2015 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan. lease note that the South Carolina Medicaid referred Drug List is updated quarterly. roviders, please visit our website at https://southcarolina.wellcare.com/provider/pharmacy to view updates to the preferred drug list. Members, please visit our website at https://southcarolina.wellcare.com/member/pharmacy to view updates to the preferred drug list. Last updated (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 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg *Amphetamines**-*Amphetamines*** dextroamphetamine sulfate oral tablet 10 mg, 5 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg VYVANSE ORAL CASULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Stimulants - Misc.**-*Stimulants - Misc.*** dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG methylphenidate hcl oral tablet 10 mg, 5 mg methylphenidate hcl oral tablet 20 mg methylphenidate hcl er oral tablet extendedrelease* 10 mg methylphenidate hcl er oral tablet extendedrelease* 18 mg, 27 mg, 36 mg QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (124 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) 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) AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) AL (Min 6 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 1
Drug Name reference Details Coverage Details methylphenidate hcl er oral tablet extendedrelease* 20 mg methylphenidate hcl er oral tablet extendedrelease* 54 mg *Aminoglycosides* *Aminoglycosides**-*Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS* 10 MG/0.2ML HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML HUMIRA EN SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA EN-SORIASIS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML simponi subcutaneous* 100 mg/ml, 50 mg/0.5ml A *Gold Compounds**-*Gold Compounds*** RIDAURA ORAL CASULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 100 mg/5ml diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg 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) A A A A A A ST; Notes (Must fail preferred meloxicam and one other generic DL NSAID within the past 100 days); QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 2
Drug Name reference Details Coverage Details diclofenac sodium er oral tablet extended release 24 hr* 100 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg ibuprofen junior strength oral tablet chewable 100 mg indomethacin oral capsule 25 mg, 50 mg infants ibuprofen oral suspension 50 mg/1.25ml ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine oral tablet 10 mg QL (20 EA per 31 days) meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5ml QL (2000 ML per 31 days) naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 220 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg sm ibuprofen jr oral tablet 100 mg sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg *yrimidine Synthesis Inhibitors**-*yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg *Analgesics - Nonnarcotic* *Analgesic Combinations**-*Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 mg QL (186 EA per 31 days) butalbital-apap-caffeine oral capsule 50-325-40 mg QL (186 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 3
Drug Name reference Details Coverage Details butalbital-apap-caffeine oral tablet 50-325-40 mg butalbital-asa-caffeine oral capsule 50-325-40 mg QL (186 EA per 31 days) QL (186 EA per 31 days) marten-tab oral tablet 50-325 mg QL (186 EA per 31 days) *Analgesics Other**-*Analgesics Other*** acetaminophen oral capsule 500 mg acetaminophen oral solution 160 mg/5ml acetaminophen oral suspension 80 mg/0.8ml acetaminophen oral tablet 325 mg, 500 mg acetaminophen er oral tablet extendedrelease* 650 mg acetaminophen extra strength oral liquid 500 mg/15ml childrens non-aspirin oral suspension 160 mg/5ml infants silapap oral solution 100 mg/ml non-aspirin childrens oral liquid 160 mg/5ml non-aspirin jr strength oral tablet chewable 160 mg pain & fever childrens oral suspension 160 mg/5ml pain & fever childrens oral tablet chewable 80 mg *Salicylates**-*Salicylates*** aspirin oral tablet 325 mg aspirin oral tablet delayed release 81 mg aspirin suppository 600 mg aspirin ec oral tablet delayed release 325 mg, 81 mg aspirin low dose oral tablet chewable 81 mg diflunisal oral tablet 500 mg eq aspirin low dose oral tablet delayed release 81 mg ra aspirin oral tablet 500 mg salsalate oral tablet 500 mg, 750 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 4
Drug Name reference Details Coverage Details *Analgesics - Opioid* *Opioid Agonists**-*Opioid Agonists*** codeine sulfate oral tablet 15 mg, 30 mg QL (248 EA per 31 days) codeine sulfate oral tablet 60 mg QL (186 EA per 31 days) fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydromorphone hcl oral liquid 1 mg/ml A; QL (10 EA per 30 days) hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg QL (248 EA per 31 days) hydromorphone hcl suppository 3 mg methadone hcl oral solution 10 mg/5ml, 5 mg/5ml methadone hcl oral tablet 10 mg, 5 mg A; QL (248 EA per 31 days) METHADOSE ORAL TABLET 10 MG QL (248 EA per 31 days) morphine sulfate injection solution 10 mg/ml, 15 mg/ml, 5 mg/ml, 8 mg/ml morphine sulfate intravenous* solution 1 mg/ml, 25 mg/ml, 50 mg/ml morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg QL (248 EA per 31 days) morphine sulfate suppository 10 mg, 20 mg, 30 mg, 5 mg morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 200 mg, 30 mg, 60 mg QL (248 EA per 31 days) oxycodone hcl oral capsule 5 mg QL (248 EA per 31 days) oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg QL (248 EA per 31 days) tramadol hcl oral tablet 50 mg QL (248 EA per 31 days) *Opioid Combinations**-*Codeine Combinations*** acetaminophen-codeine oral solution 120-12 mg/5ml acetaminophen-codeine #2 oral tablet 300-15 mg QL (248 EA per 31 days) acetaminophen-codeine #3 oral tablet 300-30 mg QL (248 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 5
Drug Name reference Details Coverage Details acetaminophen-codeine #4 oral tablet 300-60 mg QL (248 EA per 31 days) ASCOM-CODEINE ORAL CASULE 50-325-40-30 MG butalbital-apap-caff-cod oral capsule 50-325-40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg *Opioid Combinations**-*Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg QL (186 EA per 31 days) QL (186 EA per 31 days) QL (186 EA per 31 days) QL (3720 ML per 31 days) QL (248 EA per 31 days) hydrocodone-ibuprofen oral tablet 7.5-200 mg QL (155 EA per 31 days) *Opioid Combinations**-*Opioid Combinations*** ENDOCET ORAL TABLET 5-325 MG QL (248 EA per 31 days) ENDODAN ORAL TABLET 4.8355-325 MG QL (186 EA per 31 days) oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg QL (248 EA per 31 days) oxycodone-aspirin oral tablet 4.8355-325 mg QL (186 EA per 31 days) *Opioid artial Agonists**-*Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg butorphanol tartrate nasal solution 10 mg/ml QL (2.5 ML per 31 days) pentazocine-naloxone hcl oral tablet 50-0.5 mg QL (248 EA per 31 days) zubsolv sublingual tablet sublingual 1.4-0.36 mg, 5.7-1.4 mg *Androgens-Anabolic* *Anabolic Steroids**-*Anabolic Steroids*** oxandrolone oral tablet 10 mg, 2.5 mg A *Androgens**-*Androgens*** danazol oral capsule 100 mg, 200 mg, 50 mg Notes (For female patients only) methitest oral tablet 10 mg TESTIM TRANSDERMAL 50 MG/5GM A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 6
Drug Name reference Details Coverage Details testosterone transdermal 12.5 mg/act (1%), 50 mg/5gm testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular* solution 200 mg/ml *Anorectal Agents* *Intrarectal Steroids**-*Intrarectal Steroids*** hydrocortisone enema 100 mg/60ml *Rectal Combinations**-*Rectal Combinations - Misc.*** hemorrhoidal ointment 0.25-3-14-71.9 % hemorrhoidal suppository 0.25-3-85.5 % ra hemorrhoidal cream 0.25-3-12-18 % *Rectal roducts - Misc.**-*Rectal roducts - Misc.*** TUCKS SUOSITORY 51 % *Rectal Steroids**-*Rectal Steroids*** ROCTOSOL HC CREAM 2.5 % *Antacids* *Antacid Combinations**-*Antacid & Simethicone*** MAALOX MAX ORAL SUSENSION 400-400-40 MG/5ML MAALOX MAX ORAL TABLET CHEWABLE 1000-60 MG MINTOX LUS ORAL TABLET CHEWABLE 200-200-25 MG MYLANTA ORAL SUSENSION 200-200-20 MG/5ML *Antacid Combinations**-*Antacid Combinations*** heartburn antacid ex st oral tablet chewable 160-105 mg MYLANTA ULTRA ORAL TABLET CHEWABLE 700-300 MG A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 7
Drug Name reference Details Coverage Details *Antacids - Aluminum Salts**-*Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml *Antacids - Bicarbonate**-*Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids - Calcium Salts*** calcium antacid oral tablet chewable 500 mg calcium antacid ultra max st oral tablet chewable 1000 mg MAALOX ORAL TABLET CHEWABLE 600 MG smooth antacid extra strength oral tablet chewable 750 mg *Antacids - Magnesium Salts**-*Antacids - Magnesium Salts*** magnesium oxide oral tablet 400 mg, 420 mg *Anthelmintics* *Anthelmintics**-*Anthelmintics*** ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 mg QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 mg/ml STROMECTOL ORAL TABLET 3 MG QL (10 EA per 31 days) *Antianginal Agents* *Nitrates**-*Nitrates*** isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate er oral tablet extendedrelease* 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 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, =-Covered w/rx, UERCASE= Brand name drugs/ 8
Drug Name reference Details Coverage Details NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/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 mg, 15 mg, 30 mg, 5 mg, 7.5 mg hydroxyzine hcl oral solution 10 mg/5ml hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg meprobamate oral tablet 200 mg, 400 mg *Benzodiazepines**-*Benzodiazepines*** alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg diazepam injection solution 5 mg/ml AL (Min 9 Years) diazepam oral solution 1 mg/ml QL (1240 ML per 31 days) diazepam oral tablet 10 mg, 2 mg, 5 mg lorazepam injection solution 2 mg/ml, 4 mg/ml lorazepam oral tablet 0.5 mg, 1 mg, 2 mg oxazepam oral capsule 10 mg, 15 mg, 30 mg *Antiarrhythmics* *Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg quinidine gluconate er oral tablet extendedrelease* 324 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 9
Drug Name reference Details Coverage Details quinidine sulfate oral tablet 300 mg *Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous* solution 20 mg/ml mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg *Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg *Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii*** amiodarone hcl intravenous* solution 150 mg/3ml amiodarone hcl oral tablet 200 mg, 400 mg 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 mg/2ml *Bronchodilators - Anticholinergics**-*Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT A QL (248 ML per 31 days) QL (25.8 GM per 31 days) ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT QL (1 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 10
Drug Name reference Details Coverage Details *Leukotriene Modulators**-*Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 mg montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable 4 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg *Steroid Inhalants**-*Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT AL (Min 1 Months and Max 2 Years) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) Notes (Covered for members less than 8 years old. Members greater than or equal to 8 years old will require prior authorization); QL (120 ML per 31 days); AL (Min 1 Months and Max 8 Years) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (24 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, =-Covered w/rx, UERCASE= Brand name drugs/ 11
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) mg/3ml SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Sympathomimetics**-*Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml Notes (Covered for members 8 years old and younger. Members greater than 8 years old will require prior authorization); QL (120 ML per 31 days); AL (Min 1 Months and 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 (60 EA per 30 days) A; Notes (rior authorization is required for members 8 years of age or older); AL (Max 8 Years) albuterol sulfate oral syrup 2 mg/5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2 mg, 4 mg FORADIL AEROLIZER INHALATION CASULE 12 MCG metaproterenol sulfate oral syrup 10 mg/5ml SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 mg/ml QL (60 EA per 30 days) QL (60 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 12
Drug Name reference Details Coverage Details terbutaline sulfate oral tablet 2.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines**-*Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline oral solution 80 mg/15ml theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg *Anticoagulants* *Coumarin Anticoagulants**-*Coumarin Anticoagulants*** COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG 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 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors**-*Direct Factor Xa Inhibitors*** QL (36 GM per 31 days) XARELTO ORAL TABLET 10 MG QL (35 EA per 365 days) *Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous* solution 100 mg/ml, 150 mg/ml enoxaparin sodium subcutaneous* solution 120 mg/0.8ml, 80 mg/0.8ml enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml Notes (A only applies for quantities greater than 14 days); QL (24 ML per 31 days) Notes (A only applies for quantities greater than 14 days); QL (28 ML per 31 days) Notes (A only applies for quantities greater than 14 days); QL (22.4 ML per 31 days) Notes (A only applies for quantities greater than 14 days); QL (8.4 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 13
Drug Name reference Details Coverage Details enoxaparin sodium subcutaneous* solution 60 mg/0.6ml *Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous* solution 10 mg/0.8ml fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml fondaparinux sodium subcutaneous* solution 5 mg/0.4ml fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Notes (A only applies for quantities greater than 14 days); QL (16.8 ML per 31 days) QL (11.2 ML per 31 days) QL (16 ML per 31 days) QL (5.6 ML per 31 days) QL (8.4 ML per 31 days) diazepam 10 mg, 2.5 mg, 20 mg QL (3 EA per 31 days) ONFI ORAL SUSENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG, 20 MG *Anticonvulsants - Misc.**-*Anticonvulsants - Misc.*** ST; Notes (31 day trial of two of the following: lamotrigine, divalproex, or topiramate.) ST; Notes (31 day trial of two of the following: lamotrigine, divalproex, or topiramate.) carbamazepine oral suspension 100 mg/5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 mg QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 mg QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 mg QL (310 EA per 31 days) gabapentin oral capsule 300 mg QL (372 EA per 31 days) gabapentin oral capsule 400 mg QL (279 EA per 31 days) gabapentin oral solution 250 mg/5ml QL (2230 ML per 31 days) gabapentin oral tablet 600 mg, 800 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 14
Drug Name reference Details Coverage Details lamotrigine oral tablet 25 mg QL (310 EA per 31 days) lamotrigine oral tablet chewable 25 mg, 5 mg QL (310 EA per 31 days) levetiracetam intravenous* solution 500 mg/5ml levetiracetam oral solution 100 mg/ml QL (1000 ML per 31 days) levetiracetam oral tablet 1000 mg, 500 mg, 750 mg levetiracetam oral tablet 250 mg QL (372 EA per 31 days) oxcarbazepine oral suspension 300 mg/5ml QL (1240 ML per 31 days) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg QL (248 EA per 31 days) primidone oral tablet 250 mg QL (248 EA per 31 days) primidone oral tablet 50 mg QL (310 EA per 31 days) topiramate oral capsule sprinkle 15 mg, 25 mg QL (310 EA per 31 days) topiramate oral tablet 100 mg, 25 mg, 50 mg QL (310 EA per 31 days) topiramate oral tablet 200 mg QL (248 EA per 31 days) zonisamide oral capsule 100 mg QL (186 EA per 31 days) zonisamide oral capsule 25 mg, 50 mg QL (93 EA per 31 days) *Gaba Modulators**-*Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2 mg, 4 mg *Hydantoins**-*Hydantoins*** fosphenytoin sodium injection solution 100 mg pe/2ml ST; Notes (31 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 12 years of age and older. Members less than 12 require prior authorization.); AL (Min 12 Years) ST; Notes (31 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 12 years of age and older. Members less than 12 require prior authorization.) peganone oral tablet 250 mg QL (372 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, =-Covered w/rx, UERCASE= Brand name drugs/ 15
Drug Name reference Details Coverage Details phenytoin oral suspension 125 mg/5ml QL (930 ML per 31 days) phenytoin sodium injection solution 50 mg/ml phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg *Succinimides**-*Succinimides*** ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml QL (930 ML per 31 days) *Valproic Acid**-*Valproic Acid*** divalproex sodium oral capsule sprinkle 125 mg QL (310 EA per 31 days) divalproex sodium oral tablet delayed release 125 mg divalproex sodium oral tablet delayed release 250 mg divalproex sodium oral tablet delayed release 500 mg divalproex sodium er oral tablet extended release 24 hr* 250 mg divalproex sodium er oral tablet extended release 24 hr* 500 mg QL (310 EA per 10 days) QL (310 EA per 31 days) QL (279 EA per 31 days) QL (310 EA per 31 days) QL (279 EA per 31 days) valproic acid oral capsule 250 mg QL (310 EA per 31 days) valproic acid oral syrup 250 mg/5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg *Antidepressants - Misc.**-*Antidepressants - Misc.*** bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 16
Drug Name reference Details Coverage Details *Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 mg tranylcypromine sulfate oral tablet 10 mg *Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10 mg, 40 mg QL (31 EA per 31 Days) citalopram hydrobromide oral tablet 20 mg QL (47 EA per 31 Days) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg fluoxetine hcl oral solution 20 mg/5ml fluoxetine hcl oral tablet 10 mg, 20 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg sertraline hcl oral tablet 100 mg, 25 mg, 50 mg *Serotonin Modulators**-*Serotonin Modulators*** nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg effexor xr oral capsule extended release 24 hour 150 mg ST; Notes (Requires 62 day trial/failure of one of the following: citalopram, fluoxetine, fluvoxamine, paroxetine,venlafaxine, sertraline, bupropion) 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, =-Covered w/rx, UERCASE= Brand name drugs/ 17
Drug Name reference Details Coverage Details venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine hcl er oral capsule extended release 24 hour 150 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg *Tricyclic Agents**-*Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg, 50 mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg QL (31 EA per 31 days) ST; Notes (Requires 62 day trial/failure of one of the following: citalopram, fluoxetine, fluvoxamine, paroxetine,venlafaxine, sertraline, bupropion.); QL (31 EA per 31 days) nortriptyline hcl oral solution 10 mg/5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10 mg, 5 mg *Antidiabetics* *Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg *Antidiabetic Combinations**-*Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 50-500 MG ST; Notes (Requires at least a 93 day trial of 1500mg/day of metformin, metformin er, riomet.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 18
Drug Name reference Details Coverage Details 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 mg, 2.5-500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg *Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedion e Combinations*** AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 8-4 MG *Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET 2-1000 MG, 4-500 MG pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg *Biguanides**-*Biguanides*** metformin hcl oral tablet 1000 mg, 500 mg, 850 mg metformin hcl er oral tablet extended release 24 hr* 500 mg, 750 mg ST; Notes (Requires at least a 93 day trial of 1500mg/day of metformin, metformin er, riomet.) ST; Notes (Requires at least a 93 day trial of 1500mg/day of metformin, metformin er, riomet.); QL (62 EA per 31 days) ST 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 (Requires at least a 93 day trial of 1500mg/day of metformin, metformin er, riomet.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 19
Drug Name reference Details Coverage Details metformin hcl er (osm) oral tablet extended release 24 hr* 1000 mg, 500 mg RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other**-*Diabetic Other*** GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm *Diabetic Other**-*rogesterone Receptor Antagonists*** KORLYM ORAL TABLET 300 MG A *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 *Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG QL (2 EA per 31 days) QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Notes (Requires at least a 93 day trial of 1500mg/day of metformin, metformin er, riomet.) ST; Notes (Requires at least a 93 day trial of 1500mg/day of metformin, metformin er, riomet.); 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) 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, =-Covered w/rx, UERCASE= Brand name drugs/ 20
Drug Name reference Details Coverage Details pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg *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 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors**-*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG ST; Notes (Requires at least a 93 day trial of 1500mg/day of metformin, metformin er, riomet.) 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) ST =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 21
Drug Name reference Details Coverage Details JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylureas**-*Sulfonylureas*** chlorpropamide oral tablet 100 mg, 250 mg glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide oral tablet 10 mg, 5 mg glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg *Antidiarrheals* *Antidiarrheal Agents - Misc.**-*Antidiarrheal Agents - Misc.*** acidophilus oral capsule acidophilus oral tablet acidophilus oral tablet chewable, 90-25 mg acidophilus oral wafer acidophilus probiotic blend oral capsule acidophilus/bifidus oral wafer, 100 mg acidophilus/l-sporogenes oral tablet FLORANEX ORAL ACKET FLORANEX ORAL TABLET gnp pink bismuth oral tablet chewable 262 mg LACTINEX ORAL TABLET CHEWABLE sm stomach relief oral tablet 262 mg *Antidiarrheal Combinations**-*Antidiarrheal Combinations*** acidophilus/citrus pectin oral tablet acidophilus/pectin oral capsule *Antidiarrheal Combinations**-*Diarrhea Combinations - Opiates*** anti-diarrheal plus gas relief oral tablet 2-125 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 22 ST
Drug Name reference Details Coverage Details *Antiperistaltic Agents**-*Antiperistaltic Agents*** anti-diarrheal oral tablet 2 mg diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5-0.025 mg gnp anti-diarrheal oral liquid 1 mg/5ml LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral capsule 2 mg loperamide hcl oral suspension 1 mg/7.5ml *Antidotes* *Antidotes - Chelating Agents**-*Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG *Opioid Antagonists**-*Opioid Antagonists*** naltrexone hcl oral tablet 50 mg *Antiemetics* *5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists*** ondansetron oral tablet dispersible 4 mg, 8 mg ondansetron hcl oral solution 4 mg/5ml ondansetron hcl oral tablet 4 mg, 8 mg *Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg motion sickness oral tablet 50 mg travel sickness oral tablet chewable 25 mg univert oral tablet 32 mg *Antiemetics - Miscellaneous**-*Antiemetic Combinations*** anti-nausea oral solution 1.87-1.87-21.5 *Antifungals* *Antifungals**-*Antifungals*** griseofulvin microsize oral suspension 125 mg/5ml A QL (450 ML per 31 days) griseofulvin microsize oral tablet 500 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 23
Drug Name reference Details Coverage Details griseofulvin ultramicrosize oral tablet 125 mg, 250 mg nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg *Imidazole-Related Antifungals**-*Imidazoles*** ketoconazole oral tablet 200 mg *Imidazole-Related Antifungals**-*Triazoles*** fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg *Antihistamines* *Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** chlorpheniramine maleate er oral tablet extendedrelease* 12 mg WAL-FINATE ORAL TABLET 4 MG *Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 mg allergy oral tablet 25 mg altaryl oral syrup 12.5 mg/5ml childrens complete allergy oral tablet chewable 12.5 mg clemastine fumarate oral syrup 0.67 mg/5ml clemastine fumarate oral tablet 1.34 mg diphenhist oral liquid 12.5 mg/5ml diphenhydramine hcl oral capsule 25 mg, 50 mg diphenhydramine hcl oral elixir 12.5 mg/5ml *Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** all day allergy childrens oral solution 5 mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 24
Drug Name reference Details Coverage Details ALLEGRA ALLERGY CHILDRENS ORAL SUSENSION 30 MG/5ML allergy relief child oral syrup 5 mg/5ml allergy relief childrens oral syrup 5 mg/5ml ; QL (310 ML per 31 days) cetirizine hcl oral syrup 5 mg/5ml cetirizine hcl oral tablet 10 mg, 5 mg cetirizine hcl childrens oral solution 5 mg/5ml ; QL (300 ML per 31 days) cetirizine hcl childrens alrgy oral syrup 1 mg/ml childrens loratadine oral syrup 5 mg/5ml ; QL (310 ML per 31 days) fexofenadine hcl oral tablet 180 mg, 60 mg fexofenadine hcl childrens oral suspension 30 mg/5ml levocetirizine dihydrochloride oral solution 2.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg loratadine oral tablet 10 mg loratadine childrens oral solution 5 mg/5ml loratadine hives relief oral solution 5 mg/5ml sm loratadine oral tablet dispersible 10 mg *Antihistamines - henothiazines**-*antihistamines - henothiazines*** promethazine hcl injection solution 25 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl suppository 12.5 mg, 25 mg, 50 mg ROMETHEGAN SUOSITORY 25 MG *Antihistamines - iperidines**-*antihistamines - iperidines*** ST; Notes (Must fail preferred loratadine solution and cetirizine syrup within the past 100 days) cyproheptadine hcl oral syrup 2 mg/5ml QL (300 ML per 31 days) cyproheptadine hcl oral tablet 4 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 25
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 mg, 54 mg fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg gemfibrozil oral tablet 600 mg *Hmg Coa Reductase Inhibitors**-*Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg lovastatin oral tablet 10 mg, 20 mg, 40 mg pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg *Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 MG A *Microsomal Triglyceride Transfer rotein (Mtp) Inhibitors**-*Microsomal Triglyceride Transfer rotein Inhibitors*** JUXTAID ORAL CASULE 10 MG, 20 MG, 5 MG *Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extendedrelease* 750 mg NIACOR ORAL TABLET 500 MG ST; Notes (Trial/failure of a statin or 90 days of gemfibrozil within the previous 180 days.) ST; Notes (Trial/failure of a statin or 90 days of gemfibrozil within the previous 180 days.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 26 A
Drug Name reference Details Coverage Details *Antihypertensives* *Ace Inhibitors**-*Ace Inhibitors*** benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule 2.5 mg, 5 mg *Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** losartan potassium oral tablet 100 mg, 25 mg, 50 mg *Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg guanfacine hcl oral tablet 1 mg, 2 mg methyldopa oral tablet 250 mg, 500 mg methyldopate hcl intravenous* solution 250 mg/5ml *Antiadrenergic Antihypertensives**-*Antiadrenergics - eripherally Acting*** doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg prazosin hcl oral capsule 1 mg, 2 mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 27
Drug Name reference Details Coverage Details *Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg *Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg *Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg propranolol-hctz oral tablet 40-25 mg, 80-25 mg *Vasodilators**-*Vasodilators*** hydralazine hcl injection solution 20 mg/ml hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.*** metronidazole oral tablet 250 mg, 500 mg trimethoprim oral tablet 100 mg vancomycin hcl intravenous* solution reconstituted 1000 mg, 500 mg, 750 mg vancomycin hcl oral capsule 125 mg, 250 mg 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 28
Drug Name reference Details Coverage Details *Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** sulfamethoxazole-tmp ds oral tablet 800-160 mg sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg *Antiprotozoal Agents**-*Antiprotozoal Agents*** atovaquone oral suspension 750 mg/5ml A *Leprostatics**-*Leprostatics*** dapsone oral tablet 100 mg, 25 mg *Lincosamides**-*Lincosamides*** clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml clindamycin phosphate intravenous* solution 300 mg/2ml *Oxazolidinones**-*Oxazolidinones*** SIVEXTRO ORAL TABLET 200 MG A *Antimalarials* *Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg *Antimalarials**-*Antimalarials*** DARARIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg primaquine phosphate oral tablet 26.3 mg 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, =-Covered w/rx, UERCASE= Brand name drugs/ 29
Drug Name reference Details Coverage Details *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 mg REGONOL INJECTION SOLUTION 5 MG/ML *Antimycobacterial Agents* *Antimycobacterial Agents**-*Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg isoniazid injection solution 100 mg/ml isoniazid oral tablet 100 mg, 300 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin intravenous* solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg *Antineoplastics And Adjunctive Therapies* *Alkylating Agents**-*Alkylating Agents*** HEXALEN ORAL CASULE 50 MG MYLERAN ORAL TABLET 2 MG *Alkylating Agents**-*Imidazotetrazines*** temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg *Alkylating Agents**-*Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG cyclophosphamide oral capsule 25 mg, 50 mg A LEUKERAN ORAL TABLET 2 MG melphalan hcl intravenous* solution reconstituted 50 mg *Alkylating Agents**-*Nitrosoureas*** lomustine oral capsule 10 mg, 100 mg, 40 mg A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 30
Drug Name reference Details Coverage Details *Antimetabolites**-*Antimetabolites*** adrucil intravenous* solution 500 mg/10ml A capecitabine oral tablet 150 mg, 500 mg A fluorouracil intravenous* solution 500 mg/10ml A gemcitabine hcl intravenous* solution 1 gm/26.3ml, 2 gm/52.6ml, 200 mg/5.26ml gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, 200 mg mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg methotrexate sodium injection solution 25 mg/ml methotrexate sodium injection solution reconstituted 1 gm methotrexate sodium (pf) injection solution 1 gm/40ml, 100 mg/4ml, 25 mg/ml, 250 mg/10ml, 50 mg/2ml TABLOID ORAL TABLET 40 MG *Antineoplastic - Angiogenesis Inhibitors**-*Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML *Antineoplastic - Hedgehog athway Inhibitors**-*Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 MG A *Antineoplastic - Hormonal And Related Agents**-*Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG A *Antineoplastic - Hormonal And Related Agents**-*Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antineoplastic - Hormonal And Related Agents**-*Antiandrogens*** bicalutamide oral tablet 50 mg flutamide oral capsule 125 mg XTANDI ORAL CASULE 40 MG A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 31
Drug Name reference Details Coverage Details *Antineoplastic - Hormonal And Related Agents**-*Antiestrogens*** FARESTON ORAL TABLET 60 MG tamoxifen citrate oral tablet 20 mg *Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors*** anastrozole oral tablet 1 mg exemestane oral tablet 25 mg letrozole oral tablet 2.5 mg *Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 MG *Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs*** leuprolide acetate injection kit 1 mg/0.2ml A LURON DEOT INTRAMUSCULAR* KIT 22.5 MG, 3.75 MG, 30 MG, 45 MG, 7.5 MG TRELSTAR DEOT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 MG TRELSTAR DEOT MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 MG TRELSTAR LA INTRAMUSCULAR* SUSENSION RECONSTITUTED 11.25 MG TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 11.25 MG TRELSTAR MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 22.5 MG *Antineoplastic - Hormonal And Related Agents**-*rogestins-Antineoplastic*** megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 800 mg/20ml megestrol acetate oral tablet 20 mg, 40 mg A A A A A A QL (600 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, =-Covered w/rx, UERCASE= Brand name drugs/ 32
Drug Name reference Details Coverage Details *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 MG A *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 MG A SUTENT ORAL CASULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100 MG, 500 MG A CARELSA ORAL TABLET 100 MG, 300 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG, 400 MG ICLUSIG ORAL TABLET 15 MG, 45 MG A SRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CASULE 150 MG, 200 MG TYKERB ORAL TABLET 250 MG A XALKORI ORAL CASULE 200 MG, 250 MG 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ A A A A A 33