2017 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan. lease note that the South Carolina Medicaid referred Drug List is updated quarterly. roviders, please visit our website at https://southcarolina.wellcare.com/provider/pharmacy to view updates to the preferred drug list. Members, please visit our website at https://southcarolina.wellcare.com/member/pharmacy to view updates to the preferred drug list. Last updated (4/01/2017)
Vaccines:VaccinesarecoveredundertheVaccinesforChildrenprogramformembersthrough18yearsofage. 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 *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *AdhdAgent-SelectiveAlphaAdrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 *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 extended release 10, 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36 reference Details CoverageDetails QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days) QL (62 EA per 31 days) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) 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) QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 1
methylphenidate hcl er oral tablet extended release 24 hour 54 *Analgesics - Anti - Inflammatory* reference Details CoverageDetails QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet chewable 10, 2.5, 5 *Alternative Medicines* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 *Aminoglycosides* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS REFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML SIMONISUBCUTANEOUSSOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML SIMONISUBCUTANEOUSSOLUTION REFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 *Gold Compounds*** RIDAURA ORAL CASULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 100 /5ml QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) A A A A A A QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 2
diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen childrens oral suspension 100 /5ml ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200, 400, 600, 800 indomethacin oral capsule 25, 50 infants ibuprofen oral suspension 50 /1.25ml ketoprofen oral capsule 50, 75 reference Details CoverageDetails ketorolac tromethamine oral tablet 10 QL (20 EA per 31 days) meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 220, 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 *yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *SolubleTumorNecrosisFactorReceptor Agents*** ENBREL SUBCUTANEOUS SOLUTION REFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBRELSUBCUTANEOUSSOLUTION RECONSTITUTED 25 MG A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 3
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics- Nonnarcotic* *Analgesics Other*** acetaminophen extra strength oral liquid 500 /15ml acetaminophen oral solution 160 /5ml reference Details CoverageDetails 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 childrens non-aspirin oral suspension 160 /5ml infants silapap oral solution 100 /ml mapap oral liquid 160 /5ml pain & fever childrens oral suspension 160 /5ml *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 QL (186 EA per 31 days) butalbital-apap-caffeine oral capsule 50-325-40 butalbital-apap-caffeine oral tablet 50-325-40 butalbital-asa-caffeine oral capsule 50-325-40 A QL (186 EA per 31 days) QL (186 EA per 31 days) marten-tab oral tablet 50-325 QL (186 EA per 31 days) *Salicylates*** aspirin ec oral tablet delayed release 325, 81 aspirin low dose oral tablet chewable 81 aspirin oral tablet 325 aspirin oral tablet delayed release 81 aspirin rectal suppository 600 diflunisal oral tablet 500 eq aspirin low dose oral tablet delayed release 81 salsalate oral tablet 500, 750 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 4
*Analgesics - Opioid* *Codeine Combinations*** reference Details CoverageDetails acetaminophen-codeine #2 oral tablet 300-15 QL (248 EA per 31 days) acetaminophen-codeine #3 oral tablet 300-30 QL (248 EA per 31 days) acetaminophen-codeine #4 oral tablet 300-60 QL (248 EA per 31 days) acetaminophen-codeine oral solution 120-12 /5ml ASCOM-CODEINE ORAL CASULE 50-325-40-30 MG butalbital-apap-caff-cod oral capsule 50-325-40-30 butalbital-asa-caff-codeine oral capsule 50-325- 40-30 *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 7.5-325 /15ml hydrocodone-acetaminophen oral tablet 10-325, 5-325, 7.5-325 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 7.5-200 QL (155 EA per 31 days) *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QL (248 EA per 31 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr hydromorphone hcl oral liquid 1 /ml A; QL (10 EA per 30 days) hydromorphone hcl oral tablet 2, 4, 8 QL (248 EA per 31 days) hydromorphone hcl rectal suppository 3 methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 QL (248 EA per 31 days) morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate (pf) injection solution 0.5 /ml morphine sulfate (pf) intravenous solution 2 /ml, 4 /ml morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 5
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 *Androgens- Anabolic* reference Details CoverageDetails morphine sulfate oral tablet 15, 30 QL (248 EA per 31 days) morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl er oral tablet er 12 hour abusedeterrent 10, 15, 20, 30, 40, 60, 80 ST; Must fail preferred Morphine ER tablets within the past 100 days; QL (62 EA per 31 days); AL (Min 11 Years) oxycodone hcl oral capsule 5 QL (248 EA per 31 days) oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 QL (248 EA per 31 days) tramadol hcl oral tablet 50 QL (248 EA per 31 days) *Opioid Combinations*** ENDOCET ORAL TABLET 5-325 MG QL (248 EA per 31 days) oxycodone-acetaminophen oral tablet 10-325, 5-325, 7.5-325 QL (248 EA per 31 days) oxycodone-aspirin oral tablet 4.8355-325 QL (186 EA per 31 days) *Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 butorphanol tartrate nasal solution 10 /ml QL (2.5 ML per 31 days) pentazocine-naloxone hcl oral tablet 50-0.5 QL (248 EA per 31 days) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL1.4-0.36MG,11.4-2.9MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG ZUBSOLV TABLET SUBLINGUAL 0.7-0.18 MG SUBLINGUAL 0.7-0.18 MG *Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A *Androgens*** danazol oral capsule 100, 200, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 6 A A A
methitest oral tablet 10 TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 12.5 /act (1%), 50 /5gm (1%) *Anorectal Agents* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml *Rectal Steroids*** ROCTOSOL HC RECTAL CREAM 2.5 % *Antacids* *Antacid & Simethicone*** antacid i oral suspension 200-200-20 /5ml MAALOX MAX ORAL SUSENSION 400-400-40 MG/5ML MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION 400-400-40 MG/5ML MYLANTA ORAL SUSENSION 200-200- 20 MG/5ML *Antacids-AluminumSalts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325, 650 *Antacids - Calcium Salts*** antacid oral tablet chewable 500 calcium antacid extra strength oral tablet chewable 750 calcium antacid oral tablet chewable 500 calcium carbonate antacid oral tablet 648 calcium carbonate antacid oral tablet chewable 750 reference Details CoverageDetails A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 7
*Antacids - Magnesium Salts*** magnesium oxide oral tablet 250, 400, 420 *Anthelmintics* *Anthelmintics*** reference Details CoverageDetails ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 hydroxyzine hcl oral solution 10 /5ml QL (450 ML per 31 days) hydroxyzine hcl oral syrup 10 /5ml QL (450 ML per 31 days) hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 meprobamate oral tablet 200, 400 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 8
*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 reference Details CoverageDetails AL (Min 9 Years) diazepam oral solution 1 /ml QL (1240 ML per 31 days) diazepam oral tablet 10, 2, 5 lorazepam injection solution 2 /ml, 4 /ml lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous solution 20 /ml mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 MULTAQ ORAL TABLET 400 MG A ACERONE ORAL TABLET 200 MG, 400 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 9
*Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT DULERA INHALATION AEROSOL 100-5 MCG/ACT,200-5MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) /3ml SYMBICORTINHALATIONAEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Anti-Ige Monoclonal Antibodies*** XOLAIRSUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml reference Details CoverageDetails 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) A QL (720 ML per 31 days) QL (60 EA per 30 days) QL (300 ML per 31 days) albuterol sulfate oral syrup 2 /5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG SEREVENT DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED50MCG/DOSE terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 QL (60 EA per 30 days) QL (60 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 10
VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED 62.5 MCG/INH reference Details CoverageDetails QL (36 GM per 31 days) QL (25.8 GM per 31 days) QL (1 EA per 31 days) ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) SIRIVA RESIMAT INHALATION AEROSOL SOLUTION1.25MCG/ACT,2.5 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL100MCG/ACT,200MCG/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 QL (4 GM per 31 days) AL (Min 1 Months and Max 2 Years) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 11
FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44MCG/ACT *Xanthines*** aminophylline intravenous solution 25 /ml ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct FactorXaInhibitors*** reference Details CoverageDetails QL (12 GM per 30 days) QL (24 GM per 30 days) QL (10.6 GM per 30 days) XARELTO ORAL TABLET 10 MG QL (35 EA per 365 days) *Heparins And Heparinoid-Like Agents*** heparin sodium lock flush intravenous solution 100 unit/ml *LowMolecularWeightHeparins*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 150 /ml enoxaparin sodium subcutaneous solution 120 /0.8ml, 80 /0.8ml A only applies for quantities greater than 14 days; QL (93 ML per 31 days) A only applies for quantities greater than 14 days; QL (28 ML per 31 days) A only applies for quantities greater than 14 days; QL (24.8 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 12
enoxaparin sodium subcutaneous solution 30 /0.3ml enoxaparin sodium subcutaneous solution 40 /0.4ml enoxaparin sodium subcutaneous solution 60 /0.6ml *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml fondaparinux sodium subcutaneous solution 2.5 /0.5ml fondaparinux sodium subcutaneous solution 5 /0.4ml fondaparinux sodium subcutaneous solution 7.5 /0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 reference Details CoverageDetails A only applies for quantities greater than 14 days; QL (9.3 ML per 31 days) A only applies for quantities greater than 14 days; QL (12.4 ML per 31 days) A only applies for quantities greater than 14 days; QL (18.6 ML per 31 days) QL (11.2 ML per 31 days) QL (16 ML per 31 days) QL (5.6 ML per 31 days) QL (8.4 ML per 31 days) diazepam rectal gel 10, 2.5, 20 QL (3 EA per 31 days) *Anticonvulsants-Misc.*** carbamazepine oral suspension 100 /5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 QL (310 EA per 31 days) gabapentin oral capsule 300 QL (372 EA per 31 days) 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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 13
levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 reference Details CoverageDetails primidone oral tablet 250 QL (248 EA per 31 days) primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml peganone oral tablet 250 QL (372 EA per 31 days) phenytoin oral suspension 125 /5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 QL (372 EA per 31 days) phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml *Succinimides*** ethosuximide oral capsule 250 AL (Min 3 Years) 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 QL (930 ML per 31 days); AL (Min 3 Years) QL (310 EA per 31 days) QL (279 EA per 31 days) divalproex sodium oral capsule delayed release QL (310 EA per 31 days) sprinkle 125 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 14
divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 reference Details CoverageDetails 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 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 bupropionhcler(xl)oraltabletextended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *MonoamineOxidaseInhibitors(Maois)*** phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20 citalopram hydrobromide oral tablet 40 QL (31 EA per 31 days) 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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 15
fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 60 duloxetine hcl oral capsule delayed release particles 30, 40 IRENKA ORAL CASULE DELAYED RELEASE ARTICLES 40 MG venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 reference Details CoverageDetails QL (62 EA per 31 days) QL (31 EA per 31 days) QL (31 EA per 31 days) nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 16
*Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hour 500 metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 reference Details CoverageDetails RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 50-500 MG JANUMET XR ORAL TABLET EXTENDEDRELEASE24HOUR100-1000 MG, 50-1000 MG, 50-500 MG *Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML BASAGLARKWIKENSUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 200 UNIT/ML QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (30 ML per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 17
HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSENSION (75-25) 100 UNIT/ML HUMALOGSUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOGSUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS SUSENSIONEN- INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 KWIKEN SUBCUTANEOUS SOLUTION EN- INJECTOR 500 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSENSION 100 UNIT/ML NOVOLIN NSUBCUTANEOUS SUSENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML reference Details CoverageDetails QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 18
NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOGFLEXENSUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLOG ENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOGSUBCUTANEOUSSOLUTION 100 UNIT/ML *IncretinMimeticAgents(Glp-1Receptor Agonists)*** BYDUREON SUBCUTANEOUS EN- INJECTOR 2 MG BYDUREONSUBCUTANEOUS SUSENSION RECONSTITUTED ER 2 MG *Meglitinide Analogues*** nateglinide oral tablet 120, 60 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250, 2.5-500, 5-500 glyburide-metformin oral tablet 1.25-250, 2.5-500, 5-500 *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 reference Details CoverageDetails QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) A; QL (4 EA per 28 days) A; QL (4 EA per 28 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 19
glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinedione-Biguanide Combinations*** AVANDAMETORAL TABLET2-1000MG pioglitazone hcl-metformin hcl oral tablet 15-500, 15-850 *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Antidiarrheals* *Antidiarrheal Agents - Misc.*** acidophilus oral tablet acidophilus probiotic blend oral capsule acidophilus/bifidus oral wafer 100 acidophilus/l-sporogenes oral tablet FLORANEX ORAL ACKET FLORASTOR KIDS ORAL ACKET 250 MG stomach relief oral suspension 262 /15ml *Antidiarrheal Combinations*** CULTURELLE DIGESTIVE HEALTH ORAL CASULE *Antiperistaltic Agents*** anti-diarrheal oral tablet 2 reference Details CoverageDetails ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 20
diphenoxylate-atropine oral liquid 2.5-0.025 /5ml diphenoxylate-atropine oral tablet 2.5-0.025 LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral capsule 2 *Antidotes And Specific Antagonists* *AntidotesAndSpecificAntagonists*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Antidotes* *Antidotes -Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG JADENU ORAL TABLET 180 MG, 360 MG, 90 MG *Antidotes*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Opioid Antagonists*** naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 *Antiemetics* *5-Ht3 Receptor Antagonists*** ondansetron hcl oral solution 4 /5ml ondansetron oral tablet dispersible 4, 8 *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5, 25 travel sickness oral tablet chewable 25 *Antifungals* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 reference Details CoverageDetails A A QL (4 ML per 31 days) QL (450 ML per 31 days) nystatin oral tablet 500000 unit =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 21
terbinafine hcl oral tablet 250 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *Antihistamines* *Antihistamines - Alkylamines*** WAL-FINATE ORAL TABLET 4 MG *Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 allergy oral tablet 25 diphenhist oral liquid 12.5 /5ml diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral elixir 12.5 /5ml *Antihistamines - Non-Sedating*** ALLEGRA ALLERGY CHILDRENS ORAL SUSENSION 30 MG/5ML cetirizine hcl childrens alrgy oral syrup 1 /ml reference Details CoverageDetails cetirizine hcl childrens oral solution 5 /5ml QL (300 ML per 31 days) cetirizine hcl oral solution 1 /ml QL (300 ML per 31 days) cetirizine hcl oral syrup 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) fexofenadine hcl childrens oral suspension 30 /5ml fexofenadine hcl oral tablet 180, 60 levocetirizine dihydrochloride oral solution 2.5 /5ml levocetirizine dihydrochloride oral tablet 5 loratadine hives relief oral solution 5 /5ml QL (310 ML per 31 days) loratadine oral tablet 10 sm loratadine oral tablet dispersible 10 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 22
*Antihistamines - henothiazines*** promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 25 ROMETHEGAN RECTAL SUOSITORY 25 MG *Antihistamines - iperidines*** reference Details CoverageDetails cyproheptadine hcl oral syrup 2 /5ml QL (300 ML per 31 days) cyproheptadine hcl oral tablet 4 *Antihyperlipidemics* *BileAcidSequestrants*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 54 gemfibrozil oral tablet 600 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 fluvastatin sodium er oral tablet extended release 24 hour 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe tablet 10 oral 10 A *NicotinicAcidDerivatives*** NIACOR ORAL TABLET 500 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 23
*Antihypertensives* *AceInhibitor&CalciumChannelBlocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 2.5-10, 5-10, 5-20, 5-40 *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25, 5-6.25 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, 50-25 enalapril-hydrochlorothiazide oral tablet 10-25, 5-12.5 lisinopril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 *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 Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet 100-12.5, 100-25, 50-12.5 valsartan-hydrochlorothiazide oral tablet 160-12.5, 160-25, 320-12.5, 320-25, 80-12.5 reference Details CoverageDetails QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 24
*Angiotensin II Receptor Antagonists*** losartan potassium oral tablet 100, 25, 50 olmesartan medoxomil oral tablet 20, 40, 5 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antiadrenergics - eripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 *BetaBlocker&DiureticCombinations*** atenolol-chlorthalidone oral tablet 100-25, 50-25 bisoprolol-hydrochlorothiazide oral tablet 10-6.25, 2.5-6.25, 5-6.25 *Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti- Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 tinidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 750 reference Details CoverageDetails vancomycin hcl oral capsule 125, 250 A QL (31 EA per 31 days) ST; Must fail 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 25
*Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml sulfamethoxazole-trimethoprim oral tablet 400-80, 800-160 *Antiprotozoal Agents*** reference Details CoverageDetails atovaquone oral suspension 750 /5ml A *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous solution 150 /ml *Oxazolidinones*** linezolid oral tablet 600 A *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250-100, 62.5-25 *Antimalarials*** DARARIM ORAL TABLET 25 MG A hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimyasthenic Agents* *Antimyasthenic Agents*** MESTINON ORAL SYRU 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 QL (1200 ML per 31 days) QL (2400 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 26
*Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** reference Details CoverageDetails HEXALEN ORAL CASULE 50 MG A MYLERAN ORAL TABLET 2 MG A *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG A *Antiadrenals*** LYSODREN ORAL TABLET 500 MG A *Antiandrogens*** bicalutamide oral tablet 50 *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** capecitabine oral tablet 150, 500 A fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 /10ml gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/52.6ml, 200 /5.26ml gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 200 mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 1 gm/40ml, 100 /4ml, 25 /ml, 250 /10ml, 50 /2ml methotrexate sodium injection solution reconstituted 1 gm TABLOID ORAL TABLET 40 MG A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= A A A 27
*Antineoplastic - Braf Kinase Inhibitors*** reference Details CoverageDetails ZELBORAF ORAL TABLET 240 MG A *Antineoplastic-Hedgehogathway Inhibitors*** ERIVEDGE ORAL CASULE 150 MG A *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 MG A *Antineoplastic - Monoclonal Antibodies*** HERCETIN INTRAVENOUS SOLUTION RECONSTITUTED 440 MG ODIVO INTRAVENOUS SOLUTION 100 MG/10ML, 40 MG/4ML *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG A SUTENT ORAL CASULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *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 ICLUSIG ORAL TABLET 15 MG, 45 MG A imatinib mesylate oral tablet 100, 400 A SRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CASULE 150 MG, 200 MG TYKERB ORAL TABLET 250 MG A XALKORI ORAL CASULE 200 MG, 250 MG A A A A A A; QL (31 EA per 31 days) A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 28
reference Details CoverageDetails ZYKADIA ORAL CASULE 150 MG A; QL (155 EA per 31 days) *Antineoplastic Enzymes*** ONCASAR INJECTION SOLUTION 750 UNIT/ML *Antineoplastics Misc.*** hydroxyurea oral capsule 500 *Aromatase Inhibitors*** anastrozole oral tablet 1 exemestane oral tablet 25 A; QL (31 EA per 31 days) letrozole oral tablet 2.5 *Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 MG A *Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100, 200, 350 leucovorin calcium oral tablet 10, 15, 25, 5 *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 *JanusAssociatedKinase(Jak)Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Lhrh Analogs*** TRELSTAR INTRAMUSCULAR SUSENSION RECONSTITUTED 11.25 MG, 3.75 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG *Mitotic Inhibitors*** etoposide oral capsule 50 A *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG A cyclophosphamide oral capsule 25, 50 A LEUKERAN ORAL TABLET 2 MG A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= A A A A A 29
*Nitrosoureas*** reference Details CoverageDetails lomustine oral capsule 10, 100, 40 A *rogestins-antineoplastic*** megestrol acetate oral suspension 40 /ml QL (600 ML per 31 days) megestrol acetate oral tablet 20, 40 *Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release 25-100, 50-200 carbidopa-levodopa oral tablet 10-100, 25-100, 25-250 *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 A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 30
*Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles*** RISERDAL CONSTA INTRAMUSCULAR SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml reference Details CoverageDetails QL (62 EA per 31 days) A; QL (2 EA per 28 days) QL (62 EA per 31 days); AL (Min 5 Years) QL (496 ML per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) AL (Min 18 Years) haloperidol lactate injection solution 5 /ml AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 12.5 AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 18 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 31
*Dibenzo-Oxepino yrroles*** SAHRISSUBLINGUALTABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 reference Details CoverageDetails ST; Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.; AL (Min 10 Years) AL (Min 10 Years) AL (Min 18 Years) AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 days); AL (Min 18 Years) QL (2480 ML per 31 days); AL (Min 18 Years) AL (Min 18 Years) AL (Min 12 Years) AL (Min 2 Years) prochlorperazine rectal suppository 25 AL (Min 2 Years) thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15, 2, 20, 30, 5 ARISTADA INTRAMUSCULAR REFILLED SYRINGE 441 MG/1.6ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 662 MG/2.4ML AL (Min 2 Years) AL (Min 6 Years) A; QL (1.6 ML per 28 days) A; QL (2.4 ML per 28 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 32
ARISTADA INTRAMUSCULAR REFILLED SYRINGE 882 MG/3.2ML *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antiretrovirals Adjuvants*** *Antiretrovirals Adjuvants*** reference Details CoverageDetails A; QL (3.2 ML per 42 days) QL (31 EA per 31 days); AL (Min 13 Years) AL (Min 12 Years) tybost oral tablet 150 QL (31 EA per 31 days) *Antiseptics & Disinfectants* *Chlorine Antiseptics*** chlorhexidine gluconate external liquid 4 % QL (480 ML per 31 days) *Antivirals* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet 600-300 abacavir-lamivudine-zidovudine oral tablet 300-150-300 ATRILA ORAL TABLET 600-200-300 MG COMLERA ORAL TABLET 200-25-300 MG QL (31 EA per 31 days) QL (62 EA per 31 days) DESCOVY ORAL TABLET 200-25 MG QL (31 EA per 31 days) GENVOYA ORAL TABLET 150-150-200-10 MG KALETRA ORAL TABLET 100-25 MG, 200-50 MG lamivudine-zidovudine oral tablet 150-300 lopinavir-ritonavir oral solution 400-100 /5ml QL (31 EA per 31 days) ODEFSEYORALTABLET200-25-25MG QL (31 EA per 31 days) REZCOBIXORALTABLET800-150MG STRIBILD ORAL TABLET 150-150-200-300 MG QL (31 EA per 31 days) TRIUMEQORALTABLET600-50-300MG QL (31 EA per 31 days) TRUVADAORAL TABLET100-150MG, 133-200 MG, 167-250 MG, 200-300 MG QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 33
*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 300 MG *Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL ACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG *Antiretrovirals - rotease Inhibitors*** ATIVUS ORAL CASULE 250 MG CRIXIVAN ORAL CASULE 200 MG, 400 MG INVIRASE ORAL CASULE 200 MG INVIRASE ORAL TABLET 500 MG LEXIVA ORAL SUSENSION 50 MG/ML reference Details CoverageDetails QL (62 EA per 31 days) LEXIVA ORAL TABLET 700 MG QL (124 EA per 31 days) NORVIR ORAL CASULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG REZISTAORAL SUSENSION100 MG/ML REZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG REYATAZ ORAL CASULE 150 MG, 200 MG, 300 MG VIRACET ORAL TABLET 250 MG, 625 MG *Antiretrovirals - Rti-Non-Nucleoside Analogues*** QL (62 EA per 31 days) QL (310 EA per 31 days) EDURANT ORAL TABLET 25 MG QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 34
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG nevirapine oral suspension 50 /5ml nevirapine oral tablet 200 RESCRITOR ORAL TABLET 100 MG, 200 MG SUSTIVA ORAL CASULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG *Antiretrovirals - Rti-Nucleoside Analogues- urines*** abacavir sulfate oral tablet 300 didanosine oral capsule delayed release 125, 200, 250, 400 VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM ZIAGEN ORAL SOLUTION 20 MG/ML *Antiretrovirals - Rti-Nucleoside Analogues- yrimidines*** reference Details CoverageDetails EMTRIVA ORAL CASULE 200 MG QL (31 EA per 31 days) EMTRIVA ORAL SOLUTION 10 MG/ML QL (170 ML per 31 days) lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 *Antiretrovirals - Rti-Nucleoside Analogues- Thymidines*** stavudine oral capsule 15, 20, 30, 40 stavudine oral solution reconstituted 1 /ml zidovudine oral capsule 100 zidovudine oral syrup 50 /5ml QL (1860 ML per 31 days) zidovudine oral tablet 300 *Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG *Hepatitis B Agents*** entecavir oral tablet 0.5, 1 A EIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 100 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 35