00 9 2015 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care 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 Inter-pregnancy Care referred Drug List is updated quarterly. roviders, please visit our website at http://georgia.wellcare.com/provider/p4hb to view updates to the preferred drug list. Members, please visit our website at https://georgia.wellcare.com/member/p4hb to view updates to the preferred drug list. Last updated (1/01/2015)
Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines**-*Amphetamine Mixtures*** 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 *Stimulants - Misc.**-*Stimulants - Misc.*** dexmethylphenidate hcl oral tablet 10, 2.5, 5 METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG 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) QL (62 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 QL (93 EA per 31 days); AL (Min 6 Years) methylphenidate hcl er oral tablet AL (Min 6 Years and Max 20 extendedrelease* 10 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/ 1
Drug Name reference Details Coverage Details 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*** melatonin oral tablet 5 OTC melatonin maximum strength oral tablet 5 OTC *Aminoglycosides* *Aminoglycosides**-*Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML A *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS* 10 MG/0.2ML A HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML A HUMIRA EN SUBCUTANEOUS* KIT 40 MG/0.8ML A HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML A simponi subcutaneous* 100 /ml, 50 /0.5ml A *Gold Compounds**-*Gold Compounds*** RIDAURA ORAL CASULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CASULE 100 MG, 200 MG, 400 MG, 50 MG 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) ST; Notes (Must fail 2 preferred, generic DL NSAIDs within the past 100 days.); QL (31 EA per 31 days) celecoxib oral capsule 100, 200, 400, ST; QL (31 EA per 31 days) 50 =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/ 2
Drug Name reference Details Coverage Details *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium oral tablet delayed release 25, 50, 75 diclofenac sodium er oral tablet extended release 24 hr* 100 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml OTC ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 ketorolac tromethamine oral tablet 10 Notes (Maximum of a 5 day supply per Rx per month); QL (20 EA per 31 days) meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 *yrimidine Synthesis Inhibitors**-*yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Analgesics - Nonnarcotic* *Salicylates**-*Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *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/ 3
Drug Name reference Details Coverage Details *Androgens**-*Androgens*** danazol oral capsule 100, 200, 50 *Anthelmintics* *Anthelmintics**-*Anthelmintics*** ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML OTC reeses pinworm medicine oral suspension 144 /ml OTC *Antianginal Agents* *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 meprobamate oral tablet 200, 400 *Benzodiazepines**-*Benzodiazepines*** diazepam oral solution 1 /ml QL (1240 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/ 4
Drug Name reference Details Coverage Details *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*** 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*** cromolyn sodium inhalation nebulization solution 20 /2ml 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/ 5
Drug Name reference Details Coverage Details *Bronchodilators - Anticholinergics**-*Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT 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 QL (1 EA per 30 days) ACTIVATED 400 MCG/ACT *Leukotriene Modulators**-*Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 AL (Min 1 Months and Max 2 Years) 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, QL (1 EA per 30 days) BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 QL (1 EA per 30 days) MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, QL (1 EA per 30 days) BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT 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 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) =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/ 6
Drug Name reference Details Coverage Details ULMICORT INHALATION SUSENSION 1 MG/2ML *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 QL (120 ML per 31 days); AL (Max 8 Years) 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 QL (60 EA per 30 days) metaproterenol sulfate oral syrup 10 /5ml SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH QL (60 EA per 30 days) 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 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/ 7
Drug Name reference Details Coverage Details *Xanthines**-*Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML 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 *Anticonvulsants* *Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 *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) =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/ 8
Drug Name reference Details Coverage Details levetiracetam oral tablet 1000, 500, 750 levetiracetam oral tablet 250 QL (372 EA per 31 days) oxcarbazepine oral suspension 300 /5ml QL (1240 ML per 31 days) oxcarbazepine oral tablet 150 QL (310 EA per 31 days) oxcarbazepine oral tablet 300 QL (248 EA per 31 days) oxcarbazepine oral tablet 600 primidone oral tablet 250 QL (248 EA per 31 days) primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators**-*Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins**-*Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml EGANONE ORAL TABLET 250 MG QL (372 EA per 31 days) phenytoin oral suspension 125 /5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 QL (372 EA per 31 days) 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 QL (310 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 9
Drug Name reference Details Coverage Details divalproex sodium oral tablet delayed release 500 QL (279 EA per 31 days) divalproex sodium er oral tablet extended release 24 hr* 250 QL (310 EA per 31 days) divalproex sodium er oral tablet extended release 24 hr* 500 QL (279 EA per 31 days) valproic acid oral capsule 250 QL (310 EA per 31 days) valproic acid oral solution 250 /5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.**-*Antidepressants - Misc.*** bupropion hcl 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 =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/ 10
Drug Name reference Details Coverage Details fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral tablet 100, 25, 50 *Serotonin Modulators**-*Serotonin Modulators*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 QL (31 EA per 31 days) *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 nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 =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/ 11
Drug Name reference Details Coverage Details *Antidiabetics* *Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Antidiabetic Combinations**-*Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** 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**-*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 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-Thiazolidinedion e Combinations*** AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 8-4 MG *Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations*** 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 (31 EA per 31 days) ST ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) AVANDAMET ORAL TABLET 2-1000 MG, 4-500 MG 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/ 12
Drug Name reference Details Coverage Details pioglitazone hcl-metformin hcl oral tablet 15-500, 15-850 ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) *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 RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other**-*Diabetic Other*** GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG QL (2 EA per 31 days) GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG QL (2 EA per 31 days) GLUCAGON EMERGENCY INJECTION KIT 1 MG QL (2 EA per 31 days) *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* 2 MG BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 MG ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); 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, Riomet); QL (4 EA per 28 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/ 13
Drug Name reference Details Coverage Details *Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Insulin**-*Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML 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 KWIKEN 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 LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) OTC; QL (60 ML per 31 days) OTC; QL (60 ML per 31 days) QL (60 ML per 31 days) OTC; QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 14
Drug Name reference Details Coverage Details *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors**-*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylureas**-*Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide 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 *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 *Imidazole-Related Antifungals**-*Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 ST ST 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/ 15
Drug Name reference Details Coverage Details *Antihyperlipidemics* *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*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 MG A *Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG *Antihypertensives* *Ace Inhibitors**-*Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 =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/ 16
Drug Name reference Details Coverage Details 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 *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 *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 QL (31 EA per 31 days) QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 17
Drug Name reference Details Coverage Details 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 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 *Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** 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 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/ 18
Drug Name reference Details Coverage Details *Antimalarials* *Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250-100 *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 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 *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 =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/ 19
Drug Name reference Details Coverage Details *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* 25-100, 50-200 *Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents**-*Antimanic Agents*** lithium oral solution 8 meq/5ml lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium carbonate er oral tablet extendedrelease* 300, 450 *Benzisoxazoles**-*Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 MG/0.75ML ST; Notes (Must fail preferred ropinirole within the past 100 days.) A; QL (0.75 ML per 28 days); AL (Min 18 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/ 20
Drug Name reference Details Coverage Details 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 risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG *Butyrophenones**-*Butyrophenones*** haloperidol oral tablet 0.5, 1, 10, 2, 5 haloperidol decanoate intramuscular* solution 100 /ml, 50 /ml 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) QL (62 EA per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) AL (Min 3 Years) AL (Min 18 Years) haloperidol lactate injection solution 5 /ml AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) *Dibenzapines**-*Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 AL (Min 18 Years) clozapine oral tablet dispersible 12.5 QL (31 EA per 31 days); AL (Min 18 Years) *Dibenzapines**-*Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG ST; Notes (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.); AL (Min 18 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/ 21
Drug Name reference Details Coverage Details *Dibenzapines**-*Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzapines**-*Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *Dibenzapines**-*Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *henothiazines**-*henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 AL (Min 10 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 13 Years) AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 days); AL (Min 18 Years) QL (2480 ML per 31 days); AL (Min 18 Years) AL (Min 18 Years and Max 999 Years) AL (Min 12 Years) prochlorperazine suppository 25 AL (Min 2 Years) prochlorperazine maleate oral tablet 10, 5 AL (Min 2 Years) thioridazine hcl oral tablet 10, 100, 25, 50 AL (Min 2 Years) trifluoperazine hcl oral tablet 1, 10, 2, 5 AL (Min 6 Years) *Quinolinone Derivatives**-*Quinolinone Derivatives*** ABILIFY ORAL SOLUTION 1 MG/ML ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.) ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone 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/ 22
Drug Name reference Details Coverage Details ABILIFY MAINTENA INTRAMUSCULAR* SUSENSION A RECONSTITUTED 300 MG, 400 MG *Thioxanthenes**-*Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 AL (Min 12 Years) *Antivirals* *Hepatitis Agents**-*Hepatitis B Agents*** entecavir oral tablet 0.5, 1 A *Herpes Agents**-*Herpes Agents - urine Analogues*** acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml QL (3500 ML per 31 days) acyclovir oral tablet 400, 800 valacyclovir hcl oral tablet 1 gm, 500 QL (62 EA per 31 days) *Influenza Agents**-*Influenza Agents*** rimantadine hcl oral tablet 100 *Influenza Agents**-*Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 5 MG/BLISTER QL (40 EA per 365 days); AL (Min 7 Years) TAMIFLU ORAL CASULE 30 MG QL (40 EA per 365 days) TAMIFLU ORAL CASULE 45 MG, 75 MG QL (20 EA per 365 days) TAMIFLU ORAL SUSENSION RECONSTITUTED 6 MG/ML *Assorted Classes* *Immunosuppressive Agents**-*Cyclosporine Analogs*** cyclosporine oral capsule 100, 25 cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml GENGRAF ORAL CASULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML QL (360 ML per 365 days); AL (Max 18 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/ 23
Drug Name reference Details Coverage Details SANDIMMUNE ORAL SOLUTION 100 MG/ML *Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 *Immunosuppressive Agents**-*Macrolide Immunosuppressants*** HECORIA ORAL CASULE 0.5 MG, 1 MG, 5 MG tacrolimus oral capsule 0.5, 1, 5 *Immunosuppressive Agents**-*urine Analogs*** azathioprine oral tablet 50 *Beta Blockers* *Alpha-Beta Blockers**-*Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl intravenous* solution 5 /ml labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective*** atenolol oral tablet 100, 25, 50 bisoprolol fumarate oral tablet 10, 5 metoprolol succinate er oral tablet extended release 24 hr* 100, 200, 25, 50 metoprolol tartrate intravenous* solution 1 /ml metoprolol tartrate oral tablet 100, 25, 50 *Beta Blockers Non-Selective**-*Beta Blockers Non-Selective*** nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl intravenous* solution 1 /ml =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/ 24
Drug Name reference Details Coverage Details propranolol hcl oral tablet 10, 20, 40, 60, 80 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG sotalol hcl oral tablet 120, 160, 240, 80 sotalol hcl (af) oral tablet 120, 160, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers**-*Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG dilt-xr oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl intravenous* solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG =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/ 25
Drug Name reference Details Coverage Details NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG nifedipine oral capsule 10 nifedipine er oral tablet extended release 24 hr* 90 nifedipine er osmotic oral tablet extended release 24 hr* 30, 60, 90 verapamil hcl oral tablet 120, 40, 80 verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300, 360 verapamil hcl er oral tablet extendedrelease* 120, 180, 240 *Cardiotonics* *Cardiac Glycosides**-*Cardiac Glycosides*** digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml digoxin oral tablet 0.125, 250 mcg *Cardiovascular Agents - Misc.* *eripheral Vasodilators**-*eripheral Vasodilators*** no flush niacin oral tablet 500 OTC *ulmonary Hypertension - Endothelin Receptor Antagonists**-*ulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG A *ulmonary Hypertension - hosphodiesterase Inhibitors**-*ulmonary Hypertension - hosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 A *Cephalosporins* *Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 =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/ 26
Drug Name reference Details Coverage Details cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml cephalexin oral suspension reconstituted 250 /5ml *Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral suspension reconstituted 125 /5ml cefuroxime axetil oral tablet 250, 500 *Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 *Contraceptives* *Combination Contraceptives - Oral**-*Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) *Combination Contraceptives - Oral**-*Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET 0.15-30 MG-MCG ARI ORAL TABLET 0.15-30 MG-MCG AVIANE ORAL TABLET 0.1-20 MG-MCG QL (300 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/ 27
Drug Name reference Details Coverage Details BALZIVA ORAL TABLET 0.4-35 MG-MCG briellyn oral tablet 0.4-35 -mcg CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG EMOQUETTE ORAL TABLET 0.15-30 MG-MCG ESTARYLLA ORAL TABLET 0.25-35 MG-MCG GIANVI ORAL TABLET 3-0.02 MG JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG JUNEL 1/20 ORAL TABLET 1-20 MG-MCG JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG KELNOR 1/35 ORAL TABLET 1-35 MG-MCG LESSINA ORAL TABLET 0.1-20 MG-MCG LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG LORYNA ORAL TABLET 3-0.02 MG LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG LUTERA ORAL TABLET 0.1-20 MG-MCG MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG MONONESSA ORAL TABLET 0.25-35 MG-MCG NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG =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/ 28
Drug Name reference Details Coverage Details NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG OCELLA ORAL TABLET 3-0.03 MG ORTIA-28 ORAL TABLET 0.15-30 MG-MCG REVIFEM ORAL TABLET 0.25-35 MG-MCG RECLISEN ORAL TABLET 0.15-30 MG-MCG SOLIA ORAL TABLET 0.15-30 MG-MCG SRINTEC 28 ORAL TABLET 0.25-35 MG-MCG SRONYX ORAL TABLET 0.1-20 MG-MCG SYEDA ORAL TABLET 3-0.03 MG VESTURA ORAL TABLET 3-0.02 MG ZARAH ORAL TABLET 3-0.03 MG ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG *Combination Contraceptives - Oral**-*Extended-Cycle Contraceptives - Oral*** QUASENSE ORAL TABLET 0.15-0.03 MG QL (91 EA per 91 days) *Combination Contraceptives - Oral**-*Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/0.15-0.025 MG ENRESSE-28 ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG =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/ 29
Drug Name reference Details Coverage Details NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/0.15-0.025 MG *Combination Contraceptives - Vaginal**-*Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING 0.12-0.015 MG/24HR *Emergency Contraceptives**-*Emergency Contraceptives*** levonorgestrel oral tablet 0.75 QL (4 EA per 31 days) NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG OTC LAN B ONE-STE ORAL TABLET 1.5 MG OTC *rogestin Contraceptives - Injectable**-*rogestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular* suspension 150 /ml QL (1 ML per 93 days) *rogestin Contraceptives - Oral**-*rogestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 MG ERRIN ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG NORA-BE ORAL TABLET 0.35 MG =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/ 30
Drug Name reference Details Coverage Details *Corticosteroids* *Glucocorticosteroids**-*Glucocorticosteroids* ** hydrocortisone oral tablet 10, 20, 5 prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 20, 5 *Mineralocorticoids**-*Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Dermatologicals* *Acne roducts**-*acne Combinations*** benzoyl peroxide-erythromycin external 5-3 % *Acne roducts**-*acne roducts*** LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID 4 % LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID 8 % *Antibiotics - Topical**-*Antibiotics - Topical*** bacitracin zinc external ointment 500 unit/gm OTC *Antifungals - Topical**-*Antifungals - Topical*** ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % nystatin external cream 100000 unit/gm nystatin external ointment 100000 unit/gm nystatin external powder 100000 unit/gm terbinafine hcl external cream 1 % OTC *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** baza antifungal external cream 2 % OTC clotrimazole external cream 1 % OTC clotrimazole external solution 1 % OTC econazole nitrate external cream 1 % ketoconazole external cream 2 % ketoconazole external shampoo 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/ 31
Drug Name reference Details Coverage Details *Anti-Inflammatory Agents - Topical**-*Anti-Inflammatory Agents - Topical*** VOLTAREN TRANSDERMAL 1 % QL (300 GM per 31 days) *Antivirals - Topical**-*Antivirals - Topical*** DENAVIR EXTERNAL CREAM 1 % ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.) ZOVIRAX EXTERNAL CREAM 5 % ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.) *Emollient/Keratolytic Agents**-*Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % X-VIATE EXTERNAL CREAM 40 % *Rosacea Agents**-*Rosacea Agents*** metronidazole external 1 % metronidazole external cream 0.75 % *Scabicides & ediculicides**-*scabicides & ediculicides*** malathion external lotion 0.5 % QL (118 ML per 31 days); AL (Min 6 Years) spinosad external suspension 0.9 % AL (Min 4 Years) *Diagnostic roducts* *Diagnostic Drugs**-*Diagnostic Drugs*** dipyridamole intravenous* solution 5 /ml *Diagnostic Tests**-*Diagnostic Tests*** ACCU-CHEK ACTIVE IN VITRO STRI ACCU-CHEK AVIVA LUS IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC =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/ 32
Drug Name reference Details Coverage Details ACCU-CHEK COMFORT CURVE IN VITRO STRI ACCU-CHEK COMACT TEST DRUM IN VITRO STRI ACCU-CHEK SMARTVIEW IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 204/31 DS for Members 21 years old and younger; QL: 102/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC CLINISTIX IN VITRO STRI OTC; QL (100 EA per 31 days) DIASTIX IN VITRO STRI OTC; QL (100 EA per 31 days) FREESTYLE INSULINX TEST IN VITRO STRI FREESTYLE LITE TEST IN VITRO STRI FREESTYLE TEST IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC KETOSTIX IN VITRO STRI OTC; QL (100 EA per 31 days) RECISION XTRA BLOOD GLUCOSE IN VITRO STRI RECISION XTRA KETONE IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC OTC =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/ 33
Drug Name reference Details Coverage Details *Digestive Aids* *Digestive Enzymes**-*Digestive Enzymes*** CREON ORAL CASULE DELAYED RELEASE ARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT ERTZYE ORAL CASULE DELAYED RELEASE ARTICLES 16000 UNIT, 8000 UNIT *Diuretics* *Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors*** acetazolamide oral tablet 125, 250 methazolamide oral tablet 25, 50 *Diuretic Combinations**-*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5-50 spironolactone-hctz oral tablet 25-25 triamterene-hctz oral capsule 37.5-25 triamterene-hctz oral tablet 37.5-25, 75-50 *Loop Diuretics**-*Loop Diuretics*** bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5, 1, 2 furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 torsemide oral tablet 10, 100, 20, 5 *otassium Sparing Diuretics**-*otassium Sparing Diuretics*** spironolactone oral tablet 100, 25, 50 *Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 hydrochlorothiazide oral capsule 12.5 =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/ 34
Drug Name reference Details Coverage Details hydrochlorothiazide oral tablet 12.5, 25, 50 indapamide oral tablet 1.25, 2.5 metolazone oral tablet 10, 2.5, 5 *Endocrine And Metabolic Agents - Misc.* *Bone Density Regulators**-*Bisphosphonates*** alendronate sodium oral tablet 10, 35, 40, 5, 70 *Bone Density Regulators**-*Calcitonins*** calcitonin (salmon) nasal solution 200 unit/act FORTICAL NASAL SOLUTION 200 UNIT/ACT *Metabolic Modifiers**-*Gaa Deficiency Treatment - Agents*** LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG A *Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml *osterior ituitary Hormones**-*Vasopressin*** desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate oral tablet 0.1, 0.2 desmopressin acetate spray nasal solution 0.01 % *Estrogens* *Estrogen Combinations**-*Estrogen & rogestin*** estradiol-norethindrone acet oral tablet 0.5-0.1, 1-0.5 REMHASE ORAL TABLET 0.625-5 MG REMRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG *Estrogens**-*Estrogens*** estradiol 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/ 35