2017 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia lanning for Healthy Babies: Interpregnancy Care lease read: This document tells about the drugs we cover in this plan. If you speak a different language or need something in Braille or audio, don t worry. We can provide translations and alternate formats at no cost to you. Just give us a call tollfree. Georgia Families and eachcare for Kids members call 1-866-231-1821. lanning for Healthy Babies members call 1-877-379-0020. All TTY users call 1-877- 247-6272. Si habla otro idioma o si necesita información en Braille o en audio, no se preocupe. odemos ofrecerle traducciones y formatos alternativos sin costo para usted. Simplemente llámenos sin costo. Los miembros de Georgia Families y eachcare for Kids llamen al 1-866-231-1821. Los miembros de lanning for Healthy Babies llamen al 1-877-379-0020. Todos los usuarios de TTY llamen al 1-877-247-6272. This list is updated each quarter. roviders, please visit our website for updates to the preferred drug list: https://www.wellcare.com/georgia/roviders/medicaid Members, please visit our website for updates to the preferred drug list: https://www.wellcare.com/georgia/members/medicaid-lans/4hb Last updated (1/01/2017) WellCare proudly serves Georgia Families, eachcare for Kids and lanning for Healthy Babies members. GA032872_CAD_LTR_ENG State Approved 04212016 72830 WellCare 2016 GA_01_16_v2 GA6CADLTR72830E_0116
Vaccines:VaccinesarecoveredundertheVaccinesforChildrenprogramformembersthrough18yearsofage. Coverage beyond the age of 18 is evaluated through the A process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexia nts* *AdhdAgent-SelectiveAlphaAdrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hr* 1, 2, 3, 4 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er oral tablet extendedrelease* 10, 20 methylphenidate hcl er oral tablet extendedrelease* 18, 27, 36 reference Details CoverageDetails QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days) QL (62 EA per 31 days) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 1
methylphenidate hcl er oral tablet extendedrelease* 54 *Analgesics - Anti - Inflammatory* reference Details CoverageDetails QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet chewable 10, 2.5, 5 *Alternative Medicines* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 melatonin oral tablet 5 *Aminoglycosides* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA EN SUBCUTANEOUS* 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML SIMONI SUBCUTANEOUS* 100 MG/ML, 50 MG/0.5ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 *Gold Compounds*** RIDAURA ORAL CASULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hr* 100 diclofenac sodium oral tablet delayed release 25, 50, 75 QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years and Max 6 Years) A A A A A QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 2
etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 MEDI-ROFEN ORAL SUSENSION 40 MG/ML meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 *Analgesics- Nonnarcotic* *Androgens- Anabolic* reference Details CoverageDetails 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 220, 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 *yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A *Androgens*** danazol oral capsule 100, 200, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 3
*Anthelmintics* *Anthelmintics*** reference Details CoverageDetails ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* *Nitrates*** isosorbide dinitrate er oral tablet extendedrelease* 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hr* 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 meprobamate oral tablet 200, 400 *Benzodiazepines*** diazepam oral solution 1 /ml QL (1240 ML per 31 days) *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200, 300 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 4
*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 reference Details CoverageDetails MULTAQ ORAL TABLET 400 MG A ACERONE ORAL TABLET 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT DULERA INHALATION AEROSOL 100-5 MCG/ACT,200-5MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) /3ml SYMBICORTINHALATIONAEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml QL (60 EA per 30 days) QL (12 GM per 30 days) QL (4 GM per 20 days) QL (13 GM per 30 days) QL (720 ML per 31 days) QL (10.2 GM per 30 days) A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 5
*Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml reference Details CoverageDetails QL (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 SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED50MCG/DOSE terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT INCRUSE ELLITA INHALATION AEROSOL OWDER, BREATH ACTIVATED 62.5 MCG/INH QL (60 EA per 30 days) QL (60 EA per 30 days) QL (36 GM per 31 days) QL (25.8 GM per 31 days) QL (1 EA per 31 days) ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) SIRIVA RESIMAT INHALATION AEROSOL,SOLUTION1.25MCG/ACT,2.5 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 QL (4 GM per 31 days) AL (Min 1 Months and Max 2 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 6
*Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110MCG/ACT,220MCG/ACT FLOVENT HFA INHALATION AEROSOL 44MCG/ACT *Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hr* 100, 200, 300, 450 theophylline er oral tablet extended release 24 hr* 400, 600 theophylline oral solution 80 /15ml *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 reference Details CoverageDetails 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 7
*LowMolecularWeightHeparins*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous* solution 100 /ml, 150 /ml enoxaparin sodium subcutaneous* solution 120 /0.8ml, 80 /0.8ml enoxaparin sodium subcutaneous* solution 30 /0.3ml enoxaparin sodium subcutaneous* solution 40 /0.4ml enoxaparin sodium subcutaneous* solution 60 /0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 *Anticonvulsants-Misc.*** reference Details CoverageDetails QL (93 ML per 31 days) QL (31 ML per 31 days) QL (24.8 ML per 31 days) QL (9.3 ML per 31 days) QL (12.4 ML per 31 days) QL (18.6 ML per 31 days) 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 levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 primidone oral tablet 250 QL (248 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 8
reference Details CoverageDetails primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml 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 extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml *Succinimides*** ethosuximide oral capsule 250 AL (Min 3 Years) ethosuximide oral solution 250 /5ml *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hr* 250 divalproex sodium er oral tablet extended release 24 hr* 500 QL (930 ML per 31 days); AL (Min 3 Years) QL (310 EA per 31 days) QL (279 EA per 31 days) divalproex sodium oral 125 QL (310 EA per 31 days) divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 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) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 9
reference Details CoverageDetails valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants-Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hr* 100, 150, 200 bupropionhcler(xl)oraltabletextended release 24 hr* 150, 300 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *MonoamineOxidaseInhibitors(Maois)*** phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20, 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 concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 10
*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 60 duloxetine hcl oral capsule delayed release particles 30, 40 IRENKA ORAL CASULE DELAYED RELEASE ARTICLES 40 MG venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 reference Details CoverageDetails QL (62 EA per 31 days) QL (31 EA per 31 days) QL (31 EA per 31 days) nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hr* 500 metformin hcl er oral tablet extended release 24 hr* 500, 750 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 11
metformin hcl oral tablet 1000, 500, 850 reference Details CoverageDetails RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 50-500 MG JANUMET XR ORAL TABLET EXTENDEDRELEASE24HR*100-1000 MG, 50-1000 MG, 50-500 MG *Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML BASAGLAR KWIKEN 100 UNIT/ML SUBCUTANEOUS* 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS* (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 12
HUMALOG SUBCUTANEOUS* 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMULIN 70/30 KWIKEN SUBCUTANEOUS* (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS* 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS* SUSENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXEN SUBCUTANEOUS* 100 UNIT/ML NOVOLOG MIX 70/30 FLEXEN SUBCUTANEOUS* (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML NOVOLOG ENFILL SUBCUTANEOUS* 100 UNIT/ML NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML reference Details CoverageDetails QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 13
*IncretinMimeticAgents(Glp-1Receptor Agonists)*** reference Details CoverageDetails BYDUREON SUBCUTANEOUS* 2 MG A; QL (4 EA per 28 days) *Meglitinide Analogues*** nateglinide oral tablet 120, 60 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250, 2.5-500, 5-500 glyburide-metformin oral tablet 1.25-250, 2.5-500, 5-500 *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hr* 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hr* 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinedione-Biguanide Combinations*** AVANDAMETORAL TABLET2-1000MG pioglitazone hcl-metformin hcl oral tablet 15-500, 15-850 ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 14
*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Antidiarrheals* *Antidiarrheal Agents - Misc.*** pink bismuth oral suspension 262 /15ml *Antidotes* *Opioid Antagonists*** reference Details CoverageDetails ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days naloxone hcl injection solution 1 /ml QL (4 ML per 31 days) *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 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *Antihyperlipidemics* *BileAcidSequestrants*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 15
*Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 54 gemfibrozil oral tablet 600 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors*** reference Details CoverageDetails ZETIA ORAL TABLET 10 MG A *NicotinicAcidDerivatives*** NIACOR ORAL TABLET 500 MG *Antihypertensives* *AceInhibitor&CalciumChannelBlocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 2.5-10, 5-10, 5-20, 5-40 *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25, 5-6.25 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, 50-25 enalapril-hydrochlorothiazide oral tablet 10-25, 5-12.5 lisinopril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40, 5 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 16
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 ReceptorAntag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet 100-12.5, 100-25, 50-12.5 valsartan-hydrochlorothiazide oral tablet 160-12.5, 160-25, 320-12.5, 320-25, 80-12.5 *Angiotensin II Receptor Antagonists*** losartan potassium oral tablet 100, 25, 50 olmesartan medoxomil oral tablet 20 olmesartan medoxomil oral tablet 40, 5 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *BetaBlocker&DiureticCombinations*** atenolol-chlorthalidone oral tablet 100-25, 50-25 reference Details CoverageDetails QL (31 EA per 31 days) QL (31 EA per 31 days) ST; Must have trial of preferred losartan potassium and valsartan tablets within the past 100 days ST; Must have trial of preferred losartan potassium and valsartan tablets within the past 100 days =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 17
bisoprolol-hydrochlorothiazide oral tablet 10-6.25, 2.5-6.25, 5-6.25 *Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti- Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml sulfamethoxazole-trimethoprim oral tablet 400-80, 800-160 *Antiprotozoal Agents*** reference Details CoverageDetails atovaquone oral suspension 750 /5ml A *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous* solution 150 /ml *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250-100 *Antimalarials*** DARARIM ORAL TABLET 25 MG A hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 QL (1200 ML per 31 days) QL (2400 ML per 31 days) primaquine phosphate oral tablet 26.3 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 18
*Antimyasthenic Agents* *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 MG/5ML pyridostigmine bromide er oral tablet extendedrelease* 180 pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous* solution reconstituted 600 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Androgen Biosynthesis Inhibitors*** reference Details CoverageDetails ZYTIGA ORAL TABLET 250 MG A *Lhrh Analogs*** TRELSTAR INTRAMUSCULAR* SUSENSION RECONSTITUTED 11.25 MG, 3.75 MG *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 19
*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extendedrelease* 25-100, 50-200 carbidopa-levodopa oral tablet 10-100, 25-100, 25-250 *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extendedrelease* 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles*** RISERDAL CONSTA INTRAMUSCULAR* SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 reference Details CoverageDetails QL (62 EA per 31 days) A; QL (2 EA per 28 days) QL (62 EA per 31 days); AL (Min 5 Years) QL (496 ML per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 20
risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones*** haloperidol decanoate intramuscular* solution 100 /ml, 50 /ml reference Details CoverageDetails QL (62 EA per 31 days); AL (Min 5 Years) AL (Min 18 Years) haloperidol lactate injection solution 5 /ml AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 12.5 *Dibenzo-Oxepino yrroles*** SAHRISSUBLINGUALTABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 18 Years) ST; Must fail preferred quetiapine, olanzapine, risperidone, or risperidone ODT within the past 100 days.; AL (Min 10 Years) AL (Min 10 Years) AL (Min 18 Years) AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 days); AL (Min 18 Years) QL (2480 ML per 31 days); AL (Min 18 Years) AL (Min 18 Years) AL (Min 12 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 21
prochlorperazine maleate oral tablet 10, 5 reference Details CoverageDetails AL (Min 2 Years) prochlorperazine suppository 25 AL (Min 2 Years) thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15, 2, 20, 30, 5 ARISTADA INTRAMUSCULAR* 441 MG/1.6ML ARISTADA INTRAMUSCULAR* 662 MG/2.4ML ARISTADA INTRAMUSCULAR* 882 MG/3.2ML *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antivirals* *Hepatitis B Agents*** entecavir oral tablet 0.5, 1 A EIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 100 *Herpes Agents - urine Analogues*** acyclovir oral capsule 200 AL (Min 2 Years) AL (Min 6 Years) A; QL (1.6 ML per 28 days) A; QL (2.4 ML per 28 days) A; QL (3.2 ML per 42 days) QL (31 EA per 31 days); AL (Min 13 Years) AL (Min 12 Years) 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*** rimantadine hcl oral tablet 100 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 22
*Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED5MG/BLISTER reference Details CoverageDetails 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* *Cyclosporine Analogs*** cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml cyclosporine oral capsule 100, 25 GENGRAF ORAL CASULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML SANDIMMUNE ORAL SOLUTION 100 MG/ML *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 *Macrolide Immunosuppressants*** tacrolimus oral capsule 0.5, 1, 5 *urine Analogs*** azathioprine oral tablet 50 *BetaBlockers* *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*** acebutolol hcl oral capsule 200, 400 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 23
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, 37.5, 50, 75 *Beta Blockers Non-Selective*** nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous* solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG 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 reference Details CoverageDetails =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 24
diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 240 diltiazem hcl intravenous* solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 felodipine er oral tablet extended release 24 hr* 10, 2.5, 5 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 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG nifedipine er oral tablet extended release 24 hr* 60, 90 nifedipine er osmotic release oral tablet extended release 24 hr* 30, 60, 90 nifedipine oral capsule 10 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 verapamil hcl oral tablet 120, 40, 80 *Cardiotonics* *Cardiac Glycosides*** digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg reference Details CoverageDetails QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 25
*CardiovascularAgents- Misc.* *eripheral Vasodilators*** no flush niacin oral tablet 500 *ulmonary Hypertension - Endothelin Receptor Antagonists*** reference Details CoverageDetails LETAIRIS ORAL TABLET 10 MG, 5 MG A *ulmonary Hypertension - hosphodiesterase Inhibitors*** ADCIRCA ORAL TABLET 20 MG A sildenafil citrate oral tablet 20 A *Cephalosporins* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 10 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml cephalexin oral suspension reconstituted 250 /5ml *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 *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 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, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 26
*Contraceptives* *Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) *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 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 MICROGESTIN1.5/30ORALTABLET 1.5-30 MG-MCG MICROGESTIN1/20 ORAL TABLET 1-20 MG-MCG reference Details CoverageDetails =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 27
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 NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG norethin-eth estradiol-fe oral tablet chewable 0.8-25 -mcg NORTREL0.5/35(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 REVIFEMORALTABLET0.25-35 MG-MCG RECLISEN ORAL TABLET 0.15-30 MG-MCG SOLIAORALTABLET0.15-30MG-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 reference Details CoverageDetails =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 28
*Combination Contraceptives - Vaginal*** NUVARING VAGINALRING0.12-0.015 MG/24HR *Continuous Contraceptives - Oral*** AMETHYST ORAL TABLET 90-20 MCG levonorgestrel-ethinyl estrad oral tablet 90-20 mcg *Emergency Contraceptives*** reference Details CoverageDetails QL (1 EA per 28 days) levonorgestrel oral tablet 0.75 QL (4 EA per 31 days) NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG LAN B ONE-STE ORAL TABLET 1.5 MG *Extended-Cycle Contraceptives - Oral*** QL (1 EA per 31 days) QL (1 EA per 31 days) QUASENSE ORAL TABLET 0.15-0.03 MG QL (91 EA per 91 days) *rogestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular* suspension 150 /ml *rogestincontraceptives-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 *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 norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25-25 mcg 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 TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG QL (1 ML per 93 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 29
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 TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/0.15-0.025 MG *Corticosteroids* *Glucocorticosteroids*** hydrocortisone oral tablet 10, 20, 5 methylprednisolone oral tablet 4 prednisolone sodium phosphate oral solution 25 /5ml prednisone (pak) oral tablet 10, 5 prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Dermatologicals* *Acne Combinations*** benzoyl peroxide-erythromycin external gel 5-3 % *Acne roducts*** cvs creamy acne face wash external liquid 4 % *Antibiotics -Topical*** bacitracin zinc external ointment 500 unit/gm *Antifungals-Topical*** ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 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 % reference Details CoverageDetails =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 30
*Anti-Inflammatory Agents - Topical*** reference Details CoverageDetails diclofenac sodium transdermal gel 1 % QL (300 GM per 31 days) *Antivirals - Topical*** acyclovir external ointment 5 % DENAVIR EXTERNAL CREAM 1 % ZOVIRAX EXTERNAL CREAM 5 % *Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % urea external cream 40 % *Imidazole-Related Antifungals - Topical*** baza antifungal external cream 2 % clotrimazole external cream 1 % clotrimazole external solution 1 % econazole nitrate external cream 1 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % *Misc. Topical*** HYERCARE EXTERNAL SOLUTION 20 % *Rosacea Agents*** metronidazole external cream 0.75 % metronidazole external gel 1 % *Scabicides & ediculicides*** malathion external lotion 0.5 % ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days.; QL (5 GM per 28 days) ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days.; QL (5 GM per 28 days) QL (118 ML per 31 days); AL (Min 6 Years) spinosad external suspension 0.9 % AL (Min 6 Months) *Diagnostic roducts* *Diagnostic Drugs*** dipyridamole intravenous* solution 5 /ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 31
*Diagnostic Tests*** ACCU-CHEK AVIVA LUS IN VITRO STRI ACCU-CHEK COMFORT CURVE IN VITRO STRI ACCU-CHEK COMACT TEST DRUM IN VITRO STRI ACCU-CHEK SMARTVIEW IN VITRO STRI reference Details CoverageDetails QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old QL: 204/31 days for members 21 years old and younger; QL: 102/31 days for members over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old CLINISTIX IN VITRO STRI QL (100 EA per 31 days) DIASTIX IN VITRO STRI QL (100 EA per 31 days) FREESTYLE INSULINX TEST IN VITRO STRI FREESTYLE LITE TEST IN VITRO STRI FREESTYLE RECISION NEO TEST STRI IN VITRO FREESTYLE TEST IN VITRO STRI QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for member's over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old KETOSTIX IN VITRO STRI QL (100 EA per 31 days) RECISION XTRA BLOOD GLUCOSE IN VITRO STRI QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 32
RECISION XTRA KETONE IN VITRO STRI *Digestive Aids* *Digestive Enzymes*** CREON ORAL CASULE DELAYED RELEASEARTICLES12000UNIT,24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT ZENE ORAL CASULE DELAYED RELEASEARTICLES10000UNIT,15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT, 5000 UNIT *Diuretics* *Carbonic Anhydrase Inhibitors*** acetazolamide oral tablet 125, 250 methazolamide oral tablet 25, 50 *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*** 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*** amiloride hcl oral tablet 5 spironolactone oral tablet 100, 25, 50 *Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250, 500 reference Details CoverageDetails =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 33
chlorthalidone oral tablet 25, 50 DIURIL ORAL SUSENSION 250 MG/5ML hydrochlorothiazide oral capsule 12.5 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.* *Bisphosphonates*** alendronate sodium oral tablet 10, 35, 40, 5, 70 reference Details CoverageDetails ibandronate sodium oral tablet 150 QL (1 EA per 28 days) *Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 A *Gaa Deficiency Treatment - Agents*** LUMIZYMEINTRAVENOUS* SOLUTION RECONSTITUTED 50 MG *Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml *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&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*** estradiol oral tablet 0.5, 1, 2 A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 34
estradiol transdermal patch biweekly 0.025 /24hr, 0.0375 /24hr, 0.05 /24hr, 0.075 /24hr, 0.1 /24hr estradiol transdermal patch weekly 0.025 /24hr, 0.0375 /24hr, 0.05 /24hr, 0.06 /24hr, 0.075 /24hr, 0.1 /24hr estropipate oral tablet 0.75, 1.5, 3 REMARIN INJECTION SOLUTION RECONSTITUTED 25 MG REMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG *Fluoroquinolones* *Fluoroquinolones*** ciprofloxacin hcl oral tablet 250, 500, 750 levofloxacin oral tablet 250, 500, 750 *Gastrointestinal Agents - Misc.* *Antiflatulents*** gas relief oral suspension 20 /0.3ml simethicone oral suspension 40 /0.6ml simethicone oral tablet chewable 80 *Gallstone Solubilizing Agents*** ursodiol oral capsule 300 *Inflammatory Bowel Agents*** ARISO ORAL CASULE EXTENDED RELEASE 24 HOUR 0.375 GM balsalazide disodium oral capsule 750 reference Details CoverageDetails mesalamine enema 4 gm QL (1800 ML per 31 days) sulfasalazine oral tablet 500 sulfasalazine oral tablet delayed release 500 *Intestinal Acidifiers*** generlac oral solution 10 gm/15ml QL (4185 ML per 31 days) *hosphate Binder Agents*** AURYXIA ORAL TABLET 1 GM 210 MG(FE) ST; Must fail preferred Calcium acetate tablet or Calcium acetate capsule =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 35
calcium acetate (phos binder) oral capsule 667 calcium acetate (phos binder) oral tablet 667 *Genitourinary Agents - Miscellaneous* *Hematological Agents - Misc.* reference Details CoverageDetails QL (372 EA per 31 days) QL (372 EA per 31 days) ELIHOS ORAL TABLET 667 MG QL (372 EA per 31 days) *Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended release 24 hr* 10 *Urinary Analgesics*** phenazopyridine hcl oral tablet 200 QL (12 EA per 31 days) *Gout Agents* *Gout Agent Combinations*** colchicine-probenecid oral tablet 0.5-500 *Gout Agents*** allopurinol oral tablet 100, 300 colchicine oral tablet 0.6 *Uricosurics*** probenecid oral tablet 500 *Hematorheologic Agents*** pentoxifylline er oral tablet extendedrelease* 400 *hosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100, 50 *latelet Aggregation Inhibitors*** dipyridamole oral tablet 25, 50, 75 *Quinazoline Agents*** anagrelide hcl oral capsule 0.5, 1 *Thienopyridine Derivatives*** clopidogrel bisulfate oral tablet 75 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 36