2018 Supplemental Drug List (List of Covered Drugs)

Transcription

1 2018 upplemental Drug List (List of Covered Drugs) WellCare of Nebraska 00 Please read: This document contains information about the we cover in this plan. Please note that the Nebraska upplemental Drug List is updated quarterly. Providers, 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 (10/01/2018)

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 PA process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name Preference Details Coverage Details *Alternative Medicines* *Alternative Medicine - Ly*** lycopene oral capsule 10 *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 melatonin oral tablet 1, 3 *Analgesics - Anti-Inflammatory* *Pyrimidine ynthesis Inhibitors*** leflunomide oral tablet 10, 20 *Analgesics - Nonnarcotic* *Analgesic Combinations*** EXCEDRIN EXTRA TRENGTH ORAL TABLET MG sm tension headache oral tablet v-r womens menstrual relief oral tablet *Analgesics Other*** ACEPHEN RECTAL UPPOITORY 120 MG, 325 MG acetaminophen oral solution 160 /5ml acetaminophen oral tablet 325 QL (279 EA per 31 days) acetaminophen oral tablet 500 QL (186 EA per 31 days) acetaminophen rectal suppository 650 apap oral tablet 325 QL (279 EA per 31 days) childrens mapap rapid tabs oral tablet dispersible 80 FEVERALL INFANT RECTAL UPPOITORY 80 MG infants pain relief oral suspension 80 /0.8ml infants silapap oral solution 100 /ml JUNIOR MAPAP ORAL TABLET DIPERIBLE 160 MG =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 1

3 MAPAP ACETAMINOPHEN EXTRA TR ORAL LIQUID 500 MG/15ML mapap oral capsule 500 mapap oral liquid 160 /5ml pain & fever childrens oral solution 160 /5ml pain & fever childrens oral suspension 160 /5ml pain & fever childrens oral tablet chewable 80 pain relief 8 hour oral tablet extended release 650 *Analgesics-edatives*** 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 *alicylate Combinations*** effervescent pain relief oral tablet effervescent tri-buffered aspirin oral tablet 325 *alicylates*** 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 oral tablet delayed release 81 aspirin rectal suppository 300, 600 eq aspirin low dose oral tablet delayed release 81 salsalate oral tablet 500, 750 sb backache extra strength oral tablet 500 v-r aspirin ec max str oral tablet delayed release 500 QL (186 EA per 31 days) QL (186 EA per 31 days) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 2

4 *Androgens-Anabolic* *Anabolic teroids*** oxandrolone oral tablet 10, 2.5 PA *Androgens*** danazol oral capsule 100, 200, 50 methitest oral tablet 10 *Anorectal Agents* *Intrarectal teroids*** hydrocortisone rectal enema 100 /60ml *Rectal Anesthetic Combinations*** hemorrhoidal rectal cream % *Rectal Combinations - Misc.*** goodsense hemorrhoidal rectal ointment % hemorrhoidal rectal ointment % hemorrhoidal rectal suppository 0.25 % sm hemorrhoidal rectal cream % *Rectal Local Anesthetics*** dibucaine rectal ointment 1 % lidocaine (anorectal) external cream 5 % PROCTOFOAM RECTAL FOAM 1 % *Antacids* *Antacid & imethicone*** ALMACONE ORAL TABLET CHEWABLE MG aluminum-magnesium-simethicone oral suspension /5ml gnp antacid & anti-gas oral tablet chewable MAALOX MULTI YMPTOM MAX T ORAL UPENION MG/5ML *Antacid Combinations*** GAVICON EXTRA RELIEF FORMULA ORAL UPENION MG/10ML GAVICON EXTRA TRENGTH ORAL TABLET CHEWABLE MG =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 3

5 GAVICON ORAL UPENION MG/15ML GAVICON ORAL TABLET CHEWABLE MG gnp antacid oral tablet chewable mag-al oral liquid /5ml MI-ACID ORAL TABLET CHEWABLE MG sm foaming antacid oral tablet chewable *Antacids - Aluminum alts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325, 650 *Antacids - Calcium alts*** calcium antacid ultra max st oral tablet chewable 1000 calcium carbonate antacid oral suspension 1250 /5ml calcium carbonate antacid oral tablet 648 calcium carbonate antacid oral tablet chewable 500, 750 TUM CHEWY DELIGHT ORAL TABLET CHEWABLE 1177 MG *Antacids - Magnesium alts*** magnesium oxide oral tablet 250, 400, 420 *Antianxiety Agents* *Antianxiety Agents - Misc.*** hydroxyzine pamoate oral capsule 100, 25, 50 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200, 300 =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 4

6 *Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous solution 20 /ml mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 MULTAQ ORAL TABLET 400 MG PA PACERONE ORAL TABLET 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Anti-Ige Monoclonal Antibodies*** XOLAIR UBCUTANEOU OLUTION RECONTITUTED 150 MG *Beta Adrenergics*** terbutaline sulfate injection solution 1 /ml *Mixed Adrenergics*** 2 (RACEPINEPHRINE) INHALATION NEBULIZATION OLUTION 2.25 % *Anticoagulants* *Heparins And Heparinoid-Like Agents*** heparin sodium lock flush intravenous solution 100 unit/ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 diazepam rectal gel 10, 2.5 QL (5 EA per 31 days) diazepam rectal gel 20 QL (5 EA per 30 days) *Anticonvulsants - Misc.*** carbamazepine oral suspension 100 /5ml PA QL (2480 ML per 31 days); AL (Min 4 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 5

7 carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 EPITOL ORAL TABLET 200 MG QL (248 EA per 31 days); AL (Min 4 Years) QL (310 EA per 31 days); AL (Min 4 Years) QL (248 EA per 31 days); AL (Min 4 Years) 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 QL (186 EA per 31 days) gabapentin oral tablet 800 QL (124 EA per 31 days) lamotrigine oral tablet 100, 150, 200 lamotrigine oral tablet 25 QL (310 EA per 31 days) lamotrigine oral tablet chewable 25, 5 QL (310 EA per 31 days) levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300 AL (Min 4 Years) 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); AL (Max 11 Years) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins*** DILANTIN ORAL CAPULE 30 MG QL (310 EA per 31 days) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 6

8 fosphenytoin sodium injection solution 100 pe/2ml PEGANONE 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 *uccinimides*** ethosuximide oral capsule 250 AL (Min 3 Years) ethosuximide oral solution 250 /5ml *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 divalproex sodium er oral tablet extended release 24 hour 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 QL (930 ML per 31 days); AL (Min 3 Years) QL (310 EA per 31 days); AL (Min 4 Years) QL (279 EA per 31 days); AL (Min 4 Years) QL (310 EA per 31 days); AL (Min 4 Years) QL (310 EA per 31 days); AL (Min 4 Years) QL (279 EA per 31 days); AL (Min 4 Years) valproic acid oral capsule 250 QL (310 EA per 31 days) valproic acid oral solution 250 /5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 AL (Min 4 Years) AL (Min 4 Years) AL (Min 4 Years) Maximum of 1 tablet day; AL (Min 4 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 7

9 bupropion hcl oral tablet 100, 75 AL (Min 4 Years) maprotiline hcl oral tablet 25, 50, 75 AL (Min 4 Years) *Modified Cyclics*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 AL (Min 4 Years) trazodone hcl oral tablet 100, 150, 50 Max 100 if *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 AL (Min 4 Years) tranylcypromine sulfate oral tablet 10 AL (Min 4 Years) *elective erotonin Reuptake Inhibitors (sris)*** 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 Maximum dose of 40 per day for age 4-18; AL (Min 4 Years) Maximum dose of 20 per day for age 6-12; Maximum dose of 30 per day for age 13-18; AL (Min 6 Years) Maximum dose of 60 per day for age 4-18; AL (Min 4 Years) Maximum dose of 60 per day for age 4-18; AL (Min 4 Years) Maximum dose of 60 per day for age 4-18; AL (Min 4 Years) AL (Min 8 Years) Maximum dose of 40 IR per day for age 13-18; AL (Min 13 Years) sertraline hcl oral concentrate 20 /ml AL (Min 4 Years) sertraline hcl oral tablet 100, 25, 50 *erotonin-norepinephrine Reuptake Inhibitors (nris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Maximum dose of 200 per day for age 4-18; AL (Min 4 Years) Maximum dose of 60 per day for age 13-18; AL (Min 13 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 8

10 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 Maximum dose of 375 per day for age 13-18; AL (Min 13 Years) Maximum dose of 375 per day for age 13-18; AL (Min 13 Years) AL (Min 4 Years) AL (Min 4 Years) AL (Min 4 Years) AL (Min 4 Years) doxepin hcl oral concentrate 10 /ml AL (Min 4 Years) imipramine hcl oral tablet 10, 25, 50 AL (Min 4 Years) nortriptyline hcl oral capsule 10, 25, 50, 75 AL (Min 4 Years) nortriptyline hcl oral solution 10 /5ml AL (Min 4 Years) protriptyline hcl oral tablet 10, 5 AL (Min 4 Years) *Antidiabetics* *Diabetic Other - Combinations*** ra glucose oral tablet chewable 4-6 gm- *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION OLUTION RECONTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm INTA-GLUCOE ORAL GEL 77.4 % *Antidiarrheal/Probiotic Agents* *Antidiarrheal/Probiotic Agents - Misc.*** FLORANEX ORAL PACKET FLORATOR KID ORAL PACKET 250 MG QL (2 EA per 31 days) QL (2 EA per 31 days) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 9

11 gnp pink bismuth oral tablet 262 peptic relief oral tablet chewable 262 pink bismuth oral suspension 262 /15ml stomach relief max st oral suspension 525 /15ml *Antidiarrheal/Probiotic Combinations*** acidophilus/pectin oral capsule CULTURELLE DIGETIVE HEALTH ORAL CAPULE *Antidiarrheals* *Antidiarrheal Agents - Misc.*** FLORANEX ORAL PACKET FLORATOR KID ORAL PACKET 250 MG gnp pink bismuth oral tablet 262 peptic relief oral tablet chewable 262 pink bismuth oral suspension 262 /15ml stomach relief max st oral suspension 525 /15ml *Antidiarrheal Combinations*** acidophilus/pectin oral capsule CULTURELLE DIGETIVE HEALTH ORAL CAPULE *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml LOPERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral capsule 2 loperamide hcl oral liquid 1 /5ml loperamide hcl oral suspension 1 /7.5ml *Antidotes And pecific Antagonists* *Antidotes And pecific Antagonists*** actidose/sorbitol oral liquid 25 gm/120ml actidose-aqua oral liquid 25 gm/120ml deferoxamine mesylate injection solution reconstituted 2 gm, 500 =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 10

12 EZ CHAR ORAL UPENION RECONTITUTED *Antidotes* *Antidotes - Chelating Agents*** JADENU ORAL TABLET 180 MG, 360 MG, 90 MG JADENU PRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG *Antidotes*** actidose/sorbitol oral liquid 25 gm/120ml actidose-aqua oral liquid 25 gm/120ml EZ CHAR ORAL UPENION RECONTITUTED v-r ipecac oral syrup *Antihistamines* *Antihistamines - Alkylamines*** ALA-HIT IR ORAL TABLET 2 MG allergy oral tablet 4 chlorpheniramine maleate er oral tablet extended release 12 ed chlorped jr oral syrup 2 /5ml ED CHLORPED ORAL LIQUID 2 MG/ML J-TAN PD ORAL LIQUID 1 MG/ML VANAHIT PD ORAL LIQUID MG/ML *Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 BENADRYL ALLERGY CHILDREN ORAL LIQUID 12.5 MG/5ML diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral elixir 12.5 /5ml diphenhydramine hcl oral tablet 25 gnp dayhist allergy oral tablet 1.34 silphen cough oral syrup 12.5 /5ml PA PA =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 11

13 *Antihypertensives* *Antiadrenergics - Peripherally Acting*** prazosin hcl oral capsule 1, 2, 5 *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.*** trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 100 gm, 1000, 500, 750 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , *Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml PA *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous solution 150 /ml *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet , *Antimalarials*** DARAPRIM ORAL TABLET 25 MG PA hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 QL (1200 ML per 31 days) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 12

14 primaquine phosphate oral tablet 26.3 *Antimyasthenic Agents* *Antimyasthenic/Cholinergic Agents*** METINON ORAL YRUP 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Antimetabolites*** fluorouracil intravenous solution 500 /10ml PA gemcitabine hcl intravenous solution 1 gm/10ml, 1.5 gm/15ml, 2 gm/20ml, 200 /2ml *Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100, 200, 350, 50 leucovorin calcium oral tablet 10, 15, 25, 5 *Mitotic Inhibitors*** etoposide oral capsule 50 PA *Progestins-Antineoplastic*** megestrol acetate oral suspension 40 /ml QL (600 ML per 31 days) megestrol acetate oral tablet 20, 40 *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 AL (Min 4 Years) AL (Min 4 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 13

15 lithium carbonate oral tablet 300 AL (Min 4 Years) lithium oral solution 8 meq/5ml AL (Min 4 Years) *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles*** INVEGA UTENNA INTRAMUCULAR UPENION 117 MG/0.75ML INVEGA UTENNA INTRAMUCULAR UPENION 156 MG/ML INVEGA UTENNA INTRAMUCULAR UPENION 234 MG/1.5ML INVEGA UTENNA INTRAMUCULAR UPENION 39 MG/0.25ML INVEGA UTENNA INTRAMUCULAR UPENION 78 MG/0.5ML INVEGA TRINZA INTRAMUCULAR UPENION 273 MG/0.875ML INVEGA TRINZA INTRAMUCULAR UPENION 410 MG/1.315ML INVEGA TRINZA INTRAMUCULAR UPENION 546 MG/1.75ML INVEGA TRINZA INTRAMUCULAR UPENION 819 MG/2.625ML RIPERDAL CONTA INTRAMUCULAR UPENION RECONTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG RIPERIDONE M-TAB ORAL TABLET DIPERIBLE 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 Maximum dose of 160 per day; AL (Min 6 Years) PA; QL (0.75 ML per 28 days) PA; QL (1 ML per 28 days) PA; QL (1.5 ML per 28 days) PA; QL (0.25 ML per 28 days) PA; QL (0.5 ML per 28 days) PA; QL (0.88 ML per 91 days) PA; QL (1.31 ML per 91 days) PA; QL (1.75 ML per 91 days) PA; QL (2.63 ML per 91 days) PA; QL (2 EA per 28 days) Maximum dose of 3 per day for age 5-12; Maximum dose of 6 per day for age 13-18; AL (Min 5 Years) Maximum dose of 3 per day for age 5-12; Maximum dose of 6 per day for age 13-18; AL (Min 5 Years) Maximum dose of 3 per day for age 5-12; Maximum dose of 6 per day for age 13-18; AL (Min 5 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 14

16 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml Maximum dose of 3 per day for age 5-12; Maximum dose of 6 per day for age 13-18; AL (Min 5 Years) AL (Min 6 Years) haloperidol lactate injection solution 5 /ml AL (Min 6 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 6 Years) haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 12.5 *Dibenzo-Oxepino Pyrroles*** APHRI UBLINGUAL TABLET UBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 Maximum dose of 6 per day for age 6-12; Maximum dose of 15 per day for age 13-18; AL (Min 6 Years) Maximum dose of 300 per day for age 6-12; Maximum dose of 600 per day for age 13-18; AL (Min 6 Years) Maximum dose of 300 per day for age 6-12; Maximum dose of 600 per day for age 13-18; QL (31 EA per 31 days); AL (Min 6 Years) T; Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days; AL (Min 10 Years) Maximum dose of 400 per day for age 6-9; Maximum dose of 800 per day for age 10-18; AL (Min 6 Years) AL (Min 6 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 15

17 *Phenothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml Maximum dose of 75 per day for age 6-12, Maximum dose of 800 per day for age 13-18; AL (Min 6 Years) AL (Min 6 Years) fluphenazine hcl oral concentrate 5 /ml AL (Min 6 Years) fluphenazine hcl oral elixir 2.5 /5ml AL (Min 6 Years) fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4 AL (Min 6 Years) Maximum dose of 64 per day; AL (Min 6 Years) perphenazine oral tablet 8 AL (Min 6 Years) thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUCULAR PREFILLED YRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUCULAR UPENION RECONTITUTED 300 MG, 400 MG ABILIFY MAINTENA INTRAMUCULAR UPENION RECONTITUTED ER 300 MG, 400 MG AL (Min 6 Years) AL (Min 6 Years) PA; QL (1 EA per 28 days) PA; QL (1 EA per 28 days) PA; QL (1 EA per 28 days) aripiprazole oral solution 1 /ml AL (Min 6 Years) aripiprazole oral tablet 10, 15, 5 aripiprazole oral tablet 2 Maximum of 1.5 tablets per day; Maximum dose of 15 per day for age 6-12; Maximum dose of 30 per day for age 13-18; AL (Min 6 Years) Maximum of 2 tablets per day; Maximum dose of 15 per day for age 6-12; Maximum dose of 30 per day for age 13-18; AL (Min 6 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 16

18 aripiprazole oral tablet 20, 30 ARITADA INTRAMUCULAR PREFILLED YRINGE 1064 MG/3.9ML ARITADA INTRAMUCULAR PREFILLED YRINGE 441 MG/1.6ML ARITADA INTRAMUCULAR PREFILLED YRINGE 662 MG/2.4ML ARITADA INTRAMUCULAR PREFILLED YRINGE 882 MG/3.2ML *Thienbenzodiazepines*** olanzapine oral tablet 10, 2.5, 5, 7.5 olanzapine oral tablet 15 olanzapine oral tablet 20 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antiseptics & Disinfectants* *Chlorine Antiseptics*** chlorhexidine gluconate external liquid 2 % Maximum of 1 tablet per day; Maximum dose of 15 per day for age 6-12; Maximum dose of 30 per day for age 13-18; AL (Min 6 Years) PA; QL (3.9 ML per 56 days) PA; QL (1.6 ML per 28 days) PA; QL (2.4 ML per 28 days) PA; QL (3.2 ML per 28 days) Maximum of 1.5 tablets per day; AL (Min 6 Years) Maximum of 1.5 tablets per day for age 0-18 yr; AL (Min 6 Years) Maximum of 1 tablet per day for age 0-18 yr; AL (Min 6 Years) AL (Min 6 Years) chlorhexidine gluconate external liquid 4 % QL (480 ML per 31 days) REMEDY ANTIMICROBIAL CLEANER EXTERNAL LIQUID 0.12 % *Iodine Antiseptics*** BETADINE KIN CLEANER EXTERNAL OLUTION 7.5 % BETADINE WAB AID EXTERNAL WAB 10 % povidone-iodine external ointment 10 % povidone-iodine external solution 10 % =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 17

19 *Antivirals* *Antiretrovirals - Protease Inhibitors*** NORVIR ORAL CAPULE 100 MG *Antiretrovirals - Rti-Non-Nucleoside Analogues*** nevirapine oral suspension 50 /5ml *Antiretrovirals - Rti-Nucleoside Analogues- Purines*** didanosine oral capsule delayed release 125 *Antiretrovirals - Rti-Nucleoside Analogues- Thymidines*** stavudine oral solution reconstituted 1 /ml *Cardiotonics* *Cardiac Glycosides*** digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg *Cardiovascular Agents - Misc.* *Peripheral Vasodilators*** niacin flush free oral capsule 500 no flush niacin oral tablet 500 *Cephalosporins* *Cephalosporins - 1t Generation*** cefazolin sodium injection solution reconstituted 10 gm *Cephalosporins - 3Rd Generation*** ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250, 500 *Chemicals* *Fixed Oils*** hm castor oil oil *Liquids*** camphor spirit spirit glycerin liquid *olvents*** sm isopropyl alcohol solution 50 % =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 18

20 *Contraceptives* *Combination Contraceptives - Transdermal*** XULANE TRANDERMAL PATCH WEEKLY MCG/24HR *Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING MG/24HR *Progestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular suspension 150 /ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 /ml *Corticosteroids* *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Cough/Cold/Allergy* *Antihistamine-Analgesics*** ACETA-GEIC ORAL TABLET MG *Antitussive - Nonnarcotic*** benzonatate oral capsule 100, 200 ROBITUIN CHILDREN COUGH LA ORAL YRUP 7.5 MG/5ML *Antitussive-Antihistamine-Analgesic*** DELYM NIGHT TIME MULTI-YMPT ORAL LIQUID MG/15ML *Antitussive-Expectorant*** DIABETIC TUIN MAX T ORAL LIQUID MG/5ML extra action cough oral syrup /5ml MUCINEX FAT-MAX DM MAX ORAL LIQUID MG/20ML mucus relief dm cough oral tablet tussin dm oral liquid /5ml *Antitussive-Expectorants-Decongestant*** robafen cf cough/cold oral syrup /5ml QL (1 EA per 21 days) QL (1 ML per 93 days) QL (1 ML per 93 days) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 19

21 ROBITUIN TO GO COUGH/COLD CF ORAL LIQUID MG/5ML *Aromatic Inhalants*** gnp chest rub external ointment % sm medicated chest rub external ointment % *Decongestant & Antihistamine*** ALAVERT ALLERGY/INU ORAL TABLET EXTENDED RELEAE 12 HOUR MG ALLEGRA-D ALLERGY & CONGETION ORAL TABLET EXTENDED RELEAE 12 HOUR MG allergy relief/nasal decongest oral tablet extended release 24 hour BENADRYL-D ALLERGY/INU CHILD ORAL OLUTION MG/5ML BROTAPP ORAL LIQUID 1-15 MG/5ML cetirizine-pseudoephedrine er oral tablet extended release 12 hour DALLERGY ORAL LIQUID 1-2 MG/ML DELYM NIGHT TIME COUGH/COLD ORAL LIQUID MG/5ML DIMETAPP COLD/ALLERGY ORAL ELIXIR MG/5ML ED A-HIT ORAL TABLET 4-10 MG fexofenadine-pseudoephed er oral tablet extended release 24 hour promethazine vc oral syrup /5ml promethazine vc plain oral syrup /5ml UDOGET INU/ALLERGY ORAL TABLET 4-60 MG TRIAMINIC COLD & ALLERGY ORAL YRUP MG/5ML triprolidine-pse oral tablet *Decongestant W/ Expectorant*** MUCINEX D ORAL TABLET EXTENDED RELEAE 12 HOUR MG =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 20

22 tussin pe oral liquid /5ml *Expectorants*** guaifenesin oral solution 100 /5ml MUCINEX MAXIMUM TRENGTH ORAL TABLET EXTENDED RELEAE 12 HOUR 1200 MG mucus relief er oral tablet extended release 12 hour 600 mucus relief oral tablet 400 refenesen 400 oral tablet 400 refenesen oral tablet 200 robafen oral syrup 100 /5ml *Iodine Expectorants*** KI ORAL OLUTION 1 GM/ML *Misc. Respiratory Inhalants*** BRONCHO ALINE INHALATION AEROOL OLUTION 0.9 % sodium chloride inhalation nebulization solution 0.9 %, 3 % *Mucolytics*** acetylcysteine inhalation solution 10 %, 20 % *Non-Narc Antitussive-Antihistamine*** DIMETAPP LONG ACT COUGH/COLD ORAL YRUP MG/5ML promethazine-dm oral syrup /5ml ROBITUIN CHILD COUGH/COLD LA ORAL LIQUID MG/5ML *Non-Narc Antitussive-Decongestant- Antihistamine*** brotapp dm oral liquid /5ml cold/cough childrens oral elixir /5ml kidkare cough/cold oral liquid /5ml m-end dm oral liquid /5ml nohist-dm oral liquid /5ml pseudoeph-bromphen-dm oral syrup /5ml rynex dm oral liquid /5ml =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 21

23 VANACOF ORAL LIQUID MG/5ML *Dermatologicals* *Acne Products*** AMNETEEM ORAL CAPULE 10 MG, 20 MG, 40 MG CLARAVI ORAL CAPULE 10 MG, 20 MG, 30 MG, 40 MG *Analgesics - Topical*** MINERAL ICE EXTERNAL GEL 2 % *Antifungals - Topical Combinations*** BAZA EXTERNAL KIT BREEZEE MIT EXTERNAL AEROOL POWDER *Antifungals - Topical*** gnp gentian violet external solution 1 % *Antihistamines - Topical*** anti-itch maximum strength external solution 2 % *Antihistamine-Topical Combinations*** gnp itch relief extra strength external liquid % itch relief extra strength external cream % sm caldyphen clear external lotion 1-2 % *Antineoplastic Antimetabolites - Topical*** fluorouracil external cream 5 % PA fluorouracil external solution 2 %, 5 % PA *Antipruritic Combinations - Topical*** camphor phenol cold sore external gel % T; Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks; QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years) T; Must fail preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks; QL (62 EA per 31 days); AL (Min 12 Years and Max 20 Years) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 22

24 gnp anti-itch external lotion % qc antiseptic pain relief external liquid % *Antiseborrheic Combinations*** sebex external shampoo 2-2 % *Antiseborrheic Products*** anti-dandruff external shampoo 1 % DH ZINC EXTERNAL HAMPOO 2 % selenium sulfide external lotion 2.25 %, 2.5 % selenium sulfide external shampoo 2.25 % *Antivirals - Topical*** ABREVA EXTERNAL CREAM 10 % *Astringents*** DR MITH DIAPER EXTERNAL OINTMENT 10 % medi pads external pad % ECURA PROTECTIVE EXTERNAL CREAM 10 % zinc oxide external ointment 20 % *Burn Products*** silver sulfadiazine external cream 1 % QL (400 GM per 31 days) D EXTERNAL CREAM 1 % QL (400 GM per 31 days) *Emollient Combinations*** mineral oil-hydrophil petrolat external ointment *Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % urea 20 intensive hydrating external cream 20 % urea external cream 40 % *Emollients*** AMLACTIN EXTERNAL LOTION 12 % QL (400 GM per 31 days) ammonium lactate external cream 12 % QL (400 GM per 31 days) ammonium lactate external lotion 12 % QL (400 GM per 31 days) BAZA CLEAR EXTERNAL OINTMENT gnp glycerin external liquid 99.5 % ra hydrating healing external ointment =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 23

25 WEEN 24 EXTERNAL CREAM *Enzymes - Topical*** ANTYL EXTERNAL OINTMENT 250 UNIT/GM *Eyelid Cleansers & Lubricants*** YTANE LID WIPE EXTERNAL PAD *Keratolytic/Antimitotic Agents*** CLEAR AWAY 1-TEP WART REMOVER EXTERNAL PAD 40 % COMPOUND W EXTERNAL LIQUID 17 % COMPOUND W MAXIMUM TRENGTH EXTERNAL GEL 17 % DH AL EXTERNAL HAMPOO 3 % gnp scalp relief external liquid 3 % podofilox external solution 0.5 % ALACTIC FILM EXTERNAL OLUTION 17 % *Liniment Combinations*** gnp cold & hot extra strength external ointment % THERA-GEIC PLU EXTERNAL CREAM *Liniments*** MOBIYL EXTERNAL CREAM 10 % sm cold & hot therapy balm external ointment % sm pain relief/menthol external gel 7 % trixaicin external cream % v-r muscle rub ultra strength external cream % *Local Anesthetics - Topical*** burn relief external aerosol 0.5 % capsaicin external cream % dibucaine external ointment 1 % gnp capsaicin external liquid 0.15 % lidocaine external cream 4 % PA =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 24

26 lidocaine hcl external gel 2 % lidocaine hcl external solution 4 % trixaicin hp external cream % *Lubricants*** MAXILUBE EXTERNAL GEL *Misc. Topical Combinations*** ENI-CARE PROTECTIVE BARRIER EXTERNAL OINTMENT % *Misc. Topical*** HYPERCARE EXTERNAL OLUTION 20 % sm medicated wipes external pad 50 % sm witch hazel external liquid sm witch hazel external solution 86 % *Rosacea Agents*** metronidazole external cream 0.75 % metronidazole external gel 0.75 %, 1 % *kin Cleansers*** BEDIDE-CARE EXTERNAL OLUTION *kin Protectants*** ALOE VETA KIN CONDITIONER EXTERNAL LOTION 3 % AMERIPHOR EXTERNAL OINTMENT BAZA CLEANE & PROTECT EXTERNAL LOTION 2 % MINERIN EXTERNAL CREAM ECURA DIMETHICONE PROTECTANT EXTERNAL CREAM 5 % WEEN 24 KIN PROTECTANT EXTERNAL CREAM 6 % THERAEAL HAND PROTECTION EXTERNAL LOTION 1 % *Tar Products*** DH TAR GEL EXTERNAL HAMPOO 0.5 % IONIL-T EXTERNAL HAMPOO 1 % =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 25

27 X-EB T PEARL EXTERNAL HAMPOO 10 % *Topical Anesthetic Combinations*** CALADRYL EXTERNAL LOTION 1-8 % CALLERGY CLEAR EXTERNAL LOTION % gnp aloe vera/lidocaine external gel 0.5 % gnp medicated first aid spray external aerosol % ITCH-X EXTERNAL GEL 1-10 % ITCH-X EXTERNAL OLUTION 1-10 % LANACANE FIRT AID 2-IN-1 EXTERNAL AEROOL % lidocaine-prilocaine external cream % lidocaine-transparent dressing external kit 4 % *Diagnostic Products* *Diagnostic Drugs*** dipyridamole intravenous solution 5 /ml *Diagnostic Tests*** CLINITIX IN VITRO TRIP QL (100 EA per 31 days) DIATIX IN VITRO TRIP QL (100 EA per 31 days) KETOTIX IN VITRO TRIP QL (100 EA per 31 days) ONETOUCH ULTRA BLUE IN VITRO TRIP ONETOUCH VERIO IN VITRO TRIP PRECIION XTRA KETONE IN VITRO TRIP *Multiple Urine Tests*** KETO-DIATIX IN VITRO TRIP QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 26

28 *Dietary Products/Dietary Management Products* *Dietary Management Product Combinations*** FOLBIC RF ORAL TABLET MG FOLTANX ORAL TABLET MG FOLTANX RF ORAL CAPULE MG l-methylfolate forte oral capsule , METAFOLBIC ORAL TABLET MG METAFOLBIC PLU ORAL TABLET MG METAFOLBIC PLU RF ORAL TABLET MG *Digestive Aids* *Digestive Enzymes*** lactase enzyme oral tablet 3000 unit lactase fast acting oral tablet 9000 unit ZENPEP ORAL CAPULE DELAYED RELEAE PARTICLE UNIT *Endocrine And Metabolic Agents - Misc.* *Carnitine Replenisher - Agents*** CARNITOR INTRAVENOU OLUTION 200 MG/ML levocarnitine oral solution 1 gm/10ml QL (900 ML per 31 days) levocarnitine oral tablet 330 *Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml *Vasopressin*** desmopressin ace rhinal tube nasal solution 0.01 % desmopressin ace spray refrig nasal solution 0.01 % =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 27

29 desmopressin acetate oral tablet 0.1, 0.2 desmopressin acetate spray nasal solution 0.01 % *Estrogens* *Estrogen & Progestin*** estradiol-norethindrone acet oral tablet , PREMPHAE ORAL TABLET MG PREMPRO ORAL TABLET MG, MG, MG, MG *Estrogens*** estradiol oral tablet 0.5, 1, 2 estradiol transdermal patch twice weekly /24hr, /24hr, 0.05 /24hr, /24hr, 0.1 /24hr estradiol transdermal patch weekly /24hr, /24hr, 0.05 /24hr, 0.06 /24hr, /24hr, 0.1 /24hr estropipate oral tablet 0.75, 1.5, 3 PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG *Gastrointestinal Agents - Misc.* *Antiflatulents*** gas relief oral suspension 20 /0.3ml GA-X EXTRA TRENGTH ORAL CAPULE 125 MG GA-X EXTRA TRENGTH ORAL TABLET CHEWABLE 125 MG GA-X ULTRA TRENGTH ORAL CAPULE 180 MG simethicone oral suspension 40 /0.6ml simethicone oral tablet chewable 80 v-r anti-gas maximum strength oral capsule 166 *Genitourinary Agents - Miscellaneous* *Citrates*** cytra-2 oral solution /5ml QL (3600 ML per 31 days) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 28

30 *Genitourinary Irrigants*** ARGYLE TERILE ALINE IRRIGATION OLUTION 0.9 % QL (1000 ML per 31 days) sodium chloride irrigation solution 0.9 % QL (1000 ML per 31 days) *Interstitial Cystitis Agents*** ELMIRON ORAL CAPULE 100 MG PA *Urinary Analgesics*** phenazopyridine hcl oral tablet 100 phenazopyridine hcl oral tablet 200 QL (12 EA per 31 days) sb urinary pain relief max st oral tablet 97.5 sm urinary pain relief oral tablet 95 *Hematological Agents - Misc.* *Bradykinin B2 Receptor Antagonists*** FIRAZYR UBCUTANEOU OLUTION 30 MG/3ML *Hematorheologic Agents*** pentoxifylline er oral tablet extended release 400 *Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100, 50 *Quinazoline Agents*** anagrelide hcl oral capsule 0.5, 1 *Hematopoietic Agents* *Cobalamin Combinations*** vitamin b12-folic acid oral tablet mcg *Cobalamins*** b-12 oral tablet dispersible 1000 mcg cyanocobalamin injection solution 1000 mcg/ml vitamin b-12 er oral tablet extended release 1000 mcg vitamin b-12 oral lozenge 500 mcg vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250 mcg, 500 mcg vitamin b-12 sublingual tablet sublingual 1000 mcg PA =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 29

31 *Folic Acid/Folate Combinations*** folbee oral tablet FOLTAB 800 ORAL TABLET MCG-MG-MCG *Folic Acid/Folates*** folic acid oral tablet 1, 400 mcg, 800 mcg *Iron Combinations*** FOLITAB 500 ORAL TABLET EXTENDED RELEAE MG INTEGRA ORAL CAPULE MG iron 100 plus oral tablet poly-iron 150 forte oral capsule mcg- TANDEM ORAL CAPULE MG *Iron*** FERATE ORAL TABLET 240 (27 FE) MG ferretts oral tablet 325 (106 fe) FERRIMIN 150 ORAL TABLET 150 MG ferrous fumarate oral tablet 29, 324 (106 fe), 324 ferrous gluconate oral tablet 239 (27 fe), 324 (37.5 fe), 324 (38 fe) ferrous sulfate er oral tablet extended release 140 (45 fe) ferrous sulfate oral elixir 220 (44 fe) /5ml ferrous sulfate oral liquid 220 (44 fe) /5ml ferrous sulfate oral solution 75 (15 fe) /ml ferrous sulfate oral syrup 300 (60 fe) /5ml ferrous sulfate oral tablet 325 (65 fe) ferrous sulfate oral tablet delayed release 324 (65 fe), 325 (65 fe) gnp iron oral tablet 200 (65 fe) gnp iron oral tablet extended release 142 (45 fe) HEMOCYTE ORAL TABLET 324 (106 FE) MG =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 30

32 POLY-IRON 150 ORAL CAPULE 150 MG slow release iron oral tablet extended release 160 (50 fe) sm slow release iron oral tablet extended release 143 (45 fe) *Hypnotics* *Antihistamine Hypnotic Combinations*** headache pm oral tablet *Antihistamine Hypnotics*** diphenhydramine hcl (sleep) oral tablet 50 nighttime sleep aid oral tablet 25 qc sleep aid max st oral capsule 50 sleep aid oral tablet 25 *Barbiturate Hypnotics*** phenobarbital oral elixir 20 /5ml QL (2000 ML per 31 days) phenobarbital oral tablet 100, 30, 32.4, 60, 64.8, 97.2 phenobarbital oral tablet 15 QL (310 EA per 31 days) phenobarbital oral tablet 16.2 QL (383 EA per 31 days) phenobarbital sodium injection solution 130 /ml, 65 /ml *Interleukin-5 Antagonists (Igg1 Kappa)*** *Interleukin-5 Antagonists (Igg1 Kappa)*** NUCALA UBCUTANEOU OLUTION RECONTITUTED 100 MG *Interleukin-5 Antagonists (Igg4 Kappa)*** *Interleukin-5 Antagonists (Igg4 Kappa)*** CINQAIR INTRAVENOU OLUTION 100 MG/10ML *Laxatives* *Bowel Evacuant Combinations*** GOLYTELY ORAL OLUTION RECONTITUTED GM *Bulk Laxatives*** CITRUCEL ORAL POWDER CITRUCEL ORAL TABLET 500 MG =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic PA PA 31

33 fiber oral tablet 625 konsyl daily fiber oral packet 100 % KONYL ORAL PACKET 60.3 % KONYL ORAL POWDER 30.9 % METAMUCIL ORAL CAPULE 0.52 GM METAMUCIL ORAL POWDER % METAMUCIL ORAL WAFER METAMUCIL MOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % natural fiber laxative oral powder % UNIFIBER ORAL POWDER *Laxative Combinations*** ENNA PROMPT ORAL CAPULE MG *Laxatives - Miscellaneous*** glycerin (adult) rectal suppository 2 gm lactulose oral solution 10 gm/15ml QL (4185 ML per 31 days) PEDIA-LAX RECTAL UPPOITORY 1 GM polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder QL (527 GM per 31 days) ANI-UPP PEDIATRIC RECTAL UPPOITORY 1.2 GM sorbitol oral solution 70 % *Laxatives & Dss*** sennosides-docusate sodium oral tablet *Lubricant Laxatives*** FLEET OIL RECTAL ENEMA sm mineral oil oral oil *aline Laxative Mixtures*** enema disposable rectal enema FLEET PEDIATRIC RECTAL ENEMA GM/59ML sm oral saline laxative oral solution gm/5ml =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 32

34 *aline Laxatives*** gnp epsom salt oral granules magnesium citrate oral solution gm/30ml milk of magnesia concentrate oral suspension 2400 /10ml milk of magnesia oral suspension 1200 /15ml *timulant Laxatives*** bisacodyl ec oral tablet delayed release 5 bisacodyl rectal suppository 10 EX-LAX MAXIMUM TRENGTH ORAL TABLET 25 MG EX-LAX ORAL TABLET 15 MG EX-LAX ORAL TABLET CHEWABLE 15 MG FLEET BIACODYL RECTAL ENEMA 10 MG/30ML gnp castor oil oral oil 100 % senna laxative oral tablet 8.6 senna oral syrup 8.8 /5ml ENOKOT XTRA ORAL TABLET 17.2 MG *urfactant Laxatives*** COLACE CLEAR ORAL CAPULE 50 MG diocto oral syrup 60 /15ml docusate calcium oral capsule 240 docusate sodium oral liquid 50 /5ml docusate sodium oral tablet 100 ENEMEEZ MINI RECTAL ENEMA 283 MG ENEMEEZ PLU RECTAL ENEMA MG PEDIA-LAX ORAL LIQUID 50 MG/15ML stool softener oral capsule 100, 250 *Local Anesthetics-Parenteral* *Local Anesthetics - Amides*** lidocaine hcl (pf) injection solution 1.5 %, 2 % lidocaine hcl injection solution 0.5 %, 1 %, 1.5 % =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 33

35 *Medical Devices* *Applicators,Cotton Balls,Etc*** alcohol pads pad 70 % *Condoms - Female*** FC FEMALE CONDOM *Condoms - Male*** premium condoms lubricated TROJAN TROJAN NATURALAMB *Glucose Monitoring Test upplies*** glucose control in vitro solution lancet device lancets QL (200 EA per 31 days) ONETOUCH ULTRA 2 KIT W/DEVICE 1 KIT PER 365 DAY ONETOUCH ULTRA MINI KIT W/DEVICE ONETOUCH ULTRALINK KIT W/DEVICE ONETOUCH VERIO FLEX YTEM KIT W/DEVICE ONETOUCH VERIO IQ YTEM KIT W/DEVICE 1 KIT PER 365 DAY 1 KIT PER 365 DAY 1 KIT PER 365 DAY 1 KIT PER 365 DAY ONETOUCH VERIO KIT W/DEVICE 1 KIT PER 365 DAY ONETOUCH VERIO YNC YTEM KIT W/DEVICE *Needles & yringes*** BD AUTOHIELD 29G X 5MM 29G X 5MM BD AUTOHIELD 29G X 8MM 29G X 8MM BD AUTOHIELD DUO 30G X 5 MM 30G X 5 MM 1 KIT PER 365 DAY QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 34

36 BD INULIN YRINGE ULTRAFINE 31G X 5/16" 1 ML BD PEN NEEDLE MINI U/F 31G X 5 MM 31G X 5 MM BD PEN NEEDLE NANO U/F 32G X 4 MM (OTC) 32G X 4 MM BD PEN NEEDLE NANO U/F 32G X 4 MM (RX) 32G X 4 MM BD PEN NEEDLE HORT U/F 31G X 8 MM 31G X 8 MM BD PEN NEEDLE ULTRAFINE 29G X 12.7MM 29G X 12.7MM insulin syringe 29g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml *Peak Flow Meters*** All yringes Are Covered; QL (100 EA per 31 days) QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old All yringes Are Covered; QL (100 EA per 31 days) peak flow meter device QL (2 EA per 365 days) *Respiratory Therapy upplies*** IN-CHECK DIAL FLOW TRAINER DEVICE *pacer/aerosol-holding Chambers & upplies*** QL (2 EA per 365 days) AEROCHAMBER PLU FLO-VU QL (2 EA per 365 days) AEROCHAMBER PLU FLO-VU LARGE QL (2 EA per 365 days) AEROCHAMBER PLU FLO-VU MALL QL (2 EA per 365 days) AEROCHAMBER PLU FLO-VU W/MAK QL (2 EA per 365 days) E-Z PACER DEVICE QL (2 EA per 365 days) MICROCHAMBER QL (2 EA per 365 days) MICROPACER QL (2 EA per 365 days) =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 35

37 OPTICHAMBER ADVANTAGE QL (2 EA per 365 days) OPTICHAMBER ADVANTAGE-LG MAK QL (2 EA per 365 days) OPTICHAMBER ADVANTAGE-MED MAK OPTICHAMBER ADVANTAGE-M MAK QL (2 EA per 365 days) QL (2 EA per 365 days) OPTICHAMBER FACE MAK-LARGE QL (2 EA per 365 days) OPTICHAMBER FACE MAK-MEDIUM QL (2 EA per 365 days) OPTICHAMBER FACE MAK-MALL QL (2 EA per 365 days) OPTIHALER QL (2 EA per 365 days) *Minerals & Electrolytes* *Calcium Combinations*** cal/mag oral tablet CALCET CREAMY BITE ORAL TABLET CHEWABLE MG-UNIT CALCITRATE ORAL TABLET MG-UNIT cal-citrate plus vitamin d oral tablet unit calcium + d3 oral tablet unit calcium 500/d oral tablet chewable unit calcium 600+d oral tablet unit calcium carbonate-vitamin d oral tablet unit calcium oral tablet chewable unit calcium+d3 oral tablet unit calcium-magnesium-vitamin d oral tablet unit calcium-magnesium-zinc oral tablet gnp vitamin d-400 oral tablet unit MAGNEBIND 300 ORAL TABLET MG O-CAL CALCIUM + D3 ORAL TABLET MG-UNIT =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 36

38 O-CAL EXTRA D3 ORAL TABLET MG-UNIT OYCO D ORAL TABLET MG- UNIT oyster shell calcium/d oral tablet unit parva-cal oral tablet unit, unit risacal-d oral tablet unit sm calcium citrate-vit d oral tablet unit sm calcium soft chews oral tablet chewable unt-mcg sm calcium/vitamin d/minerals oral tablet unit sm oyster shell calcium/vit d3 oral tablet unit super cal/mag oral tablet super calcium/d oral tablet unit *Calcium*** CALCITRATE ORAL TABLET 950 MG calcium acetate oral tablet 668 (169 ca) calcium carbonate oral suspension 1250 (500 ca) /5ml calcium carbonate oral tablet 1250 (500 ca), 1500 (600 ca), 600 calcium carbonate oral tablet chewable 260 calcium citrate oral granules 760 /3.5gm calcium citrate oral tablet 250 calcium gluconate oral tablet 50, 500 calcium lactate oral tablet 100, 648 cal-lac oral capsule 500 chelated calcium oral tablet 200 cvs oyster shell calcium oral tablet 500 oyster calcium oral tablet 500 oyster shell calcium oral tablet 500 ra oyster shell calcium oral tablet 500 =upplemental, Asterisk(*)=N/A, PA=Prior Authorization, T=tep Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCAE= Brand name / lowercase italics= Generic 37