2018 Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "2018 Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs)"

Transcription

1 2018 Georgia Families Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. lease read: This document tells about the drugs we cover in this plan. If you speak a different language or need something in Braille or audio, don t worry. We can provide translations and alternate formats at no cost to you. Just give us a call tollfree. Georgia Families and eachcare for Kids members call lanning for Healthy Babies members call All TTY users call Si habla otro idioma o si necesita información en Braille o en audio, no se preocupe. odemos ofrecerle traducciones y formatos alternativos sin costo para usted. Simplemente llámenos sin costo. Los miembros de Georgia Families y eachcare for Kids llamen al Los miembros de lanning for Healthy Babies llamen al Todos los usuarios de TTY llamen al This list is updated each quarter. roviders, please visit our website for updates to the preferred drug list: Members, please visit our website for updates to the preferred drug list: Families/harmacy-Services Last updated (4/01/2018) WellCare proudly serves Georgia Families, eachcare for Kids and lanning for Healthy Babies members. GA032872_CAD_LTR_ENG State Approved WellCare 2016 GA_01_16_v1 GA6CADLTR72830E_0116

2 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. Drug Name This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10, 100, 40, 60, 80 reference Details Coverage Details QL (31 EA per 31 days) atomoxetine hcl oral capsule 18 QL (62 EA per 31 days) atomoxetine hcl oral capsule 25 QL (93 EA per 31 days) *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 *Lipase Inhibitors*** XENICAL ORAL CASULE 120 MG *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 40, 5 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) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) A; AL (Min 12 Years and Max 21 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 1

3 reference Details Coverage Details dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er oral tablet extended release 10, 20 methylphenidate hcl er oral tablet extended release 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 54 methylphenidate hcl er oral tablet extended release 54 QL (62 EA per 31 days); AL (Min 6 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 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) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet chewable 10, 2.5, 5 *Alternative Medicines* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 *Aminoglycosides* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) XELJANZ ORAL TABLET 5 MG A; QL (62 EA per 31 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML A A; QL (31 EA per 31 days) A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 2

4 HUMIRA EN-SORIASIS STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS REFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 40 /ml diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen childrens oral suspension 100 /5ml ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200, 400, 600, 800 indomethacin oral capsule 25, 50 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 reference Details Coverage Details =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 3 A A QL (31 EA per 31 days) Maximum of a 5 day supply per Rx per month; QL (20 EA per 31 days) naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 220 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20

5 reference Details Coverage Details sulindac oral tablet 150, 200 *yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION REFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics Other*** acetaminophen oral solution 160 /5ml acetaminophen oral tablet 325 QL (279 EA per 31 days) acetaminophen oral tablet 500 QL (186 EA per 31 days) acetaminophen rectal suppository 650 apap oral tablet 325 QL (279 EA per 31 days) infants silapap oral solution 100 /ml mapap oral liquid 160 /5ml pain & fever childrens oral solution 160 /5ml pain & fever childrens oral suspension 160 /5ml *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet QL (186 EA per 31 days) butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet butalbital-asa-caffeine oral capsule *Salicylates*** aspirin adult low strength oral tablet delayed release 81 aspirin ec oral tablet delayed release 325 aspirin oral tablet 325 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 4 A A A QL (186 EA per 31 days) QL (186 EA per 31 days)

6 reference Details Coverage Details aspirin oral tablet chewable 81 aspirin oral tablet delayed release 81 aspirin rectal suppository 600 diflunisal oral tablet 500 eq aspirin low dose oral tablet delayed release 81 salsalate oral tablet 500, 750 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet QL (248 EA per 31 days) acetaminophen-codeine #3 oral tablet QL (248 EA per 31 days) acetaminophen-codeine #4 oral tablet QL (248 EA per 31 days) acetaminophen-codeine oral solution /5ml ASCOM-CODEINE ORAL CASULE MG butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet , 5-325, =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 5 QL (186 EA per 31 days) 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 QL (155 EA per 31 days) *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QL (248 EA per 31 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr hydromorphone hcl oral liquid 1 /ml A; QL (10 EA per 30 days) hydromorphone hcl oral tablet 2, 4, 8 QL (248 EA per 31 days) hydromorphone hcl rectal suppository 3 methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 QL (248 EA per 31 days)

7 reference Details Coverage Details morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate (pf) injection solution 0.5 /ml morphine sulfate (pf) intravenous solution 2 /ml, 4 /ml, 8 /ml morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate injection solution 10 /ml, 15 /ml, 5 /ml, 8 /ml morphine sulfate intravenous solution 1 /ml, 25 /ml, 50 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml QL (248 EA per 31 days) morphine sulfate oral tablet 15, 30 QL (248 EA per 31 days) morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl er oral tablet er 12 hour abusedeterrent 10, 15, 20, 30, 40, 60, 80 ST; Must fail preferred Morphine ER tablets within the past 100 days; QL (62 EA per 31 days); AL (Min 11 Years) oxycodone hcl oral capsule 5 QL (248 EA per 31 days) oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 QL (248 EA per 31 days) tramadol hcl oral tablet 50 QL (248 EA per 31 days) *Opioid Combinations*** ENDOCET ORAL TABLET MG, MG, MG oxycodone-acetaminophen oral tablet , 5-325, QL (248 EA per 31 days) QL (248 EA per 31 days) oxycodone-aspirin oral tablet QL (186 EA per 31 days) *Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 butorphanol tartrate nasal solution 10 /ml QL (2.5 ML per 31 days) pentazocine-naloxone hcl oral tablet A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 6

8 reference Details Coverage Details ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG, MG *Androgens-Anabolic* *Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A *Androgens*** danazol oral capsule 100, 200, 50 methitest oral tablet 10 TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 12.5 /act (1%), 50 /5gm (1%) *Anorectal Agents* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml *Rectal Steroids*** ROCTOSOL HC RECTAL CREAM 2.5 % ROCTOZONE-HC RECTAL CREAM 2.5 % *Antacids* *Antacid & Simethicone*** aluminum-magnesium-simethicone oral suspension /5ml MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION MG/5ML *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325, 650 A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 7

9 *Antacids - Calcium Salts*** calcium carbonate antacid oral suspension 1250 /5ml calcium carbonate antacid oral tablet 648 calcium carbonate antacid oral tablet chewable 500, 750 *Antacids - Magnesium Salts*** magnesium oxide oral tablet 250, 400, 420 *Anthelmintics* *Anthelmintics*** reference Details Coverage Details ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 hydroxyzine hcl oral solution 10 /5ml QL (450 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 8

10 reference Details Coverage Details hydroxyzine hcl oral syrup 10 /5ml QL (450 ML per 31 days) hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 *Benzodiazepines*** alprazolam oral tablet 0.25, 0.5, 1, 2 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75, 7.5 AL (Min 9 Years) diazepam oral solution 1 /ml QL (1240 ML per 31 days) diazepam oral tablet 10, 2, 5 lorazepam injection solution 2 /ml, 4 /ml lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous solution 20 /ml mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 MULTAQ ORAL TABLET 400 MG A 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 9

11 *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED MCG/DOSE ANORO ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED MCG/INH COMBIVENT RESIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, mcg/act, mcg/act ipratropium-albuterol inhalation solution (3) /3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml reference Details Coverage Details QL (60 EA per 30 days); AL (Min 4 Years and Max 5 Years) QL (60 EA per 31 days) QL (4 GM per 20 days) QL (13 GM per 30 days) QL (1 EA per 31 days); AL (Min 12 Years) QL (720 ML per 31 days) QL (10.2 GM per 30 days) A QL (720 ML per 31 days) QL (60 EA per 30 days) QL (300 ML per 31 days) albuterol sulfate oral syrup 2 /5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG levalbuterol tartrate inhalation aerosol 45 mcg/act QL (60 EA per 30 days) QL (30 GM per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 10

12 reference Details Coverage Details STRIVERDI RESIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** QL (4 GM per 31 days) QL (36 GM per 31 days) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT QL (25.8 GM per 31 days) INCRUSE ELLITA INHALATION AEROSOL OWDER BREATH QL (1 EA per 31 days) ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) SIRIVA RESIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 *Steroid Inhalants*** ARNUITY ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT 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 QL (4 GM per 31 days) AL (Min 1 Months and Max 2 Years) QL (30 EA per 31 days) 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 11

13 reference Details Coverage Details ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /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 QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT *Xanthines*** aminophylline intravenous solution 25 /ml ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml *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, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 12 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 (8.7 GM per 31 days) QL (10.6 GM per 31 Days) XARELTO ORAL TABLET 15 MG QL (62 EA per 31 days) XARELTO ORAL TABLET 20 MG ST; Must failed preferred Warfarin within the past 90 days; QL (31 EA per 31 days)

14 reference Details Coverage Details XARELTO STARTER ACK ORAL TABLET THERAY ACK 15 & 20 MG *Heparins And Heparinoid-Like Agents*** heparin sodium lock flush intravenous solution 100 unit/ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 150 /ml enoxaparin sodium subcutaneous solution 120 /0.8ml, 80 /0.8ml enoxaparin sodium subcutaneous solution 30 /0.3ml enoxaparin sodium subcutaneous solution 40 /0.4ml enoxaparin sodium subcutaneous solution 60 /0.6ml *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml fondaparinux sodium subcutaneous solution 2.5 /0.5ml fondaparinux sodium subcutaneous solution 5 /0.4ml fondaparinux sodium subcutaneous solution 7.5 /0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 13 QL (51 EA per 30 days) QL (93 ML per 31 days) QL (31 ML per 31 days) QL (24.8 ML per 31 days) QL (9.3 ML per 31 days) QL (12.4 ML per 31 days) QL (18.6 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 rectal gel 10, 2.5, 20 QL (3 EA per 31 days) *Anticonvulsants - Misc.*** carbamazepine oral suspension 100 /5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 QL (310 EA per 31 days) gabapentin oral capsule 300 QL (372 EA per 31 days)

15 reference Details Coverage Details gabapentin oral capsule 400 QL (279 EA per 31 days) gabapentin oral solution 250 /5ml QL (2230 ML per 31 days) gabapentin oral tablet 600, 800 lamotrigine oral tablet 100, 150, 200 lamotrigine oral tablet 25 QL (310 EA per 31 days) lamotrigine oral tablet chewable 25, 5 QL (310 EA per 31 days) levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 primidone oral tablet 250 QL (248 EA per 31 days) primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml EGANONE ORAL TABLET 250 MG QL (372 EA per 31 days) phenytoin oral suspension 125 /5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 QL (372 EA per 31 days) phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml *Succinimides*** ethosuximide oral capsule 250 AL (Min 3 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 14

16 reference Details Coverage Details ethosuximide oral solution 250 /5ml *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 divalproex sodium er oral tablet extended release 24 hour 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 QL (930 ML per 31 days); AL (Min 3 Years) QL (310 EA per 31 days) QL (279 EA per 31 days) QL (310 EA per 31 days) QL (310 EA per 31 days) QL (279 EA per 31 days) valproic acid oral capsule 250 QL (310 EA per 31 days) valproic acid oral solution 250 /5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 15

17 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 60 duloxetine hcl oral capsule delayed release particles 30, 40 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 reference Details Coverage Details QL (62 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 16

18 reference Details Coverage Details nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 17

19 BASAGLAR KWIKEN SOLUTION EN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 200 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR 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 HUMULIN R U-500 KWIKEN SUBCUTANEOUS SOLUTION EN- INJECTOR 500 UNIT/ML reference Details Coverage Details QL (60 ML per 31 days) QL (60 ML per 31 days) QL (30 ML per 30 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 18

20 NOVOLIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLOG ENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML BYDUREON SUBCUTANEOUS EN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSENSION RECONSTITUTED ER 2 MG VICTOZA SUBCUTANEOUS SOLUTION EN-INJECTOR 18 MG/3ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG reference Details Coverage Details 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) A; QL (4 ML per 28 days) A; QL (4 EA per 28 days) A; QL (4 EA per 28 days) A; QL (9 ML per 30 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 19

21 reference Details Coverage Details STEGLATRO ORAL TABLET 15 MG, 5 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , , *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET MG pioglitazone hcl-metformin hcl oral tablet , *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Antidiarrheals* *Antidiarrheal Agents - Misc.*** FLORANEX ORAL ACKET FLORASTOR KIDS ORAL ACKET 250 MG ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 20

22 reference Details Coverage Details pink bismuth oral suspension 262 /15ml *Antidiarrheal Combinations*** CULTURELLE DIGESTIVE HEALTH ORAL CASULE *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral capsule 2 *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Antidotes* *Antidotes - Chelating Agents*** JADENU ORAL TABLET 180 MG, 360 MG, 90 MG JADENU SRINKLE ORAL ACKET 180 MG, 360 MG, 90 MG *Antidotes*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml, 4 /10ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML *Antiemetics* *5-Ht3 Receptor Antagonists*** ondansetron hcl oral solution 4 /5ml ondansetron oral tablet dispersible 4, 8 *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5, 25 meclizine hcl oral tablet chewable 25 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 21 A A

23 reference Details Coverage Details travel sickness oral tablet chewable 25 *Antifungals* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *Antihistamines* *Antihistamines - Alkylamines*** allergy oral tablet 4 *Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral elixir 12.5 /5ml diphenhydramine hcl oral tablet 25 *Antihistamines - Non-Sedating*** allergy oral tablet dispersible 10 cetirizine hcl childrens oral solution 1 /ml cetirizine hcl oral syrup 1 /ml, 5 /5ml QL (450 ML per 31 days) ST; Must fail preferred Loratadine within the past 180 days; QL (300 ML per 31 days) ST; Must fail preferred Loratadine within the past 180 days; QL (300 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 22

24 reference Details Coverage Details cetirizine hcl oral tablet 10, 5 ST; Must fail preferred Loratadine within the past 180 days childrens loratadine oral syrup 5 /5ml QL (310 ML per 31 days) fexofenadine hcl childrens oral suspension 30 /5ml fexofenadine hcl oral tablet 180, 60 levocetirizine dihydrochloride oral solution 2.5 /5ml levocetirizine dihydrochloride oral tablet 5 loratadine hives relief oral solution 5 /5ml QL (310 ML per 31 days) loratadine oral tablet 10 *Antihistamines - henothiazines*** promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 25 ROMETHEGAN RECTAL SUOSITORY 25 MG *Antihistamines - iperidines*** cyproheptadine hcl oral syrup 2 /5ml QL (300 ML per 31 days) cyproheptadine hcl oral tablet 4 *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm *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 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 54 gemfibrozil oral tablet 600 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 23

25 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 fluvastatin sodium er oral tablet extended release 24 hour 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors*** reference Details Coverage Details ezetimibe oral tablet 10 A *Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet , , 20-25, captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet 10-25, lisinopril-hydrochlorothiazide oral tablet , , *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 24

26 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 *Angiotensin II Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet , , valsartan-hydrochlorothiazide oral tablet , , , , *Angiotensin II Receptor Antagonists*** irbesartan oral tablet 150, 300, 75 losartan potassium oral tablet 100, 25, 50 olmesartan medoxomil oral tablet 20, 40, 5 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antiadrenergics - eripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet , reference Details Coverage Details QL (31 EA per 31 days) QL (31 EA per 31 days) ST; Must fail 2 of 3 preferred(losartan potassium, irbesartan, and valsartan tablets) within the past 100 days =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 25

27 reference Details Coverage Details bisoprolol-hydrochlorothiazide oral tablet , , *Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 tinidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 100 gm, 1000, 500, 750 vancomycin hcl oral capsule 125, 250 A *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , *Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml A *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous solution 150 /ml *Oxazolidinones*** linezolid oral tablet 600 A 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 26

28 *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet , *Antimalarials*** reference Details Coverage Details DARARIM ORAL TABLET 25 MG A hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimyasthenic Agents* *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CASULE 50 MG A MYLERAN ORAL TABLET 2 MG A *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG, 500 MG A *Antiadrenals*** LYSODREN ORAL TABLET 500 MG A *Antiandrogens*** bicalutamide oral tablet 50 flutamide oral capsule 125 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 27

29 *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** reference Details Coverage Details capecitabine oral tablet 150, 500 A fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 /10ml gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/52.6ml, 200 /5.26ml gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 200 mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 1 gm/40ml, 100 /4ml, 200 /8ml, 25 /ml, 250 /10ml, 50 /2ml methotrexate sodium injection solution 250 /10ml, 50 /2ml methotrexate sodium injection solution reconstituted 1 gm TABLOID ORAL TABLET 40 MG A *Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG A *Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 MG A *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 MG A *Antineoplastic - Monoclonal Antibodies*** HERCETIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 440 MG ODIVO INTRAVENOUS SOLUTION 100 MG/10ML, 40 MG/4ML *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 28 A A A A A A

30 SUTENT ORAL CASULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic - Tyrosine Kinase Inhibitors*** reference Details Coverage Details BOSULIF ORAL TABLET 100 MG, 500 MG A CARELSA ORAL TABLET 100 MG, 300 MG A GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG A; QL (31 EA per 31 days) ICLUSIG ORAL TABLET 15 MG, 45 MG A imatinib mesylate oral tablet 100, 400 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 A TYKERB ORAL TABLET 250 MG A XALKORI ORAL CASULE 200 MG, 250 MG A ZYKADIA ORAL CASULE 150 MG A; QL (155 EA per 31 days) *Antineoplastic Enzymes*** ONCASAR INJECTION SOLUTION 750 UNIT/ML *Antineoplastics Misc.*** hydroxyurea oral capsule 500 *Aromatase Inhibitors*** anastrozole oral tablet 1 exemestane oral tablet 25 A; QL (31 EA per 31 days) letrozole oral tablet 2.5 *Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 MG A *Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100, 200, 350, 50 leucovorin calcium oral tablet 10, 15, 25, 5 A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 29

31 *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Lhrh Analogs*** TRELSTAR INTRAMUSCULAR SUSENSION RECONSTITUTED MG, 3.75 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG *Mitotic Inhibitors*** reference Details Coverage Details etoposide oral capsule 50 A *Nitrogen Mustards*** cyclophosphamide oral capsule 25, 50 A LEUKERAN ORAL TABLET 2 MG A melphalan oral tablet 2 A *Nitrosoureas*** lomustine oral capsule 10, 100, 40 A *rogestins-antineoplastic*** megestrol acetate oral suspension 40 /ml QL (600 ML per 31 days) megestrol acetate oral tablet 20, 40 *Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 30 A A A A A

32 reference Details Coverage Details amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 31 QL (62 EA per 31 days) A; QL (0.75 ML per 28 days) A; QL (1 ML per 28 days) A; QL (1.5 ML per 28 days) A; QL (0.25 ML per 28 days)

33 INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 273 MG/0.875ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 410 MG/1.315ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 546 MG/1.75ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 819 MG/2.625ML RISERDAL CONSTA INTRAMUSCULAR SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml reference Details Coverage Details A; QL (0.5 ML per 28 days) A; QL (0.88 ML per 91 days) A; QL (1.31 ML per 91 days) A; QL (1.75 ML per 91 days) A; QL (2.63 ML per 91 days) A; QL (2 EA per 28 days) QL (62 EA per 31 days); AL (Min 5 Years) QL (496 ML per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) AL (Min 18 Years) haloperidol lactate injection solution 5 /ml AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 12.5 AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 18 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 32

34 *Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 reference Details Coverage Details ST; Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.; AL (Min 10 Years) AL (Min 10 Years) AL (Min 18 Years) AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 days); AL (Min 18 Years) QL (2480 ML per 31 days); AL (Min 18 Years) AL (Min 18 Years) AL (Min 12 Years) AL (Min 2 Years) prochlorperazine rectal suppository 25 AL (Min 2 Years) thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR REFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED 300 MG, 400 MG AL (Min 2 Years) AL (Min 6 Years) A; QL (1 EA per 28 days) A; QL (1 EA per 28 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 33

35 reference Details Coverage Details ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED ER 300 MG, 400 MG aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15, 2, 20, 30, 5 ARISTADA INTRAMUSCULAR REFILLED SYRINGE 1064 MG/3.9ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 441 MG/1.6ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 662 MG/2.4ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 882 MG/3.2ML *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antiretrovirals Adjuvants*** *Antiretrovirals Adjuvants*** =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 34 A; QL (1 EA per 28 days) A; QL (3.9 ML per 56 days) A; QL (1.6 ML per 28 days) A; QL (2.4 ML per 28 days) A; QL (3.2 ML per 28 days) QL (31 EA per 31 days); AL (Min 13 Years) AL (Min 12 Years) tybost oral tablet 150 QL (31 EA per 31 days) *Antiseptics & Disinfectants* *Chlorine Antiseptics*** chlorhexidine gluconate external liquid 4 % QL (480 ML per 31 days) *Antivirals* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet ATRILA ORAL TABLET MG COMLERA ORAL TABLET MG QL (31 EA per 31 days) QL (62 EA per 31 days) DESCOVY ORAL TABLET MG QL (31 EA per 31 days) GENVOYA ORAL TABLET MG QL (31 EA per 31 days)

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 New York Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare Health lans, Inc. 00 lease read: This document has information about drugs we cover in this plan. lease note that

More information

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

2018 New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 New Jersey Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of New Jersey 00 lease read: This document contains information about the drugs we cover in this plan. lease note

More information

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky 00 lease read: This document contains information about the drugs we cover in this plan. lease note

More information

2018 South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina lease read: This document contains information about the drugs we cover in this plan. lease

More information

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

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

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan.

More information

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

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

2019 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2019 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2019 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

2018 Florida Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Florida Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Florida Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Florida 00 lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

2019 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

2019 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs) 2019 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan.

More information

2018 South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina lease read: This document contains information about the drugs we cover in this plan. lease

More information

2018 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan.

More information

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

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

Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Georgia Families Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document tells about the drugs we cover in this plan. If you speak a different

More information

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

2018 Florida Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Florida Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Florida Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Florida lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 New York Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare Health lans, Inc. 00 lease read: This document has information about drugs we cover in this plan. lease note that

More information

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2018 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan 00 lease read this document. It has details about the drugs we cover for the Ohana QUEST

More information

2017 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2017 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2017 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan 00 lease read this document. It has details about the drugs we cover for the Ohana QUEST

More information

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2018 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan 00 lease read this document. It has details about the drugs we cover for the Ohana QUEST

More information

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2018 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan lease read this document. It has details about the drugs we cover for the Ohana QUEST Integration

More information

2019 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2019 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2019 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan lease read this document. It has details about the drugs we cover for the Ohana QUEST Integration

More information

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 New York Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare Health lans, Inc. 00 lease read: This document has information about drugs we cover in this plan. lease note that

More information

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan.

More information

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan.

More information

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2016 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan.

More information

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

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan 00 9 lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

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

Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 00 9 Last updated (1/01/2015) 2015 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky lease read: This document contains information about the drugs we cover

More information

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

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 00 9 2015 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 New Jersey Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of New Jersey 00 lease read: This document contains information about the drugs we cover in this plan. lease note

More information

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

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Georgia Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

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

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2014 Georgia Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

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

Florida Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2014 Florida Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Florida 00 lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 New Jersey Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of New Jersey 00 lease read: This document contains information about the drugs we cover in this plan. lease note

More information

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 New York Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare Health lans, Inc. 00 lease read: This document has information about drugs we cover in this plan. lease note that

More information

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2014 New Jersey Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of New Jersey 00 lease read: This document contains information about the drugs we cover in this plan. lease note

More information

New York Medicaid and FHP Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid and FHP Comprehensive Preferred Drug List (List of Covered Drugs) 2014 New York Medicaid and FH Comprehensive referred Drug List (List of Covered Drugs) WellCare of New York, Inc. 00 lease read: This document contains information about the drugs we cover in this plan.

More information

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 New York Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare Health lans, Inc. 00 lease read: This document has information about drugs we cover in this plan. lease note that

More information

2019 Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs)

2019 Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs) 2019 Georgia Families Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. lease read: This document tells about the drugs we cover in this plan. If you speak a different

More information

Comprehensive Drug List (List of Covered Drugs)

Comprehensive Drug List (List of Covered Drugs) 2017 Comprehensive Drug List (List of Covered Drugs) WellCare of Nebraska- Family lanning 00 lease read: This document contains information about the drugs we cover in this plan. lease note that the Nebraska

More information

2018 Comprehensive Drug List (List of Covered Drugs)

2018 Comprehensive Drug List (List of Covered Drugs) 2018 Comprehensive Drug List (List of Covered Drugs) WellCare of Nebraska Children s Health Insurance lan (CHI) lease read: This document contains information about the drugs we cover in this plan. lease

More information

2018 Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia lanning for Healthy Babies: Interpregnancy Care lease read: This document tells about the drugs we cover in this plan.

More information

2018 Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Comprehensive referred Drug List (List of Covered Drugs) Care1st Health lan Arizona Family lanning lease read: This document contains information about the drugs we cover in this plan. lease note

More information

PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing

PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing Presbyterian Health Plan Presbyterian Insurance Company, Inc. PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing This list is in order by therapeutic class. To find

More information

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective Generic_Name Current NJ SUL New NJ SUL Proposed ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG 0.12455 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG 0.25688 ALBUTEROL SULFATE

More information

2018 Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia lanning for Healthy Babies: Interpregnancy Care lease read: This document tells about the we cover in this plan. If you

More information

2018 Care1st Health Plan Arizona Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Care1st Health Plan Arizona Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Care1st Health lan Arizona Medicaid Comprehensive referred Drug List (List of Covered Drugs) Care1st Health lan Arizona lease read: This document contains information about the we cover in this plan.

More information

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2014 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan.

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 2014 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 00 9 2015 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

2017 Drug List for Qualified Health Plans

2017 Drug List for Qualified Health Plans 207 Drug List for Qualified Health Plans HAP Personal Alliance and small group Use this drug list also known as a formulary to learn about the prescription drugs we cover in all qualified health plans.

More information

PHP Centennial Care Formulary/Preferred Drug Listing

PHP Centennial Care Formulary/Preferred Drug Listing PHP Centennial Care Formulary/Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. Presbyterian Centennial Care This list is in order by therapeutic class. To find a specific

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 00 9 2014 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018

4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018 4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) 4-Tier High Deductible Health Plan Formulary was developed to serve as a

More information

Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs

Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs THIS DOCUMENT HAS INFORMATION ABOUT THE PRESCRIPTION DRUGS WE COVER FOR QUALIFIED HEALTH PLANS. Qualified Health Plans (QHP) are Affordable

More information

3-TIER FORMULARY Effective November 2017

3-TIER FORMULARY Effective November 2017 3-TIER FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) 3-Tier Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals

More information

2017 Drug List for Commercial Health Plans

2017 Drug List for Commercial Health Plans 2017 Drug List for Commercial Health Plans Use this drug list also known as a formulary to learn about the prescription drugs we cover in all commercial health plans. Commercial health plans are a type

More information

Signature Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs

Signature Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs Signature Advantage (HMO SNP) 208 Comprehensive Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission

More information

Antibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol

Antibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol MAX Saver Plan Drug List 08/06/14 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG

More information

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. Last Updated: January 1,

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. Last Updated: January 1, Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 2017 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia lanning for Healthy Babies: Interpregnancy Care lease read: This document tells about the drugs we cover in this plan.

More information

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Updated: April 1,

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Updated: April 1, Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details

More information

Step Therapy Criteria Last Updated 6/1/2018

Step Therapy Criteria Last Updated 6/1/2018 Step Therapy Last Updated 6/1/2018 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide October 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide October 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide October 2017 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2018 AETNA BETTER HEALTH Formulary Guide 2018 Aetna Better Health Pennsylvania Formulary Guide April 2018 AETNA BETTER HEALTH Formulary Guide 2018 What is the Aetna Better Health in Pennsylvania Formulary?

More information

Allergies and Cold & Flu

Allergies and Cold & Flu MAX Saver Plan Drug List 01/23/17 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide August 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide August 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide August 2017 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide June 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide June 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide June 2017 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide April 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide April 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide April 2017 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health New Jersey Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil

More information

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

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2014 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan 00 9 lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide December 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide December 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide December 2017 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better

More information

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: July 1,

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: July 1, Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

Memorial Hermann Advantage HMO & PPO Abridged Formulary. (Partial List of Covered Drugs)

Memorial Hermann Advantage HMO & PPO Abridged Formulary. (Partial List of Covered Drugs) Memorial Hermann Advantage H & PPO 2017 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary

More information

WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014)

WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) **To get updated information about the drugs covered by WellCare, please visit our website (https://www.wellcare.com) or

More information

Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Kentucky Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous

More information

Aetna Better Health Virginia. Table of Contents

Aetna Better Health Virginia. Table of Contents Aetna Better Health Virginia Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...4 *ALTERNATIVE MEDICINES*...6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*...7 *ANALGESICS -

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...5 *ALTERNATIVE MEDICINES*... 8 *AMINOGLYCOSIDES*... 8 *ANALGESICS - ANTI-INFLAMMATORY*... 8 *ANALGESICS - NONNARCOTIC*...11

More information

COMMERCIAL FORMULARY Effective April 2018

COMMERCIAL FORMULARY Effective April 2018 COMMERCIAL FORMULARY Effective April 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Commercial Formulary was developed to serve as a guide for physicians, pharmacists, health care

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List April 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *ALTERNATIVE MEDICINES*... 6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*... 6 *ANALGESICS -

More information

Aetna Better Health of Louisiana

Aetna Better Health of Louisiana AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Louisiana Formulary Guide January 2019 www.aetnabetterhealth.com/louisiana 1 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List January 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *ALTERNATIVE MEDICINES*... 6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*... 6 *ANALGESICS

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List February 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *ALTERNATIVE MEDICINES*... 6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*... 6 *ANALGESICS

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide September 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide September 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide September 2017 http://www.aetnabetterhealth.com/kentucky AETNA BETTER HEALTH Formulary Guide What is the Aetna Better

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List January 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...5 *ALTERNATIVE MEDICINES*... 8 *AMINOGLYCOSIDES*... 8 *ANALGESICS - ANTI-INFLAMMATORY*... 8 *ANALGESICS

More information

Aetna Better Health of Louisiana. December 2018

Aetna Better Health of Louisiana. December 2018 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Louisiana Formulary Guide December 2018 www.aetnabetterhealth.com/louisiana 1 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

2018 FORMULARY (List of Covered Drugs)

2018 FORMULARY (List of Covered Drugs) InterCommunity Health Network CCO 2018 FORMULARY (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/01/2017.

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2019

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2019 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2019 http://www.aetnabetterhealth.com/kentucky AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

2017 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing

2017 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. 207 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing This list in order

More information

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians,

More information