2014 Georgia Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar este documento en español o para escuchar la traducción, llame al Servicio al Cliente al 1-866-231-1821 (TTY/TDD: 1-877-247-6272). lease note that the Georgia Medicaid referred Drug List is updated quarterly. roviders, please visit our website at http://georgia.wellcare.com/provider/pharmacyservices to view updates to the preferred drug list. Members, please visit our website at http://georgia.wellcare.com/member/preferreddruglist to view updates to the preferred drug list. Last updated (08/01/2014)
Non-referred Drugs Georgia Medicaid Cough & Cold Drug List LEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger. ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 MG CASULE BENZONATATE 100 MG CASULE BENZONATATE 200 MG CASULE Dextromethorphan olistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSENSION Dextromethorphan HBr ROBITUSSIN EDIATRIC COUGH SY Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF LUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/seudoephedrine HCl ALLANHIST DX DROS BROMHIST DX DROS BROTA DM LIQUID Q-TA DM ELIXIR BROMFED DM SYRU ENDACOF-D DROS Brophenaramine/Dextromethorphan HBr/henylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/henylephrine HCl C-HEN DM RONDEX-DM SYRU DE-CHLOR DM LIQUID NOHIST-DM D-COF SYRU SILDEC E-DM SYRU CORFEN DM TRI-DEX E Chlorpheniramine/Dextromethorphan HBr/seudoephedrine HCl EDIATRIC COUGH-COLD LIQUID MESEHIST DM KIDKARE COUGH/COLD Dexchlorpheniramine/seudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETA LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID romethazine HCl/Dextromethorphan HBr ROMETHAZINE-DM SYRU Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMTOM EXECTORANTS DECONGESTANT-EXECTORANT COMBINATIONS Guaifenesin/henylephrine HCl DONATUSSIN DROS E-GUAI DROS DESEC LIQUID RESCON-GG LIQUID Guaifenesin/Dextromethorphan HBr/henylephreine ROBAFEN CF SYRU referred Drugs NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION NON-NARCOTIC DECONGESTANT-EXECTORANT-ANTITUSSIVE Last updated 07/31/14 age 1 of 2
Georgia Medicaid Cough & Cold Drug List LEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger. Non-referred Drugs referred Drugs NON-NARCOTIC ANTITUSSIVE AND EXECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID SIMUC-DM ELIXIR GUAIFENESIN DM SYRU Q-TUSSIN-DM SYRU EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRU REFENESEN DM SILTUSSIN DM DAS COUGH SYRU MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID Chlorpheniramine/Hydrocodone olistirex TUSSIONEX ENNKINETIC SUS TUSSICAS (min. age 6 years old) HYDROCODONE-CHLORHENIRAMINE SUSENSION (min. age 6 years old) Codeine hosphate/romethazine HCl ROMETHAZINE-CODEINE SYRU (min. age 6 years old) Dexbrompheniramine/Hydrocodone Bit/henylephrine HCl Codeine/henylephrine HCl/romethazine CYTUSS-HC NR SYRU HC/E/DBROM SYRU ROMETH VC W/COD SYRU ROMETHAZINE VC/COD SYRU HC 2.5-E 5-DBROM 1 MG SYRU seudoephedrine HCl/Codeine/Chlorpheniramine HENYLHISTINE DH HYDROMET SYRU NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROINE NARCOTIC ANTITUSSIVE-EXECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine hosphate/guaifenesin HYDROCODONE-GUAIFENESIN SYRU CHERATUSSIN AC SYRU NARCOF SYRU TUSSICLEAR DH SYRU GUAIFENESIN-CODEINE SYRU IOHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXECTORANT COMBINATIONS Codeine hosphate/guaifenesin/seudoephedrine HCl CHERATUSSIN DAC SYRU Last updated 07/31/14 age 2 of 2
Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. Drug Name *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexi ants* *Amphetamines**-*Amphetamine Mixtures*** ADDERALL XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines**-*Amphetamines*** dextroamphetamine sulfate oral tablet 10, 5 dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 VYVANSE ORAL CASULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Anti-Obesity Agents**-*Lipase Inhibitors*** XENICAL ORAL CASULE 120 MG *Stimulants - Misc.**-*Stimulants - Misc.*** dexmethylphenidate hcl oral tablet 10, 2.5, 5 METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG reference Details Coverage Details QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days) QL (62 EA per 31 days) ST; Notes (Must fail preferred Vyvanse or Adderall XR within the past 100 days.); QL (31 EA per 31 Days); AL (Min 5 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) A; AL (Min 12 Years and Max 21 Years) QL (62 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 1
reference Details Coverage Details methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 methylphenidate hcl er oral tablet extendedrelease* 10 methylphenidate hcl er oral tablet extendedrelease* 18, 27, 36 methylphenidate hcl er oral tablet extendedrelease* 20 methylphenidate hcl er oral tablet extendedrelease* 54 *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) melatonin maximum strength oral tablet 5 Notes (OTC-Covered w/rx); OTC *Aminoglycosides* *Aminoglycosides**-*Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML HUMIRA EN SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML SIMONI SUBCUTANEOUS* SOLUTION 100 MG/ML, 50 MG/0.5ML *Gold Compounds**-*Gold Compounds*** RIDAURA ORAL CASULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** A A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 2
CELEBREX ORAL CASULE 100 MG, 200 MG, 400 MG, 50 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** reference Details Coverage Details ST; Notes (Must fail 2 preferred, generic DL NSAIDs within the past 100 days.); QL (31 EA per 31 days) childrens ibuprofen oral suspension 40 /ml Notes (OTC-Covered w/rx); OTC diclofenac potassium oral tablet 50 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml Notes (OTC-Covered w/rx); OTC ibuprofen oral tablet 200 Notes (OTC-Covered w/rx); OTC ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 ketorolac tromethamine oral tablet 10 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 Notes (Maximum of a 5 day supply per Rx per month); QL (20 EA per 31 days) naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 *yrimidine Synthesis Inhibitors**-*yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Analgesics - Nonnarcotic* *Analgesic Combinations**-*Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 QL (186 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 3
butalbital-apap-caffeine oral capsule 50-325-40 butalbital-apap-caffeine oral tablet 50-325-40 butalbital-asa-caffeine oral capsule 50-325-40 reference Details Coverage Details QL (186 EA per 31 days) QL (186 EA per 31 days) TENCON ORAL TABLET 50-650 MG QL (124 EA per 31 days) *Analgesics Other**-*Analgesics Other*** acetaminophen oral solution 160 /5ml Notes (OTC-Covered w/rx); OTC acetaminophen oral tablet 325 acetaminophen oral tablet 500 Notes (OTC-Covered w/rx); OTC; QL (279 EA per 31 days) Notes (OTC-Covered w/rx); OTC; QL (186 EA per 31 days) mapap oral liquid 160 /5ml Notes (OTC-Covered w/rx); OTC mapap infants oral suspension 160 /5ml Notes (OTC-Covered w/rx); OTC pain & fever childrens oral solution 160 /5ml Notes (OTC-Covered w/rx); OTC *Salicylates**-*Salicylate Combinations*** choline & mag trisalicylate oral tablet 1000 choline-mag trisalicylate oral liquid 500 /5ml *Salicylates**-*Salicylates*** aspirin oral tablet 325, 81 Notes (OTC-Covered w/rx); OTC aspirin oral tablet chewable 81 Notes (OTC-Covered w/rx); OTC aspirin suppository 300, 600 Notes (OTC-Covered w/rx); OTC aspirin adult low strength oral tablet delayed release 81 Notes (OTC-Covered w/rx); OTC aspirin low dose oral tablet 81 Notes (OTC-Covered w/rx); OTC diflunisal oral tablet 500 salsalate oral tablet 500, 750 *Analgesics - Opioid* *Opioid Agonists**-*Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QL (248 EA per 31 days) fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 4
hydromorphone hcl suppository 3 methadone hcl oral solution 10 /5ml, 5 /5ml reference Details Coverage Details methadone hcl oral tablet 10, 5 QL (248 EA per 31 days) METHADOSE ORAL TABLET 10 MG QL (248 EA per 31 days) 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 morphine sulfate oral tablet 15, 30 QL (248 EA per 31 days) morphine sulfate suppository 10, 20, 30, 5 morphine sulfate (concentrate) oral solution 20 /ml morphine sulfate (pf) injection solution 0.5 /ml morphine sulfate (pf) intravenous* solution 2 /ml, 4 /ml, 8 /ml morphine sulfate er oral tablet extendedrelease* 100, 15, 200, 30, 60 QL (248 EA per 31 days) oxycodone hcl oral capsule 5 QL (248 EA per 31 days) oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 5 oxycodone hcl oral tablet 30 QL (248 EA per 31 days) tramadol hcl oral tablet 50 QL (248 EA per 31 days) *Opioid Combinations**-*Codeine Combinations*** acetaminophen-codeine oral solution 120-12 /5ml acetaminophen-codeine #2 oral tablet 300-15 acetaminophen-codeine #3 oral tablet 300-30 acetaminophen-codeine #4 oral tablet 300-60 QL (248 EA per 31 days) QL (248 EA per 31 days) QL (248 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 5
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 *Opioid Combinations**-*Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 7.5-325 /15ml, 7.5-500 /15ml hydrocodone-acetaminophen oral tablet 10-325, 10-500, 10-650, 10-660, 10-750, 5-325, 5-500, 7.5-325, 7.5-500, 7.5-650, 7.5-750 reference Details Coverage Details 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) HYDROGESIC ORAL CASULE 5-500 MG QL (248 EA per 31 days) *Opioid Combinations**-*Opioid Combinations*** ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG QL (248 EA per 31 days) oxycodone-acetaminophen oral capsule 5-500 QL (248 EA per 31 days) oxycodone-acetaminophen oral tablet 10-325, 5-325, 7.5-325, 7.5-500 QL (248 EA per 31 days) oxycodone-acetaminophen oral tablet 10-650 QL (186 EA per 31 days) oxycodone-aspirin oral tablet 4.8355-325 QL (186 EA per 31 days) ROXICET ORAL TABLET 5-325 MG QL (248 EA per 31 days) *Opioid artial Agonists**-*Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 butorphanol tartrate nasal solution 10 /ml QL (2.5 ML per 31 days) pentazocine-naloxone hcl oral tablet 50-0.5 SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG *Androgens-Anabolic* *Anabolic Steroids**-*Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 6 A A
*Androgens**-*Androgens*** danazol oral capsule 100, 200, 50 methitest oral tablet 10 reference Details Coverage Details TESTIM TRANSDERMAL 50 MG/5GM A testosterone cypionate intramuscular* oil 100 /ml, 200 /ml testosterone enanthate intramuscular* oil 200 /ml *Anorectal Agents* *Intrarectal Steroids**-*Intrarectal Steroids*** hydrocortisone enema 100 /60ml *Rectal Steroids**-*Rectal Steroids*** ROCTOSOL HC CREAM 2.5 % ROCTOZONE-HC CREAM 2.5 % *Antacids* *Antacids - Aluminum Salts**-*Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Calcium Salts**-*Antacids - Calcium Salts*** calcium carbonate antacid oral tablet chewable 500 *Antacids - Magnesium Salts**-*Antacids - Magnesium Salts*** magnesium oxide oral tablet 250, 400, 420 *Anthelmintics* *Anthelmintics**-*Anthelmintics*** ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A reeses pinworm medicine oral suspension 144 /ml Notes (OTC-Covered w/rx); OTC Notes (OTC-Covered w/rx); OTC Notes (OTC-Covered w/rx); OTC Notes (OTC- Covered w/rx); OTC STROMECTOL ORAL TABLET 3 MG QL (10 EA per 31 days) *Antianginal Agents* =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 7
*Nitrates**-*Nitrates*** isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide dinitrate er oral tablet extendedrelease* 40 isosorbide mononitrate oral tablet 10, 20 isosorbide mononitrate er oral tablet extended release 24 hr* 120, 30, 60 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG *Antianxiety Agents* *Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 reference Details Coverage Details 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 *Benzodiazepines**-*Benzodiazepines*** alprazolam oral tablet 0.25, 0.5, 1, 2 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75, 7.5 diazepam injection solution 5 /ml AL (Min 9 Years) diazepam oral solution 1 /ml QL (1240 ML per 31 days) diazepam oral tablet 10, 2, 5 lorazepam injection solution 2 /ml, 4 /ml lorazepam oral tablet 0.5, 1, 2 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 8
oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 procainamide hcl injection solution 100 /ml, 500 /ml quinidine gluconate injection solution 80 /ml quinidine gluconate er oral tablet extendedrelease* 324 quinidine sulfate oral tablet 300 *Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous* solution 20 /ml mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii*** amiodarone hcl intravenous* solution 150 /3ml amiodarone hcl oral tablet 200, 400 ACERONE ORAL TABLET 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies**-*Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents**-*Anti-Inflammatory Agents*** reference Details Coverage Details A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 9
cromolyn sodium inhalation nebulization solution 20 /2ml *Bronchodilators - Anticholinergics**-*Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT reference Details Coverage Details QL (25.8 GM per 31 days) ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators**-*Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 *Steroid Inhalants**-*Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH 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 budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ULMICORT INHALATION SUSENSION 1 MG/2ML QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (10.6 GM per 30 days) QL (120 ML per 31 days); AL (Max 8 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 10
*Sympathomimetics**-*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, 200-5 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) /3ml SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Sympathomimetics**-*Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml reference Details Coverage Details QL (60 EA per 30 days) QL (12 GM per 30 days) QL (4 GM per 20 days) QL (13 GM per 30 days) QL (720 ML per 31 days) QL (10.2 GM per 30 days) QL (720 ML per 31 days) QL (300 ML per 31 days) albuterol sulfate oral syrup 2 /5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG metaproterenol sulfate oral syrup 10 /5ml SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines**-*Xanthines*** aminophylline intravenous* solution 25 /ml ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML QL (60 EA per 30 days) QL (60 EA per 30 days) QL (36 GM per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 11
theophylline oral solution 80 /15ml theophylline er oral tablet extended release 12 hr* 100, 200, 300, 450 theophylline er oral tablet extended release 24 hr* 400, 600 *Anticoagulants* *Coumarin Anticoagulants**-*Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors**-*Direct Factor Xa Inhibitors*** reference Details Coverage Details XARELTO ORAL TABLET 10 MG QL (35 EA per 365 days) *Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml QL (24 ML per 31 days) enoxaparin sodium subcutaneous* solution 100 /ml, 150 /ml enoxaparin sodium subcutaneous* solution 120 /0.8ml, 80 /0.8ml enoxaparin sodium subcutaneous* solution 30 /0.3ml, 40 /0.4ml enoxaparin sodium subcutaneous* solution 60 /0.6ml *Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous* solution 10 /0.8ml fondaparinux sodium subcutaneous* solution 2.5 /0.5ml fondaparinux sodium subcutaneous* solution 5 /0.4ml fondaparinux sodium subcutaneous* solution 7.5 /0.6ml QL (28 ML per 31 days) QL (22.4 ML per 31 days) QL (8.4 ML per 31 days) QL (16.8 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 12
*Anticonvulsants* *Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 reference Details Coverage Details diazepam 10, 2.5, 20 QL (3 EA per 31 days) *Anticonvulsants - Misc.**-*Anticonvulsants - Misc.*** carbamazepine oral suspension 100 /5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 QL (310 EA per 31 days) gabapentin oral capsule 300 QL (372 EA per 31 days) gabapentin oral capsule 400 QL (279 EA per 31 days) gabapentin oral solution 250 /5ml QL (2230 ML per 31 days) gabapentin oral tablet 600, 800 lamotrigine oral tablet 100, 150, 200 lamotrigine oral tablet 25 QL (310 EA per 31 days) lamotrigine oral tablet chewable 25, 5 QL (310 EA per 31 days) levetiracetam intravenous* solution 500 /5ml levetiracetam oral solution 100 /ml QL (1000 ML per 31 days) levetiracetam oral tablet 1000, 500, 750 levetiracetam oral tablet 250 QL (372 EA per 31 days) oxcarbazepine oral suspension 300 /5ml QL (1240 ML per 31 days) oxcarbazepine oral tablet 150 QL (310 EA per 31 days) oxcarbazepine oral tablet 300 QL (248 EA per 31 days) oxcarbazepine oral tablet 600 primidone oral tablet 250 QL (248 EA per 31 days) primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 13
reference Details Coverage Details zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators**-*Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins**-*Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml EGANONE ORAL TABLET 250 MG QL (372 EA per 31 days) phenytoin oral suspension 125 /5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 QL (372 EA per 31 days) phenytoin sodium injection solution 50 /ml phenytoin sodium extended oral capsule 100, 200, 300 *Succinimides**-*Succinimides*** ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml QL (930 ML per 31 days) *Valproic Acid**-*Valproic Acid*** divalproex sodium oral capsule sprinkle 125 QL (310 EA per 31 days) divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 divalproex sodium er oral tablet extended release 24 hr* 250 divalproex sodium er oral tablet extended release 24 hr* 500 QL (310 EA per 31 days) QL (279 EA per 31 days) QL (310 EA per 31 days) QL (279 EA per 31 days) valproic acid oral capsule 250 QL (310 EA per 31 days) valproic acid oral solution 250 /5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 14
*Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.**-*Antidepressants - Misc.*** bupropion hcl oral tablet 100, 75 bupropion hcl er (sr) oral tablet extended release 12 hr* 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hr* 150, 300 maprotiline hcl oral tablet 25, 50, 75 *Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral tablet 100, 25, 50 *Serotonin Modulators**-*Serotonin Modulators*** reference Details Coverage Details =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 15
nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 *Tricyclic Agents**-*Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 reference Details Coverage Details 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**-*Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Antidiabetic Combinations**-*Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 16
JANUMET ORAL TABLET 50-1000 MG, 50-500 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG *Antidiabetic Combinations**-*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 *Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedi one Combinations*** AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 4-4 MG, 8-2 MG, 8-4 MG *Antidiabetic Combinations**-*Thiazolidinedione-Biguanid e Combinations*** AVANDAMET ORAL TABLET 2-1000 MG, 2-500 MG, 4-1000 MG, 4-500 MG pioglitazone hcl-metformin hcl oral tablet 15-500, 15-850 *Biguanides**-*Biguanides*** metformin hcl oral tablet 1000, 500, 850 metformin hcl er oral tablet extended release 24 hr* 500, 750 metformin hcl er (osm) oral tablet extended release 24 hr* 500 reference Details Coverage Details ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (62 EA per 31 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 17
reference Details Coverage Details RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other**-*Diabetic Other*** GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG QL (2 EA per 31 days) QL (2 EA per 31 days) GLUCAGON EMERGENCY INJECTION KIT 1 MG QL (2 EA per 31 days) glucose oral tablet chewable 4 gm Notes (OTC-Covered w/rx); OTC *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG TRADJENTA ORAL TABLET 5 MG *Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 MG *Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Insulin**-*Human Insulin*** ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (31 EA per 31 Days) ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) AIDRA INJECTION SOLUTION 100 UNIT/ML QL (60 ML per 31 days) AIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 18
HUMALOG KWIKEN SUBCUTANEOUS* 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* (75-25) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN N EN SUBCUTANEOUS* 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML *Sulfonylureas**-*Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide oral tablet 10, 5 glipizide er oral tablet extended release 24 hr* 10, 2.5, 5 GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG glyburide oral tablet 1.25, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 *Antidiarrheals* *Antiperistaltic Agents**-*Antiperistaltic Agents*** diphenoxylate-atropine oral liquid 2.5-0.025 /5ml diphenoxylate-atropine oral tablet 2.5-0.025 reference Details Coverage Details QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) Notes (OTC-Covered w/rx); OTC; QL (60 ML per 31 days) Notes (OTC- Covered w/rx); OTC; QL (60 ML per 31 days) Notes (OTC-Covered w/rx); OTC; QL (60 ML per 31 days) Notes (OTC-Covered w/rx); OTC; QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 19
loperamide hcl oral capsule 2 *Antidotes* *Antidotes - Chelating Agents**-*Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG *Antidotes**-*Antidotes*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Opioid Antagonists**-*Opioid Antagonists*** naltrexone hcl oral tablet 50 *Antiemetics* *5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists*** ondansetron oral tablet dispersible 4, 8 ondansetron hcl oral solution 4 /5ml ondansetron hcl oral tablet 4, 8 *Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic*** reference Details Coverage Details meclizine hcl oral tablet 12.5, 25 Notes (OTC-Covered w/rx); OTC meclizine hcl oral tablet chewable 25 Notes (OTC-Covered w/rx); OTC travel sickness oral tablet chewable 25 Notes (OTC-Covered w/rx); OTC *Antifungals* *Antifungals**-*Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 *Imidazole-Related Antifungals**-*Imidazoles*** ketoconazole oral tablet 200 A QL (450 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 20
*Imidazole-Related Antifungals**-*Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *Antihistamines* *Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** reference Details Coverage Details allergy oral tablet 4 Notes (OTC-Covered w/rx); OTC *Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 Notes (OTC-Covered w/rx); OTC BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML Notes (OTC-Covered w/rx); OTC diphenhydramine hcl oral capsule 25 Notes (OTC-Covered w/rx); OTC diphenhydramine hcl oral capsule 50 Notes (OTCCovered w/rx); OTC diphenhydramine hcl oral tablet 25 Notes (OTC-Covered w/rx); OTC *Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG Notes (OTC-Covered w/rx); OTC allergy oral tablet dispersible 10 Notes (OTC-Covered w/rx); OTC cetirizine hcl oral syrup 1 /ml, 5 /5ml Notes (OTC-Covered w/rx); OTC; QL (300 ML per 31 days) cetirizine hcl oral tablet 10, 5 Notes (OTC-Covered w/rx); OTC cetirizine hcl childrens oral solution 1 /ml childrens loratadine oral syrup 5 /5ml Notes (OTC-Covered w/rx); OTC; QL (300 ML per 31 days) Notes (OTC-Covered w/rx); OTC; QL (310 ML per 31 days) fexofenadine hcl oral tablet 180, 60 Notes (OTC-Covered w/rx); OTC levocetirizine dihydrochloride oral solution 2.5 /5ml ST; Notes (Must fail preferred loratadine solution, cetirizine syrup within the past 100 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 21
levocetirizine dihydrochloride oral tablet 5 reference Details Coverage Details loratadine oral tablet 10 Notes (OTC-Covered w/rx); OTC loratadine hives relief oral solution 5 /5ml Notes (OTC-Covered w/rx); OTC *Antihistamines - henothiazines**-*antihistamines - henothiazines*** promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl suppository 25 ROMETHEGAN SUOSITORY 25 MG, 50 MG *Antihistamines - iperidines**-*antihistamines - iperidines*** cyproheptadine hcl oral syrup 2 /5ml QL (300 ML per 31 days) cyproheptadine hcl oral tablet 4 *Antihyperlipidemics* *Antihyperlipidemics - Combinations**-*Intest Cholest Absorp Inhib-H Coa Reductase Inhib Comb*** VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG *Bile Acid Sequestrants**-*Bile Acid Sequestrants*** cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose *Fibric Acid Derivatives**-*Fibric Acid Derivatives*** fenofibrate oral tablet 160, 54 fenofibrate micronized oral capsule 134, 200, 67 gemfibrozil oral tablet 600 *H Coa Reductase Inhibitors**-*H Coa Reductase Inhibitors*** A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 22
atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors*** reference Details Coverage Details ZETIA ORAL TABLET 10 MG A *Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG *Antihypertensives* *Ace Inhibitors**-*Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 *Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** losartan potassium oral tablet 100, 25, 50 ST; Notes (Must fail preferred pravastatin, simvastatin, or lovastatin within the past 100 days.) QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 23
*Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antiadrenergic Antihypertensives**-*Antiadrenergics - eripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 *Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 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 *Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet 100-12.5, 100-25, 50-12.5 *Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet 100-25, 50-25 bisoprolol-hydrochlorothiazide oral tablet 10-6.25, 2.5-6.25, 5-6.25 propranolol-hctz oral tablet 40-25, 80-25 *Vasodilators**-*Vasodilators*** hydralazine hcl injection solution 20 /ml reference Details Coverage Details QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 24
hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl intravenous* solution reconstituted 1000, 500, 750 reference Details Coverage Details vancomycin hcl oral capsule 125, 250 A *Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** erythromycin-sulfisoxazole oral suspension reconstituted 200-600 /5ml sulfamethoxazole-tmp ds oral tablet 800-160 sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml sulfamethoxazole-trimethoprim oral tablet 400-80 *Antiprotozoal Agents**-*Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml *Leprostatics**-*Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides**-*Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous* solution 300 /2ml *Antimalarials* QL (1200 ML per 31 days) QL (2400 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 25
*Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250-100, 62.5-25 *Antimalarials**-*Antimalarials*** DARARIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimyasthenic/Cholinergic Agents* *Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 MG/5ML MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG ROSTIGMIN ORAL TABLET 15 MG pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* *Antimycobacterial Agents**-*Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous* solution reconstituted 600 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Alkylating Agents**-*Alkylating Agents*** reference Details Coverage Details HEXALEN ORAL CASULE 50 MG A MYLERAN ORAL TABLET 2 MG A *Alkylating Agents**-*Imidazotetrazines*** =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 26
temozolomide oral capsule 100, 140, 180, 20, 250, 5 *Alkylating Agents**-*Nitrogen Mustards*** reference Details Coverage Details ALKERAN ORAL TABLET 2 MG A cyclophosphamide oral tablet 25, 50 A LEUKERAN ORAL TABLET 2 MG A *Alkylating Agents**-*Nitrosoureas*** lomustine oral capsule 10, 100, 40 A *Antimetabolites**-*Antimetabolites*** ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML capecitabine oral tablet 150, 500 A fluorouracil intravenous* solution 500 /10ml A gemcitabine hcl intravenous* solution 1 gm/26.3ml, 2 gm/52.6ml, 200 /5.26ml gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, 200 mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 methotrexate sodium injection solution 25 /ml methotrexate sodium injection solution reconstituted 1 gm methotrexate sodium (pf) injection solution 25 /ml TABLOID ORAL TABLET 40 MG A *Antineoplastic - Angiogenesis Inhibitors**-*Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML *Antineoplastic - Hedgehog athway Inhibitors**-*Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiadrenals*** =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= A A A A A 27
reference Details Coverage Details LYSODREN ORAL TABLET 500 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiandrogens*** XTANDI ORAL CASULE 40 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiestrogens*** tamoxifen citrate oral tablet 10, 20 *Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors*** anastrozole oral tablet 1 letrozole oral tablet 2.5 *Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 MG A *Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs*** TRELSTAR DEOT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 MG TRELSTAR DEOT MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 MG TRELSTAR LA INTRAMUSCULAR* SUSENSION RECONSTITUTED 11.25 MG TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 11.25 MG TRELSTAR MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 22.5 MG *Antineoplastic - Hormonal And Related Agents**-*rogestins-Antineoplastic*** megestrol acetate oral suspension 40 /ml QL (600 ML per 31 days) megestrol acetate oral tablet 20, 40 *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors*** =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 28 A A A A A
reference Details Coverage Details ZOLINZA ORAL CASULE 100 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG A SUTENT ORAL CASULE 12.5 MG, 25 MG, 50 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100 MG, 500 MG A CARELSA ORAL TABLET 100 MG, 300 MG A GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG A; QL (31 EA per 31 days) GLEEVEC ORAL TABLET 100 MG, 400 MG A ICLUSIG ORAL TABLET 15 MG, 45 MG A SRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CASULE 150 MG, 200 MG A TYKERB ORAL TABLET 250 MG A XALKORI ORAL CASULE 200 MG, 250 MG A *Antineoplastic Enzyme Inhibitors**-*Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Antineoplastic Enzymes**-*Antineoplastic Enzymes*** ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT *Antineoplastics Misc.**-*Antineoplastics Misc.*** hydroxyurea oral capsule 500 A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= A A A A A 29
*Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100, 200, 350 leucovorin calcium intravenous* solution 10 /ml leucovorin calcium oral tablet 10, 15, 25, 5 *Mitotic Inhibitors**-*Mitotic Inhibitors*** reference Details Coverage Details etoposide oral capsule 50 A *Antiparkinson Agents* *Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Dopaminergics**-*Levodopa Combinations*** carbidopa-levodopa oral tablet 10-100, 25-100, 25-250 carbidopa-levodopa er oral tablet extendedrelease* 50-200 *Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists*** =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 30
pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents**-*Antimanic Agents*** lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium carbonate er oral tablet extendedrelease* 300, 450 lithium citrate oral solution 8 meq/5ml *Antipsychotics - Misc.**-*Antipsychotics - Misc.*** LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG *Benzisoxazoles**-*Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 39 MG/0.25ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 78 MG/0.5ML risperidone oral solution 1 /ml reference Details Coverage Details ST; Notes (Must fail preferred ropinirole within the past 100 days.) ST; Notes (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.) A; QL (0.75 ML per 28 days); AL (Min 18 Years) A; QL (1 ML per 28 days); AL (Min 18 Years) A; QL (1.5 ML per 28 Days); AL (Min 18 Years) A; QL (0.25 ML per 28 days); AL (Min 18 Years) A; QL (0.5 ML per 28 days); AL (Min 18 Years) QL (496 ML per 31 days); AL (Min 5 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ lowercase italics= 31