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

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1 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 we update this drug list quarterly. roviders: lease go to to view updates to this drug list. Members: lease go to to view updates to this drug list. Last updated (10/01/2015) roudly serving New York Medicaid and Child Health lus members. NY028730_CAD_CVR_ENG Internal Approved WellCare 2015 NY_01_

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

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

4 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines**-*Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 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 *Stimulants - Misc.**-*Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er oral tablet extendedrelease* 10, 20 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 dexmethylphenidate ER capsules or amphetamine-dextroamphetami ne ER capsules within the past 100 days.); QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years) QL (93 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, =-Covered w/rx, UERCASE= Brand name drugs/ 1

5 Drug Name reference Details Coverage Details methylphenidate hcl er oral tablet extendedrelease* 18, 27, 36 methylphenidate hcl er oral tablet extendedrelease* 54 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) 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 *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 EN-SORIASIS 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 QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) A A A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 2

6 Drug Name reference Details Coverage Details *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen 100 oral suspension 100 /5ml ST; Notes (Must fail preferred meloxicam and one other generic DL NSAID within the past 100 days); QL (31 EA per 31 days) childrens ibuprofen oral suspension 40 /ml 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 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200 ibuprofen oral tablet 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 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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 3

7 Drug Name reference Details Coverage Details sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 *yrimidine Synthesis Inhibitors**-*yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Analgesics - Nonnarcotic* *Analgesic Combinations**-*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 QL (186 EA per 31 days) QL (186 EA per 31 days) marten-tab oral tablet QL (186 EA per 31 days) *Analgesics Other**-*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 suppository 650 apap oral tablet 325 infants silapap oral solution 100 /ml MAA CHILDRENS ORAL SUSENSION 160 MG/5ML mapap oral liquid 160 /5ml pain & fever childrens oral solution 160 /5ml *Salicylates**-*Salicylates*** aspir-81 oral tablet delayed release 81 aspirin adult low strength oral tablet delayed release 81 aspirin ec oral tablet delayed release 325 aspirin oral tablet 325 aspirin oral tablet chewable 81 aspirin suppository 600 diflunisal oral tablet 500 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 4

8 Drug Name reference Details Coverage Details eq aspirin low dose oral tablet delayed release 81 salsalate oral tablet 500, 750 *Analgesics - Opioid* *Opioid Agonists**-*Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QL (248 EA per 31 days) fentanyl transdermal patch 72 hr 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 suppository 3 methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 QL (248 EA per 31 days) morphine sulfate (concentrate) oral solution 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 extendedrelease* 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 suppository 10, 20, 30, 5 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 5

9 Drug Name reference Details Coverage Details *Opioid Combinations**-*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 *Opioid Combinations**-*Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet , 5-325, 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 Combinations**-*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) ROXICET ORAL TABLET MG QL (248 EA per 31 days) *Opioid artial Agonists**-*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 ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 6

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

11 Drug Name reference Details Coverage Details *Antacids - Calcium Salts**-*Antacids - Calcium Salts*** calcium carbonate antacid oral tablet chewable 500, 750 *Antacids - Magnesium Salts**-*Antacids - Magnesium Salts*** magnesium oxide oral tablet 250, 400, 420 *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) pin-x oral suspension 50 /ml 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 hydroxyzine hcl oral solution 10 /5ml QL (450 ML per 31 days) hydroxyzine hcl oral syrup 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 8

12 Drug Name reference Details Coverage Details hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 meprobamate oral tablet 200, 400 *Benzodiazepines**-*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 diazepam injection solution 5 /ml 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**-*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*** lidocaine hcl (cardiac) intravenous* solution 20 /ml 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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 9

13 Drug Name reference Details Coverage Details *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) 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 QL (1 EA per 30 days) AL (Min 1 Months and Max 2 Years) QL (1 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 10

14 Drug Name reference Details Coverage Details 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, 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 *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% 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 (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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 11

15 Drug Name reference Details Coverage Details 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 (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 *Xanthines**-*Xanthines*** aminophylline intravenous* solution 25 /ml 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 *Direct Factor Xa Inhibitors**-*Direct Factor Xa Inhibitors*** QL (60 EA per 30 days) QL (60 EA per 30 days) QL (36 GM per 31 days) XARELTO ORAL TABLET 10 MG QL (35 EA per 365 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 12

16 Drug Name reference Details Coverage Details *Heparins And Heparinoid-Like Agents**-*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 *Heparins And Heparinoid-Like Agents**-*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**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 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 10, 2.5, 20 QL (3 EA per 31 days) *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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 13

17 Drug Name reference Details Coverage Details 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) 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 14

18 Drug Name reference Details Coverage Details phenytoin sodium extended oral capsule 100, 200 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) 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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 15

19 Drug Name reference Details Coverage Details *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 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)*** duloxetine hcl oral capsule delayed release particles 20, 60 duloxetine hcl oral capsule delayed release particles 30 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 QL (62 EA per 31 days) QL (31 EA per 31 days) QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 16

20 Drug Name reference Details Coverage Details 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 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**-*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 ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (62 EA per 31 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. ) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 17

21 Drug Name reference Details Coverage Details *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 , *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 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.) 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 glucose oral tablet chewable 4 gm *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG TRADJENTA ORAL TABLET 5 MG 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 18

22 Drug Name reference Details Coverage Details *Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* 2 MG BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 MG BYETTA 10 MCG EN SUBCUTANEOUS* 10 MCG/0.04ML BYETTA 5 MCG EN SUBCUTANEOUS* 5 MCG/0.02ML *Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Insulin**-*Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* 200 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 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.) 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 (60 ML per 31 days) 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 19

23 Drug Name reference Details Coverage Details 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, 25 MG *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 ; QL (60 ML per 31 days) QL (60 ML per 31 days) ; QL (60 ML per 31 days) ; QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. ) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days. ) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 20

24 Drug Name reference Details Coverage Details *Antidiarrheals* *Antidiarrheal Agents - Misc.**-*Antidiarrheal Agents - Misc.*** bismatrol oral suspension 262 /15ml *Antiperistaltic Agents**-*Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet loperamide a-d oral tablet 2 loperamide hcl oral capsule 2 *Antidotes* *Antidotes - Chelating Agents**-*Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG *Antidotes**-*Antidotes*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Opioid Antagonists**-*Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml QL (5 ML per 31 days) naltrexone hcl oral tablet 50 *Antiemetics* *5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists*** ondansetron hcl oral solution 4 /5ml ondansetron hcl oral tablet 4, 8 ondansetron oral tablet dispersible 4, 8 *Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5, 25 meclizine hcl oral tablet chewable 25 travel sickness oral tablet chewable 25 *Antifungals* *Antifungals**-*Antifungals*** griseofulvin microsize oral suspension 125 /5ml A 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, =-Covered w/rx, UERCASE= Brand name drugs/ 21

25 Drug Name reference Details Coverage Details 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 *Antihistamines* *Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** allergy oral tablet 4 *Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral tablet 25 *Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** ALLEGRA ALLERGY CHILDRENS ORAL SUSENSION 30 MG/5ML allergy oral tablet dispersible 10 cetirizine hcl childrens oral solution 1 /ml ; QL (300 ML per 31 days) cetirizine hcl oral syrup 1 /ml, 5 /5ml ; QL (300 ML per 31 days) cetirizine hcl oral tablet 10, 5 childrens loratadine oral syrup 5 /5ml ; QL (310 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 22

26 Drug Name reference Details Coverage Details 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 loratadine oral tablet 10 *Antihistamines - henothiazines**-*antihistamines - henothiazines*** promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl suppository 25, 50 ROMETHEGAN SUOSITORY 25 MG *Antihistamines - iperidines**-*antihistamines - iperidines*** ST; Notes (Must fail preferred loratadine solution and cetirizine syrup within the past 100 days) cyproheptadine hcl oral syrup 2 /5ml QL (300 ML per 31 days) cyproheptadine hcl oral tablet 4 *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 *Fibric Acid Derivatives**-*Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 23

27 Drug Name reference Details Coverage Details *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 *Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** BENICAR ORAL TABLET 20 MG ST; Notes (Must have trial of preferred losartan potassium 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 24

28 Drug Name reference Details Coverage Details BENICAR ORAL TABLET 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 *Antiadrenergic Antihypertensives**-*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 *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 , , 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, =-Covered w/rx, UERCASE= Brand name drugs/ 25

29 Drug Name reference Details Coverage Details *Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , *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 vancomycin hcl intravenous* solution reconstituted 1000, 500, 750 vancomycin hcl oral capsule 125, 250 A *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 A *Leprostatics**-*Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides**-*Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml QL (1200 ML per 31 days) QL (2400 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 26

30 Drug Name reference Details Coverage Details clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous* solution 300 /2ml *Oxazolidinones**-*Oxazolidinones*** SIVEXTRO ORAL TABLET 200 MG A *Antimalarials* *Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet , *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 pyridostigmine bromide er oral tablet extendedrelease* 180 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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 27

31 Drug Name reference Details Coverage Details *Antineoplastics And Adjunctive Therapies* *Alkylating Agents**-*Alkylating Agents*** HEXALEN ORAL CASULE 50 MG A MYLERAN ORAL TABLET 2 MG A *Alkylating Agents**-*Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 *Alkylating Agents**-*Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG A cyclophosphamide oral capsule 25, 50 A LEUKERAN ORAL TABLET 2 MG A *Alkylating Agents**-*Nitrosoureas*** lomustine oral capsule 10, 100, 40 A *Antimetabolites**-*Antimetabolites*** capecitabine oral tablet 150, 500 A fluorouracil intravenous* solution 500 /10ml A 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, 25 /ml, 250 /10ml, 50 /2ml methotrexate sodium injection solution 25 /ml methotrexate sodium injection solution reconstituted 1 gm TABLOID ORAL TABLET 40 MG A *Antineoplastic - Angiogenesis Inhibitors**-*Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML *Antineoplastic - Hedgehog athway Inhibitors**-*Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 MG A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 28 A A A A

32 Drug Name reference Details Coverage Details *Antineoplastic - Hormonal And Related Agents**-*Antiadrenals*** LYSODREN ORAL TABLET 500 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiandrogens*** bicalutamide oral tablet 50 XTANDI ORAL CASULE 40 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiestrogens*** tamoxifen citrate oral tablet 10, 20 *Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors*** anastrozole oral tablet 1 letrozole oral tablet 2.5 *Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 MG A *Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs*** TRELSTAR INTRAMUSCULAR* SUSENSION RECONSTITUTED MG, 3.75 MG TRELSTAR MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG *Antineoplastic - Hormonal And Related Agents**-*rogestins-Antineoplastic*** megestrol acetate oral suspension 40 /ml QL (600 ML per 31 days) megestrol acetate oral tablet 20, 40 *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 MG A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 29

33 Drug Name reference Details Coverage Details *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG A SUTENT ORAL CASULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100 MG, 500 MG A CARELSA ORAL TABLET 100 MG, 300 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG, 400 MG ICLUSIG ORAL TABLET 15 MG, 45 MG A SRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CASULE 150 MG, 200 MG TYKERB ORAL TABLET 250 MG A XALKORI ORAL CASULE 200 MG, 250 MG A A A A; QL (31 EA per 31 days) ZYKADIA ORAL CASULE 150 MG A; QL (155 EA per 31 days) *Antineoplastic Enzyme Inhibitors**-*Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG A A A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 30

34 Drug Name reference Details Coverage Details *Antineoplastic Enzymes**-*Antineoplastic Enzymes*** ONCASAR INJECTION SOLUTION 750 UNIT/ML *Antineoplastics Misc.**-*Antineoplastics Misc.*** hydroxyurea oral capsule 500 *Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100, 200, 350 leucovorin calcium oral tablet 10, 15, 25, 5 *Mitotic Inhibitors**-*Mitotic Inhibitors*** etoposide oral capsule 50 A *Antiparkinson Agents* *Antiparkinson Anticholinergics**-*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**-*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 , , =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ A 31

35 Drug Name reference Details Coverage Details *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 *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 ST; Notes (Must fail preferred ropinirole within the past 100 days.) A; QL (0.75 ML per 31 days); AL (Min 18 Years) A; QL (1 ML per 31 days); AL (Min 18 Years) A; QL (1.5 ML per 31 days); AL (Min 18 Years) A; QL (0.25 ML per 31 days); AL (Min 18 Years) A; QL (0.5 ML per 31 days); AL (Min 18 Years) QL (62 EA per 31 days); AL (Min 5 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 32

36 Drug Name reference Details Coverage Details 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 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 *Dibenzapines**-*Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG SAHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 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 AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 18 Years) ST; Notes (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.); AL (Min 10 Years) 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 33

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