Preferred Drug List (PDL)

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3 Preferred List INTRODUCTION UnitedHealthcare is pleased to provide this Preferred List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare PDL have been reviewed and approved by the Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the prior authorization process. The drugs represented have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare, solely for the convenience of medical providers. UnitedHealthcare does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. UnitedHealthcare assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at PREFACE The UnitedHealthcare PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. The UnitedHealthcare PDL covers selected over-thecounter (OTC) products. You are encouraged to prescribe OTC medications when clinically appropriate. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare medical directors and pharmacists also participate in the P&T Committee. The P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received the PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare internet site. UHC1004a {Released 2/25/11} i

4 OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Benefits and copays are based on the individual member s benefit plan. PRODUCT SELECTION CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations Medical outcome and pharmacoeconomic studies When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited name product. carvedilol Coreg All strengths of Coreg would be covered by this listing. Extended-release and delayed-release products require their own entry. diltiazem sustained release CARDIZEM SR Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymixin B/ Cortisporin Hydrocortisone As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not citalopram 40 mg tabs Celexa tabs GENERIC SUBSTITUTION The UnitedHealthcare PDL requires substitution on the majority of products when a equivalent is available. Generic substitution is a pharmacy action whereby a equivalent is dispensed rather than the name product. The PDL indicates availability in the column. If a name drug is medically necessary, please submit a prior authorization request. The UnitedHealthcare MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most s but not ed versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA s review and approval process. An important consideration for substitution is the knowledge that all approvals of drugs by the FDA since 1984, and many approvals prior to 1984, have a showing of bioequivalence between the versions and the reference product. To gain FDA approval: 1. The drug must contain the same active ingredient(s), be the same strength and the same dosage form as the name product. 2. The FDA has given the an A rating compared to the ed product indicating bioequivalence, and has determined the is therapeutically equivalent UHC1004a ii

5 to the reference. The ratings of drugs are available by referring to the FDA reference, Approved Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent drug product is substituted for the name product. There are now many name products that are repackaged or distributed under a label. The label version should always be considered therapeutically equivalent and substitutable for the source ed product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS s first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare s PDL does not cover DESI less than fully effective drug products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare PDL. UHC1004a DESI drugs Antiobesity agents Experimental / research drugs Cosmetic drugs Immunization agents Nutritional / diet supplements Blood and blood plasma products Agents used to promote fertility Agents used for erectile dysfunction Agents used for cosmetic hair growth iii s from manufacturers that do not participate in the FFS Medicaid Rebate Program Diagnostic products Medical supplies and DME except as listed: syringes, needles, lancets, alcohol swabs, spacers, preferred diabetes test strips, peak flow meters (Astech, Assess, Peak Air s, max two per year), vaporizer (limit of 1 per 3 years), humidifier (limit of 1 per 3 years) Mirena DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare members may receive up to a one month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when eighty-five percent (85%) of the medication has been utilized. If a claim is submitted before 85% of the medication has been used, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare PDL requires mandatory substitution on the vast majority of products when a equivalent is available; however, name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare PDL prior authorization (PA) list does not include ed items where a equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. Requests for these exceptions should be either made in writing by the physician and faxed or called into: UnitedHealthcare Pharmacy Services Department Fax Phone A prior authorization request form is available in the UnitedHealthcare provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-pdl request. The UnitedHealthcare Pharmacy Department will respond to all requests in accordance with state requirements.

6 Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare. If a pharmacist receives a prescription for a non-pdl drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Pharmacy Prior Notification Service at with questions concerning the prior authorization process. NON-PDL DRUGS 5-DAY TEMPORARY SUPPLY OVERRIDES To ensure the use of PDL drugs, all non- PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 5-day supply of the newly prescribed non-pdl drug. The pharmacy should submit a claim for a 5 day supply, with a PA Type of 8 and Prior Authorization number of Please note that non-preferred drugs are available for a 5-day supply, however availability is subject to the benefit design. For assistance, pharmacies may call The pharmacy should contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare at QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician. Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period: opiate analgesics benzodiazepines sedative hypnotic agents barbiturates UHC1004a iv select muscle relaxants Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits. Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Pharmacy Prior Notification Service at with questions. Specialty Pharmaceutical Management Program UnitedHealthcare is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Pharmacy Department via fax at The UnitedHealthcare Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare will coordinate the delivery of the product to the member or provider. s that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Pharmacy Department at MEDICATIONS REQUIRING DIAGNOSIS UnitedHealthcare requires that the diagnosis for prescriptions for HIV medications for UnitedHealthcare Community Plan members match the FDA-approved use or a use supported by current published evidence. The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the prescriber to verify the diagnosis and submit it on the claim. If the diagnosis provided still does not match the approved use, prior authorization may be requested through the standard process by faxing a request to

7 STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA). STEP Amerge Aricept 23mg Banzel Breo Ellipta Cymbalta Ditropan XL First-Line Agent(s) Trial at a minimum dose of 50mg of sumatriptan tablets. 90 day trial of Aricept 10mg daily 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. 1) 30 day trial of one inhaled corticosteroid (e.g. Arnuity Ellipta, Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Foradil, Serevent) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). Minimum 2 month trial of 2 PDL antidepressants in the preceding 6 months 30 day trial of oxybutynin immediate release. DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Tradjenta, metformin. Jentadueto, Onglyza, Kombiglyze) Dulera Elidel fenofibrate 1) 30 day trial of one inhaled corticosteroid (e.g. Arnuity Ellipta, Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Foradil, Serevent) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Fill of a statin or 90 days of gemfibrozil within the previous 180 days. Gabitril 30 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. GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Tanzeum, metformin Victoza) Intuniv levocetirizine midodrine Nucynta ER Onfi Opana ER Optivar 30 day trial of one of the following: methylphenidate, methylphenidate SR, Concerta, amphetamine salts, Adderall XR, dextroamphetamine, Vyvanse, or dextroamphetamine SA. 30 day trial of loratadine and cetirizine. Trial of fludrocortisone 30 day trial of at least 200mg per day of morphine sulfate ER. 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. 30 day trial of at least 200mg per day of morphine sulfate ER. 14 day trial of ketotifen within previous 90 days required first. lansoprazole/ 30 day trial of omeprazole 40mg and Prevacid OTC pantoprazole 40mg within previous 180 days is required first Potiga 30-day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 18 years of age and older. Members less than 18 require prior authorization. Protopic 0.03% Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Protopic 0.1% Ranexa Minimum age of 16. Trial of two different topical corticosteroids. Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates fentanyl patches 30 day trial of at least 200mg per day of morphine sulfate ER. Renvela 8 week trial of calcium acetate UHC1004a v

8 SGLT-2 Inhibitors (Jardiance, Invokana, Invokamet) Strattera At least a 90 day trial of 1500mg/day of metformin 30 day trial of one of the following: methylphenidate, methylphenidate SR, Concerta, amphetamine salts, Adderall XR, dextroamphetamine, Vyvanse, or dextroamphetamine SA. should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting. EDITOR Your comments and suggestions regarding the UnitedHealthcare PDL are encouraged. Your input is vital to this PDL s continued success. All responses will be reviewed and considered. Please send your comments to: tolterodine trospium 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. TZD s At least a 90 day trial of 1500mg/day of {ActosPlusMet, metformin ActoPlusMet XR Duetact) Uloric Vancocin Vimpat 8 week trial of up to 600mg of allopurinol required first. One fill of metronidazole tabs or caps 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 17 years of age and older. Members less than 17 require prior authorization. Vytorin 90 day trial of simvastatin 40mg, simvastatin 80mg or atorvastatin within previous 180 days is required first. Xopenex 30 day trial of Albuterol.083% or.5% Respules respules. PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the UnitedHealthcare Director of Pharmacy Services by either mail or fax. Attn: Director of Pharmacy Services UnitedHealthcare Unison Plaza 1001 Brinton Road Pittsburgh, PA Phone: UnitedHealthcare by UnitedHealthcare Director of Pharmacy Services Unison Plaza 1001 Brinton Road Pittsburgh, PA Phone: LEGEND # Only the dosage forms/strengths of the name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustainedrelease) PA Prior Authorization required QL Quantity Limits apply ST SP Step Therapy, see pages V-VI for details Specialty Pharmaceuticals, see pages IV-V for details NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare. These trademarked names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare and such third-party pharmaceutical companies. If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification. Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature UHC1004a vi

9 Table of Contents Antineoplastics & Immunosuppressants 4 Antineoplastic Agents...4 Hormonal Antineoplastic Agents....5 Immunomodulators...5 Immunosuppressants...6 Miscellaneous...6 Blood Modifiers - Anticoagulants Anticoagulants...7 Blood Cell Formation...7 Platelet Inhibitors...7 Miscellaneous...7 Cardiovascular Agents...8 Ace Inhibitors...8 Ace Inhibitor/Diuretic Combinations....8 Adrenolytics, Central... 8 Alpha Blockers...8 Angiotensin II Receptor Blockers (Antagonists)....8 Angiotensin II Receptor Blocker Combinations...8 Antiarrhythmics and Cardiac Glycosides...9 Beta Blockers and Beta Blocker/ Diuretic Combinations...9 Calcium Channel Blockers...9 Diuretics Lipid Lowering Agents...11 Nitrates...11 Potassium-Removing Agents...11 Miscellaneous...12 Central Nervous System Alzheimer s Disease...12 Analgesics...12 Migraine Acute Therapy...14 Migraine Prophylactic Therapy...15 Multiple Sclerosis...15 Myasthenia Gravis...15 Parkinson s Disease Seizures Miscellaneous Dermatology Acne Vulgaris...17 Bacterial Infections Corticosteroids...17 Fungal Infections Psoriasis...19 Rosacea Scabies and Pediculosis...19 Viral Infections Miscellaneous...19 Ear, Nose & Throat Ear...20 Nose Throat and Mouth Endocrinology...22 Adrenal Corticosteroids...22 Androgens Diabetes Mellitus...23 Growth Stimulating Agents...25 Osteoporosis Thyroid Disease...25 Miscellaneous...25 Gastrointestinal...25 Diarrhea...25 Emesis...25 Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers...25 Gastrointestinal Spasm...27 Inflammatory Bowel Disease...27 Laxatives...28 Pancreatic Enzymes...28 Probiotic Supplementation...28 Miscellaneous...28 Infectious Diseases Anthelmintics Antibacterials Antifungals Antivirals...30 Miscellaneous...32

10 Musculoskeletal Arthritis Gout Skeletal Muscle Relaxants...35 OB-GYN Contraceptives...35 Endometriosis...36 Hormone Therapy/Menopause...36 Vaginal Infections...37 Miscellaneous...37 Ophthalmic...38 Allergy...38 Anti-Inflammatories Glaucoma...39 Infections...40 Miscellaneous...40 Psychiatric...40 Alcohol Deterrents...40 Anxiety...40 Attention Deficit Hyperactivity Disorder (ADHD) Bipolar Disorder...41 Depression...42 Insomnia Narcotic Antagonists...43 Psychoses...43 Smoking Cessation...44 Miscellaneous...44 Respiratory s...44 Antitussives, Decongestants, Expectorants and Combinations...44 Asthma/COPD...50 Vitamins and Minerals...52 Potassium...55 Miscellaneous...56 Anaphylaxis...56 Cystic Fibrosis...56 Hereditary Angioedema...56 Hyperphosphatemia...56 Idiopathic Pulmonary Fibrosis (IPF)...56 Immune Thrombocytopenic Purpura...56 Medical Devices...56 Metabolic Modifiers...56 Vaccine (oral)...56 OTC MEDICATIONS Acne Antifungals Atopic Dermatitis...57 Cough/Cold Allergy...57 Diabetes...58 Earwax Removal Products...58 Family Planning...58 First Aid...58 Gastrointestinal Lice Products...59 Motion Sickness...59 Ophthalmics...59 Pain...59 Smoking Cessation Products...59 Vitamins/Minerals...59 Warts...60 Miscellaneous...60 Index of s...61 Urological...51 Symptomatic Benign Prostatic Hypertrophy..51 Miscellaneous

11 Generic Name Brand Name Antineoplastics & Immunosuppressants Antineoplastic Agents Alkylating Agents altretamine HEXALEN busulfan MYLERAN chlorambucil LEUKERAN cyclophosphamide CYTOXAN estramustine phosphate sodium EMCYT lomustine CEENU melphalan ALKERAN temozolomide TEMODAR PA, SP Antimetabolites capecitabine XELODA PA, SP fludarabine OFORTA PA, SP mercaptopurine PURINETHOL thioguanine TABLOID QL Histone Deacetylase Inhibitors panobinostat FARYDAK PA, SP vorinostat ZOLINZA PA, SP Kinase Inhibitor afatinib GILOTRIF PA, SP axitinib INLYTA PA, SP bosutinib BOSULIF PA, SP cabozantinib COMETRIQ PA, SP ceritinib ZYKADIA PA, SP crizotinib XALKORI PA, SP dabrafenib TAFINLAR PA, SP dasatinib SPRYCEL PA, SP erlotinib TARCEVA PA, SP everolimus AFINITOR AFINITOR DISPERZ PA, SP ibrutinib IMBRUVICA PA, SP idelalisib ZYDELIG PA, SP imatinib mesylate GLEEVEC PA, QL, SP lapatinib ditosylate TYKERB PA, SP levatinib LENVIMA PA, SP 4

12 Generic Name Brand Name nilotinib TASIGNA PA, SP palbociclib IBRANCE PA, SP pazopanib VOTRIENT PA, SP ponatinib ICLUSIG PA, SP regorafenib STIVARGA PA, SP ruxolitinib JAKAFI PA, SP sorafenib NEXAVAR PA, SP sunitinib SUTENT PA, SP trametinib MEKINIST PA, SP vandetanib CAPRELSA PA, SP vemurafenib ZELBORAF PA, SP Hormonal Antineoplastic Agents Androgen Biosynthesis Inhibitors abiraterone ZYTIGA PA, SP Antiandrogens bicalutamide CASODEX flutamide EULEXIN Antiestrogens tamoxifen NOLVADEX toremifene FARESTON Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Gonadotropin Releasing Hormone Analog leuprolide LUPRON PA, SP leuprolide LUPRON DEPOT LUPRON DEPOT 6-MONTH PA, SP LUPRON DEPOT-PED Progestin megestrol acetate MEGACE Immunomodulators Interferons interferon alfa-2a PA, SP interferon alfa-2b INTRON A PA, SP peginterferon alfa-2b SYLATRON PA, SP 5

13 Generic Name Brand Name Miscellaneous lenalidomide REVLIMID PA, SP pomalidomide POMALYST PA, SP Immunosuppressants Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified NEORAL GENGRAF tacrolimus HECORIA PROGRAF Rapamycin Derivative sirolimus RAPAMUNE Miscellaneous everolimus ZORTRESS Miscellaneous alitretinoin 1% gel PANRETIN PA bexarotene caps and topical gel TARGRETIN PA cysteamine bitartrate CYSTAGON etoposide VEPESID hydroxyurea DROXIA HYDREA mitotane LYSODREN octreotide SANDOSTATIN olaparib LYNPARZA PA, SP pasireotide SIGNIFOR PA, SP procarbazine MATULANE topotecan HYCAMTIN PA, SP tretinoin VESANOID caps vismodegib ERIVEDGE PA, SP 6

14 Generic Name Brand Name Blood Modifiers - Anticoagulants Anticoagulants apixaban ELIQUIS PA enoxaparin LOVENOX PA, QL, SP, SP and PA only applies for quantities greater than 14 days heparin HEPARIN rivaroxaban XARELTO PA warfarin COUMADIN Blood Cell Formation darbepoetin alfa ARANESP PA, SP epoetin alfa EPOGEN PROCRIT PA, SP filgrastim ZARXIO PA, SP oprelvekin NEUMEGA PA, SP pegfilgrastim NEULASTA PA, SP plerixafor MOZOBIL PA, SP sargramostim LEUKINE PA, SP TBO-filgrastim GRANIX PA, SP Platelet Inhibitors anagrelide AGRYLIN aspirin BAYER ECOTRIN OTC cilostazol PLETAL clopidogrel PLAVIX QL dipyridamole PERSANTINE Miscellaneous aminocaproic acid AMICAR 500 mg tabs & syrup only deferasirox EXJADE PA, SP pentoxifylline extended-release TRENTAL 7

15 Generic Name Brand Name Cardiovascular Agents Ace Inhibitors benazepril LOTENSIN captopril CAPOTEN enalapril VASOTEC enalapril oral soln EPANED Members 8 years of age will require prior authorization. fosinopril MONOPRIL QL lisinopril ZESTRIL QL quinapril ACCUPRIL QL Ace Inhibitor/Diuretic Combinations benazepril/ LOTENSIN HCT hydrochlorothiazide captopril/ hydrochlorothiazide CAPOZIDE enalapril/ hydrochlorothiazide VASERETIC fosinopril/ hydrochlorothiazide MONOPRIL-HCT QL lisinopril/ hydrochlorothiazide ZESTORETIC QL quinapril/ hydrochlorothiazide ACCURETIC QL Adrenolytics, Central clonidine CATAPRES guanfacine TENEX Alpha Blockers doxazosin CARDURA prazosin MINIPRESS terazosin HYTRIN Angiotensin II Receptor Blockers (Antagonists) losartan COZAAR QL Angiotensin II Receptor Blocker Combinations losartan/hctz HYZAAR QL 8

16 Generic Name Brand Name Antiarrhythmics and Cardiac Glycosides amiodarone tabs CORDARONE 200 mg and 400 mg digoxin LANOXIN disopyramide NORPACE disopyramide extended-release NORPACE CR dofetilide TIKOSYN flecainide TAMBOCOR mexiletine MEXITIL propafenone RYTHMOL IR only quinidine gluconate QUINIDINE GLUCONATE extended-release EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate QUINIDINE SULFATE extended-release EXT-REL Beta Blockers and Beta Blocker/Diuretic Combinations acebutalol SECTRAL atenolol TENORMIN atenolol/chlorthalidone TENORETIC bisoprolol ZEBETA bisoprolol/ hydrochlorothiazide ZIAC carvedilol COREG QL labetalol TRANDATE metoprolol LOPRESSOR 50 mg and 100 mg only metoprolol succinate TOPROL XL pindolol PINDOLOL propranolol INDERAL IR only propranolol/hctz INDERIDE sotalol BETAPACE timolol maleate tablets Calcium Channel Blockers Dihydropyridines amlodipine NORVASC QL felodipine extended-release PLENDIL QL nicardipine CARDENE nifedipine PROCARDIA 9

17 Generic Name Brand Name nifedipine ADALAT CC extended-release PROCARDIA XL QL nimodipine NIMOTOP QL nimodipine oral soln NYMALIZE Nondihydropyridines diltiazem CARDIZEM diltiazem extended-release CARDIZEM CD QL diltiazem DILACOR XR extended-release TIAZAC QL diltiazem sustained-release CARDIZEM SR QL verapamil CALAN verapamil extended-release CALAN SR QL Diuretics amiloride MIDAMOR amiloride/ hydrochlorothiazide MODURETIC bumetanide BUMEX chlorthalidone CHLORTHALIDONE chlorothiazide DIURIL chlorothiazide DIURIL ORAL SUSPENSION QL furosemide LASIX hydrochlorothiazide HYDROCHLOROTHIAZIDE soln, tabs hydrochlorothiazide MICROZIDE 12.5 mg caps indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone/ hydrochlorothiazide ALDACTAZIDE torsemide DEMADEX triamterene/ DYAZIDE hydrochlorothiazide MAXZIDE 10

18 Generic Name Lipid Lowering Agents Bile Acid Resin cholestyramine Brand Name QUESTRAN QUESTRAN-LIGHT Only the bulk products are covered (cans). Individual packets are not covered. Fibrates fenofibrate LOFIBRA ST gemfibrozil LOPID HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR ezetimibe/simvastatin VYTORIN ST lovastatin MEVACOR QL simvastatin ZOCOR QL Niacins niacin NIACOR niacin extended-release NIASPAN Miscellaneous Nitrates Oral isosorbide dinitrate ISORDIL isosorbide dinitrate ISOSORBIDE extended-release DINITRATE ER isosorbide mononitrate ISMO isosorbide mononitrate exteneded-release IMDUR Sublingual isosorbide dinitrate ISORDIL S.L. nitroglycerin NITROLINGUAL nitroglycerin NITROSTAT Transdermal nitroglycerin NITREK NITRO-DUR nitroglycerin NITRO-BID oint Potassium-Removing Agents sodium polysterene sulfonate transdermal, QL KAYEXALATE susp (susp only) 11

19 Generic Name Brand Name Miscellaneous ambrisentan LETAIRIS PA, SP bosentan TRACLEER PA, SP guanabenz WYTENSIN hydralazine APRESOLINE lomitapide JUXTAPID PA, SP methyldopa ALDOMET methyldopa/hctz ALDORIL midodrine PROAMATINE ST minoxidil LONITEN ranolazine RANEXA ST sildenafil REVATIO PA Central Nervous System Alzheimer s Disease donepezil ARICEPT donepezil ARICEPT galantamine RAZADYNE memantine NAMENDA rivastigmine EXELON 5 mg and 10 mg, QL, Members <18 years of age will require prior authorization. 23 mg, ST, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. Analgesics Barbiturate Non-Narcotic Analgesics butalbital/acetaminophen PHRENILIN QL butalbital/acetaminophen SEDAPAP QL butalbital/acetaminophen/ caffeine FIORICET QL butalbital/aspirin/caffeine FIORINAL QL 12

20 Generic Name Brand Name Non-Narcotic Analgesics acetaminophen TYLENOL OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE mg, OTC tramadol ULTRAM QL NSAIDS choline magnesium trisalicylate TRILISATE diclofenac sodium delayed-release VOLTAREN etodolac LODINE IR Only fenoprofen NALFON 600 mg ibuprofen ADVIL tabs, chew tabs ibuprofen MOTRIN and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only ketorolac tromethamine TORADOL QL meloxicam MOBIC QL nabumetone RELAFEN naproxen NAPROSYN Not EC naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Opioids - Narcotic Analgesics butalbital/apap/caff/cod FIORICET W/CODEINE QL, mg butalbital/asa/caff/cod FIORINAL W/CODEINE QL butorphanol STADOL nasal spray, QL codeine/acetaminophen TYLENOL W/CODEINE QL codeine sulfate QL fentanyl transdermal DURAGESIC QL, ST 13

21 Generic Name Brand Name LORCET LORTAB hydrocodone/ LORTAB ELIXIR acetaminophen NORCO QL VICODIN VICODIN ES hydromorphone DILAUDID QL meperidine DEMEROL QL methadone DOLOPHINE QL morphine MSIR QL morphine RMS QL morphine extended-release MS CONTIN QL oxycodone OXYFAST soln, QL oxycodone ROXICODONE QL oxycodone/ acetaminophen PERCOCET 5/325, QL oxycodone/aspirin PERCODAN QL oxycodone ER OXYCONTIN PA, QL, 15mg, 30mg, 60mg oxycodone ER OXYCONTIN PA, QL oxymorphone ER OXYMORPHONE ER QL, ST pentazocine/naloxone TALWIN NX QL tapentadol ER NUCYNTA ER ST Migraine Acute Therapy Ergotamine Derivatives dihydroergotamine D.H.E. 45 inj, QL dihydroergotamine MIGRANAL ergotamine/caffeine CAFERGOT Selective Serotonin Agonists naratriptan AMERGE ST rizatriptan MAXALT/MAXALT MLT QL sumatriptan IMITREX QL sumatriptan IMITREX 4 MG AND 6 MG INJ 4 mg and 6 mg inj 14

22 Generic Name Brand Name Migraine Prophylactic Therapy amitriptyline ELAVIL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE Members 8 years of age will require prior authorization. divalproex sodium delayed-release DEPAKOTE Minimum age 2 propranolol INDERAL IR only verapamil CALAN Multiple Sclerosis dimethyl fumarate TECFIDERA PA, SP fingolimod GILENYA PA, SP glatiramer acetate COPAXONE PA,QL, SP interferon beta-1a AVONEX/AVONEX PEN PA,QL, SP interferon beta-1a REBIF PA,QL, SP teriflunomide AUBAGIO PA, SP Myasthenia Gravis pyridostigmine MESTINON pyridostigmine MESTINON TIMESPAN extended-release Parkinson s Disease amantadine SYMMETREL except tabs benztropine COGENTIN biperiden AKINETON carbidopa/levodopa SINEMET carbidopa/levodopa SINEMET CR extended-release entacapone COMTAN pramipexole MIRAPEX ropinirole REQUIP selegiline ELDEPRYL tabs tolcapone TASMAR trihexyphenidyl ARTANE Seizures carbamazepine TEGRETOL carbamazepine CARBATROL extended-release TEGRETOL-XR clobazam ONFI ST clonazepam KLONOPIN tabs 15

23 Generic Name Brand Name diazepam DIASTAT ACUDIAL rectal gel, QL Members 8 years of divalproex sodium DEPAKOTE SPRINKLE age will require prior cap sprinkle authorization. divalproex sodium delayed-release DEPAKOTE Minimum age 2 ethosuximide ZARONTIN exogabine POTIGA Age Limits Apply, ST felbamate FELBATOL felbamate oral susp FELBATOL ORAL SUSP Members 8 years of age will require prior authorization. gabapentin NEURONTIN caps and tabs only lacosamide VIMPAT Age Limits Apply, ST lamotrigine LAMICTAL QL lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB levetiracetam KEPPRA methsuximide CELONTIN Members 8 years of age will require prior authorization. QL, Maximum age of 9 for solution oxcarbazepine TRILEPTAL QL, Maximum age of 9 for suspension phenobarbital PHENOBARBITAL phenytoin DILANTIN INFATABS phenytoin sodium DILANTIN extended PHENYTEK pregabalin LYR ICA PA pregabalin LYRICA SOLUTION oral solution, PA primidone MYSOLINE rufinamide BANZEL tablets only, QL, ST tiagabine GABITRIL Age Limits Apply, ST topiramate TOPAMAX QL topiramate sprinkle caps TOPAMAX SPRINKLE QL, Members 8 years of age will require prior authorization. valproic acid DEPAKENE vigabatrin oral solution SABRIL SOLUTION PA, SP zonisamide ZONEGRAN QL 16

24 Generic Name Brand Name Miscellaneous tetrabenazine XENAZINE PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE PA Topical azelaic acid FINACEA gel benzoyl peroxide BENZAC AC clindamycin CLEOCIN T gel clindamycin CLEOCIN T lotion clindamycin CLEOCIN T soln erythromycin ERYGEL gel 2% erythromycin T-STAT soln erythromycin/benzoyl peroxide BENZAMYCIN sulfacetamide SULFACET-R sulfacetamide/sulfur PLEXION tretinoin AVITA RETIN-A Bacterial Infections bacitracin BACITRACIN OTC gentamicin GENTAK mupirocin BACTROBAN ointment, 22 gram tube only neomycin/polymyxin B/ bacitracin NEOSPORIN OTC silver sulfadiazine SILVADENE Corticosteroids Low Potency alclometasone ACLOVATE 0.05% crm/oint fluocinolone acetonide DERMA-SMOOTHE OIL/FS oil 0.01% fluocinolone acetonide SYNALAR soln/crm 0.01% hydrocortisone CORTIZONE crm, oint, lot OTC 17

25 Generic Name Brand Name hydrocortisone HYTONE crm 2.5% hydrocortisone HYTONE 1% lotion Medium Potency betamethasone val BETA-VAL crm/oint/lotion 0.1% fluocinolone acetonide SYNALAR crm, oint 0.025% flurandrenolide CORDRAN tape fluticasone propionate CUTIVATE crm 0.05%, oint 0.005% hydrocortisone butyrate LOCOID crm/oint/soln 0.1% mometasone furoate ELOCON crm 0.1% mometasone furoate ELOCON oint 0.1% prednicarbate DERMATOP crm/oint 0.1% triamcinolone acetonide KENALOG crm/lot/oint 0.025% triamcinolone acetonide KENALOG crm/oint/lotion 0.1% High Potency betamethasone augmented dip DIPROLENE lotion 0.05% betamethasone augmented dip DIPROLENE AF crm 0.05% betamethasone dipropionate crm/lotion/oint 0.05% fluocinonide LIDEX crm/oint/gel 0.05% fluocinonide emulsified base LIDEX E crm 0.05% triamcinolone acetonide KENALOG crm 0.5% Very High Potency betamethasone dip augmented DIPROLENE gel 0.05% betamethasone dip augmented DIPROLENE oint 0.05% clobetasol propionate TEMOVATE crm/gel/oint/soln 0.05% Fungal Infections ciclopirox PENLAC SOLUTION 8% clotrimazole LOTRIMIN AF OTC clotrimazole MYCELEX clotrimazole with betamethasone LOTRISONE ketoconazole NIZORAL miconazole DESENEX POWDER 2% powder 18

26 Generic Name Brand Name miconazole MICATIN OTC miconazole MONISTAT-DERM nystatin MYCOSTATIN terbinafine LAMISIL AT OTC tolnaftate TINACTIN OTC Psoriasis acitretin SORIATANE oral caps, PA calcipotriene DOVONEX calcitriol VECTICAL methoxsalen OXSORALEN-ULTRA Rosacea brimonidine MIRVASO PA metronidazole METROCREAM METROGEL METROLOTION Scabies and Pediculosis crotamiton EURAX malathion OVIDE permethrin ELIMITE 5%, QL permethrin NIX CREME RINSE 1%, OTC pyrethrins/piperonyl but RID SHAMPOO/ BUTOXIDE SHAMPOO 4% OTC Viral Infections podofilox CONDYLOX SOL sol salicylic acid 17%/ collodion DUOFILM OTC Miscellaneous aluminum acetate soln/cream, OTC aluminum chloride hexahydrate HYPERCARE 20% ammonium lactate LAC-HYDRIN 12% calamine lotion/ointment, OTC chloroxine CAPITROL fluorouracil CARAC 0.5% cream fluorouracil EFUDEX fluorouracil FLUOROPLEX 1% cream 19

27 Generic Name Brand Name hexachlorophene PHISOHEX PROCTOSOL HC CREAM 2.5% hydrocortisone PROCTOZONE CREAM-HC 2.5% ANUSOL HC 2.5% imiquimod 5% cream ALDARA PA ketoconazole NIZORAL SHAMPOO shampoo 2% lidocaine LIDAMANTEL 3% cream lidocaine LMX-4 4% cream (15 gm tubes), QL lidocaine XYLOCAINE oint 5% lidocaine XYLOCAINE jelly 2% lidocaine/prilocaine EMLA 2.5% cream nitroglycerin RECTIV 0.4% rectal ointment, PA cream QL, ST, Step therapy is pimecrolimus ELIDEL not required for members ages 2-11; not covered for members less than 2 years of age selenium sulfide SELSUN shampoo 2.5% ointment 0.03% ST, Step therapy is not required for tacrolimus PROTOPIC 0.03% members ages 2-11; not covered for members less than 2 years of age tacrolimus PROTOPIC 0.1% ointment 0.1%, ST (minimum age 16) urea 40% UREA 40% CREAM AND LOTION cream and lotion Ear, Nose & Throat Ear acetic acid VOSOL OTIC otic acetic acid/ aluminum acetate DOMEBORO OTIC acetic acid/ hydrocortisone VOSOL HC OTIC 20

28 Generic Name Brand Name benzocaine/antipyrine BENZOTIC carbamide peroxide DEBROX 6.5%, OTC ciprofloxacin/ dexamethasone CIPRODEX PA neomycin/polymyxin B/ hydrocortisone CORTISPORIN OTIC otic ofloxacin FLOXIN OTIC Nose Antihistamines - First Generation, Sedating chlorpheniramine CHLOR-TRIMETON extended-release ALLERGY 12 mg, OTC chlorpheniramine maleate CHLOR-TRIMETON SYRUP 2 mg/5 ml, OTC clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE diphenhydramine diphenhydramine BENADRYL OTC hydroxyzine HCL ATARAX hydroxyzine pamoate VISTARIL Antihistamines - Second Generation, Nonsedating cetirizine ZYRTEC OTC cetirizine chew tab ZYRTEC CHEWABLE TABLET OTC, Members 8 years of age will require prior authorization. levocetirizine XYZAL tabs, ST loratadine ALAVERT CLARITIN OTC Antihistamines - Others Antihistamine/Decongestant Combinations azelastine ASTELIN spray Antihistamine/Decongestant Combinations - First Generation chlorpheniramine/ phenylephrine/ pyrilamine chlorpheniramine/ pseudoephedrine TRIOTANN ACTIFED OTC 21

29 Generic Name chlorpheniramine/ pseudoephedrine extended-release Brand Name DECONAMINE SR Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride 12 hours extended-release ZYRTEC-D 5 mg-120 mg tablet ALAVERT-D loratadine/ ALAVERT ALRG pseudoephedrine OTC TAB/SINUS extended-release ALLERGY/CONG Nasal Steroids fluticasone FLONASE triamcinolone nasal spray NASACORT ALLERGY 24 HOUR OTC Miscellaneous Nasal Decongestants oxymetazoline AFRIN OTC phenylephrine NEO-SYNEPHRINE DIMEATAPP DRO DECONGES OTC Miscellaneous Nasal cromolyn sodium NASALCROM OTC saline nasal spray 0.65% OCEAN NASAL SPRAY OTC Throat and Mouth artificial saliva OTC chlorhexidine gluconate PERIDEX lidocaine viscous XYLOCAINE pilocarpine SALAGEN triamcinolone KENALOG IN ORABASE paste 22

30 Generic Name Brand Name Endocrinology Adrenal Corticosteroids cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF methylprednisolone MEDROL prednisolone prednisolone PRELONE syrup prednisolone sodium ORAPRED phosphate PEDIAPRED prednisone DELTASONE Androgens testosterone cypionate DEPO-TESTOSTERONE testosterone enanthate DELATESTRYL testosterone gel topical tube, packet, and pump bottle Diabetes Mellitus Glucose Elevating Agents glucagon, human TESTOSTERONE 1% TOPICAL GEL Vials only. Disposable syringes not covered. PA GLUCAGON QL recombinant Insulins Insulin preparations covered include the specific s of human insulins noted in the list. Only the vials are covered. Insulin Pens are only covered for children up to age 21 and pregnant women. The PDL also includes all syringes and needles. insulin aspart NOVOLOG QL insulin aspart protamine 70%/ insulin aspart 30% NOVOLOG MIX 70/30 QL insulin detemir LEVEMIR QL insulin glargine LANTUS QL insulin human NOVOLIN R OTC, QL insulin human RELION R OTC, QL insulin isophane HUMULIN N OTC, QL insulin isophane human NOVOLIN N OTC, QL insulin isophane human RELION N OTC, QL 23

31 Generic Name Brand Name insulin isophane human 70%/regular 30% NOVOLIN 70/30 OTC, QL insulin isophane human 70%/regular 30% RELION 70/30 OTC, QL insulin isophane/regular HUMULIN 70/30 OTC, QL insulin lisopro pro/lispro HUMALOG MIX 50/50 QL insulin lisopro prot/lispro HUMALOG MIX 75/25 QL insulin lispro HUMALOG QL insulin regular HUMULIN R OTC, QL Monitoring - Strips and Kits/Diabetic Supplies QL for insulin dependent or ACCU-CHEK CARE KIT (AVIVA, COMPACT PLUS, pregnant members: allow NANO SMARTVIEW) testing up to 6 times per day ACCU-CHEK TEST STRIPS (AVIVA, AVIVA PLUS, COMPACT, SMARTVIEW) ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) ONE TOUCH TEST STRIPS (ULTRA, VERIO) QL for non-insulin dependent members: allow once daily testing QL for insulin dependent or pregnant members: allow testing up to 6 times per day QL for non-insulin dependent members: allow once daily testing Oral Agents acarbose PRECOSE canagliflozin INVOKANA ST canagliflozin/metformin INVOKAMET ST chlorpropamide DIABINESE empagliflozin JARDIANCE ST glimepiride AMARYL glipizide GLUCOTROL glipizide extended-release GLUCOTROL XL glyburide MICRONASE glyburide, micronized GLYNASE linagliptin TRADJENTA ST linagliptin/metformin JENTADUETO ST metformin GLUCOPHAGE metformin ER GLUCOPHAGE ER metformin/glyburide GLUCOVANCE 24

32 Generic Name Brand Name nateglinide STARLIX pioglitazone ACTOS QL pioglitazone/glimepiride DUETACT ST pioglitazone/metformin ACTOPLUSMET QL, ST pioglitazone/metformin ER ACTOPLUS MET XR ST repaglinide PRANDIN saxagliptin ONGLYZA ST saxagliptin/metformin KOMBIGLYZE ST tolazamide TOLINASE tolbutamide TOLBUTAMIDE Miscellaneous Antidiabetic Agents albiglutide TANZEUM ST liraglutide VICTOZA ST pramlintide SYMLIN PA Growth Stimulating Agents mecasermin INCRELEX PA, SP somatropin NUTROPIN AQ NUSPIN PA, SP Osteoporosis alendronate FOSAMAX QL calcitonin-salmon MIACALCIN inj calcitonin-salmon MIACALCIN FORTICAL nasal spray, QL etidronate DIDRONEL raloxifene EVISTA teriparatide inj FORTEO PA, SP Thyroid Disease levothyroxine LEVOXYL levothyroxine SYNTHROID liothyronine CYTOMEL liotrix THYROLAR methimazole TAPAZOLE propylthiouracil PROPYLTHIOURACIL Miscellaneous cabergoline DOSTINEX desmopressin DDAVP QL methylergonovine METHERGINE pegvisomant SOMAVERT PA, SP mifeprstone KOR LYM PA, SP 25

33 Generic Name Brand Name sapropterin KUVAN PA, SP sapropterin powder KUVAN POWDER FOR SOLUTION PA, SP Gastrointestinal Diarrhea diphenoxylate/atropine LOMOTIL loperamide IMODIUM A-D OTC loperamide LOPERAMIDE Emesis aprepitant EMEND QL applies to 40 mg, 80 mg and mg dronabinol MARINOL PA meclizine ANTIVERT metoclopramide REGLAN ondansetron ZOFRAN ZOFRAN ODT QL prochlorperazine COMPAZINE promethazine PHENERGAN thiethylperazine TORECAN trimethobenzamide TIGAN 300 mg caps Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers alginic acid/sodium bicarbonate OTC alumina/magnesia MAALOX OTC alumina/magnesia/ simethicone MYLANTA OTC cimetidine TAGAMET esomeprazole NEXIUM 24HR OTC PA esomeprazole granules famotidine NEXIUM DELAYED RELEASE PACKET PEPCID PEPCID AC Members 2 years of age will require prior authorization. OTC Pepcid AC 10 mg and 20 mg also covered/ encouraged with written prescription. lansoprazole PREVACID PA 26

34 Generic Name lansoprazole delayed-release Brand Name PREVACID SOLUTAB orally disintegrating tabs, Members 2 years of age will require prior authorization. QL omeprazole delayed-release PRILOSEC Capsules only, QL pantoprazole PROTONIX ranitidine ZANTAC 150 mg tabs ranitidine syrup ZANTAC sucralfate CARAFATE sulcralfate CARAFATE SUSPENSION Gastrointestinal Spasm dicyclomine BENTYL glycopyrrolate ROBINUL hyoscyamine sulfate LEVSIN hyoscyamine sulfate LEVSINEX suspension, Members 10 years of age up to 65 years of age will require prior authorization. extended-release Inflammatory Bowel Disease balsalazide COLAZAL budesonide ENTOCORT EC PA hydrocortisone COLOCORT enema mesalamine APRISO LIALDA mesalamine ROWASA enema only mesalamine extended-release PENTASA mesalamine supp CANASA olsalazine sodium DIPENTUM sulfasalazine AZULFIDINE sulfasalazine delayed-release AZULFIDINE EN-TABS 27