Preferred Drug List. (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary.

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1 Drug List (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary.

2 What is the Passport Health Plan formulary? The formulary is a list of preferred drugs covered by Passport. To get a drug on our formulary, you must: The formulary is not a complete list of covered drugs by Passport. Some drugs not listed may be covered, if medically necessary. These drugs may or may not need prior-authorization. How do I find my drug on the formulary?. Are there any limits to the drugs you have been prescribed? Some covered drugs may have limits on them. This could include: Prior-Authorization: not cover the drug. Quantity Limits: standard one month supply. Step Therapy: Too Early to Refill: 30 days has passed. What if my drug is not on the formulary? i

3 Can the formulary change? What are generic drugs? How much are my copays? ii

4 Table of Contents Table of Contents... 1 ANTI-INFECTIVES... 6 PENICILLINS... 6 TETRACYCLINES... 6 FIRST GENERATION CEPHALOSPOSINS... 7 SECOND GENERATION CEPHALOSPORINS... 8 THIRD GENERATION CEPHALOSPORINS... 8 ERYTHROMYCINS & OTHER MACROLIDES... 9 FLUOROQUINOLONES SULFAS & RELATED AGENTS URINARY TRACT AGENTS MISCELLANEOUS ANTIVIRALS HIV/AIDS THERAPY ANTIFUNGAL AGENTS VANCOMYCIN MISCELLANEOUS ANTIINFECTIVES ANTIPARASITICS ANTIMALARIALS ANTIMYCOBACTERIALS ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS ALKYLATING AGENTS ANTIMETABOLITES HORMONES ANTIESTROGENS ANTIANDROGENS IMMUNOSUPPRESSANT DRUGS MISCELLANEOUS ANTINEOPLASTIC DRUGS ADJUNCTIVE AGENTS AUTONOMIC & CNS DRUGS, NEUROLOGY, & PSYCH NARCOTIC ANALGESICS NARCOTICS COMBINATION NARCOTIC /ANALGESICS NON-NARCOTIC ANALGESICS NSAIDS NSAIDS- SPECIFIC COX-II INHIBITORS SALICYLATES MISCELLANEOUS ANALGESICS Page 1 Magellan Pharmacy Solutions Effective 1/1/15

5 NARCOTIC ANTAGONISTS MIGRAINE & CLUSTER HEADACHE THERAPY HEADACHE THERAPY ANTIPARKINSONISM AGENTS ANTICONVULSANTS MISCELLANEOUS NEUROLOGICAL THERAPY MUSCLE RELAXANTS & ANTISPASMODIC AGENTS MYASTHENIA GRAVIS HYPNOTIC AGENTS TRICYCLICS MISCELLANEOUS ANTIDEPRESSANTS MAO INHIBITORS SELECTIVE SEROTONIN REUPTAKE INHIBITORS PHENOTHIAZINES BUTYROPHENONES MISCELLANEOUS ANTIPSYCHOTICS MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS ANXIOLYTICS CARDIOVASCULAR, HYPERTENSION, & LIPIDS ANTIARRHYTHMIC AGENTS CARDIAC GLYCOSIDES NITRATES RAPID ACTING NITRATES LONG ACTING NITRATES COAGULATION THERAPY ANTICOAGULANTS ANTIPLATELET DRUGS HEPARIN VITAMIN K HEMOSTATICS MISCELLANEOUS COAGULATION AGENTS ANTIHYPERTENSIVE THERAPY THIAZIDE & RELATED DIURETICS BETA BLOCKERS CALCIUM CHANNEL BLOCKERS/NON-DIHYDROPYRIDINES CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES ACE INHIBITORS ADRENERGIC ANTAGONISTS & RELATED DRUGS AGENTS FOR PHEOCHROMOCYTOMA VASODILATORS is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 2 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

6 OTHER ANTIHYPERTENSIVE COMBINATIONS ANGIOTENSIN II RECEPTOR BLOCKERS & RENIN INHIBITOR LIPID/CHOLESTEROL LOWERING AGENTS DERMATOLOGICAL/TOPICAL THERAPY TOPICAL CORTICOSTEROIDS TOPICAL CORTICOSTEROIDS VERY HIGH POTENCY TOPICAL CORTICOSTEROIDS HIGH POTENCY TOPICAL CORTICOSTEROIDS MEDIUM POTENCY TOPICAL CORTICOSTEROIDS LOW POTENCY TOPICAL ANESTHETICS THERAPY FOR ACNE TOPICAL ANTIBACTERIALS TOPICAL ANTIFUNGALS TOPICAL ANTIVIRALS BURN THERAPY TOPICAL ENZYMES KERATOLYTICS ANTIPSORIATIC / ANTISEBORRHEIC TOPICAL SCABICIDES / PEDICULICIDES MISCELLANEOUS DERMATOLOGICALS DIAGNOSTICS & MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS SMOKING DETERRENTS ANOREXIANTS EAR, NOSE, & THROAT MEDICATIONS MISCELLANEOUS OTIC PREPARATIONS OTIC STEROID / ANTIBIOTIC MISCELLANEOUS AGENTS ENDOCRINE/DIABETES ANTITHYROID AGENTS THYROID HORMONES ADRENAL HORMONES ANDROGENS MISCELLANEOUS AGENTS DIABETES THERAPY INSULIN THERAPY NON-INSULIN HYPOGLYCEMIC AGENTS GLUCOSE ELEVATING AGENTS

7 INSULIN BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES INSULIN SYRINGES/MISCELLANEOUS GASTROENTEROLOGY H2 ANTAGONISTS PROSTAGLANDINS OTHER ULCER THERAPY PROTON PUMP INHIBITORS ANTIDIARRHEALS ANTISPASMODICS COMBINATION ANTICHOLINERGICS BILE ACIDS DIGESTIVE ENZYMES MISCELLANEOUS GASTROINTESTINAL AGENTS ANTIVERTIGO & ANTIEMETIC AGENTS BOWEL EVACUANTS IMMUNOLOGY, VACCINES, & BIOTECHNOLOGY ERYTHROID STIMULANTS INTERFERONS GROWTH HORMONES INTERLEUKINS VACCINES & MISCELLANEOUS IMMUNOLOGICALS MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY MISCELLANEOUS RHEUMATOLOGICAL AGENTS OSTEOPOROSIS THERAPY OBSTETRICS & GYNECOLOGY MONOPHASIC /BIPHASIC /TRIPHASIC AGENTS OXYTOCICS ESTROGENS & PROGESTINS PROGESTINS ESTROGENS ESTROGEN COMBINATIONS MISCELLANEOUS OB/GYN VAGINAL CLEANSER /ANTIINFECTIVE VAGINAL ANTIFUNGALS SPECIALIZED OB/GYN DRUGS OPHTHALMOLOGY BETA-BLOCKERS CHOLINESTERASE INHIBITOR MIOTICS DIRECT ACTING MIOTICS is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 4 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

8 OTHER GLAUCOMA DRUGS ORAL DRUGS FOR GLAUCOMA CYCLOPLEGIC MYDRIATICS NON-STEROIDAL ANTI-INFLAMMATORY AGENTS VASOCONSTRICTOR DECONGESTANTS ANTIBIOTICS SULFONAMIDES STEROIDS STEROID-ANTIBIOTIC COMBINATIONS SYMPATHOMIMETICS MISCELLANEOUS OPHTHALMOLOGICS ANTIVIRALS RESPIRATORY, ALLERGY, COUGH, & COLD ANTIHISTAMINES & ANTIALLERGENIC AGENTS ANTIHISTAMINES ADRENERGICS COUGH & COLD THERAPY ANTITUSSIVE COMBINATIONS EXPECTORANT COMBINATIONS DECONGESTANT / ANTIHISTAMINES XANTHINES BETA AGONISTS ORAL BETA AGONISTS INHALERS INHALED CORTICOSTEROIDS INTRANASAL STEROIDS MISCELLANEOUS PULMONARY AGENTS MISCELLANEOUS EQUIPMENT PEAK FLOW METERS SPACERS UROLOGICALS CHOLINERGIC STIMULANTS ANTICHOLINERGICS & ANTISPASMODICS URINARY ANESTHETICS MISCELLANEOUS UROLOGICALS BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY VITAMINS, HEMATINICS, & ELECTROLYTES VITAMINS & HEMATINICS

9 / TRADE NAME NAME DOSE DESCRIPTION PA ST ANTI-INFECTIVES PENICILLINS Amox Tr/Potassium Clavulanate Amoxicillin/ Potassium Clav Suspension; Reconstituted; Oral (Ml) Amox Tr/Potassium Clavulanate Amoxicillin/ Potassium Clav Amox Tr/Potassium Clavulanate Amoxicillin/ Potassium Clav ; Chewable Amoxicillin Amoxicillin Amoxicillin Amoxicillin Suspension; Reconstituted; Oral (Ml) Amoxicillin Amoxicillin Amoxicillin Amoxicillin ; Chewable Amoxicillin- Clavulanate Er Ampicillin Trihydrate Ampicillin Trihydrate AUGMENTIN AUGMENTIN AUGMENTIN ES AUGMENTIN XR Dicloxacillin Sodium Penicillin G Procaine Penicillin V Potassium Penicillin V Potassium TETRACYCLINES ADOXA Avidoxy Demeclocycline Hcl DORYX Amoxicillin/ Potassium Clav Ampicillin Trihydrate Ampicillin Trihydrate AMOXICILLIN/ POTASSIUM CLAV AMOXICILLIN/ POTASSIUM CLAV AMOXICILLIN/ POTASSIUM CLAV AMOXICILLIN/ POTASSIUM CLAV Dicloxacillin Sodium Penicillin G Procaine Penicillin V Potassium Penicillin V Potassium DOXYCYCLINE MONOHYDRATE Doxycycline Monohydrate Demeclocycline Hcl DOXYCYCLINE HYCLATE ; Extended Release 12 Hr Suspension; Reconstituted; Oral (Ml) SUSPENSION; RECONSTITUTED ; ORAL (ML) SUSPENSION; RECONSTITUTED ; ORAL (ML) ; EXTENDED RELEASE 12 HR Syringe (Ml) Solution; Reconstituted; Oral CAPSULE ; ENTERIC is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 6 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

10 / TRADE NAME NAME DOSE DESCRIPTION PA ST Doxycycline Hyclate Doxycycline Hyclate Doxycycline Hyclate Doxycycline Monohydrate Doxycycline Monohydrate Doxycycline Monohydrate Doxycycline Hyclate Doxycycline Hyclate Doxycycline Hyclate Doxycycline Monohydrate Doxycycline Monohydrate Doxycycline Monohydrate COATED ; Enteric Coated Suspension; Reconstituted; Oral (Ml) DYNACIN MINOCYCLINE HCL MINOCIN MINOCYCLINE HCL CAPSULE Minocycline Hcl Minocycline Hcl Minocycline Hcl Minocycline Hcl Minocycline Hcl Minocycline Hcl MONODOX Morgidox Ocudox PERIOSTAT SOLODYN DOXYCYCLINE MONOHYDRATE Doxycycline Hyclate Doxy/Eyelid Clns #3/Eye Eml #1 DOXYCYCLINE HYCLATE MINOCYCLINE HCL ; Extended Release 24 Hr CAPSULE Kit Tetracycline Hcl Tetracycline Hcl VIBRAMYCIN VIBRAMYCIN FIRST GENERATION CEPHALOSPOSINS DOXYCYCLINE MONOHYDRATE DOXYCYCLINE HYCLATE Cefadroxil Cefadroxil Hydrate ; EXTENDED RELEASE 24 HR SUSPENSION; RECONSTITUTED ; ORAL (ML) CAPSULE Cefadroxil Cefadroxil Hydrate Suspension; Reconstituted Oral (Ml) Cefadroxil Cefadroxil Hydrate Cephalexin Cephalexin 7

11 / TRADE NAME NAME DOSE DESCRIPTION PA ST Cephalexin Cephalexin Suspension; Reconstitutedoral (Ml) Cephalexin Cephalexin KEFLEX CEPHALEXIN CAPSULE SECOND GENERATION CEPHALOSPORINS Cefaclor Cefaclor Cefaclor Cefaclor Cefaclor Er Cefaclor Cefpodoxime Proxetil Cefpodoxime Proxetil Cefpodoxime Proxetil Cefpodoxime Proxetil Suspension; Reconstituted; Oral (Ml) ; Extended Release 12 Hr Suspension; Reconstitutedoral (Ml) Cefprozil Cefprozil Cefprozil Cefprozil CEFTIN CEFUROXIME AXETIL Cefuroxime Axetil Cefuroxime Axetil Suspension; Reconstitutedoral (Ml) Suspension; Reconstitutedoral (Ml) Cefuroxime Axetil Cefuroxime Axetil THIRD GENERATION CEPHALOSPORINS CEDAX CEDAX CEFTIBUTEN DIHYDRATE CEFTIBUTEN DIHYDRATE Cefdinir Cefdinir CAPSULE SUSPENSION; RECONSTITUTED ORAL (ML) Suspension; Reconstituted Oral (Ml) Cefdinir Cefdinir Cefditoren Pivoxil Cefditoren Pivoxil is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 8 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

12 / TRADE NAME NAME DOSE DESCRIPTION PA ST Ceftibuten Ceftibuten Ceftibuten Dihydrate Ceftibuten Dihydrate Suspension; Reconstitutedoral (Ml) SPECTRACEF ERYTHROMYCINS & OTHER MACROLIDES CEFDITOREN PIVOXIL Azithromycin Azithromycin Azithromycin Azithromycin Suspension; Reconstituted; Oral (Ml) tabs: 500mg:1/day 250mg:1/day Azithromycin Azithromycin Packet (Ea) BIAXIN CLARITHROMYCIN SUSPENSION; RECONSTITUTED ; ORAL (ML) 150ml/Rx BIAXIN CLARITHROMYCIN 2/day BIAXIN XL CLARITHROMYCIN Clarithromycin Clarithromycin Clarithromycin Clarithromycin Clarithromycin Er Clarithromycin PREFERRED E.E.S. E.E.S. PREFERRED ERYPED ERYTHROMYCIN ETHYLSUCCINATE Erythromycin Ethylsuccinate ERYTHROMYCIN ETHYLSUCCINATE Ery-Tab Erythromycin Base PREFERRED ERY-TAB Erythrocin Stearate ERYTHROMYCIN BASE Erythromycin Stearate ; EXTENDED RELEASE 24 HR Suspension; Reconstituted; Oral (Ml) ; Extended Release 24 Hr SUSPENSION; RECONSTITUTED ; ORAL (ML) SUSPENSION; RECONSTITUTED ; ORAL (ML) ; Enteric Coated ; ENTERIC COATED Erythromycin Erythromycin Base 2/day 250mg, 500mg tabs 20 qty/10 days 150ml/rx 9

13 / TRADE NAME NAME DOSE DESCRIPTION PA ST Erythromycin Erythromycin Base PREFERRED ERYTHROMYCIN Erythromycin Ethylsuccinate Erythromycin Ethylsuccinate ERYTHROMYCIN BASE Erythromycin Ethylsuccinate Erythromycin Ethylsuccinate ;Delayed Release (Enteric Coated) ; ENTERIC COATED Suspension; Reconstituted; Oral (Ml) Erythromycin Stearate FLUOROQUINOLONES Erythromycin W/Sulfisoxazole Erythromycin Stearate Ery E- Succ/Sulfisoxazole Suspension; Reconstituted; Oral (Ml) ZITHROMAX AZITHROMYCIN ZITHROMAX AZITHROMYCIN PACKET (EA) ZITHROMAX AVELOX AZITHROMYCIN MOXIFLOXACIN HCL PREFERRED CIPRO CIPROFLOXACIN CIPRO CIPRO XR Ciprofloxacin Er CIPROFLOXACIN HCL CIPROFLOXACIN/C IPROFLOXA HCL Ciprofloxacin/ Ciprofloxa Hcl SUSPENSION; RECONSTITUTED ; ORAL (ML) SUSPENSION; MICROCAPSULE RECONSTITUTED ;EXTEND ED RELEASE MULTIPHASE 24 HR ;Extended Release Multiphase 24 Hr tabs: 250mg: 6/30 days; 500mg 5/30 days tabs: 250mg: 6/30 days; 500mg 5/30 days 1/day 10mL/day 2 tabs/day 2 tabs/day 2 tabs/day Ciprofloxacin Hcl Ciprofloxacin Hcl 2 tabs/day LEVAQUIN LEVOFLOXACIN 5 tabs/30 days LEVAQUIN LEVOFLOXACIN SOLUTION; ORAL 480ml/Rx Levofloxacin Hemihydrate Levofloxacin Solution; Oral 480ml/rx is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 10 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

14 / TRADE NAME NAME DOSE DESCRIPTION PA ST Levofloxacin Hemihydrate Levofloxacin 5 tabs/30 days Moxifloxacin Hcl Moxifloxacin Hcl 1/day SULFAS & RELATED AGENTS BACTRIM BACTRIM DS SEPTRA SEPTRA DS Smz-Tmp Ds SULFAMETHOXAZ OLE/TRIMETHOPR IM SULFAMETHOXAZ OLE/TRIMETHOPR IM SULFAMETHOXAZ OLE/TRIMETHOPR IM SULFAMETHOXAZ OLE/TRIMETHOPR IM Sulfamethoxazole/ Trimethoprim Sulfadiazine Sulfadiazine Sulfamethoxazole/Tri methoprim Sulfamethoxazole/ Trimethoprim URINARY TRACT AGENTS Sulfamethoxazole/Tri methoprim SULFATRIM FURADANTIN HIPREX MACROBID MACRODANTIN Sulfamethoxazole/ Trimethoprim SULFAMETHOXAZ OLE/TRIMETHOPR IM NITROFURANTOIN METHENAMINE HIPPURATE NITROFURANTOIN MONOHYD/M- CRYST NITROFURANTOIN MACROCRYSTAL Suspension; Oral (Final Dose Form) SUSPENSION; ORAL (FINAL DOSE FORM) SUSPENSION; ORAL (FINAL DOSE FORM) CAPSULE CAPSULE Methenamine Hippurate Methenamine Hippurate Methenamine Mandelate Methenamine Mandelate Methylene Blue Methylene Blue (Antidotes) Ampul (Ml) 11

15 / TRADE NAME NAME DOSE DESCRIPTION PA ST Nitrofurantoin Nitrofurantoin Suspension; Oral (Final Dose Form) Nitrofurantoin Nitrofurantoin Macrocrystal Nitrofurantoin Macrocrystal Nitrofurantoin Monohyd/M-Cryst Trimethoprim Trimethoprim UREX MISCELLANEOUS ANTIVIRALS METHENAMINE HIPPURATE Acyclovir Acyclovir Suspension; Oral (Final Dose Form) Acyclovir Acyclovir Acyclovir Acyclovir Adefovir Dipivoxil Adefovir Dipivoxil PA SP Amantadine Hcl Amantadine Hcl Amantadine Hcl Amantadine Hcl Syrup Amantadine Hcl Amantadine Hcl PREFERRED BARACLUDE ENTECAVIR PA SP PREFERRED BARACLUDE ENTECAVIR SOLUTION; ORAL PA SP COPEGUS RIBAVIRIN PA SP EPIVIR HBV LAMIVUDINE PREFERRED EPIVIR HBV LAMIVUDINE SOLUTION; ORAL Famciclovir Famciclovir FAMVIR FAMCICLOVIR FLUMADINE RIMANTADINE HCL is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 12 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

16 / TRADE NAME NAME DOSE DESCRIPTION PA ST Ganciclovir Ganciclovir HEPSERA ADEFOVIR DIPIVOXIL PA SP PREFERRED INCIVEK TELAPREVIR PA SP Lamivudine Lamivudine Moderiba Ribavirin ; Dose Pack SP Moderiba Ribavirin SP PREFERRED OLYSIO SIMEPREVIR SODIUM CAPSULE REBETOL RIBAVIRIN CAPSULE PA SP PREFERRED RELENZA ZANAMIVIR DISK; WITH INHALATION DEVICE Ribapak Ribavirin ; Dose Pack SP PA SP; 1 tablet per day for a total duration of 12 weeks 20/10days; 10 days' supply Ribasphere Ribavirin SP Ribasphere Ribavirin SP RIBATAB RIBAVIRIN ; DOSE PACK PA SP Ribavirin Ribavirin SP Ribavirin Ribavirin SP Rimantadine Hcl Rimantadine Hcl PREFERRED SOVALDI SOFOSBUVIR PA SP;28/28 days PREFERRED SYNAGIS PALIVIZUMAB VIAL (ML) PA SP PREFERRED TAMIFLU OSELTAMIVIR PHOSPHATE SUSPENSION; RECONSTITUTED ; ORAL (ML) 25 ml/day 13

17 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED TAMIFLU OSELTAMIVIR PHOSPHATE CAPSULE PREFERRED TYZEKA TELBIVUDINE SP Valacyclovir Valacyclovir Hcl PREFERRED VALCYTE PREFERRED VALCYTE VALGANCICLOVIR HCL VALGANCICLOVIR HCL SOLUTION; RECONSTITUTED ; ORAL VALTREX VALACYCLOVIR HCL PREFERRED VICTRELIS BOCEPREVIR CAPSULE PA SP HIV/AIDS THERAPY ZOVIRAX ACYCLOVIR ZOVIRAX ACYCLOVIR SUSPENSION; ORAL (FINAL DOSE FORM) ZOVIRAX ACYCLOVIR CAPSULE Abacavir Abacavir Sulfate Abacavir-Lamivudine- Zidovudine Abacavir/ Lamivudine/ Zidovudine PREFERRED APTIVUS TIPRANAVIR CAPSULE PREFERRED APTIVUS PREFERRED ATRIPLA COMBIVIR PREFERRED COMPLERA TIPRANAVIR/ VITAMIN E TPGS EFAVIRENZ/ EMTRICITAB/ TENOFOVIR LAMIVUDINE/ZID OVUDINE EMTRICITAB/RILP IVIRINE/TENOFOV SOLUTION; ORAL PREFERRED CRIXIVAN INDINAVIR SULFATE Didanosine Didanosine CAPSULE ;Delayed Release (Enteric Coated) is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 14 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

18 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED EDURANT RILPIVIRINE HCL PREFERRED EMTRIVA EMTRICITABINE SOLUTION; ORAL PREFERRED EMTRIVA EMTRICITABINE CAPSULE PREFERRED EPIVIR LAMIVUDINE SOLUTION; ORAL PREFERRED EPZICOM EPIVIR LAMIVUDINE ABACAVIR SULFATE/LAMIVU DINE PREFERRED FUZEON ENFUVIRTIDE KIT PA SP PREFERRED INTELENCE ETRAVIRINE PREFERRED INVIRASE PREFERRED INVIRASE PREFERRED ISENTRESS SAQUINAVIR MESYLATE SAQUINAVIR MESYLATE RALTEGRAVIR POTASSIUM CAPSULE PA SP PREFERRED ISENTRESS RALTEGRAVIR POTASSIUM ; CHEWABLE PA SP PREFERRED KALETRA LOPINAVIR/RITON AVIR SOLUTION; ORAL PREFERRED KALETRA LOPINAVIR/RITON AVIR Lamivudine Lamivudine Lamivudine- Zidovudine PREFERRED LEXIVA PREFERRED LEXIVA Lamivudine/ Zidovudine FOSAMPRENAVIR CALCIUM FOSAMPRENAVIR CALCIUM SUSPENSION; ORAL (FINAL DOSE FORM) Nevirapine Nevirapine Suspension; Oral (Final Dose Form) Nevirapine Nevirapine 15

19 / TRADE NAME NAME DOSE DESCRIPTION PA ST Nevirapine ER 400mg Nevirapine ER PREFERRED NORVIR RITONAVIR CAPSULE PREFERRED NORVIR RITONAVIR SOLUTION; ORAL PREFERRED NORVIR RITONAVIR PREFERRED PREZISTA PREFERRED PREZISTA PREFERRED RESCRIPTOR PREFERRED RESCRIPTOR DARUNAVIR ETHANOLATE DARUNAVIR ETHANOLATE DELAVIRDINE MESYLATE DELAVIRDINE MESYLATE SUSPENSION; ORAL (FINAL DOSE FORM) ; DISPERSIBLE RETROVIR ZIDOVUDINE CAPSULE RETROVIR ZIDOVUDINE RETROVIR ZIDOVUDINE SYRUP PREFERRED REYATAZ ATAZANAVIR SULFATE CAPSULE PREFERRED SELZENTRY MARAVIROC PA Stavudine Stavudine Stavudine Stavudine PREFERRED STRIBILD ELVITEGR/ COBICIST/ EMTRIC/TENOF Solution; Reconstituted; Oral PREFERRED SUSTIVA EFAVIRENZ CAPSULE PREFERRED SUSTIVA EFAVIRENZ PREFERRED TIVICAY DOLUTEGRAVIR SODIUM SP TRIZIVIR ABACAVIR/ LAMIVUDINE/ ZIDOVUDINE is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 16 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

20 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED TRUVADA EMTRICITABINE/ TENOFOVIR PREFERRED VIDEX DIDANOSINE VIDEX EC PREFERRED VIRACEPT VIRAMUNE DIDANOSINE NELFINAVIR MESYLATE NEVIRAPINE SOLUTION; RECONSTITUTED ; ORAL CAPSULE;DELAY ED RELEASE (ENTERIC COATED) SUSPENSION; ORAL (FINAL DOSE FORM) VIRAMUNE NEVIRAPINE PREFERRED VIRAMUNE XR NEVIRAPINE PREFERRED VIREAD VIRAMUNE XR 400MG ZERIT NEVIRAPINE TENOFOVIR DISOPROXIL FUMARATE STAVUDINE ; EXTENDED RELEASE 24 HR ; EXTENDED RELEASE 24 HR SOLUTION; RECONSTITUTED ; ORAL ZERIT STAVUDINE CAPSULE ZIAGEN ABACAVIR SULFATE PREFERRED ZIAGEN ABACAVIR SULFATE SOLUTION; ORAL Zidovudine Zidovudine Zidovudine Zidovudine Syrup Zidovudine Zidovudine ANTIFUNGAL AGENTS ANCOBON FLUCYTOSINE CAPSULE Clotrimazole Clotrimazole Troche DIFLUCAN FLUCONAZOLE SUSPENSION; 17

21 / TRADE NAME NAME DOSE DESCRIPTION PA ST RECONSTITUTED ; ORAL (ML) DIFLUCAN FLUCONAZOLE 150mg: 2 EA/7 days Fluconazole Fluconazole Fluconazole Fluconazole Suspension; Reconstituted; Oral (Ml) 150mg: 2 ea/7 days Flucytosine Flucytosine GRIFULVIN V GRISEOFULVIN; MICROSIZE Griseofulvin Griseofulvin Griseofulvin; Microsize Griseofulvin; Microsize Suspension; Oral (Final Dose Form) Griseofulvin Ultramicrosize Griseofulvin Ultramicrosize GRIS-PEG GRISEOFULVIN ULTRAMICROSIZE Itraconazole Itraconazole Ketoconazole Ketoconazole PA LAMISIL TERBINAFINE HCL PREFERRED LAMISIL TERBINAFINE HCL PREFERRED NOXAFIL POSACONAZOLE PREFERRED NOXAFIL POSACONAZOLE Nystatin Nystatin GRANULES IN PACKET (EA) SUSPENSION; ORAL (FINAL DOSE FORM) ; ENTERIC COATED Suspension; Oral (Final Dose Form) 250mg: 1 tab/day;84 days of therapy per 365 days 250mg: 1 tab/day;84 days of therapy per 365 days Nystatin Nystatin SPORANOX ITRACONAZOLE CAPSULE is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 18 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

22 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED SPORANOX ITRACONAZOLE SOLUTION; ORAL Terbinafine Terbinafine Hcl Terbinafine Terbinafine Hcl VFEND VORICONAZOLE VFEND VORICONAZOLE Voriconazole Voriconazole SUSPENSION; RECONSTITUTED ; ORAL (ML) Suspension; Reconstituted; Oral (Ml) 250mg: 1 tab/day;84 days of therapy per 365 days 250mg: 1 tab/day;84 days of therapy per 365 days Voriconazole Voriconazole VANCOMYCIN VANCOCIN HCL VANCOMYCIN HCL CAPSULE Vancomycin Hcl Vancomycin Hcl MISCELLANEOUS ANTIINFECTIVES Amikacin Sulfate Amikacin Sulfate Syringe (Ml) PREFERRED CAYSTON AZTREONAM LYSINE VIAL; NEBULIZER (ML) PA SP; 3 vials per day CLEOCIN HCL CLINDAMYCIN HCL CAPSULE CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL SOLUTION; RECONSTITUTED ; ORAL Clindamycin Hcl Clindamycin Hcl Clindamycin Palmitate Hcl Clindamycin Pediatric Clindamycin Palmitate Hcl Clindamycin Palmitate Hcl Solution; Reconstituted; Oral Solution; Reconstituted; Oral PREFERRED DAPSONE DAPSONE Neomycin Sulfate Neomycin Sulfate 19

23 / TRADE NAME NAME DOSE DESCRIPTION PA ST TOBI TOBRAMYCIN IN 0.225% NACL PREFERRED TOBI PODHALER TOBRAMYCIN AMPUL FOR NEBULIZATION (ML) CAPSULE; WITH INHALATION DEVICE PA PA SP Tobramycin Sulfate Tobramycin In 0.225% Nacl Ampul For Nebulization (Ml) PA PREFERRED XIFAXAN RIFAXIMIN PREFERRED ZYVOX LINEZOLID SUSPENSION; RECONSTITUTED ; ORAL (ML) PA PREFERRED ZYVOX LINEZOLID PA ANTIPARASITICS PREFERRED ALBENZA ALBENDAZOLE PREFERRED ALINIA NITAZOXANIDE SUSPENSION; RECONSTITUTED ; ORAL (ML) PREFERRED ALINIA NITAZOXANIDE Atovaquone Atovaquone Suspension; Oral (Final Dose Form) NON- PREFERRED BILTRICIDE PRAZIQUANTEL PA FLAGYL METRONIDAZOLE CAPSULE FLAGYL METRONIDAZOLE generic preferred mebendazole mebendazole tablet; chewable MEPRON ATOVAQUONE SUSPENSION; ORAL (FINAL DOSE FORM) Metronidazole Metronidazole Metronidazole Metronidazole Paromomycin Sulfate Paromomycin Sulfate PREFERRED STROMECTOL IVERMECTIN TINDAMAX TINIDAZOLE Tinidazole Tinidazole ANTIMALARIALS ARALEN PHOSPHATE Atovaquone-Proguanil Hcl CHLOROQUINE PHOSPHATE Atovaquone/Progu anil Hcl Allow to bypass denial if provider inserts ICD-9 diagnosis code of is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 20 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

24 / TRADE NAME NAME DOSE DESCRIPTION PA ST Chloroquine Chloroquine Phosphate Phosphate PREFERRED COARTEM ARTEMETHER/LU MEFANTRINE PREFERRED DARAPRIM PYRIMETHAMINE Hydroxychloroquine Sulfate MALARONE Hydroxychloroquine Sulfate ATOVAQUONE/PR OGUANIL HCL Mefloquine Hcl Mefloquine Hcl PLAQUENIL HYDROXYCHLORO QUINE SULFATE QUALAQUIN QUININE SULFATE CAPSULE Quinine Sulfate Quinine Sulfate ANTIMYCOBACTERIALS Ethambutol Hcl Ethambutol Hcl Isonarif Rifampin/Isoniazid Isoniazid Isoniazid Isoniazid Isoniazid Solution; Oral MYAMBUTOL ETHAMBUTOL HCL PREFERRED MYCOBUTIN RIFABUTIN CAPSULE PREFERRED PRIFTIN RIFAPENTINE Pyrazinamide Pyrazinamide RIFADIN RIFAMPIN CAPSULE RIFAMATE RIFAMPIN/ISONIA ZID CAPSULE Rifampin Rifampin PREFERRED SIRTURO BEDAQUILINE FUMARATE 21

25 / TRADE NAME NAME DOSE DESCRIPTION PA ST ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS ALKYLATING AGENTS PREFERRED ALKERAN MELPHALAN SP PREFERRED CEENU LOMUSTINE CAPSULE SP Cyclophosphamide Cyclophosphamide PREFERRED LEUKERAN CHLORAMBUCIL SP PREFERRED LOMUSTINE LOMUSTINE CAPSULE PREFERRED MYLERAN BUSULFAN SP TEMODAR TEMOZOLOMIDE CAPSULE SP Temozolomide Temozolomide SP ANTIMETABOLITES Capecitabine Capecitabine PA SP Mercaptopurine Mercaptopurine Methotrexate Methotrexate Methotrexate Sodium PREFERRED OFORTA Methotrexate Sodium Methotrexate Sodium Methotrexate Sodium FLUDARABINE PHOSPHATE ; Dose Pack PURINETHOL MERCAPTOPURINE PREFERRED TABLOID THIOGUANINE SP PREFERRED TREXALL METHOTREXATE SODIUM XELODA CAPECITABINE PA SP is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 22 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

26 / TRADE NAME NAME DOSE DESCRIPTION PA ST HORMONES MEGACE MEGESTROL ACETATE Megestrol Acetate Megestrol Acetate SUSPENSION; ORAL (FINAL DOSE FORM) Suspension; Oral (Final Dose Form) Megestrol Acetate Megestrol Acetate ANTIESTROGENS Anastrozole Anastrozole ARIMIDEX ANASTROZOLE AROMASIN EXEMESTANE SP Exemestane Exemestane SP PREFERRED FARESTON TOREMIFENE CITRATE SP FEMARA LETROZOLE Letrozole Letrozole Tamoxifen Citrate Tamoxifen Citrate ANTIANDROGENS Bicalutamide Bicalutamide CASODEX BICALUTAMIDE Flutamide Flutamide PREFERRED NILANDRON NILUTAMIDE SP PREFERRED XTANDI ENZALUTAMIDE CAPSULE SP PREFERRED ZYTIGA ABIRATERONE ACETATE SP 23

27 / TRADE NAME NAME DOSE DESCRIPTION PA ST IMMUNOSUPPRESSANT DRUGS PREFERRED AZASAN AZATHIOPRINE Azathioprine Azathioprine PREFERRED CELLCEPT CELLCEPT MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL SUSPENSION; RECONSTITUTED ; ORAL (ML) CELLCEPT MYCOPHENOLATE MOFETIL CAPSULE Cyclosporine Cyclosporine Cyclosporine Cyclosporine Solution; Oral Cyclosporine Cyclosporine Gengraf Gengraf Cyclosporine; Modified Cyclosporine; Modified Cyclosporine; Modified Cyclosporine; Modified Solution; Oral Solution; Oral Hecoria Tacrolimus IMURAN AZATHIOPRINE Mycophenolate Mofetil Mycophenolate Mofetil Mycophenolate Mofetil Mycophenolate Mofetil Mycophenolic Acid MYFORTIC Mycophenolate Sodium MYCOPHENOLATE SODIUM ; Enteric Coated ; ENTERIC COATED PROGRAF TACROLIMUS CAPSULE PREFERRED RAPAMUNE SIROLIMUS SOLUTION; ORAL SP PREFERRED RAPAMUNE SIROLIMUS SP is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 24 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

28 / TRADE NAME NAME DOSE DESCRIPTION PA ST Sirolimus Sirolimus Tacrolimus Tacrolimus PREFERRED ZORTRESS EVEROLIMUS SP MISCELLANEOUS ANTINEOPLASTIC DRUGS PREFERRED AFINITOR EVEROLIMUS SP PREFERRED AFINITOR DISPERZ EVEROLIMUS FOR SUSPENSION SP PREFERRED BOSULIF BOSUTINIB SP PREFERRED CAPRELSA VANDETANIB SP PREFERRED DROXIA HYDROXYUREA CAPSULE PREFERRED EMCYT ESTRAMUSTINE PHOSPHATE SODIUM CAPSULE SP PREFERRED ERIVEDGE VISMODEGIB CAPSULE SP Etoposide Etoposide PREFERRED GILOTRIF AFATINIB DIMALEATE SP PREFERRED GLEEVEC IMATINIB MESYLATE SP PREFERRED HEXALEN ALTRETAMINE CAPSULE SP PREFERRED HYCAMTIN TOPOTECAN HCL CAPSULE SP HYDREA HYDROXYUREA CAPSULE Hydroxyurea Hydroxyurea PREFERRED IMBRUVICA IBRUTINIB CAPSULE PA SP PREFERRED INLYTA AXITINIB SP 25

29 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED IRESSA GEFITINIB SP PREFERRED JAKAFI RUXOLITINIB PHOSPHATE SP PREFERRED LYSODREN MITOTANE SP PREFERRED MATULANE PROCARBAZINE HCL CAPSULE SP PREFERRED MEKINIST TRAMETINIB DIMETHYL SULFOXIDE SP PREFERRED NEXAVAR SORAFENIB TOSYLATE SP PREFERRED POMALYST POMALIDOMIDE CAPSULE SP PREFERRED REVLIMID LENALIDOMIDE CAPSULE SP PREFERRED SIGNIFOR PASIREOTIDE DIASPARTATE AMPUL (ML) SP PREFERRED SPRYCEL DASATINIB SP PREFERRED STIVARGA REGORAFENIB SP PREFERRED SUTENT SUNITINIB MALATE CAPSULE SP PREFERRED TAFINLAR DABRAFENIB MESYLATE CAPSULE SP PREFERRED TARCEVA ERLOTINIB HCL SP PREFERRED TARGRETIN BEXAROTENE CAPSULE SP PREFERRED TARGRETIN BEXAROTENE GEL (GRAM) SP PREFERRED TASIGNA NILOTINIB HCL CAPSULE SP PREFERRED THALOMID THALIDOMIDE CAPSULE SP Tretinoin Tretinoin SP PREFERRED TYKERB LAPATINIB DITOSYLATE PA SP is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 26 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

30 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED VANDETANIB VANDETANIB PREFERRED VOTRIENT PAZOPANIB HCL SP PREFERRED XALKORI CRIZOTINIB CAPSULE SP PREFERRED ZELBORAF VEMURAFENIB SP PREFERRED ZOLINZA VORINOSTAT CAPSULE SP PREFERRED ZYKADIA CERITINIB ADJUNCTIVE AGENTS Leucovorin Calcium Leucovorin Calcium SP; 140 capsules per 28 days (5 capsules per day) PREFERRED MESNEX MESNA SP AUTONOMIC & CNS DRUGS, NEUROLOGY, & PSYCH NARCOTIC ANALGESICS NARCOTICS ACTIQ AVINZA Buprenorphine Hydrochloride FENTANYL CITRATE MORPHINE SULFATE LOZENGE ON A HANDLE CAPSULE; EXTENDED RELEASE MULTIPHASE 24HR Buprenorphine Hcl ; Sublingual PA 1/day Codeine Sulfate Codeine Sulfate DEMEROL MEPERIDINE HCL DILAUDID HYDROMORPHON E HCL DILAUDID HYDROMORPHON E HCL LIQUID (ML) Diskets Methadone Hcl ; Soluble DOLOPHINE HCL METHADONE HCL 27

31 / TRADE NAME NAME DOSE DESCRIPTION PA ST DURAGESIC EXALGO FENTANYL HYDROMORPHONE ER Fentanyl Fentanyl Fentanyl Citrate Fentanyl Citrate PATCH; TRANSDERMAL 72 HOURS Patch; Transdermal 72 Hours Lozenge On A Handle patch 12/28 days 3/day patch 12/28 days Hydromorphone Hcl Hydromorphone Hcl Suppository; Rectal Hydromorphone Hcl Hydromorphone Hcl Liquid (Ml) Hydromorphone Hcl Hydromorphone Hcl Hydromorphone Hcl ER Hydromorphone Hcl 3/day KADIAN MORPHINE SULFATE CAPSULE; EXTENDED RELEASE PELLETS PA 2/day Levorphanol Tartrate Levorphanol Tartrate Meperidine Hcl Meperidine Hcl Cartridge (Ml) Meperitab Meperidine Hcl Methadone Hcl Methadone Hcl Concentrate; Oral Methadone Hcl Methadone Hcl Solution; Oral Methadone Hcl Methadone Hcl Methadone Hcl Methadone Hcl ; Soluble Methadose Methadone Hcl Methadose Methadone Hcl Concentrate; Oral Methadose Methadone Hcl ; Soluble Morphine Sulfate Morphine Sulfate Solution; Oral is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 28 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy

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