Welcome to your guide to the Maryland Physicians Care (MPC) drug coverage for prescription medications. This booklet will provide you with information on the medications that are covered under the MPC formulary. The formulary was developed by the MPC Pharmacy and Therapeutics Committee (P&T Committee) that is comprised of physicians from various medical specialties. The P&T Committee reviews new and existing medications to ensure the formulary remains responsive to the needs of our members and providers, as well as monitoring the safety, effectiveness and cost associated with all drug categories. The formulary is the cornerstone of drug therapy quality assurance and cost containment efforts. The review process has been successfully used by hospitals and managed care organizations to provide a comprehensive and cost-effective formulary. As you use the formulary, we invite your suggestions to improve the format or content. Formulary Medications The formulary is a listing of medications marketed at the time of printing and intended for use by the health plan physicians and pharmacy providers. The first column of the chart lists the drug that is covered by the plan. Brand name drugs are capitalized (e.g., AMOXIL). Generic drugs are listed in lower case (e.g., amoxicillin). The second column serves as a reference for providing the brand name of the drug when a generic is covered by the plan. The third column lists any requirements for the drug such as prior authorization (), quantity limits (QLL), step therapy (ST). Unless exceptions are noted, all forms (tablet, capsule, liquid, topical) and strengths of a drug product are included in the formulary and will be covered by MPC. Injectable medications are only covered when noted on the formulary. The formulary applies only to medications dispensed to outpatients by participating pharmacies. The formulary does not apply to inpatient medications or to medications obtained from and administered by a physician. Formulary Status The Maryland Physicians Care formulary status information can be found online with the Formulary Search Tool available on the Maryland Physicians Care website available at www.marylandphysicianscare.com/providers/approved-drug-benefits.html. Medications HIV medications are carved out for MPC and are payable as fee-for-service through Maryland Medical Assistance. Effective November 2018
Mental Health Medications Certain mental health medications are carved out for MPC and are payable as fee-for-service through Maryland Medical Assistance. Please refer to the following website for a list of medications that are carved out and those that must be covered by MPC: https://mmcp.dhmh.maryland.gov/pap/docs/mmpp_mhf.pdf Substance Use Disorder Medications Substance use disorder medications are carved out for MPC and are payable as fee-for-service through Maryland Medical Assistance. Over-the-Counter, Non-prescription Medications Policy Some over-the-counter () products are covered according to the MPC list and will require a prescription. Generic Drug Policy Specific drugs, which have generic equivalents are covered at a generic reimbursement level and should be prescribed and dispensed in the generic form. Providers are reminded of the following: 1. When generic substitution conflicts with state regulations or restrictions, the pharmacist must gain approval from the prescribing physician to use the generic equivalent. 2. If a physician indicates Dispense As Written (DAW) and completes a MedWatch form to document any adverse effects caused by previous experience with at least 2 of the generic alternatives, MPC will pay for the brand name drug. Unapproved Use of Medications The member s benefit handbook states medications will be eligible for coverage only if they are FDA approved medications used for non-experimental indications. Non-experimental indications include the labeled indication(s) (FDA-approved) and other indications accepted as effective by the balance of currently available scientific evidence and informed professional opinion. Experimental and investigational drugs, and drugs used for cosmetic purposes are not eligible for coverage. Drugs, which have Drug Efficiency Studies Implementation (DESI) status, are not covered by MPC. Effective November 2018
Prescriptions for Non-Formulary Medications The MPC P&T Committee has attempted to include medications from all therapeutic needs. If a patient requires medication that is not listed on the formulary, the physician may request an exception to allow payment for the medication. It is anticipated that such exceptions will be rare and physicians should be able to find a medication on the formulary for most therapeutic needs. However, if a health care provider wishes that a member receive a medication not covered, he/she must submit a letter explaining the necessity, past therapeutic failures, and patient identification (name, address, and member id number). The P&T Committee will monitor prescriptions written in a non-conformance with the formulary and contact physicians who prescribe non-formulary products to request compliance. Specialty Medications Most Specialty Medications require prior authorization. Providers can call the Maryland Physicians Care Pharmacy Prior Authorization department at 1-800-953-8854 to request prior authorization, or fax a request form to 1-866-207-7231. Prior authorization forms can be downloaded from the MPC website at: http://www.marylandphysicianscare.com. Oncology Medications MPC will no longer prior authorize oncology/chemotherapy & radiation oncology services without an Eviti code. Your office should have received notification to sign up for training. If you have not had training, please go to the website www.welcometoeviti.com and sign up for training in order to receive your pin# and learn how to access the web based system, eviti. If you have any additional questions, please call eviti, Inc., our oncology vendor, @ 1-888- 678-0990 (toll free). Prior Authorization () Express Scripts, Inc. (ESI) is operating as the pharmacy benefits manager for Maryland Physicians Care. Requests for pharmacy requests (with exception of specialty medications and Hepatitis C treatment regimens) will need to be sent to ESI for processing. Please call ESI at 1-800-753-2851 or fax request to 1-877-328-9799. Pharmacy Prior Authorization Request forms can be downloaded from the MPC website at http://www.marylandphysicianscare.com. If you need to have a Prior Authorization form sent to you, you can contact the MPC Pharmacy Prior Authorization department at 1-800-953-8854. Effective November 2018
Quantity Limits (QL) Certain formulary drugs may be prescribed only in limited quantities. Quantity limits are based on clinically approved prescribing guidelines to ensure safe and proper use. Drugs that have quantity limits are identified on the formulary in the third column with QL. In order to receive an override for a medication that has a quantity limit, please call the MPC Pharmacy Prior Authorization department at 1-800-953-8854, or complete a Prior Authorization form and fax to MPC Pharmacy Prior Authorization at 1-866-207-7231. Prior Authorization forms can be downloaded from the MPC website at http://www.marylandphysicianscare.com. Step Therapy (ST) The ST program requires certain first-line drugs (generic drugs or other formulary drugs) be prescribed prior to approval of specific second-line drugs. If the prerequisite first-line agents have been filled, the member will be able to fill the prescription automatically, without requiring prior authorization. The ST requirements document can be downloaded from the MPC website at: http://www.marylandphysicianscare.com Formulary Additions If there is a new or existing medication that you would like to have added to the formulary, you will need to complete the Drug Formulary Change Request Form and send to MPC for presentation to the P&T Committee. Forms are located in the MPC Provider Manual or you can call Provider Services at (800) 953-8854, option 5 to request a form. You will be notified in writing of the decision taken at the P&T Committee. The MPC P&T Committee meets on a quarterly basis. Effective November 2018
Maryland Physicians Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*... 3 *AMINOGLYCOSIDES*... 3 *ANALGESICS - ANTI-INFLAMMATORY*... 3 *ANALGESICS - NONNARCOTIC*... 5 *ANALGESICS - OPIOID*... 7 *ANDROGENS-ANABOLIC*... 10 *ANORECTAL AGENTS*... 10 *ANTACIDS*... 11 *ANTHELMINTICS*... 11 *ANTIANGINAL AGENTS*... 12 *ANTIANXIETY AGENTS*... 12 *ANTIARRHYTHMICS*... 13 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*... 13 *ANTICOAGULANTS*... 16 *ANTICONVULSANTS*... 17 *ANTIDIABETICS*... 17 *ANTIDIARRHEALS*... 20 *ANTIDOTES AND SPECIFIC ANTAGONISTS*... 21 *ANTIDOTES*... 21 *ANTIEMETICS*... 21 *ANTIFUNGALS*... 21 *ANTIHISTAMINES*... 22 *ANTIHYPERLIPIDEMICS*... 23 *ANTIHYPERTENSIVES*... 24 *ANTI-INFECTIVE AGENTS - MISC.*... 27 *ANTIMALARIALS*... 28 *ANTIMYASTHENIC AGENTS*... 28 *ANTIMYCOBACTERIAL AGENTS*... 28 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*... 28 *ANTIRKINSON AGENTS*... 30 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*... 31 *ANTIVIRALS*... 31 *ASSORTED CLASSES*... 32 *BETA BLOCKERS*... 33 *CALCIUM CHANNEL BLOCKERS*... 34 *CARDIOTONICS*... 36 *CARDIOVASCULAR AGENTS - MISC.*... 36 *CEPHALOSPORINS*... 37 *CHEMICALS*... 38 *CONTRACEPTIVES*... 38 *CORTICOSTEROIDS*... 46 *COUGH/COLD/ALLERGY*... 47 *DERMATOLOGICALS*... 49 *DIAGNOSTIC PRODUCTS*... 56 1
*DIGESTIVE AIDS*... 57 *DIURETICS*... 57 *ENDOCRINE AND METABOLIC AGENTS - MISC.*... 58 *ESTROGENS*... 60 *FLUOROQUINOLONES*... 61 *GASTROINTESTINAL AGENTS - MISC.*... 61 *GENITOURINARY AGENTS - MISCELLANEOUS*... 62 *GOUT AGENTS*... 63 *HEMATOLOGICAL AGENTS - MISC.*... 63 *HEMATOPOIETIC AGENTS*... 64 *HETITIS C AGENT - COMBINATIONS***... 65 *HYPNOTICS*... 65 *LAXATIVES*... 65 *MACROLIDES*... 66 *MEDICAL DEVICES*... 67 *MIGRAINE PRODUCTS*... 70 *MINERALS & ELECTROLYTES*... 71 *MOUTH/THROAT/DENTAL AGENTS*... 73 *MULTIVITAMINS*... 73 *MUSCULOSKELETAL THERAPY AGENTS*... 75 *NASAL AGENTS - SYSTEMIC AND TOPICAL*... 76 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***... 76 *NUTRIENTS*... 76 *OPHTHALMIC AGENTS*... 77 *OTIC AGENTS*... 80 *SSIVE IMMUNIZING AGENTS*... 81 *PENICILLINS*... 81 *PHARMACEUTICAL ADJUVANTS*... 82 *POTASSIUM REMOVING AGENTS***... 83 *PRENATAL MV & MINERALS W/FA WITHOUT IRON***... 83 *PROGESTINS*... 83 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*... 84 *SULFONAMIDES*... 85 *TETRACYCLINES*... 85 *THYROID AGENTS*... 85 *TOXOIDS*... 86 *ULCER DRUGS*... 86 *URINARY ANTI-INFECTIVES*... 88 *URINARY ANTISSMODICS*... 88 *VACCINES*... 89 *VAGINAL PRODUCTS*... 90 *VASOPRESSORS*... 91 *VITAMINS*... 91 2
Maryland Physicians Care *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** clonidine hcl er oral tablet extended release 12 hour 0.1 guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 *ANALGESICS - ANTI- INFLAMMATORY* Kapvay Intuniv *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 50 CeleBREX ; for 17; For recipients 6-17 years old, this med is part of the mental health formulary and billed fee-for-service. For individuals not in this age range, this med continues to be part of the MCO pharmacy benefit; AL (Min 6 Years and Max 17 Years) ; for 17; For recipients 6-17 years old, this med is part of the mental health formulary and billed fee-for-service. For individuals not in this age range, this med continues to be part of the MCO pharmacy benefit; AL (Min 6 Years and Max 17 Years) ST; QLL (60 EA per 30 days) celecoxib oral capsule 400 CeleBREX ST; QLL (30 EA per 30 days) *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** 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 er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 etodolac oral tablet 500 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml Lodine Childrens Advil ibuprofen oral tablet 200 Advil ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 indomethacin sodium intravenous solution reconstituted 1 ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 4
meclofenamate sodium oral capsule 100, 50 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 500 naproxen oral tablet 375 naproxen sodium oral tablet 275 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics Other*** acetaminophen er oral tablet extended release 650 acetaminophen extra strength oral liquid 500 /15ml Mobic EC-Naprosyn Naprosyn Naprosyn Daypro Feldene Arava Tylenol 8 Hour Arthritis Pain Chloraseptic Sore Throat : Preferred : Preferred All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; 5
acetaminophen oral elixir 160 /5ml acetaminophen oral liquid 160 /5ml acetaminophen oral solution 160 /5ml acetaminophen oral tablet 325 acetaminophen oral tablet 500 acetaminophen oral tablet chewable 80 childrens acetaminophen oral tablet dispersible 80 infants pain reliever oral suspension 80 /0.8ml Medi-Tabs Childrens Little Remedies for Fever PediaCare Infant Fever/Pain Pharbetol Tylenol Extra Strength Childrens Medi-Tabs Mapap Childrens All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; 6
non-aspirin jr strength oral tablet chewable 160 JUNIOR MAP ORAL TABLET DISPERSIBLE 160 MG *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 butalbital-apap-caffeine oral capsule 50-325- 40 butalbital-apap-caffeine oral tablet 50-325-40 butalbital-aspirin-caffeine oral capsule 50-325-40 *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** Medi-Tabs Junior Strength SB Non-Aspirin Jr Strength Tencon Zebutal Esgic Fiorinal aspirin ec oral tablet delayed release 325 Ecotrin aspirin ec oral tablet delayed release 81 Aspir-Low aspirin oral tablet 325 diflunisal oral tablet 500 salsalate oral tablet 500, 750 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300-15 acetaminophen-codeine #3 oral tablet 300-30 acetaminophen-codeine #4 oral tablet 300-60 acetaminophen-codeine oral solution 120-12 /5ml acetaminophen-codeine oral tablet 300-15 Bayer Advanced Aspirin Reg St Disalcid Tylenol with Codeine #3 Tylenol with Codeine #4 All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (50 ML per 30 days) QLL (240 EA per 30 days) 7
acetaminophen-codeine oral tablet 300-60 Tylenol with Codeine #4 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 2.5-108 /5ml, 5-217 /10ml, 7.5-325 /15ml hydrocodone-acetaminophen oral tablet 10-300 hydrocodone-acetaminophen oral tablet 10-325 hydrocodone-acetaminophen oral tablet 2.5-325 hydrocodone-acetaminophen oral tablet 5-300 hydrocodone-acetaminophen oral tablet 5-325, 7.5-325 hydrocodone-acetaminophen oral tablet 7.5-300 Fiorinal/Codeine #3 Hycet Vicodin HP Norco Verdrocet Vicodin Lortab Vicodin ES hydrocodone-ibuprofen oral tablet 10-200 Xylon QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) hydrocodone-ibuprofen oral tablet 5-200 Reprexain QLL (240 EA per 30 days) hydrocodone-ibuprofen oral tablet 7.5-200 QLL (240 EA per 30 days) LORCET HD ORAL TABLET 10-325 MG Hydrocodone-Acetaminophen QLL (240 EA per 30 days) LORCET ORAL TABLET 5-325 MG LORCET PLUS ORAL TABLET 7.5-325 MG LORTAB ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 fentanyl transdermal patch 72 hour 100 mcg/hr Hydrocodone-Acetaminophen QLL (240 EA per 30 days) Hydrocodone-Acetaminophen QLL (240 EA per 30 days) Hydrocodone-Acetaminophen QLL (240 EA per 30 days) Duragesic-100 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 ; QLL (15 EA per 30 days) ; QLL (15 EA per 30 days) ; QLL (15 EA per 30 days) ; QLL (15 EA per 30 days) ; QLL (15 EA per 30 days) ; QLL (15 EA per 30 days) hydromorphone hcl oral tablet 2, 4 Dilaudid QLL (180 EA per 30 days) 8
hydromorphone hcl oral tablet 8 Dilaudid QLL (120 EA per 30 days) meperidine hcl oral tablet 100, 50 Demerol QLL (56 EA per 30 days) methadone hcl oral concentrate 10 /ml Methadose ; QLL (180 ML per 30 days) methadone hcl oral solution 10 /5ml, 5 /5ml ; QLL (180 ML per 30 days) methadone hcl oral tablet 10, 5 Dolophine ; QLL (180 EA per 30 days) morphine sulfate (concentrate) oral solution 20 /ml morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 MS Contin ; QLL (90 EA per 30 days) QLL (240 EA per 30 days) QLL (150 ML per 30 days) QLL (40 ML per 30 days) QLL (150 EA per 30 days) oxycodone hcl oral tablet 15, 30, 5 Roxicodone QLL (150 EA per 30 days) tramadol hcl oral tablet 50 Ultram ; QLL (240 EA per 30 days); AL (Min 16 Years) *Opioid Combinations*** oxycodone-acetaminophen oral tablet 10-325 oxycodone-acetaminophen oral tablet 2.5-325, 5-325, 7.5-325 ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG *Opioid Partial Agonists*** butorphanol tartrate nasal solution 10 /ml Percocet Endocet Oxycodone-Acetaminophen QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (240 EA per 30 days) QLL (2.5 ML per 30 days) 9
*Tramadol Combinations*** tramadol-acetaminophen oral tablet 37.5-325 *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 methitest oral tablet 10 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Ultracet Depo-Testosterone Fortesta testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel 25 /2.5gm (1%) AndroGel testosterone transdermal gel 50 /5gm (1%) AndroGel *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml COLOCORT RECTAL ENEMA 100 MG/60ML CORTIFOAM RECTAL FOAM 10 % *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % *Rectal Anesthetic/Steroids*** hydrocortisone ace-pramoxine rectal cream 1-1 % lidocaine-hydrocortisone ace rectal cream 3-0.5 % lidocaine-hydrocortisone ace rectal gel 2.8-0.55 % lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %, 3-2.5 % Cortenema Hydrocortisone Analpram-HC LidaZone HC ; All quantities are limited to a max daily dose of 4 grams of acetaminophen. Quantities exceeding 4 grams of acetaminophen will require prior authorization.; QLL (240 EA per 30 days); AL (Min 16 Years) ; QLL (5 ML per 60 days) ; QLL (2 packages per 30 days) ; QLL (4 packages per 30 days) ; QLL (30 ea per 30 days) ; QLL (60 ea per 30 days) ; QLL (30 GM per 30 days) 10
pramcort rectal cream 1-1 % LIDAZONE HC RECTAL CREAM 3-0.5 % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** PROCTO-K RECTAL CREAM 1 % PROCTOSOL HC RECTAL CREAM 2.5 % PROCTOZONE-HC RECTAL CREAM 2.5 % *ANTACIDS* *Antacid & Simethicone*** Analpram-HC Lidocaine-Hydrocortisone Ace Hydrocortisone Hydrocortisone Hydrocortisone ALMACONE ORAL TABLET CHEWABLE 200-200-25 MG MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Calcium Salts*** calcium antacid ultra strength oral tablet chewable 1000 calcium carbonate antacid oral tablet chewable 500 calcium carbonate antacid oral tablet chewable 750 ra smooth antacid ex st oral tablet chewable 750 ra stomach relief kids oral tablet chewable 400 TITRALAC ORAL TABLET CHEWABLE 420 MG *ANTHELMINTICS* *Anthelmintics*** ivermectin oral tablet 3 reeses pinworm medicine oral suspension 144 /ml reeses pinworm medicine oral tablet 180 Tums Ultra 1000 Tums Lasting Effects CVS Chewy Not Chalky Flavor CVS Chewy Not Chalky Flavor Childrens Soothe Stromectol 11
*ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.4 /hr nitroglycerin transdermal patch 24 hour 0.2 /hr, 0.6 /hr MINITRAN TRANSDERMAL TCH 24 HOUR 0.1 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL TCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-DUR TRANSDERMAL TCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG Isordil Titradose Nitro-Time Nitrostat Nitro-Dur Minitran Nitroglycerin Nitroglycerin Nitroglycerin ER 12
*ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, 400 MULTAQ ORAL TABLET 400 MG CERONE ORAL TABLET 100 MG, 200 MG, 400 MG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution 0.5-2.5 (3) /3ml fluticasone-salmeterol inhalation 55-14, 113-14, 232-14 Norpace Rythmol SR Pacerone Amiodarone HCl ADVAIR DISKUS INHALATION AEROSOL POWDER 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 BREO ELLIPTA INHALATION AEROSOL POWDER 100-25 & 200-25 MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT ; Prior Authorization does not apply to members between the ages of 4-11 years.; QLL (60 blisters per 30 days); AL (Min 4 Years and Max 11 Years) ; QLL (2 inhalers per 30 days) QLL (1 EA per 30 days) QLL (3 inhalers per 30 days) 3
STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4, 8 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 albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 terbutaline sulfate oral tablet 2.5, 5 ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH VoSpire ER Xopenex HFA ST; QLL (1 EA per 30 days) QLL (375 ML per 30 days) QLL (375 EA per 30 days) ST; QLL (375 ML per 30 days); AL (Max 18 Years) ST; QLL (2 INH per 30 days) QLL (1 inhaler per 30 days) QLL (1 inhaler per 30 days) QLL (2 Inhalers per 30 days) QLL (26 GM per 30 days) QLL (1 inhaler per 30 days) 14
TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT *Leukotriene Receptor Antagonists*** QLL (1 inhaler per 30 days) montelukast sodium oral packet 4 Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet 10 Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet chewable 4, 5 Singulair QLL (30 EA per 30 days) zafirlukast oral tablet 10, 20 Accolate ST; QLL (60 EA per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml ARNUITY ELLIPTA INHALATION POWDER 100 MCG/BLIST, 250 MCG/BLIST Pulmicort ; Applies for members age 6 and older.; QLL (120 ML per 30 days); AL (Max 5 Years) QLL (30 EA per 30 days) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml Theochron ; Applies for members age 6 to 8 (1 inhaler per 30 days) QLL (1 inhaler per 30 days) 15
*ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1, 2.5, 3, 4, 5, 6 warfarin sodium oral tablet 10, 2, 7.5 JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml ARIXTRA SUBCUTANEOUS SOLUTION 2.5 MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML Jantoven Coumadin Warfarin Sodium Lovenox Lovenox Arixtra Fondaparinux Sodium QLL (42 syringes per 1 year) QLL (42 syringes per 1 year) QLL (21 syringes per 1 year) QLL (21 syringes per 1 year) 16
*Thrombin Inhibitors - Selective Direct & Reversible*** ELIQUIS TABLETS 2.5 MG, 5 MG *ANTICONVULSANTS* *Anticonvulsants - Misc.*** primidone oral tablet 250, 50 *Hydantoins*** phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100 DILANTIN ORAL CAPSULE 30 MG PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG *Succinimides*** ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 *Diabetic Other*** glucose oral tablet chewable 4 gm BD GLUCOSE ORAL TABLET CHEWABLE 5 GM GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 Mysoline Dilantin Phenytoin Infatabs Dilantin Phenytoin Zarontin Zarontin Precose Glucophage XR Glucophage Dex4 Quick Dissolve Glucose Nesina QLL (30 EA per 30 days) 17
*Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet 12.5-1000, 12.5-500 *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet 12.5-15, 12.5-30, 12.5-45, 25-15, 25-30, 25-45 *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 300 UNIT/ML TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 300 UNIT/ML ADMELOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION HUMULIN N SUBCUTANEOUS (70-30) 100 SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML Kazano Oseni QLL (60 EA per 30 days) QLL (30 EA per 30 days) 18
*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC SUBCUTANEOUS PEN- INJECTOR 0.25 MG, 0.5 MG *Meglitinide Analogues*** nateglinide oral tablet 120, 60 repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500, 2-500 Starlix Prandin 19
*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** ertugliflozin oral tablet 5, 15 ertugliflozin-metformin oral tablet 2.5-250, 2.5-500, 5-500 *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250, 2.5-500, 5-500 glyburide-metformin oral tablet 1.25-250 glyburide-metformin oral tablet 2.5-500, 5-500 *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tab 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet 15-500, 15-850 *Thiazolidinediones*** STEGLATRO SEGLUROMET Glucovance Amaryl Glucotrol XL Glucotrol Glucotrol XL Glynase Duetact pioglitazone hcl oral tab 15, 30, 45 Actos *ANTIDIARRHEALS* *Antidiarrheal Agents - Misc.*** pink bismuth maximum strength oral suspension 525 /15ml Actoplus Met Pepto-Bismol Max Strength QLL (30 EA per 30 days) QLL (90 EA per 30 days) QLL (30 EA per 30 days) pink bismuth oral suspension 262 /15ml Soothe 20
*Antiperistaltic Agents*** anti-diarrheal oral capsule 2 Imodium A-D anti-diarrheal oral tablet 2 Loperamide A-D diphenoxylate-atropine oral liquid 2.5-0.025 /5ml diphenoxylate-atropine oral tablet 2.5-0.025 loperamide hcl oral liquid 1 /5ml *ANTIDOTES AND SPECIFIC ANTAGONISTS* *Antidotes And Specific Antagonists*** sm ipecac syrup oral syrup *ANTIDOTES* *Antidotes*** sm ipecac syrup oral syrup *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 Lomotil ondansetron hcl oral solution 4 /5ml Zofran QLL (150 ML per 30 days) ondansetron hcl oral tablet 24 ; QLL (12 EA per 30 days) ondansetron hcl oral tablet 4, 8 Zofran QLL (30 EA per 30 days) ondansetron oral tablet dispersible 4, 8 Zofran ODT *Antiemetics - Anticholinergic*** cvs motion sickness ii oral tablet 25 Wal-Dram II meclizine hcl oral tablet 12.5 meclizine hcl oral tablet chewable 25 trimethobenzamide hcl oral capsule 300 *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG *ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 Tigan Aprepitant QLL (30 EA per 30 days) 21
griseofulvin ultramicrosize oral tablet 125, 250 Gris-PEG nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 LamISIL QLL (84 EA per 365 days) *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 Diflucan Diflucan itraconazole oral capsule 100 Sporanox Pulsepak SPORANOX ORAL SOLUTION 10 MG/ML *ANTIHISTAMINES* *Antihistamines - Alkylamines*** allergy oral tablet extended release 12 Chlorphen SR chlorpheniramine maleate er oral tablet extended release 12 Chlorphen SR chlorpheniramine maleate oral tablet 4 Wal-finate cvs allergy relief oral tablet extended release 12 *Antihistamines - Ethanolamines*** Chlorphen SR childrens allergy oral liquid 12.5 /5ml Naramin clemastine fumarate oral tablet 2.68 cvs allergy childrens oral tablet chewable 12.5 Benadryl Allergy Childrens diphenhist oral capsule 25 Benadryl Dye-Free Allergy diphenhydramine hcl oral capsule 50 diphenhydramine hcl oral elixir 12.5 /5ml Banophen diphenhydramine hcl oral tablet 25 Benadryl Allergy eq allergy relief childrens oral elixir 12.5 /5ml kp diphenhydramine hcl oral capsule 50 Banophen ormir oral capsule 50 Banophen pharbedryl oral capsule 50 silphen cough oral syrup 12.5 /5ml Banophen BANOPHEN ORAL CAPSULE 50 MG KP DiphenhydrAMINE HCl 22
*Antihistamines - Non-Sedating*** cetirizine hcl childrens oral solution 1 /ml ZyrTEC Childrens Allergy cetirizine hcl oral tablet 10 ZyrTEC Allergy cetirizine hcl oral tablet 5 cetirizine hcl oral tablet chewable 10, 5 fexofenadine hcl childrens oral suspension 30 /5ml Wal-Zyr Childrens Allegra Allergy Childrens QLL: 150ml/month if under 6 y/o; 300ml/month if 6 y/o and older; ; QLL (150 ML per 30 days) fexofenadine hcl oral tablet 180 KLS Aller-Fex fexofenadine hcl oral tablet 60 Allegra Allergy loratadine allergy relief oral tablet dispersible 10 loratadine childrens oral syrup 5 /5ml Wal-itin Allergy Reditabs Claritin ; QLL (30 EA per 30 days) ; QLL (300 ML per 30 days) loratadine oral tablet 10 KLS AllerClear ; QLL (30 EA per 30 days) *Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 50 promethazine hcl rectal suppository 25 PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm Phenergan Promethegan Promethazine HCl Prevalite Prevalite Questran Questran Colestid Flavored Colestid Colestid 23
PREVALITE ORAL CKET 4 GM PREVALITE ORAL POWDER 4 GM/DOSE *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 48 fenofibrate oral tablet 160, 54 fenofibric acid oral capsule delayed release 135, 45 Cholestyramine Light Cholestyramine Light Lofibra Tricor Lofibra Trilipix gemfibrozil oral tablet 600 Lopid QLL (60 EA per 30 days) *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20 Lipitor QLL (30 EA per 30 days) QLL (30 EA per 30 days) lovastatin oral tablet 40 Mevacor QLL (30 EA per 30 days) pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5, 80 CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG *Intest Cholest Absorp Inhib-H Coa Reductase Inhib Comb*** VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG *Intestinal Cholesterol Absorption Inhibitors*** Pravachol Zocor Rosuvastatin Calcium Ezetimibe-Simvastatin ezetimibe oral tablet 10 Zetia ST *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 amlodipine besy-benazepril hcl oral capsule 2.5-10, 5-40 Lotrel QLL (30 EA per 30 days) QLL (30 EA per 30 days) QLL (30 EA per 30 days) ; QLL (30 EA per 30 days) ST; QLL (30 EA per 30 days) QLL (30 EA per 30 days) QLL (30 EA per 30 days) 24
*Ace Inhibitors & Thiazide/Thiazide- Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 benazepril-hydrochlorothiazide oral tablet 5-6.25 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, 50-25 enalapril-hydrochlorothiazide oral tablet 10-25 enalapril-hydrochlorothiazide oral tablet 5-12.5 fosinopril sodium-hctz oral tablet 10-12.5, 20-12.5 lisinopril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 moexipril-hydrochlorothiazide oral tablet 15-12.5, 15-25, 7.5-12.5 quinapril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 *Ace Inhibitors*** Lotensin HCT Vaseretic Zestoretic Accuretic benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 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, 30, 40 lisinopril oral tablet 20, 5 moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2 perindopril erbumine oral tablet 4, 8 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 trandolapril oral tablet 1, 2, 4 Vasotec Zestril Prinivil Aceon Accupril Altace Mavik 25
*Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet 250-15, 250-25 *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet 10-160, 10-320, 5-160, 5-320 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet 16-12.5, 32-12.5, 32-25 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 *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, 4, 8 irbesartan oral tablet 150, 300, 75 losartan potassium oral tablet 100, 25, 50 valsartan oral tablet 160, 320, 40, 80 *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet 10-160- 12.5, 10-160-25, 10-320-25, 5-160- 12.5, 5-160-25 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr clonidine hcl transdermal patch weekly 0.2 /24hr clonidine hcl transdermal patch weekly 0.3 /24hr guanfacine hcl oral tablet 1, 2 26 Exforge Atacand HCT Hyzaar Diovan HCT Atacand Avapro Cozaar Diovan Exforge HCT Catapres Catapres-TTS-1 Catapres-TTS-2 Catapres-TTS-3 QLL (30 EA per 30 days) QLL (30 EA per 30 days) QLL (30 EA per 30 days) QLL (30 EA per 30 days) QLL (60 EA per 30 days) QLL (30 EA per 30 days) QLL (5 EA per 30 days) QLL (5 EA per 30 days) QLL (5 EA per 30 days)
methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4 Cardura QLL (30 EA per 30 days) doxazosin mesylate oral tablet 8 Cardura QLL (60 EA per 30 days) prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 10 *Beta Blocker & Diuretic Combinations*** Minipress atenolol-chlorthalidone oral tablet 100-25 Tenoretic 100 atenolol-chlorthalidone oral tablet 50-25 Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet 10-6.25, 2.5-6.25, 5-6.25 metoprolol-hydrochlorothiazide oral tablet 100-25, 100-50 metoprolol-hydrochlorothiazide oral tablet 50-25 nadolol-bendroflumethiazide oral tablet 40-5, 80-5 propranolol-hctz oral tablet 40-25, 80-25 *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 metronidazole oral tablet 250, 500 trimethoprim oral tablet 100 Ziac Lopressor HCT Corzide Flagyl Flagyl QLL (30 EA per 30 days) QLL (60 EA per 30 days) vancomycin hcl oral capsule 125, 250 Vancocin HCl ; QLL (40 EA per 30 days) VANCOCIN HCL ORAL CAPSULE 125 MG *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml Vancomycin HCl Sulfatrim Pediatric 27
sulfamethoxazole-trimethoprim oral tablet 400-80 SULFATRIM PEDIATRIC ORAL SUSPENSION 200-40 MG/5ML *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml *ANTIMALARIALS* *Antimalarials*** Bactrim Sulfamethoxazole- Trimethoprim Cleocin Cleocin chloroquine phosphate oral tablet 250, 500 hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 DARAPRIM ORAL TABLET 25 MG PLAQUENIL ORAL TABLET 200 MG *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 *ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifampin oral capsule 150, 300 PRIFTIN ORAL TABLET 150 MG *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Antiandrogens*** Hydroxychloroquine Sulfate Mestinon Myambutol Rifadin bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 XTANDI ORAL CAPSULE 40 MG 28
*Antiestrogens*** tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** capecitabine oral tablet 150, 500 Xeloda mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 1 gm/40ml TABLOID ORAL TABLET 40 MG *Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG *Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG *Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100 MG, 500 MG COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG ICLUSIG ORAL TABLET 15 MG TYKERB ORAL TABLET 250 MG VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG *Antineoplastics Misc.*** hydroxyurea oral capsule 500 Hydrea INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT *Aromatase Inhibitors*** anastrozole oral tablet 1 Arimidex exemestane oral tablet 25 Aromasin 29 QLL (4 ea per 28 days)
letrozole oral tablet 2.5 Femara *Gonadotropin Releasing Hormone (Gnrh) Antagonists*** FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG *Lhrh Analogs*** leuprolide acetate injection kit 1 /0.2ml ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG *Progestins-Antineoplastic*** hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 *Retinoids*** tretinoin oral capsule 10 *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *ANTIRKINSON AGENTS* *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 Megace Oral Parlodel Parlodel Eldepryl Preferred 30
*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*** ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Peripheral Comt Inhibitors*** entacapone oral tablet 200 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Phenothiazines*** prochlorperazine maleate oral tab 5 &10 prochlorperazine rectal suppository 25 *ANTIVIRALS* *Cmv Agents*** valganciclovir hcl oral soln recon. 50 /ml Sinemet CR Sinemet Requip Comtan Compro Valcyte valganciclovir hcl oral tablet 450 Valcyte *Hepatitis B Agents*** EPIVIR HBV ORAL SOLUTION 5 MG/ML QLL (90 EA per 30 days) *Hepatitis C Agents*** glecaprevir/pibrentasvir MAVYRET ; 1 st -line (AASLD & IDSA) sofosbuvir/velpatasvir Epclusa sofosbuvir/velpatasvir/ voxilaprevir Vosevi ledipasvir/sofosbuvir Harvoni ribavirin oral tablet 200 ribavirin oral capsule 200 PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML Moderiba Rebetol ST; Requires concurrent use with other Hep C medications; QLL (2 Packs per 30 days) ST; Requires concurrent use with other Hep C medications; QLL (2 Packs per 30 days) 31
PEG-INTRON REDIPEN K 4 SUBCUTANEOUS KIT 120 MCG/0.5ML PEG-INTRON REDIPEN SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 REBETOL ORAL SOLUTION 40 MG/ML *Herpes Agents - Purine Analogues*** ST; Requires concurrent use with other Hep C medications acyclovir oral capsule 200 Zovirax QLL (60 EA per 30 days) acyclovir oral suspension 200 /5ml Zovirax QLL (300 ML per 30 days) acyclovir oral tablet 400, 800 Zovirax QLL (60 EA per 30 days) valacyclovir hcl oral tablet 1 gm, 500 *Herpes Agents - Thymidine Analogues*** famciclovir oral tablet 125 famciclovir oral tablet 250 Valtrex QLL (21 EA per 30 days) QLL (60 EA per 30 days) famciclovir oral tablet 500 Famvir QLL (21 EA per 30 days) *Influenza Agents*** rimantadine hcl oral tablet 100 Flumadine QLL (14 EA per 90 days) *Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 oseltamivir phosphate oral capsule 45, 75 RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML *ASSORTED CLASSES* *Chelating Agents*** CUPRIMINE ORAL CAPSULE 250 MG *Cyclosporine Analogs*** cyclosporine modified oral capsule 100, 25 cyclosporine modified oral capsule 50 Tamiflu Tamiflu Neoral Gengraf QLL (20 EA Max Qty Per Fill Retail) QLL (10 EA Max Qty Per Fill Retail) QLL (60 EA per 180 days) QLL (3 Bottles Max Qty Per Fill Retail) 32
cyclosporine modified oral solution 100 /ml Gengraf cyclosporine oral capsule 100, 25 GENGRAF ORAL CAPSULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG *Macrolide Immunosuppressants*** sirolimus oral tablet 0.5, 1, 2 tacrolimus oral capsule 0.5, 1, 5 *Potassium Removing Resins*** sodium polystyrene sulfonate oral suspension 15 gm/60ml *Purine Analogs*** azathioprine oral tablet 50 *Selective T-Cell Costimulation Blockers*** NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG *BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective*** acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 33 SandIMMUNE CycloSPORINE Modified CycloSPORINE Modified CellCept CellCept CellCept Mycophenolate Mofetil HCl Rapamune Prograf Kionex Imuran Coreg Tenormin
betaxolol hcl oral tablet 10, 20 bisoprolol fumarate oral tablet 10 bisoprolol fumarate oral tablet 5 metoprolol succinate er oral tablet extended release 24 hour 100, 200, 25, 50 Zebeta Toprol XL metoprolol tartrate oral tablet 100, 50 Lopressor metoprolol tartrate oral tablet 25 *Beta Blockers Non-Selective*** nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300 diltiazem hcl er beads oral capsule extended release 24 hour 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 360 diltiazem hcl er coated beads oral capsule extended release 24 hour 300 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 Corgard Inderal LA Betapace AF Sorine Norvasc Taztia XT Tiazac Cardizem CD Cartia XT QLL (60 EA per 30 days) QLL (30 EA per 30 days) QLL (60 EA per 30 days) QLL (60 EA per 30 days) QLL (60 EA per 30 days) QLL (60 EA per 30 days) QLL (60 EA per 30 days) 34