Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

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1 2015 Georgia Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc lease read: This document contains information about the drugs we cover in this plan. ara solicitar este documento en español o para escuchar la traducción, llame al Servicio al Cliente al (TTY/TDD: ). lease note that the Georgia Medicaid referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (4/01/2015)

2 Non-referred Drugs Georgia Medicaid Cough & Cold Drug List LEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger. ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 MG CASULE BENZONATATE 100 MG CASULE BENZONATATE 200 MG CASULE Dextromethorphan olistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSENSION Dextromethorphan HBr ROBITUSSIN EDIATRIC COUGH SY Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF LUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/seudoephedrine HCl ALLANHIST DX DROS BROMHIST DX DROS BROTA DM LIQUID Q-TA DM ELIXIR BROMFED DM SYRU ENDACOF-D DROS Brophenaramine/Dextromethorphan HBr/henylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/henylephrine HCl C-HEN DM RONDEX-DM SYRU DE-CHLOR DM LIQUID NOHIST-DM D-COF SYRU SILDEC E-DM SYRU CORFEN DM TRI-DEX E Chlorpheniramine/Dextromethorphan HBr/seudoephedrine HCl EDIATRIC COUGH-COLD LIQUID MESEHIST DM KIDKARE COUGH/COLD Dexchlorpheniramine/seudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETA LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID romethazine HCl/Dextromethorphan HBr ROMETHAZINE-DM SYRU Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMTOM EXECTORANTS DECONGESTANT-EXECTORANT COMBINATIONS Guaifenesin/henylephrine HCl DONATUSSIN DROS E-GUAI DROS DESEC LIQUID RESCON-GG LIQUID Guaifenesin/Dextromethorphan HBr/henylephreine ROBAFEN CF SYRU referred Drugs NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION NON-NARCOTIC DECONGESTANT-EXECTORANT-ANTITUSSIVE Last updated 07/31/14 age 1 of 2

3 Georgia Medicaid Cough & Cold Drug List LEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger. Non-referred Drugs referred Drugs NON-NARCOTIC ANTITUSSIVE AND EXECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID SIMUC-DM ELIXIR GUAIFENESIN DM SYRU Q-TUSSIN-DM SYRU EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRU REFENESEN DM SILTUSSIN DM DAS COUGH SYRU MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID Chlorpheniramine/Hydrocodone olistirex TUSSIONEX ENNKINETIC SUS TUSSICAS (min. age 6 years old) HYDROCODONE-CHLORHENIRAMINE SUSENSION (min. age 6 years old) Codeine hosphate/romethazine HCl ROMETHAZINE-CODEINE SYRU (min. age 6 years old) Dexbrompheniramine/Hydrocodone Bit/henylephrine HCl Codeine/henylephrine HCl/romethazine CYTUSS-HC NR SYRU HC/E/DBROM SYRU ROMETH VC W/COD SYRU ROMETHAZINE VC/COD SYRU HC 2.5-E 5-DBROM 1 MG SYRU seudoephedrine HCl/Codeine/Chlorpheniramine HENYLHISTINE DH HYDROMET SYRU NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROINE NARCOTIC ANTITUSSIVE-EXECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine hosphate/guaifenesin HYDROCODONE-GUAIFENESIN SYRU CHERATUSSIN AC SYRU NARCOF SYRU TUSSICLEAR DH SYRU GUAIFENESIN-CODEINE SYRU IOHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXECTORANT COMBINATIONS Codeine hosphate/guaifenesin/seudoephedrine HCl CHERATUSSIN DAC SYRU Last updated 07/31/14 age 2 of 2

4 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines**-*Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg amphetamine-dextroamphetamine oral tablet 20 mg amphetamine-dextroamphetamine oral tablet 30 mg *Amphetamines**-*Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg VYVANSE ORAL CASULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Anti-Obesity Agents**-*Lipase Inhibitors*** XENICAL ORAL CASULE 120 MG *Stimulants - Misc.**-*Stimulants - Misc.*** dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days) QL (62 EA per 31 days) ST; Notes (Must fail preferred Vyvanse or Amphetamine-dextroamphetami ne ER capsules within the past 100 days.); QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) A; AL (Min 12 Years and Max 21 Years) QL (62 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 1

5 Drug Name reference Details Coverage Details methylphenidate hcl er oral tablet extendedrelease* 10 mg methylphenidate hcl er oral tablet extendedrelease* 18 mg, 27 mg, 36 mg methylphenidate hcl er oral tablet extendedrelease* 20 mg methylphenidate hcl er oral tablet extendedrelease* 54 mg AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) methylphenidate hcl oral tablet 10 mg, 5 mg AL (Min 6 Years) methylphenidate hcl oral tablet 20 mg *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg *Aminoglycosides* *Aminoglycosides**-*Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA EN SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.2ML HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML SIMONI SUBCUTANEOUS* 100 MG/ML, 50 MG/0.5ML *Gold Compounds**-*Gold Compounds*** RIDAURA ORAL CASULE 3 MG QL (93 EA per 31 days); AL (Min 6 Years) A A A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 2

6 Drug Name reference Details Coverage Details *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 40 mg/ml diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hr* 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine oral tablet 10 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg ST; Notes (Must fail preferred meloxicam and one other generic DL NSAID within the past 100 days); QL (31 EA per 31 days) Notes (Maximum of a 5 day supply per Rx per month); QL (20 EA per 31 days) naproxen oral suspension 125 mg/5ml QL (2000 ML per 31 days) naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 3

7 Drug Name reference Details Coverage Details *yrimidine Synthesis Inhibitors**-*yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg *Analgesics - Nonnarcotic* *Analgesic Combinations**-*Analgesics-Sedatives*** butalbital-acetaminophen oral tablet mg QL (186 EA per 31 days) butalbital-apap-caffeine oral capsule mg butalbital-apap-caffeine oral tablet mg butalbital-asa-caffeine oral capsule mg *Analgesics Other**-*Analgesics Other*** acetaminophen oral solution 160 mg/5ml QL (186 EA per 31 days) QL (186 EA per 31 days) acetaminophen oral tablet 325 mg ; QL (279 EA per 31 days) acetaminophen oral tablet 500 mg ; QL (186 EA per 31 days) mapap oral liquid 160 mg/5ml pain & fever childrens oral solution 160 mg/5ml pain & fever childrens oral suspension 160 mg/5ml *Salicylates**-*Salicylates*** aspirin adult low strength oral tablet delayed release 81 mg aspirin ec oral tablet delayed release 325 mg aspirin oral tablet 325 mg aspirin oral tablet chewable 81 mg aspirin suppository 600 mg diflunisal oral tablet 500 mg eq aspirin low dose oral tablet delayed release 81 mg salsalate oral tablet 500 mg, 750 mg *Analgesics - Opioid* *Opioid Agonists**-*Opioid Agonists*** codeine sulfate oral tablet 15 mg, 30 mg, 60 mg QL (248 EA per 31 days) fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr A; QL (10 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 4

8 Drug Name reference Details Coverage Details hydromorphone hcl oral liquid 1 mg/ml hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg QL (248 EA per 31 days) hydromorphone hcl suppository 3 mg methadone hcl oral solution 10 mg/5ml, 5 mg/5ml methadone hcl oral tablet 10 mg, 5 mg QL (248 EA per 31 days) morphine sulfate (concentrate) oral solution 20 mg/ml morphine sulfate (pf) injection solution 0.5 mg/ml morphine sulfate (pf) intravenous* solution 2 mg/ml, 4 mg/ml, 8 mg/ml morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 200 mg, 30 mg, 60 mg morphine sulfate injection solution 10 mg/ml, 15 mg/ml, 5 mg/ml, 8 mg/ml morphine sulfate intravenous* solution 1 mg/ml, 25 mg/ml, 50 mg/ml morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml QL (248 EA per 31 days) morphine sulfate oral tablet 15 mg, 30 mg QL (248 EA per 31 days) morphine sulfate suppository 10 mg, 20 mg, 30 mg, 5 mg oxycodone hcl oral capsule 5 mg QL (248 EA per 31 days) oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg QL (248 EA per 31 days) tramadol hcl oral tablet 50 mg QL (248 EA per 31 days) *Opioid Combinations**-*Codeine Combinations*** acetaminophen-codeine #2 oral tablet mg QL (248 EA per 31 days) acetaminophen-codeine #3 oral tablet mg QL (248 EA per 31 days) acetaminophen-codeine #4 oral tablet mg QL (248 EA per 31 days) acetaminophen-codeine oral solution mg/5ml ASCOM-CODEINE ORAL CASULE MG QL (186 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 5

9 Drug Name reference Details Coverage Details butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule mg *Opioid Combinations**-*Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg QL (186 EA per 31 days) QL (186 EA per 31 days) QL (3720 ML per 31 days) QL (248 EA per 31 days) hydrocodone-ibuprofen oral tablet mg QL (155 EA per 31 days) *Opioid Combinations**-*Opioid Combinations*** ENDOCET ORAL TABLET MG, MG, MG oxycodone-acetaminophen oral tablet mg, mg, mg QL (248 EA per 31 days) QL (248 EA per 31 days) oxycodone-aspirin oral tablet mg QL (186 EA per 31 days) ROXICET ORAL TABLET MG QL (248 EA per 31 days) *Opioid artial Agonists**-*Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg butorphanol tartrate nasal solution 10 mg/ml QL (2.5 ML per 31 days) pentazocine-naloxone hcl oral tablet mg ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG *Androgens-Anabolic* *Anabolic Steroids**-*Anabolic Steroids*** oxandrolone oral tablet 10 mg, 2.5 mg A *Androgens**-*Androgens*** danazol oral capsule 100 mg, 200 mg, 50 mg methitest oral tablet 10 mg TESTIM TRANSDERMAL 50 MG/5GM A testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 6

10 Drug Name reference Details Coverage Details testosterone enanthate intramuscular* solution 200 mg/ml testosterone transdermal 12.5 mg/act (1%), 50 mg/5gm *Anorectal Agents* *Intrarectal Steroids**-*Intrarectal Steroids*** hydrocortisone enema 100 mg/60ml *Rectal Steroids**-*Rectal Steroids*** ROCTOSOL HC CREAM 2.5 % ROCTOZONE-HC CREAM 2.5 % *Antacids* *Antacid Combinations**-*Antacid & Simethicone*** aluminum-magnesium-simethicone oral suspension mg/5ml MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION MG/5ML *Antacids - Aluminum Salts**-*Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml *Antacids - Bicarbonate**-*Antacids - Bicarbonate*** A sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids - Calcium Salts*** calcium carbonate antacid oral tablet chewable 500 mg *Antacids - Magnesium Salts**-*Antacids - Magnesium Salts*** magnesium oxide oral tablet 250 mg, 400 mg, 420 mg *Anthelmintics* *Anthelmintics**-*Anthelmintics*** ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 mg QL (10 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 7

11 Drug Name reference Details Coverage Details IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 mg/ml *Antianginal Agents* *Nitrates**-*Nitrates*** isosorbide dinitrate er oral tablet extendedrelease* 40 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG *Antianxiety Agents* *Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg hydroxyzine hcl oral solution 10 mg/5ml QL (450 ML per 31 days) hydroxyzine hcl oral syrup 10 mg/5ml QL (450 ML per 31 days) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg meprobamate oral tablet 200 mg, 400 mg *Benzodiazepines**-*Benzodiazepines*** alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg diazepam injection solution 5 mg/ml AL (Min 9 Years) diazepam oral solution 1 mg/ml QL (1240 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 8

12 Drug Name reference Details Coverage Details diazepam oral tablet 10 mg, 2 mg, 5 mg lorazepam injection solution 2 mg/ml, 4 mg/ml lorazepam oral tablet 0.5 mg, 1 mg, 2 mg oxazepam oral capsule 10 mg, 15 mg, 30 mg *Antiarrhythmics* *Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg procainamide hcl injection solution 100 mg/ml, 500 mg/ml quinidine gluconate er oral tablet extendedrelease* 324 mg quinidine gluconate injection solution 80 mg/ml quinidine sulfate oral tablet 300 mg *Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous* solution 20 mg/ml mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg *Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg *Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii*** amiodarone hcl intravenous* solution 150 mg/3ml amiodarone hcl oral tablet 200 mg, 400 mg ACERONE ORAL TABLET 200 MG, 400 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 9

13 Drug Name reference Details Coverage Details *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies**-*Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents**-*Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 mg/2ml *Bronchodilators - Anticholinergics**-*Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT A QL (25.8 GM per 31 days) ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators**-*Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 mg montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable 4 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg *Steroid Inhalants**-*Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT QL (1 EA per 30 days) AL (Min 1 Months and Max 2 Years) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 10

14 Drug Name reference Details Coverage Details budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ULMICORT INHALATION SUSENSION 1 MG/2ML *Sympathomimetics**-*Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL, SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ipratropium-albuterol inhalation solution (3) mg/3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Sympathomimetics**-*Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (10.6 GM per 30 days) QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (4 GM per 20 days) QL (13 GM per 30 days) QL (720 ML per 31 days) QL (10.2 GM per 30 days) QL (720 ML per 31 days) QL (60 EA per 30 days) QL (300 ML per 31 days) albuterol sulfate oral syrup 2 mg/5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2 mg, 4 mg FORADIL AEROLIZER INHALATION CASULE 12 MCG QL (60 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 11

15 Drug Name reference Details Coverage Details metaproterenol sulfate oral syrup 10 mg/5ml SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 mg/ml terbutaline sulfate oral tablet 2.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines**-*Xanthines*** aminophylline intravenous* solution 25 mg/ml ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg theophylline oral solution 80 mg/15ml *Anticoagulants* *Coumarin Anticoagulants**-*Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors**-*Direct Factor Xa Inhibitors*** QL (60 EA per 30 days) QL (36 GM per 31 days) XARELTO ORAL TABLET 10 MG QL (35 EA per 365 days) *Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous* solution 100 mg/ml, 150 mg/ml enoxaparin sodium subcutaneous* solution 120 mg/0.8ml, 80 mg/0.8ml enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml QL (24 ML per 31 days) QL (28 ML per 31 days) QL (22.4 ML per 31 days) QL (8.4 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 12

16 Drug Name reference Details Coverage Details enoxaparin sodium subcutaneous* solution 60 mg/0.6ml *Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous* solution 10 mg/0.8ml fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml fondaparinux sodium subcutaneous* solution 5 mg/0.4ml fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg QL (16.8 ML per 31 days) QL (11.2 ML per 31 days) QL (16 ML per 31 days) QL (5.6 ML per 31 days) QL (8.4 ML per 31 days) diazepam 10 mg, 2.5 mg, 20 mg QL (3 EA per 31 days) *Anticonvulsants - Misc.**-*Anticonvulsants - Misc.*** carbamazepine oral suspension 100 mg/5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 mg QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 mg QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 mg QL (310 EA per 31 days) gabapentin oral capsule 300 mg QL (372 EA per 31 days) gabapentin oral capsule 400 mg QL (279 EA per 31 days) gabapentin oral solution 250 mg/5ml QL (2230 ML per 31 days) gabapentin oral tablet 600 mg, 800 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg lamotrigine oral tablet 25 mg QL (310 EA per 31 days) lamotrigine oral tablet chewable 25 mg, 5 mg QL (310 EA per 31 days) levetiracetam intravenous* solution 500 mg/5ml levetiracetam oral solution 100 mg/ml QL (1000 ML per 31 days) levetiracetam oral tablet 1000 mg, 500 mg, 750 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 13

17 Drug Name reference Details Coverage Details levetiracetam oral tablet 250 mg QL (372 EA per 31 days) oxcarbazepine oral suspension 300 mg/5ml QL (1240 ML per 31 days) oxcarbazepine oral tablet 150 mg QL (310 EA per 31 days) oxcarbazepine oral tablet 300 mg QL (248 EA per 31 days) oxcarbazepine oral tablet 600 mg primidone oral tablet 250 mg QL (248 EA per 31 days) primidone oral tablet 50 mg QL (310 EA per 31 days) topiramate oral capsule sprinkle 15 mg, 25 mg QL (310 EA per 31 days) topiramate oral tablet 100 mg, 25 mg, 50 mg QL (310 EA per 31 days) topiramate oral tablet 200 mg QL (248 EA per 31 days) zonisamide oral capsule 100 mg QL (186 EA per 31 days) zonisamide oral capsule 25 mg QL (310 EA per 31 days) zonisamide oral capsule 50 mg QL (372 EA per 31 days) *Gaba Modulators**-*Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2 mg, 4 mg *Hydantoins**-*Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 mg pe/2ml EGANONE ORAL TABLET 250 MG QL (372 EA per 31 days) phenytoin oral suspension 125 mg/5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 mg QL (372 EA per 31 days) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg phenytoin sodium injection solution 50 mg/ml *Succinimides**-*Succinimides*** ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml QL (930 ML per 31 days) *Valproic Acid**-*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hr* 250 mg divalproex sodium er oral tablet extended release 24 hr* 500 mg QL (310 EA per 31 days) QL (279 EA per 31 days) divalproex sodium oral capsule sprinkle 125 mg QL (310 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 14

18 Drug Name reference Details Coverage Details divalproex sodium oral tablet delayed release 125 mg, 250 mg divalproex sodium oral tablet delayed release 500 mg QL (310 EA per 31 days) QL (279 EA per 31 days) valproic acid oral capsule 250 mg QL (310 EA per 31 days) valproic acid oral solution 250 mg/5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 mg/5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg *Antidepressants - Misc.**-*Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg *Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 mg tranylcypromine sulfate oral tablet 10 mg *Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg fluoxetine hcl oral solution 20 mg/5ml fluoxetine hcl oral tablet 10 mg, 20 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 15

19 Drug Name reference Details Coverage Details fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg sertraline hcl oral tablet 100 mg, 25 mg, 50 mg *Serotonin Modulators**-*Serotonin Modulators*** nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 50 mg *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg *Tricyclic Agents**-*Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg, 50 mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg QL (31 EA per 31 days) nortriptyline hcl oral solution 10 mg/5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10 mg, 5 mg *Antidiabetics* *Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 16

20 Drug Name reference Details Coverage Details *Antidiabetic Combinations**-*Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* MG, MG, MG JENTADUETO ORAL TABLET MG, MG, MG *Antidiabetic Combinations**-*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** INVOKAMET ORAL TABLET MG, MG, MG, MG *Antidiabetic Combinations**-*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet mg, mg, mg glyburide-metformin oral tablet mg, mg, mg *Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedion e Combinations*** AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 8-4 MG *Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET MG, MG pioglitazone hcl-metformin hcl oral tablet mg, mg ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (62 EA per 31 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. ) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 17

21 Drug Name reference Details Coverage Details *Biguanides**-*Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hr* 500 mg metformin hcl er oral tablet extended release 24 hr* 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 mg, 850 mg RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other**-*Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG TRADJENTA ORAL TABLET 5 MG *Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* 2 MG BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 MG *Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG QL (2 EA per 31 days) QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (31 EA per 31 Days) ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days) ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 18

22 Drug Name reference Details Coverage Details pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg *Insulin**-*Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS* 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors**-*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) ; QL (60 ML per 31 days) QL (60 ML per 31 days) ; QL (60 ML per 31 days) ; QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. ) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 19

23 Drug Name reference Details Coverage Details JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylureas**-*Sulfonylureas*** chlorpropamide oral tablet 100 mg, 250 mg glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg *Antidiarrheals* *Antiperistaltic Agents**-*Antiperistaltic Agents*** diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral capsule 2 mg *Antidotes* *Antidotes - Chelating Agents**-*Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG *Antidotes**-*Antidotes*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg *Opioid Antagonists**-*Opioid Antagonists*** naltrexone hcl oral tablet 50 mg *Antiemetics* *5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists*** ondansetron hcl oral solution 4 mg/5ml ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. ) A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 20

24 Drug Name reference Details Coverage Details ondansetron hcl oral tablet 4 mg, 8 mg ondansetron oral tablet dispersible 4 mg, 8 mg *Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg meclizine hcl oral tablet chewable 25 mg travel sickness oral tablet chewable 25 mg *Antifungals* *Antifungals**-*Antifungals*** griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg nystatin oral tablet unit terbinafine hcl oral tablet 250 mg *Imidazole-Related Antifungals**-*Imidazoles*** ketoconazole oral tablet 200 mg *Imidazole-Related Antifungals**-*Triazoles*** fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg *Antihistamines* *Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** allergy oral tablet 4 mg *Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 mg BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML QL (450 ML per 31 days) diphenhydramine hcl oral capsule 25 mg, 50 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 21

25 Drug Name reference Details Coverage Details diphenhydramine hcl oral tablet 25 mg *Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** allergy oral tablet dispersible 10 mg cetirizine hcl childrens oral solution 1 mg/ml ; QL (300 ML per 31 days) cetirizine hcl oral syrup 1 mg/ml, 5 mg/5ml ; QL (300 ML per 31 days) cetirizine hcl oral tablet 10 mg, 5 mg childrens loratadine oral syrup 5 mg/5ml ; QL (310 ML per 31 days) fexofenadine hcl childrens oral suspension 30 mg/5ml fexofenadine hcl oral tablet 180 mg, 60 mg levocetirizine dihydrochloride oral solution 2.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg loratadine hives relief oral solution 5 mg/5ml loratadine oral tablet 10 mg *Antihistamines - henothiazines**-*antihistamines - henothiazines*** promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl suppository 25 mg, 50 mg ROMETHEGAN SUOSITORY 25 MG *Antihistamines - iperidines**-*antihistamines - iperidines*** ST; Notes (Must fail preferred loratadine solution and cetirizine syrup within the past 100 days) cyproheptadine hcl oral syrup 2 mg/5ml QL (300 ML per 31 days) cyproheptadine hcl oral tablet 4 mg *Antihyperlipidemics* *Bile Acid Sequestrants**-*Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 22

26 Drug Name reference Details Coverage Details *Fibric Acid Derivatives**-*Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral tablet 600 mg *Hmg Coa Reductase Inhibitors**-*Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg lovastatin oral tablet 10 mg, 20 mg, 40 mg pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg *Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 MG A *Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG *Antihypertensives* *Ace Inhibitors**-*Ace Inhibitors*** benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 23

27 Drug Name reference Details Coverage Details *Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** losartan potassium oral tablet 100 mg, 25 mg, 50 mg *Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg guanfacine hcl oral tablet 1 mg, 2 mg methyldopa oral tablet 250 mg, 500 mg *Antiadrenergic Antihypertensives**-*Antiadrenergics - eripherally Acting*** doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg prazosin hcl oral capsule 1 mg, 2 mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg *Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril-hydrochlorothiazide oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg *Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet mg, mg, mg *Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet mg, mg QL (31 EA per 31 days) QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 24

28 Drug Name reference Details Coverage Details bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg propranolol-hctz oral tablet mg, mg *Vasodilators**-*Vasodilators*** hydralazine hcl injection solution 20 mg/ml hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.*** metronidazole oral tablet 250 mg, 500 mg trimethoprim oral tablet 100 mg vancomycin hcl intravenous* solution reconstituted 1000 mg, 500 mg, 750 mg vancomycin hcl oral capsule 125 mg, 250 mg A *Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** sulfamethoxazole-tmp ds oral tablet mg sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg *Antiprotozoal Agents**-*Antiprotozoal Agents*** atovaquone oral suspension 750 mg/5ml *Leprostatics**-*Leprostatics*** dapsone oral tablet 100 mg, 25 mg *Lincosamides**-*Lincosamides*** clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml clindamycin phosphate intravenous* solution 300 mg/2ml QL (1200 ML per 31 days) QL (2400 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 25

29 Drug Name reference Details Coverage Details *Oxazolidinones**-*Oxazolidinones*** SIVEXTRO ORAL TABLET 200 MG A *Antimalarials* *Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet mg, mg *Antimalarials**-*Antimalarials*** DARARIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg primaquine phosphate oral tablet 26.3 mg *Antimyasthenic/Cholinergic Agents* *Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 MG/5ML MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG pyridostigmine bromide oral tablet 60 mg *Antimycobacterial Agents* *Antimycobacterial Agents**-*Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg isoniazid injection solution 100 mg/ml isoniazid oral tablet 100 mg, 300 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin intravenous* solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg *Antineoplastics And Adjunctive Therapies* *Alkylating Agents**-*Alkylating Agents*** HEXALEN ORAL CASULE 50 MG A MYLERAN ORAL TABLET 2 MG A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 26

30 Drug Name reference Details Coverage Details *Alkylating Agents**-*Imidazotetrazines*** temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg *Alkylating Agents**-*Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG A cyclophosphamide oral capsule 25 mg, 50 mg A LEUKERAN ORAL TABLET 2 MG A *Alkylating Agents**-*Nitrosoureas*** lomustine oral capsule 10 mg, 100 mg, 40 mg A *Antimetabolites**-*Antimetabolites*** ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML capecitabine oral tablet 150 mg, 500 mg A fluorouracil intravenous* solution 500 mg/10ml A gemcitabine hcl intravenous* solution 1 gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, 200 mg mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg methotrexate sodium (pf) injection solution 1 gm/40ml, 25 mg/ml, 250 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium injection solution reconstituted 1 gm TABLOID ORAL TABLET 40 MG A *Antineoplastic - Angiogenesis Inhibitors**-*Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML *Antineoplastic - Hedgehog athway Inhibitors**-*Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 MG A A A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 27

31 Drug Name reference Details Coverage Details *Antineoplastic - Hormonal And Related Agents**-*Antiadrenals*** LYSODREN ORAL TABLET 500 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiandrogens*** XTANDI ORAL CASULE 40 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiestrogens*** tamoxifen citrate oral tablet 10 mg, 20 mg *Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors*** anastrozole oral tablet 1 mg letrozole oral tablet 2.5 mg *Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 MG A *Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs*** TRELSTAR DEOT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 MG TRELSTAR DEOT MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 MG TRELSTAR LA INTRAMUSCULAR* SUSENSION RECONSTITUTED MG TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED MG TRELSTAR MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 22.5 MG *Antineoplastic - Hormonal And Related Agents**-*rogestins-Antineoplastic*** megestrol acetate oral suspension 40 mg/ml QL (600 ML per 31 days) megestrol acetate oral tablet 20 mg, 40 mg A A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 28

32 Drug Name reference Details Coverage Details *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG A SUTENT ORAL CASULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100 MG, 500 MG A CARELSA ORAL TABLET 100 MG, 300 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG, 400 MG ICLUSIG ORAL TABLET 15 MG, 45 MG A SRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CASULE 150 MG, 200 MG TYKERB ORAL TABLET 250 MG A XALKORI ORAL CASULE 200 MG, 250 MG A A A A; QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ A A A A A 29

33 Drug Name reference Details Coverage Details ZYKADIA ORAL CASULE 150 MG A; QL (155 EA per 31 days) *Antineoplastic Enzyme Inhibitors**-*Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Antineoplastic Enzymes**-*Antineoplastic Enzymes*** ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED UNIT *Antineoplastics Misc.**-*Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg *Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg *Mitotic Inhibitors**-*Mitotic Inhibitors*** etoposide oral capsule 50 mg A *Antiparkinson Agents* *Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg trihexyphenidyl hcl oral elixir 0.4 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg *Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet 2.5 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 30 A A

34 Drug Name reference Details Coverage Details *Antiparkinson Dopaminergics**-*Levodopa Combinations*** carbidopa-levodopa er oral tablet extendedrelease* mg, mg carbidopa-levodopa oral tablet mg, mg, mg *Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg *Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg *Antipsychotics/Antimanic Agents* *Antimanic Agents**-*Antimanic Agents*** lithium carbonate er oral tablet extendedrelease* 300 mg, 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml *Benzisoxazoles**-*Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 39 MG/0.25ML ST; Notes (Must fail preferred ropinirole within the past 100 days.) A; QL (0.75 ML per 28 days); AL (Min 18 Years) A; QL (1 ML per 28 days); AL (Min 18 Years) A; QL (1.5 ML per 28 Days); AL (Min 18 Years) A; QL (0.25 ML per 28 days); AL (Min 18 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 31

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