Additional
Information
Limitations/
Restrictions
Pyreth-Piperonyl Butox ShamPermeth Aero-Nit Remover Gel Kit
SEA-CLENS WOUND
CLEANSER
PELEVERUS WOUND 0.25%
SPRAY
WOUN'DRES WOUND
DRESSING
TRIAD WOUND DRESSING
PASTE
Aluminum Chloride Soln 20%
DERMAMED MOISTURIZING
SPRAY
DERMAMED OINTMENT
SAFE WASH SOLN
Zinc Oxide Oint 20%
CARRINGTON *Skin Protectants
Misc - Cream***
DERMAGRAN *Skin Protectants
Misc - Cream***
CARRINGTON *Skin Protectants
Misc - Cream***
ALOE VESTA *Skin Protectants
Misc - Ointment***
Misc - Ointment***
ABSORBASE *Skin Protectants
Misc - Ointment***
Misc - Ointment***
ABSORBASE *Skin Protectants
Misc - Ointment***
4-N-1 WASH CREAM
4-N-1 CREAM
REMEDY SKIN REPAIR CREAM
92
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
ALOE VESTA SKIN
CONDITIONER
Limitations/
Restrictions
NAIL SCRUB LOTION
ANTISEPTICS & DISINFECTANTS
BETADINE SKN,
BETADINE SRG
BETADINE
ANTIDOTES
REVIA
DIAGNOSTIC PRODUCTS
Chlorhexidine Gluconate Liquid 4%
Max Qty=946/claim
BETADINE 7.5% SCRUB
POVIDONE-IODINE 10%
SOLUTIO
POVIDONE-IODINE 10%
OINTMEN
Ipecac Syrup
CHEMET Cap 100 MG
Naltrexone HCl Tab 50 MG
ACETEST REAGENT TABLET
KETOSTIX Acetone (Urine) Test
Strip
ALBUSTIX REAGENT STRIPS
MICRO-BUMINTEST KIT
Glucose Blood Test Strip
CLINISTIX REAGENT STRIPS
TRUEtest™ strips
Max Qty=30/30 days
Max Qty=30/30 days
Daily Dosage=5
Max Qty=30/30 days
CLINITEST REAGENT TABLET
NOVA MAX PLUS Ketone Blood
Test Strip
VH ESSENTIALS UTI STICK
MULTISTIX 10 SG REAGENT
STR
KETO-DIASTIX REAGENT
STRIPS
Max Qty=30/30 days
Max Qty=30/30 days
Max Qty=30/30 days
Max Qty=30/30 days
Q-GEL MEGA 100 MG SOFTGEL
MEDICAL DEVICES
CHEW Q 100 MG CHEWABLE
TAB
Melatonin Tab 3 MG
Melatonin Tab 5 MG
CYTO-Q MAX 100 MG/ML
LIQUID
LIQ-10 SYRUP
Promethazine HCl (Bulk) Powder
Insulin Syringe (Disp) U-100 1 ML
Max Qty=155/30 days
Insulin Syringe/Needle U-40 1 ML
26 x 1/2"
Insulin Syringe/Needle U-100 0.3
ML 28 x 1/2"
ML 29 x 1/2"
ML 30 x 3/8"
ML 30 x 5/16"
ML 30 x 1/2"
ML 30 x 7/16"
Insulin Syringe/Needle U-100 1/2
ML 27 x 1/2"
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
93
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
ML 28 G x 1"
ML 29 x 7/16"
ML 30 x 3/8"
ML 30 x 7/16"
ML 30 G x 1"
ML 31 x 5/16"
ML 28 x 1/2"
ML 29 x 1"
ML 28 x 1"
ML 29 x 5/16"
ML 29 x 1/2"
ML 30 x 5/16"
ML 30 x 1/2"
25 x 5/8"
25 x 1"
26 x 1/2"
27 x 1/2"
27 x 5/8"
28 x 5/16"
28 x 1/2"
30 G x 1"
29 x 7/16"
29 x 1/2"
29 x 1"
29 x 5/16"
30 x 5/16"
30 x 7/16"
30 x 1/2"
31 x 5/16"
ML 31 x 5/16"
27.5 x 5/8"
29 x 1/2"
Limitations/
Restrictions
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
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
94
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
ML 29 x 7/16"
ML 29 x 5/16"
ML 29 x 1"
ML 30 x 1"
Limitations/
Restrictions
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Insulin Pen Needle 29 G X 12 MM
Max Qty=150/30 days
Insulin Pen Needle 29 G X 12.7 MM
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
Max Qty=150/30 days
*Respiratory Therapy Supplies Misc**
*Respiratory Therapy Supplies Mouthpieces**
Max Qty=1/360 days
Max Qty=1/180 days
AEROCHAMBER *Spacer/AerosolHolding Chambers - Device***
Max Qty=2/360 days
INSPIREASE *Spacer/AerosolHolding Chamber Supplies - Bags***
Max Qty=3/180 days
INSPIREASE *Spacer/AerosolHolding Chamber Supplies Mouthpieces***
TRUZONE PEAK FLOW METER
Max Qty=2/360 days
INNOVO INSULIN DOSER
*Blood Glucose Calibration Liquid***
*Blood Glucose Calibration - Liquid High***
*Blood Glucose Calibration - Liquid Normal***
*Blood Glucose Calibration - Liquid Low***
*Blood Glucose Monitoring
TRUEresult®
Devices****
Max Qty=2/360 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
*Blood Glucose Monitoring Kit**** TRUEresult®
Max Qty=1/730 days
*Blood Glucose Monitoring Kit w/
Device****
Max Qty=1/730 days
TRUEresult®
*Lancets****
Max Qty=200/30 days
*Lancet Devices****
*Gauze Pads & Dressings - Pads 2"
X 2"***
X 3"***
X 4"***
Condoms Latex Lubricated
Max Qty=1/180 days
Max Qty=36/30 days
Limit=1/30 days; Pkg
Size 3: Package
Limit=4/30 days
Condoms Latex Non-Lubricated
95
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
Additional
Information
Product Description
FC CONDOM, FEMALE
Diaphragm Arc-Spring 65 MM
Diaphragm Arc-Spring Kit 55 MM
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
ORTHO FLEX
Diaphragm Coil Spring Kit 50 MM
ORTHO COIL
Limitations/
Restrictions
Max Qty=36/30 days
Max Qty=1/365 days
Diaphragm Coil Spring Kit 100 MM ORTHO COIL
Diaphragm Coil Spring Kit 105 MM ORTHO COIL
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
ORTHO FLAT
Diaphragm Flat Spring Kit 55 MM
*Alcohol Swabs***
Max Qty=400/30 days
PHARMACEUTICAL ADJUVANTS
Simply Thick
ORA-SWEET-SF SYRUP
ORA-BLEND SF SUSPENSION
ORA-BLEND SUSPENSION
ORA-SWEET ORAL SYRUP
ORA-PLUS SUSPENDING
VEHICLE
SORBITOL 70% SOLUTION
Lanolin
HYDROPHILIC OINTMENT
Age Limit > 1
HYDROPHILIC PETROLATUM
ASSORTED CLASSES
CUPRIMINE Cap 125 MG
CUPRIMINE Cap 250 MG
SANDIMMUNE
Cyclosporine Cap 25 MG
SANDIMMUNE
Cyclosporine Cap 100 MG
Cyclosporine Oral Soln 100 MG/ML
NEORAL
Cyclosporine Modified Cap 25 MG
NEORAL
NEORAL
Cyclosporine Modified Oral Soln 100
MG/ML
CELLCEPT
Mycophenolate Mofetil Cap 250 MG
96
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Step Therapy
PREFERRED DRUG LIST
Column1
Common Brand
Name(s)
CELLCEPT
Additional
Information
Product Description
Mycophenolate Mofetil Tab 500 MG
CELLCEPT Oral Susp 200 MG/ML
MYFORTIC (Mycophenolate
Sodium Tab DR 180 MG
(Mycophenolic Acid Equiv))
MYFORTIC (Mycophenolate
Sodium Tab DR 360 MG
(Mycophenolic Acid Equiv))
Limitations/
Restrictions
Acaria
Acaria
Acaria
Acaria
PROGRAF
Tacrolimus Cap 0.5 MG
PROGRAF
Tacrolimus Cap 1 MG
PROGRAF
Tacrolimus Cap 5 MG
IMURAN
Azathioprine Tab 50 MG
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Acaria
Daily Dosage=3
Azathioprine (AZASAN) Tab 75 MG
Daily Dosage=3
RAPAMUNE 0.5 MG TABLET
RAPAMUNE Tab 1 MG
RAPAMUNE Tab 2 MG
RAPAMUNE Oral Soln 1 MG/ML
SPS
KAYEXALATE
Azathioprine ((AZASAN))Tab 100
MG
Sodium Polystyrene Sulfonate Oral
Susp 15 GM/60ML
*Sodium Polystyrene Sulfonate
Powder**
STERILE WATER FOR
IRRIGATIO
Daily Dosage=3
Max Qty=454/claim
97
Step Therapy
Preferred Specialty Drug List
Buckeye Community Health Plan provides coverage of a number of specialty drugs. All specialty drugs, such as
biopharmaceuticals and injectables, require PA to be approved for payment by Buckeye Community Health
Plan. PA requirements are programmed specific to the drug. The following products are the Buckeye
Community Health Plan 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
Brand
TEV-TROPIN
PA
Peginterferon Alfa-2a
Brand
PEGASYS
PA
Peginterferon Alfa-2b
Brand
PEG-INTRON
PA
Telaprevir
Brand
INCIVEK
PA
Boceprevir
Brand
VICTRELIS
PA
HUMAN GROWTH HORMONE
Somatropin, rh-GH
ALPHA INTERFERONS
ANTI-HEPATITIS AGENTS

Buckeye Community Health Plan Preferred Drug List

Transcription

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