Comprehensive Preferred Drug List (List of Covered Drugs)

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1 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 este documento en español o para escuchar la traducción, llame al Servicio al Cliente al (TTY/TDD: ). lease note that the Georgia Inter-pregnancy Care 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 (7/01/2015)

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. 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, 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**-*Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 VYVANSE ORAL CASULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Stimulants - Misc.**-*Stimulants - Misc.*** dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er oral tablet extendedrelease* 10 methylphenidate hcl er oral tablet extendedrelease* 18, 27, 36 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 5 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years and Max 20 Years) QL (62 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, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 1

3 Drug Name reference Details Coverage Details methylphenidate hcl er oral tablet extendedrelease* 20 methylphenidate hcl er oral tablet extendedrelease* 54 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, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet chewable 10, 2.5, 5 *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 OTC melatonin oral tablet 5 OTC *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* 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 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 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CASULE 100 MG, 200 MG, 400 MG, 50 MG QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years and Max 6 Years) A A A A A ST; Notes (Must fail 2 preferred, generic DL NSAIDs within the past 100 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 2

4 Drug Name reference Details Coverage Details celecoxib oral capsule 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hr* 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 oral suspension 100 /5ml OTC ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 ketorolac tromethamine oral tablet 10 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 ST; Notes (Must fail 2 preferred generic DL NSAIDs 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 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 *yrimidine Synthesis Inhibitors**-*yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Analgesics - Nonnarcotic* *Salicylates**-*Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 3

5 Drug Name reference Details Coverage Details *Androgens-Anabolic* *Anabolic Steroids**-*Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A *Androgens**-*Androgens*** danazol oral capsule 100, 200, 50 *Anthelmintics* *Anthelmintics**-*Anthelmintics*** 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 OTC reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* *Nitrates**-*Nitrates*** isosorbide dinitrate er oral tablet extendedrelease* 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hr* 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /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, 15, 30, 5, 7.5 meprobamate oral tablet 200, 400 *Benzodiazepines**-*Benzodiazepines*** OTC diazepam oral solution 1 /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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 4

6 Drug Name reference Details Coverage Details *Antiarrhythmics* *Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine gluconate er oral tablet extendedrelease* 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 ACERONE ORAL TABLET 200 MG, 400 MG *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 /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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 5

7 Drug Name reference Details Coverage Details TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators**-*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**-*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 budesonide inhalation suspension 0.25 /2ml, 0.5 /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 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) 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 6

8 Drug Name reference Details Coverage Details *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) /3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Sympathomimetics**-*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 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 (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 metaproterenol sulfate oral syrup 10 /5ml SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT QL (60 EA per 30 days) QL (60 EA per 30 days) QL (36 GM per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 7

9 Drug Name reference Details Coverage Details *Xanthines**-*Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hr* 100, 200, 300, 450 theophylline er oral tablet extended release 24 hr* 400, 600 theophylline oral solution 80 /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, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Anticonvulsants* *Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 *Anticonvulsants - Misc.**-*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) 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 QL (1000 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 8

10 Drug Name reference Details Coverage Details levetiracetam oral tablet 1000, 500, 750 levetiracetam oral tablet 250 QL (372 EA per 31 days) oxcarbazepine oral suspension 300 /5ml QL (1240 ML per 31 days) oxcarbazepine oral tablet 150 QL (310 EA per 31 days) oxcarbazepine oral tablet 300 QL (248 EA per 31 days) oxcarbazepine oral tablet 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**-*Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins**-*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**-*Succinimides*** ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml QL (930 ML per 31 days) *Valproic Acid**-*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hr* 250 divalproex sodium er oral tablet extended release 24 hr* 500 QL (310 EA per 31 days) QL (279 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 9

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

12 Drug Name reference Details Coverage Details fluoxetine hcl oral tablet 10, 20 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral tablet 100, 25, 50 *Serotonin Modulators**-*Serotonin Modulators*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** 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**-*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, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 QL (31 EA per 31 days) nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 11

13 Drug Name reference Details Coverage Details *Antidiabetics* *Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *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 , , glyburide-metformin oral tablet , , *Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET MG pioglitazone hcl-metformin hcl oral tablet , 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 (31 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.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 12

14 Drug Name reference Details Coverage Details *Biguanides**-*Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hr* 500 metformin hcl er oral tablet extended release 24 hr* 500, 750 metformin hcl oral tablet 1000, 500, 850 RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other**-*Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *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 pioglitazone hcl oral tablet 15, 30, 45 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.) 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 13

15 Drug Name reference Details Coverage Details *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 JARDIANCE ORAL TABLET 10 MG JARDIANCE ORAL TABLET 25 MG ST 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) OTC; QL (60 ML per 31 days) QL (60 ML per 31 days) OTC; QL (60 ML per 31 days) OTC; 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.) 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 14

16 Drug Name reference Details Coverage Details *Sulfonylureas**-*Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hr* 10, 2.5, 5 glipizide oral tablet 10, 5 GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 *Antifungals* *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 *Imidazole-Related Antifungals**-*Imidazoles*** ketoconazole oral tablet 200 *Imidazole-Related Antifungals**-*Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *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 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, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 15

17 Drug Name reference Details Coverage Details *Fibric Acid Derivatives**-*Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 160, 54 gemfibrozil oral tablet 600 *H Coa Reductase Inhibitors**-*H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5, 80 *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, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 16

18 Drug Name reference Details Coverage Details *Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG losartan potassium oral tablet 100, 25, 50 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antihypertensive Combinations**-*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 , , *Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet , , *Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , ST; Notes (Must have Trial of preferred losartan potassium and valsartan tablets within the past 100 days) QL (31 EA per 31 days) ST; Notes (Must have Trial of preferred losartan potassium tablets within the past 100 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 17

19 Drug Name reference Details Coverage Details *Vasodilators**-*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.**-*Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** sulfamethoxazole-tmp ds oral tablet sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet *Antiprotozoal Agents**-*Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml *Leprostatics**-*Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides**-*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 300 /2ml *Antimalarials* *Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 18

20 Drug Name reference Details Coverage Details *Antimalarials**-*Antimalarials*** DARARIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *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 *Antimycobacterial Agents* *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 intravenous* solution reconstituted 600 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs*** TRELSTAR INTRAMUSCULAR* SUSENSION RECONSTITUTED MG, 3.75 MG *Antiparkinson Agents* *Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ A 19

21 Drug Name reference Details Coverage Details trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Dopaminergics**-*Levodopa Combinations*** carbidopa-levodopa er oral tablet extendedrelease* , carbidopa-levodopa oral tablet , , *Antiparkinson Dopaminergics**-*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 *Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents**-*Antimanic Agents*** lithium carbonate er oral tablet extendedrelease* 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml ST; Notes (Must fail preferred ropinirole 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 20

22 Drug Name reference Details Coverage Details *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 INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 78 MG/0.5ML 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**-*Butyrophenones*** haloperidol decanoate intramuscular* solution 100 /ml, 50 /ml 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) A; QL (0.5 ML per 28 days); AL (Min 18 Years) 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 *Dibenzapines**-*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, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 21

23 Drug Name reference Details Coverage Details *Dibenzapines**-*Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzapines**-*Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzapines**-*Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *Dibenzapines**-*Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *henothiazines**-*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 ST; Notes (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.); AL (Min 18 Years) AL (Min 10 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 13 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 and Max 999 Years) AL (Min 12 Years) AL (Min 2 Years) prochlorperazine suppository 25 AL (Min 2 Years) thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 AL (Min 2 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, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 22

24 Drug Name reference Details Coverage Details *Quinolinone Derivatives**-*Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR* SUSENSION RECONSTITUTED 300 MG, 400 MG aripiprazole oral tablet 10, 15, 2, 20, 30, 5 *Thioxanthenes**-*Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antivirals* *Hepatitis Agents**-*Hepatitis B Agents*** entecavir oral tablet 0.5, 1 A *Herpes Agents**-*Herpes Agents - urine Analogues*** acyclovir oral capsule 200 A ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.) AL (Min 12 Years) acyclovir oral suspension 200 /5ml QL (3500 ML per 31 days) acyclovir oral tablet 400, 800 valacyclovir hcl oral tablet 1 gm, 500 QL (62 EA per 31 days) *Influenza Agents**-*Influenza Agents*** rimantadine hcl oral tablet 100 *Influenza Agents**-*Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 5 MG/BLISTER QL (40 EA per 365 days); AL (Min 7 Years) TAMIFLU ORAL CASULE 30 MG QL (40 EA per 365 days) TAMIFLU ORAL CASULE 45 MG, 75 MG QL (20 EA per 365 days) TAMIFLU ORAL SUSENSION RECONSTITUTED 6 MG/ML *Assorted Classes* *Immunosuppressive Agents**-*Cyclosporine Analogs*** cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml QL (360 ML per 365 days); AL (Max 18 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 23

25 Drug Name reference Details Coverage Details cyclosporine oral capsule 100, 25 GENGRAF ORAL CASULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML SANDIMMUNE ORAL SOLUTION 100 MG/ML *Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 *Immunosuppressive Agents**-*Macrolide Immunosuppressants*** tacrolimus oral capsule 0.5, 1, 5 *Immunosuppressive Agents**-*urine Analogs*** azathioprine oral tablet 50 *Beta Blockers* *Alpha-Beta Blockers**-*Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl intravenous* solution 5 /ml labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective*** atenolol oral tablet 100, 25, 50 bisoprolol fumarate oral tablet 10, 5 metoprolol succinate er oral tablet extended release 24 hr* 100, 200, 25, 50 metoprolol tartrate intravenous* solution 1 /ml metoprolol tartrate oral tablet 100, 25, 50 *Beta Blockers Non-Selective**-*Beta Blockers Non-Selective*** nadolol oral tablet 20, 40, 80 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 24

26 Drug Name reference Details Coverage Details pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous* solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers**-*Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl intravenous* solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 25

27 Drug Name reference Details Coverage Details MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG nifedipine er oral tablet extended release 24 hr* 90 nifedipine er osmotic oral tablet extended release 24 hr* 30, 60, 90 nifedipine oral capsule 10 verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300, 360 verapamil hcl er oral tablet extendedrelease* 120, 180, 240 verapamil hcl oral tablet 120, 40, 80 *Cardiotonics* *Cardiac Glycosides**-*Cardiac Glycosides*** digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml digoxin oral tablet 0.125, 250 mcg *Cardiovascular Agents - Misc.* *eripheral Vasodilators**-*eripheral Vasodilators*** no flush niacin oral tablet 500 OTC *ulmonary Hypertension - Endothelin Receptor Antagonists**-*ulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG A *ulmonary Hypertension - hosphodiesterase Inhibitors**-*ulmonary Hypertension - hosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 26

28 Drug Name reference Details Coverage Details *Cephalosporins* *Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml cephalexin oral suspension reconstituted 250 /5ml *Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 *Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 *Contraceptives* *Combination Contraceptives - Oral**-*Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET /0.01 MG (21/5) 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, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 27

29 Drug Name reference Details Coverage Details *Combination Contraceptives - Oral**-*Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET MG-MCG ARI ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG briellyn oral tablet mcg CRYSELLE-28 ORAL TABLET MG-MCG EMOQUETTE ORAL TABLET MG-MCG ESTARYLLA ORAL TABLET MG-MCG GIANVI ORAL TABLET MG JUNEL 1.5/30 ORAL TABLET MG-MCG JUNEL 1/20 ORAL TABLET 1-20 MG-MCG JUNEL FE 1.5/30 ORAL TABLET MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG KELNOR 1/35 ORAL TABLET 1-35 MG-MCG LESSINA ORAL TABLET MG-MCG LEVORA 0.15/30 (28) ORAL TABLET MG-MCG LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG-MCG LUTERA ORAL TABLET MG-MCG MICROGESTIN 1.5/30 ORAL TABLET MG-MCG MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET MG-MCG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 28

30 Drug Name reference Details Coverage Details MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG MONONESSA ORAL TABLET MG-MCG NECON 0.5/35 (28) ORAL TABLET MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG norethin-eth estradiol-fe oral tablet chewable mcg NORTREL 0.5/35 (28) ORAL TABLET MG-MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG OCELLA ORAL TABLET MG ORTIA-28 ORAL TABLET MG-MCG REVIFEM ORAL TABLET MG-MCG RECLISEN ORAL TABLET MG-MCG SOLIA ORAL TABLET MG-MCG SRINTEC 28 ORAL TABLET MG-MCG SRONYX ORAL TABLET MG-MCG SYEDA ORAL TABLET MG VESTURA ORAL TABLET MG ZARAH ORAL TABLET MG ZENCHENT FE ORAL TABLET CHEWABLE MG-MCG ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG *Combination Contraceptives - Oral**-*Continuous Contraceptives - Oral*** AMETHYST ORAL TABLET MCG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 29

31 Drug Name reference Details Coverage Details levonorgestrel-ethinyl estrad oral tablet mcg *Combination Contraceptives - Oral**-*Extended-Cycle Contraceptives - Oral*** QUASENSE ORAL TABLET MG QL (91 EA per 91 days) *Combination Contraceptives - Oral**-*Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/ MG ENRESSE-28 ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/ MG *Combination Contraceptives - Vaginal**-*Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING MG/24HR *Emergency Contraceptives**-*Emergency Contraceptives*** levonorgestrel oral tablet 0.75 QL (4 EA per 31 days) NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG LAN B ONE-STE ORAL TABLET 1.5 MG OTC OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 30

32 Drug Name reference Details Coverage Details *rogestin Contraceptives - Injectable**-*rogestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular* suspension 150 /ml *rogestin Contraceptives - Oral**-*rogestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 MG ERRIN ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG NORA-BE ORAL TABLET 0.35 MG *Corticosteroids* *Glucocorticosteroids**-*Glucocorticosteroids* ** hydrocortisone oral tablet 10, 20, 5 methylprednisolone oral tablet 4 prednisone (pak) oral tablet 10, 5 prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 *Mineralocorticoids**-*Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Dermatologicals* *Acne roducts**-*acne Combinations*** benzoyl peroxide-erythromycin external 5-3 % *Acne roducts**-*acne roducts*** cvs creamy acne face wash external liquid 4 % OTC *Antibiotics - Topical**-*Antibiotics - Topical*** bacitracin zinc external ointment 500 unit/gm OTC *Antifungals - Topical**-*Antifungals - Topical*** ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % nystatin external cream unit/gm nystatin external ointment unit/gm QL (1 ML per 93 days) nystatin external powder unit/gm =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 31

33 Drug Name reference Details Coverage Details terbinafine hcl external cream 1 % OTC *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** baza antifungal external cream 2 % OTC clotrimazole external cream 1 % OTC clotrimazole external solution 1 % OTC econazole nitrate external cream 1 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % *Anti-Inflammatory Agents - Topical**-*Anti-Inflammatory Agents - Topical*** VOLTAREN TRANSDERMAL 1 % QL (300 GM per 31 days) *Antivirals - Topical**-*Antivirals - Topical*** acyclovir external ointment 5 % DENAVIR EXTERNAL CREAM 1 % ZOVIRAX EXTERNAL CREAM 5 % *Emollient/Keratolytic Agents**-*Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % urea external cream 40 % *Rosacea Agents**-*Rosacea Agents*** metronidazole external 1 % metronidazole external cream 0.75 % *Scabicides & ediculicides**-*scabicides & ediculicides*** malathion external lotion 0.5 % ST; Notes (Must have Trial of preferred oral Acyclovir or Valacyclovir within the past 100 days) ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.) ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.) QL (118 ML per 31 days); AL (Min 6 Years) spinosad external suspension 0.9 % AL (Min 6 Months) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 32

34 Drug Name reference Details Coverage Details *Diagnostic roducts* *Diagnostic Drugs**-*Diagnostic Drugs*** dipyridamole intravenous* solution 5 /ml *Diagnostic Tests**-*Diagnostic Tests*** ACCU-CHEK ACTIVE IN VITRO STRI ACCU-CHEK AVIVA LUS IN VITRO STRI ACCU-CHEK COMFORT CURVE IN VITRO STRI ACCU-CHEK COMACT TEST DRUM IN VITRO STRI ACCU-CHEK SMARTVIEW IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 204/31 DS for Members 21 years old and younger; QL: 102/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC CLINISTIX IN VITRO STRI OTC; QL (100 EA per 31 days) DIASTIX IN VITRO STRI OTC; QL (100 EA per 31 days) FREESTYLE INSULINX TEST IN VITRO STRI FREESTYLE LITE TEST IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 33

35 Drug Name reference Details Coverage Details FREESTYLE TEST IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC KETOSTIX IN VITRO STRI OTC; QL (100 EA per 31 days) RECISION XTRA BLOOD GLUCOSE IN VITRO STRI RECISION XTRA KETONE IN VITRO STRI *Digestive Aids* *Digestive Enzymes**-*Digestive Enzymes*** CREON ORAL CASULE DELAYED RELEASE ARTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT ERTZYE ORAL CASULE DELAYED RELEASE ARTICLES UNIT, 8000 UNIT *Diuretics* *Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors*** acetazolamide oral tablet 125, 250 methazolamide oral tablet 25, 50 *Diuretic Combinations**-*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5-50 spironolactone-hctz oral tablet triamterene-hctz oral capsule triamterene-hctz oral tablet , *Loop Diuretics**-*Loop Diuretics*** bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5, 1, 2 furosemide oral solution 10 /ml, 8 /ml Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 34 OTC

36 Drug Name reference Details Coverage Details furosemide oral tablet 20, 40, 80 torsemide oral tablet 10, 100, 20, 5 *otassium Sparing Diuretics**-*otassium Sparing Diuretics*** spironolactone oral tablet 100, 25, 50 *Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 hydrochlorothiazide oral capsule 12.5 hydrochlorothiazide oral tablet 12.5, 25, 50 indapamide oral tablet 1.25, 2.5 metolazone oral tablet 10, 2.5, 5 *Endocrine And Metabolic Agents - Misc.* *Bone Density Regulators**-*Bisphosphonates*** alendronate sodium oral tablet 10, 35, 40, 5, 70 *Bone Density Regulators**-*Calcitonins*** calcitonin (salmon) nasal solution 200 unit/act *Metabolic Modifiers**-*Gaa Deficiency Treatment - Agents*** LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG *Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml *osterior ituitary Hormones**-*Vasopressin*** desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate oral tablet 0.1, 0.2 desmopressin acetate spray nasal solution 0.01 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ A 35

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