Preferred Drug List (PDL)

Transcription

1 Preferred List (PDL) Mississippi CHIP Effective Date: 10/15/ United Healthcare Services, Inc. All rights reserved.

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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, Easivent MDI spacer, 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. All requests will be responded to within 24 hours of receipt.

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 all requests within 24 hours, 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 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 Advair Amerge First-Line Agent(s) 1) 30 day trial of one inhaled corticosteroid (e.g. Flovent, Qvar, Asmanex, Pulmicort, Azmacort) OR 2) 60 day trial of a long-acting beta2- agonist (e.g. Foradil, Serevent) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent). Trial at a minimum dose of 50mg of sumatriptan tablets.

7 Aricept 23mg Banzel Breo Ellipta Cymbalta Ditropan XL 90 day trial of Aricept 10mg daily 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. (1) 60 day trial of a long-acting beta2- agonist (e.g. Foradil, Serevent). OR (2) 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent). 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 (Januvia, metformin. Janumet, Janumet XR, Onglyza, Kombiglyze) Dulera Elidel fenofibrate 30 day trial of inhaled corticosteroid 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. fentanyl patches 30 day trial of at least 200mg per day of morphine sulfate ER. Gabitril Intuniv levocetirizine 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. 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. Opana ER Optivar 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 Renvela Strattera Symbicort tolterodine 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 8 week trial of calcium acetate 30 day trial of one of the following: methylphenidate, methylphenidate SR, Concerta, amphetamine salts, Adderall XR, dextroamphetamine, Vyvanse, or dextroamphetamine SA. 1) 30 day trial of one inhaled corticosteroid (e.g. Flovent, Qvar, Asmanex, Pulmicort, Azmacort) OR 2) 60 day trial of a long-acting beta2- agonist (e.g. Foradil, Serevent) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent). 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. Maxalt/MLT Nucynta ER Onfi UHC1004a Trial at a minimum dose of 50mg of sumatriptan tablets. 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. v trospium 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. TZD s (Actos, At least a 90 day trial of 1500mg/day of ActosPlusMet, metformin ActoPlusMet XR Duetact)

8 Uloric Vancocin Vimpat Vytorin 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. 90 day trial of simvastatin 40mg, simvastatin 80mg or atorvastatin within previous 180 days is required first. Xopenex Respules 30 day trial of Albuterol.083% or.5% 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: 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 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. 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. 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: UnitedHealthcare by UnitedHealthcare Director of Pharmacy Services Unison Plaza 1001 Brinton Road Pittsburgh, PA Phone: UHC1004a vi

9 Table of Contents Antineoplastics & Immunosuppressants 4 Hormonal Antineoplastic Agents....4 Oral Agents...4 Immunosuppressants...5 Immunomodulators...6 Interferons...6 Miscellaneous...6 Blood Modifiers - Anticoagulants Oral...6 Blood Cell Formation...6 Platelet Synthesis Inhibitor....7 Miscellaneous...7 Platelet Aggregation Inhibitors...7 Cardiovascular Agents...7 Ace Inhibitors...7 Ace Inhibitor/Diuretic Combinations....7 Adrenolytics, Central... 8 Alpha Blockers...8 Angiotensin II Receptor Blockers (Antagonists)....8 Angiotensin II Receptor Blocker Combinations...8 Antiarrhythmics And Cardiac Glycosides....8 Beta Blockers And Beta Blocker/ Diuretic Combinations...8 Calcium Channel Blockers...9 Diuretics....9 Nitrates...10 Lipid Lowering Agents...10 Miscellaneous...11 Central Nervous System Alzheimer s Disease...11 Analgesics...12 Abortive Therapy Prophylactic Therapy...14 Multiple Sclerosis...14 Myasthenia Gravis...14 Parkinson s Disease Seizures Miscellaneous...16 Dermatology Acne Vulgaris...16 Bacterial Infections Corticosteroids...16 Fungal Infections Psoriasis...18 Rosacea Scabies And Pediculosis...18 Viral Infections Miscellaneous...18 Ear, Nose & Throat Ear...19 Nose Miscellaneous Nasal Throat And Mouth Endocrinology...21 Adrenal Corticosteroids...21 Androgens Diabetes Mellitus...21 Growth Stimulating Agents...23 Osteoporosis Thyroid Disease...23 Miscellaneous...23 Gastrointestinal...24 Diarrhea...24 Emesis...24 Gastroesophageal reflux disease (gerd)/ peptic ulcers Gastrointestinal Spasm...25 Inflammatory Bowel Disease...25 Pancreatic Enzymes...25 Laxatives...25 Probiotic Supplementation...26 Miscellaneous

10 Infectious Diseases Anthelmintics Antibacterials Antifungals Antivirals...28 Miscellaneous...29 Musculoskeletal Arthritis Gout Skeletal Muscle Relaxants...32 OB-GYN Contraceptives...32 Endometriosis...33 Hormone Therapy/Menopause...33 Vaginal Infections...34 Miscellaneous...34 Ophthalmic...34 Allergy...34 Anti-Inflammatories Glaucoma...35 Infections...36 Miscellaneous Ophthalmics Psychiatric...37 Alcohol Dete rrents Anxiety...37 Miscellaneous...37 Attention Deficit Hyperactivity Disorder (ADHD) Bipolar Disorder...38 Depression...38 Insomnia Narcotic Antagonists...39 Smoking Cessation...39 Psychoses...39 Miscellaneous...40 Respiratory s...40 Antitussives, Decongestants, Expectorants And Combinations...40 Asthma/COPD...45 Potassium...46 Potassium-Removing Agents...47 Vitamins And Minerals...47 Urological...50 Symptomatic Benign Prostatic Hypertrophy.50 Miscellaneous...50 Miscellaneous...51 Anaphylaxis...51 Cystic Fibrosis...51 Hereditary Angioedema...51 Hyperphosphatemia...51 Immune Thrombocytopenic Purpura...51 Medical Devices...52 Metabolic Modifiers...52 OTC MEDICATIONS Acne Antifungals Cough/Cold Allergy...53 Atopic Dermatitis...54 Diabetes...54 Earwax Removal Products...54 Family Planning...54 First Aid...54 Gastrointestinal Lice Products...55 Motion Sickness...55 Ophthalmics...55 Pain...55 Smoking Cessation Products...55 Vitamins/Minerals...55 Warts...56 Miscellaneous...56 Index of s

11 Generic Name Brand Name Antineoplastics & Immunosuppressants 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 Progestin megestrol acetate MEGACE Oral Agents Alkylating Agents busulfan MYLERAN chlorambucil LUEKERAN 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 THIOGUANINE Tyrosine Kinase Inhibitor afatinib GILOTRIF PA, SP axitinib INLYTA PA, SP 4

12 Generic Name Brand Name bosutinib BOSULIF PA, SP cabozantinib COMETRIQ PA, SP crizotinib XALKORI PA, SP dabrafenib TAFINLAR PA, SP dasatanib SPRYCEL PA, SP erlotinib tarceva PA, SP ibrutinib IMBRUVICA PA, SP imatinib mesylate GLEEVEC PA, QL, SP lapatinib ditosylate TYKERB PA, SP nilotinib TASIGNA 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 Vandetanib PA, SP vemurafenib ZELBORAF PA, SP Miscellaneous altretamine hexalen alitretinoin 1% gel PANRETIN PA bexarotene caps and topical gel TARGRETIN PA etoposide VEPESID everolimus afinitor AFINITOR DISPERZ PA, SP hydroxyurea droxia HYDREA mitotane LYSODREN octreotide Sandostatin pasireotide SIGNIFOR PA, SP procarbazine MATULANE tretinoin VESANOID caps vismodegib ERIVEDGE PA, SP vorinostat ZOLINZA PA, SP Immunosuppressants Antimetabolites azathioprine IMURAN 5

13 Generic Name Brand Name mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified GENGRAF NEORAL tacrolimus HECORIA PROGRAF Other everolimus Zortress Rapamycin Derivative sirolimus RAPAMUNE Immunomodulators Interferons interferon alfa-2a PA, SP interferon alfa-2b INTRON A PA, SP Other lenalidomide REVLIMID PA, SP Miscellaneous cysteamine bitartrate CYSTAGON leuprolide Lupron Lupron Depot LUPRON DEPOT PA, SP 6-MONTH Lupron Depot-PED pomalidomide POMALYST PA, SP Blood Modifiers - Anticoagulants Oral warfarin COUMADIN Blood Cell Formation darbepoetin alfa ARANESP PA, SP epoetin alfa EPOGEN PROCRIT PA, SP filgrastim NEUPOGEN PA, SP oprelvekin neumega SP pegfilgrastim NEULASTA PA, SP sargramostim leukine PA, SP 6

14 Generic Name Brand Name Platelet Synthesis Inhibitor anagrelide AGRYLIN Miscellaneous aminocaproic acid AMICAR 500 mg tabs only apixaban ELIQUIS PA cilostazol PLETAL deferasirox EXJADE PA, SP enoxaparin LOVENOX PA, QL, SP, SP and PA only applies for quantities greater than 14 days heparin HEPARIN pentoxifylline ext-rel TRENTAL plerixafor mozobil PA, SP rivaroxaban XARELTO PA Platelet Aggregation Inhibitors aspirin BAYER OTC ECOTRIN clopidogrel PLAVIX dipyridamole PERSANTINE Cardiovascular Agents Ace Inhibitors benazepril LOTENSIN captopril CAPOTEN enalapril VASOTEC enalapril oral soln EPANED Applies to 300 mg tab only, QL Members 8 years of age will require prior authorization. fosinopril MONOPRIL QL lisinopril ZESTRIL QL quinapril ACCUPRIL QL Ace Inhibitor/Diuretic Combinations benazepril/ hydrochlorothiazide captopril/ hydrochlorothiazide enalapril/ hydrochlorothiazide LOTENSIN HCT CAPOZIDE VASERETIC 7

15 Generic Name Brand Name 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 Antiarrhythmics And Cardiac Glycosides amiodarone tabs CORDARONE 200 mg and 400 mg digoxin LANOXIN digoxin LANOXICAPS disopyramide NORPACE disopyramide ext-rel NORPACE CR dofetilide tikosyn flecainide tambocor mexiletine MEXITIL moricizine ETHMOZINE procainamide PRONESTYL procainamide ext-rel PROCANBID procainamide ext-rel PROCAINAMIDE EXT-REL propafenone RYTHMOL IR only QUINIDINE GLUCONATE quinidine gluconate ext-rel EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate ext-rel QUINIDINE SULFATE EXT-REL sotalol BETAPACE Beta Blockers And Beta Blocker/Diuretic Combinations acebutalol SECTRAL atenolol TENORMIN atenolol/chlorthalidone TENORETIC 8

16 Generic Name Brand Name bisoprolol ZEBETA bisoprolol/ hydrochlorothiazide ZIAC carvedilol COREG QL labetalol TRANDATE 50 mg and 100 mg only metoprolol LOPRESSOR metoprolol succinate TOPROL XL pindolol PINDOLOL propranolol INDERAL IR only propranolol/hctz INDERIDE timolol maleate tablets Calcium Channel Blockers Dihydropyridines amlodipine NORVASC QL felodipine ext-rel PLENDIL QL nicardipine CARDENE nifedipine PROCARDIA nifedipine ext-rel ADALAT CC QL PROCARDIA XL nimodipine NIMOTOP QL nimodipine oral soln NYMALIZE Nondihydropyridines diltiazem CARDIZEM diltiazem ext release CARDIZEM CD QL diltiazem sustained release CARDIZEM SR QL diltiazem ext-rel DILACOR XR TIAZAC QL verapamil CALAN verapamil ext-rel CALAN SR Applies to 120 mg only, QL Diuretics amiloride MIDAMOR amiloride/ MODURETIC hydrochlorothiazide bumetanide BUMEX chlorothiazide DIURIL chlorthalidone CHLORTHALIDONE furosemide LASIX hydrochlorothiazide Microzide 12.5 mg caps 9

17 Generic Name Brand Name hydrochlorothiazide HYDROCHLOROTHIA- ZIDE soln, tabs indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone/ hydrochlorothiazide ALDACTAZIDE triamterene/ hydrochlorothiazide DYAZIDE 37.5/25 triamterene/ hydrochlorothiazide MAXZIDE /25 triamterene/ hydrochlorothiazide DYAZIDE 50/25 triamterene/ hydrochlorothiazide MAXZIDE 75/50 Nitrates Oral isosorbide dinitrate ext-rel ISOSORBIDE DINITRATE ER isosorbide dinitrate ISORDIL isosorbide mononitrate ISMO isosorbide mononitrate ext-rel IMDUR nitroglycerin ext-rel Sublingual isosorbide dinitrate ISORDIL S.L. nitroglycerin NITROSTAT nitroglycerin NITROLINGUAL Transdermal nitroglycerin NITRO-BID oint nitroglycerin NITREK NITRO-DUR transdermal, QL niacin NIACOR niacin ext-rel NIASPAN Lipid Lowering Agents Bile Acid Resin cholestyramine QUESTRAN Only the bulk products are covered (cans). Individual QUESTRAN-LIGHT packets are not covered. 10

18 Generic Name Brand Name Fibrates fenofibrate LOFIBRA ST gemfibrozil LOPID HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR ezetimibe/simvastatin VYTORIN ST lovastatin MEVACOR QL pravastatin PRAVACHOL QL simvastatin ZOCOR QL simvastatin/niacin ER SIMCOR Miscellaneous ambrisentan LETAIRIS PA, SP bosentan TRACLEER PA, SP guanabenz WYTENSIN hydralazine APRESOLINE lomitapide JUXTAPID PA, SP methyldopa ALDOMET methyldopa/hctz aldoril midodrine PROAMATINE 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. 11

19 Generic Name Brand Name Analgesics Analgesic, Other acetaminophen TYLENOL OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE mg, OTC tramadol Ultram QL Miscellaneous Non-Narcotic analgesics butalbital/acetaminophen PHRENILIN QL butalbital/acetaminophen SEDAPAP QL butalbital/acetaminophen/ FIORICET caffeine QL butalbital/aspirin/caffeine FIORINAL 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 naproxen NAPROSYN Not EC naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Opioids Narcotic analgesics butalbital/apap/caff/cod FIORICET w/codeine QL butalbital/asa/caff/cod FIORINAL w/codeine QL butorphanol STADOL nasal spray, QL codeine sulfate QL codeine/acetaminophen TYLENOL w/codeine QL fentanyl transdermal DURAGESIC QL, ST hydrocodone/ acetaminophen NORCO 5/325, 7.5/325, 10/325, QL 12

20 Generic Name hydrocodone/ acetaminophen hydrocodone/ acetaminophen hydrocodone/ acetaminophen Brand Name LORTAB ELIXIR QL LORTAB 2.5/ /500, QL LORTAB 5/500 BANCAP HC, VICODIN 5/500 5/500, QL hydrocodone/ acetaminophen LORTAB 7.5/ /500, QL hydrocodone/ acetaminophen LORCET PLUS 7.5/650, QL hydrocodone/ acetaminophen VICODIN ES 7.5/750, QL hydrocodone/ acetaminophen LORTAB 10/500 10/500, QL hydrocodone/ acetaminophen LORCET 10/650 10/650, QL hydromorphone DILAUDID QL meperidine DEMEROL QL methadone tablets, PA, QL morphine MSIR QL morphine RMS QL morphine ext-rel MS CONTIN QL oxycodone ROXICODONE QL oxycodone ER OXYCONTIN QL, ST oxycodone/ PERCOCET 5/325, QL acetaminophen oxycodone/ acetaminophen TYLOX 5/500, QL oxycodone/aspirin PERCODAN QL oxycodone OXYFAST soln, QL oxymorphone ER OPANA ER QL, ST tapentadol ER NUCYNTA ER ST Abortive 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, ST 13

21 Generic Name Brand Name sumatriptan IMITREX QL sumatriptan IMITREX 4 mg and 6 mg INJ Prophylactic Therapy amitriptyline ELAVIL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE 4 mg and 6 mg inj Members 8 years of age will require prior authorization. divalproex sodium delayed-rel DEPAKOTE Minimum age 2 propranolol INDERAL IR only verapamil CALAN Multiple Sclerosis dimethyl fumarate TECFIDERA PA, SP fingolimod GILENYA PA, SP glatiramer acetate COPAXONE 20 mg only, 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 ext-rel MESTINON TIMESPAN Parkinson s Disease amantadine SYMMETREL except tabs benztropine COGENTIN biperiden AKINETON bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa SINEMET CR ext-rel entacapone COMTAN pramipexole MIRAPEX ropinirole REQUIP selegiline ELDEPRYL tabs tolcapone TASMAR trihexyphenidyl ARTANE Seizures carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL TEGRETOL-XR 14

22 Generic Name Brand Name clobazam ONFI ST clonazepam KLONOPIN tabs diazepam DIASTAT ACUDIAL rectal gel, QL Members 8 years of divalproex sodium DEPAKOTE SPRINKLE age will require prior cap sprinkle authorization. divalproex sodium delayed-rel 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 15

23 Generic Name Brand Name Miscellaneous tetrabenazine XENAZINE PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE PA Topical azelaic acid FINACEA benzoyl peroxide BENZAC AC clindamycin CLEOCIN T gel clindamycin CLEOCIN T lotion clindamycin CLEOCIN T soln erythromycin/benzoyl peroxide BENZAMYCIN erythromycin ERYGEL gel 2% erythromycin T-STAT soln sulfacetamide SULFACET-R sulfacetamide/sulfur PLEXION tretinoin AVITA RETIN-A Max age 20 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 HYTONE crm 2.5% hydrocortisone HYTONE 1% lotion hydrocortisone CORTIZONE crm, oint, lot OTC Medium Potency betamethasone val. BETA-VAL crm/oint/lotion 0.1% 16

24 Generic Name Brand Name fluocinolone acetonide DERMA-SMOOTHE OIL/ FS oil 0.01% 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 AF crm 0.05% betamethasone augmented dip DIPROLENE lotion 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 MYCELEX clotrimazole LOTRIMIN AF OTC clotrimazole with betamethasone Lotrisone econazole SPECTAZOLE ketoconazole NIZORAL miconazole MICATIN OTC miconazole MONISTAT-DERM miconazole DESENEX POWDER 2% powder nystatin MYCOSTATIN terbinafine LAMISIL AT OTC 17

25 Generic Name Brand Name 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 NIX CREME RINSE 1%, OTC permethrin ELIMITE 5%, QL 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 EFUDEX fluorouracil Carac 0.5% cream fluorouracil FLUOROPLEX 1% cream hexachlorophene PHISOHEX hydrocortisone PROCTOCREAM-HC 2.5% cream ketoconazole NIZORAL SHAMPOO shampoo 2% lidocaine lidamantel 3% cream lidocaine XYLOCAINE jelly 2% lidocaine XYLOCAINE oint 5% lidocaine LMX-4 4% cream (15 gm tubes), QL lidocaine/prilocaine Emla 2.5% cream 18

26 Generic Name Brand Name nitroglycerin RECTIV 0.4% rectal ointment, PA pimecrolimus ELIDEL cream QL, ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age selenium sulfide SELSUN shampoo 2.5% tacrolimus Protopic 0.03% ointment 0.03% ST, Step therapy is not required for 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 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 maleate CHLOR-TRIMETON SYRUP 2 mg/5 ml, OTC chlorpheniramine ext-rel CHLOR-TRIMETON 12 mg, OTC ALLERGY clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE diphenhydramine BENADRYL OTC diphenhydramine 19

27 Generic Name Brand Name 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 TRIOTANN chlorpheniramine/pseudoephedrine ext-rel DECONAMINE SR triprolidine/ ACTIFED OTC pseudoephedrine 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 ext-rel 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 20

28 Generic Name Brand Name 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 Endocrinology Adrenal Corticosteroids cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF methylprednisolone MEDROL prednisolone prednisolone sodium ORAPRED phosphate PEDIAPRED prednisolone PRELONE syrup prednisone DELTASONE Androgens testosterone cypionate DEPO-TESTOSTERONE testosterone Androgel 1.62% gel, PA testosterone enanthate DELATESTRYL Vials only. Disposable syringes not covered. testosterone ANDRODERM patch 2 mg and 4 mg, PA Diabetes Mellitus Glucose Elevating Agents glucagon, human GLUCAGON QL recombinant Insulins 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 21

29 Generic Name Brand Name insulin isophane HUMULIN N OTC, QL insulin isophane human NOVOLIN N OTC, QL insulin isophane human Relion N OTC, QL insulin isophane human 70%/regular 30% NOVOLIN 70/30 OTC, QL insulin isophane human 70%/regular 30% Relion 70/30 OTC, QL insulin lisopro pro/lispro HUMALOG MIX 50/50 QL insulin lisopro prot/lispro HUMALOG MIX 75/25 QL insulin isophane/regular HUMULIN 70/30 OTC, QL insulin lispro HUMALOG QL insulin regular HUMULIN R OTC, QL Monitoring- Strips and Kits/Diabetic Supplies Accu-Chek Test Strips (Aviva, AVIVA PLUS, Compact, SMARTVIEW) Accu-Chek Care Kit (Aviva, Compact Plus, Nano Smartview) One Touch Test Strips (Basic/Profile, SureStep, Ultra) One Touch Systems (Ultra, UltraSmart, Ultra2, UltraMini) 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 QL for insulin dependent or pregnant members: allow testing up to 6 times per day Oral Agents acarbose precose chlorpropamide DIABINESE glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL glyburide MICRONASE glyburide, micronized GLYNASE metformin GLUCOPHAGE metformin ER GLUCOPHAGE ER metformin/glyburide GLUCOVANCE nateglinide STARLIX pioglitazone ACTOS QL, ST pioglitazone/metformin ER ACTOPLUS MET XR ST pioglitazone/metformin ACTOPLUSMET QL, ST pioglitazone/glimiperide DUETACT ST 22

30 Generic Name Brand Name repaglinide PRANDIN saxagliptin ONGLYZA ST saxagliptin/metformin KOMBIGLYZE ST sitagliptan JANUVIA QL, ST sitagliptan/metformin JANUMET QL, ST sitagliptan/metformin ER JANUMET XR QL, ST tolazamide TOLINASE tolbutamide tolbutamide Miscellaneous Antidiabetic Agents exenatide BYETTA PA liraglutide Victoza PA pramlintide SYMLIN PA Growth Stimulating Agents mecasermin INCRELEX PA, SP somatropin NORDITROPIN TEV-TROPIN 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 bromocriptine PARLODEL desmopressin DDAVP QL methylergonovine METHERGINE mifeprstone KOR LYM PA, SP sapropterin KUVAN PA, SP sapropterin powder KUVAN POWDER FOR SOLUTION PA, SP 23

31 Generic Name Brand Name Gastrointestinal Diarrhea diphenoxylate/atropine LOMOTIL loperamide LOPERAMIDE loperamide IMODIUM A-D OTC 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 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 lansoprazole del-rel PREVACID SOLUTAB omeprazole delayed-rel PRILOSEC orally disintegrating tabs, Members 2 years of age will require prior authorization. QL Capsules only, QL for 20 mg only pantoprazole Protonix ranitidine ZANTAC 150 mg tabs 24

32 Generic Name Brand Name 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. ext-rel Inflammatory Bowel Disease balsalazide COLAZAL budesonide ENTOCORT EC PA hydrocortisone COLOCORT enema mesalamine APRISO LIALDA mesalamine ext-rel PENTASA mesalamine ROWASA enema only mesalamine supp CANASA olsalazine sodium DIPENTUM sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS Pancreatic Enzymes pancrelipase Laxatives casanthranol-docusate sodium creon CREON 3000 UNIT zenpep OTC docusate calcium plus OTC docusate potasssium OTC lactulose ENULOSE glycerin GLYCERIN SUPPOSITORY suppository, OTC peg 3350/electrolytes COLYTE peg 3350/sodium bicarbonate/sodium chloride/potassium chloride NULYTELY 25

33 Generic Name Brand Name peg 3350/sodium bicarbonate/sodium TRILYTE chloride polyethylene glycol 3350 MIRALAX sennosides SENOKOT 8.6 mg tab, OTC Probiotic Supplementation acidophilus Acidophilus caps and tabs, OTC acidophilus Acidophilus XTRA OTC acidophilus/bifidus Acidophilus/ Bifidus Wafer OTC acidophilus/citrus pectin Acidophilus/ tabs, OTC Citrus Pectin acidophilus/pectin Acidophilus/Pectin caps, OTC lactobacillus Floranex chewable tablets, OTC probiotic product Probiotic Formula caps, OTC Miscellaneous atropine sulfate SAL-TROPINE bismuth subsalicylate + metronidazole + tetracycline HELIDAC methylnaltrexone RELISTOR PA misoprostol CYTOTEC teduglutide GATTEX PA, SP ursodiol Infectious Diseases URSO URSO FORTE ACTIGALL Anthelmintics albendazole ALBENZA PA ivermectin STROMECTOL praziquantel BILTRICIDE PA Antibacterials Cephalosporins - First Generation cefadroxil DURICEF cephalexin KEFLEX tabs are not covered Cephalosporins - Second Generation cefaclor CECLOR cefprozil CEFZIL cefuroxime axetil CEFTIN 26