2014 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky 00 9 lease read: This document contains information about the drugs we cover in this plan. lease note that the WellCare of Kentucky Medicaid referred Drug List is updated quarterly. roviders, please visit our website at https://kentucky.wellcare.com/provider/pharmacy to view updates to the preferred drug list. Members, please visit our website at https://kentucky.wellcare.com/member/pharmacy to view updates to the preferred drug list. Last updated (01/01/2014) WC02201237 WC - MCD_rovider_Kentucky_DL 01/01/2014
WellCare of Kentucky Medicaid Cough & Cold Drug List Non-referred Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 CASULE BENZONATATE 100 CASULE BENZONATATE 200 CASULE Dextromethorphan olistirex DELSYM 30 /5 ML EXTENDED-RELEASE SUSENSION Dextromethorphan HBr ROBITUSSIN EDIATRIC COUGH SY Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF LUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/seudoephedrine HCl ALLANHIST DX DROS BROMHIST DX DROS BROTA DM LIQUID Q-TA DM ELIXIR BROMFED DM SYRU ENDACOF-D DROS Brophenaramine/Dextromethorphan HBr/henylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/henylephrine HCl C-HEN DM RONDEX-DM SYRU DE-CHLOR DM LIQUID NOHIST-DM D-COF SYRU SILDEC E-DM SYRU CORFEN DM TRI-DEX E Chlorpheniramine/Dextromethorphan HBr/seudoephedrine HCl EDIATRIC COUGH-COLD LIQUID MESEHIST DM KIDKARE COUGH/COLD Dexchlorpheniramine/seudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETA LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID romethazine HCl/Dextromethorphan HBr ROMETHAZINE-DM SYRU Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMTOM EXECTORANTS DECONGESTANT-EXECTORANT COMBINATIONS referred Drugs NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Guaifenesin/henylephrine HCl DONATUSSIN DROS E-GUAI DROS DESEC LIQUID RESCON-GG LIQUID Last updated 01/01/14 age 1 of 2
WellCare of Kentucky Medicaid Cough & Cold Drug List Non-referred Drugs referred Drugs NON-NARCOTIC DECONGESTANT-EXECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/henylephreine ROBAFEN CF SYRU Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID SIMUC-DM ELIXIR GUAIFENESIN DM SYRU Q-TUSSIN-DM SYRU EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRU REFENESEN DM SILTUSSIN DM DAS COUGH SYRU MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID Chlorpheniramine/Hydrocodone olistirex TUSSIONEX ENNKINETIC SUS TUSSICAS (min. age 6 years old) HYDROCODONE-CHLORHENIRAMINE SUSENSION (min. age 6 years old) Dexbrompheniramine/Hydrocodone Bit/henylephrine HCl Codeine/henylephrine HCl/romethazine CYTUSS-HC NR SYRU HC/E/DBROM SYRU ROMETH VC W/COD SYRU ROMETHAZINE VC/COD SYRU HC 2.5-E 5-DBROM 1 SYRU seudoephedrine HCl/Codeine/Chlorpheniramine HENYLHISTINE DH HYDROMET SYRU NON-NARCOTIC ANTITUSSIVE AND EXECTORANT COMB. NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Codeine hosphate/romethazine HCl ROMETHAZINE-CODEINE SYRU (min. age 6 years old) NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROINE NARCOTIC ANTITUSSIVE-EXECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine hosphate/guaifenesin HYDROCODONE-GUAIFENESIN SYRU CHERATUSSIN AC SYRU NARCOF SYRU TUSSICLEAR DH SYRU GUAIFENESIN-CODEINE SYRU IOHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXECTORANT COMBINATIONS Codeine hosphate/guaifenesin/seudoephedrine HCl CHERATUSSIN DAC SYRU Last updated 01/01/14 age 2 of 2
Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. UERCASE = Brand name drugs italics = Generic drugs reference Details = referred Dagger ( ) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A Coverage Details A = rior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit = - Covered w/rx Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines** *Amphetamine Mixtures*** ADDERALL XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15, 20, 25, 30, 5 Amphetamine-Dextroamphetamine ORAL TABLET 10, 12.5, 15, 5, 7.5 Amphetamine-Dextroamphetamine ORAL TABLET 20 Amphetamine-Dextroamphetamine ORAL TABLET 30 *Amphetamines*** Dextroamphetamine Sulfate ORAL TABLET 10, 5 Dextroamphetamine Sulfate ER ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15, 5 VYVANSE ORAL CASULE 20, 30, 40, 50, 60, 70 *Stimulants - Misc.** QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 day(s)) QL (62 EA per 31 day(s)) ST; QL (31 EA per 31 Day(s)); AL (Min 5 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) 1
Drug Name reference Details Coverage Details *Stimulants - Misc.*** Dexmethylphenidate HCl ORAL TABLET 10, 2.5, 5 METHYLIN ORAL TABLET CHEWABLE 10, 2.5, 5 Methylphenidate HCl ORAL TABLET 10, 5 Methylphenidate HCl ORAL TABLET 20 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 10 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 18, 27, 36 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 20 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 54 *Alternative Medicines* *Alternative Medicine - M's** *Alternative Medicine - Me's*** Melatonin Maximum Strength ORAL TABLET 5 *Aminoglycosides* *Aminoglycosides** *Aminoglycosides*** TOBI INHALATION NEBULIZATION SOLUTION 300 /5ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies** *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS* KIT 20 /0.4ML, 40 /0.8ML HUMIRA EN SUBCUTANEOUS* KIT 40 /0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 /0.8ML SIMONI SUBCUTANEOUS* SOLUTION 100 /ML, 50 /0.5ML QL (62 EA per 31 day(s)); AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) QL (93 EA per 31 day(s)); AL (Min 6 Years) AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) A A A A A 2
Drug Name reference Details Coverage Details *Gold Compounds** *Gold Compounds*** RIDAURA ORAL CASULE 3 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)** *Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CASULE 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** Childrens Ibuprofen ORAL SUSENSION 40 /ML Diclofenac otassium ORAL TABLET 50 Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Diclofenac Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 Etodolac ORAL CASULE 200, 300 Etodolac ORAL TABLET 400, 500 Fenoprofen Calcium ORAL TABLET 600 Flurbiprofen ORAL TABLET 100, 50 Ibuprofen ORAL SUSENSION 100 /5ML ST; QL (31 EA per 31 day(s)) Ibuprofen ORAL TABLET 200 Ibuprofen ORAL TABLET 400, 600, 800 Indomethacin ORAL CASULE 25, 50 Ketoprofen ORAL CASULE 50, 75 Ketorolac Tromethamine ORAL TABLET 10 Meloxicam ORAL TABLET 15, 7.5 Nabumetone ORAL TABLET 500, 750 Naproxen ORAL SUSENSION 125 /5ML Naproxen ORAL TABLET 250, 375, 500 QL (20 EA per 31 day(s)) QL (2000 ML per 31 day(s)) 3
Drug Name reference Details Coverage Details Naproxen DR ORAL TABLET DELAYED RELEASE 500 Naproxen Sodium ORAL TABLET 275, 550 Oxaprozin ORAL TABLET 600 iroxicam ORAL CASULE 10, 20 Sulindac ORAL TABLET 150, 200 Tolmetin Sodium ORAL CASULE 400 *yrimidine Synthesis Inhibitors** *yrimidine Synthesis Inhibitors*** Leflunomide ORAL TABLET 10, 20 *Analgesics - Nonnarcotic* *Analgesic Combinations** *Analgesics-Sedatives*** Butalbital-Acetaminophen ORAL TABLET 50-325 Butalbital-AA-Caffeine ORAL CASULE 50-325-40 Butalbital-AA-Caffeine ORAL TABLET 50-325-40, 50-500-40 Butalbital-ASA-Caffeine ORAL CASULE 50-325-40 QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) Marten-Tab ORAL TABLET 50-325 QL (186 EA per 31 day(s)) Repan ORAL TABLET 50-325-40 QL (186 EA per 31 day(s)) TENCON ORAL TABLET 50-650 QL (124 EA per 31 day(s)) ZEBUTAL ORAL CASULE 50-500-40 QL (186 EA per 31 day(s)) *Analgesics Other** *Analgesics Other*** Acetaminophen ORAL SOLUTION 160 /5ML Acetaminophen ORAL TABLET 325 ; QL (279 EA per 31 day(s)) Acetaminophen ORAL TABLET 500 ; QL (186 EA per 31 day(s)) Mapap ORAL LIQUID 160 /5ML Mapap Infants ORAL SUSENSION 160 /5ML ain & Fever Childrens ORAL SOLUTION 160 /5ML *Salicylates** 4
Drug Name reference Details Coverage Details *Salicylate Combinations*** Choline & Mag Trisalicylate ORAL TABLET 1000 Choline-Mag Trisalicylate ORAL LIQUID 500 /5ML *Salicylates*** Aspirin ORAL TABLET 325, 81 Aspirin ORAL TABLET CHEWABLE 81 Aspirin RE SUOSITORY 300, 600 Diflunisal ORAL TABLET 500 Salsalate ORAL TABLET 500, 750 *Analgesics - Opioid* *Opioid Agonists** *Opioid Agonists*** Codeine hosphate INJECTION SOLUTION 15 /ML, 30 /ML Codeine Sulfate ORAL TABLET 15, 30, 60 FentaNYL TRANSDERMAL ATCH 72 HR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR HYDROmorphone HCl ORAL LIQUID 1 /ML HYDROmorphone HCl ORAL TABLET 2, 4, 8 HYDROmorphone HCl RE SUOSITORY 3 Methadone HCl ORAL SOLUTION 10 /5ML, 5 /5ML Methadone HCl ORAL TABLET 10, 5 QL (248 EA per 31 day(s)) A; QL (10 EA per 30 day(s)) QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) METHADOSE ORAL TABLET 10 QL (248 EA per 31 day(s)) Morphine Sulfate INJECTION SOLUTION 10 /ML, 15 /ML, 5 /ML, 8 /ML Morphine Sulfate INTRAVENOUS* SOLUTION 1 /ML, 25 /ML, 50 /ML Morphine Sulfate ORAL SOLUTION 10 /5ML, 20 /5ML 5
Drug Name reference Details Coverage Details Morphine Sulfate ORAL TABLET 15, 30 Morphine Sulfate RE SUOSITORY 10, 20, 30, 5 Morphine Sulfate (Concentrate) ORAL SOLUTION 20 /ML Morphine Sulfate (F) INJECTION SOLUTION 0.5 /ML Morphine Sulfate (F) INTRAVENOUS* SOLUTION 8 /ML Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 100, 15, 200, 30, 60 QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) OxyCODONE HCl ORAL CASULE 5 QL (248 EA per 31 day(s)) OxyCODONE HCl ORAL SOLUTION 5 /5ML OxyCODONE HCl ORAL TABLET 10, 15, 20, 5 OxyCODONE HCl ORAL TABLET 30 QL (248 EA per 31 day(s)) TraMADol HCl ORAL TABLET 50 QL (248 EA per 31 day(s)) *Opioid Combinations** *Codeine Combinations*** Acetaminophen-Codeine ORAL SOLUTION 120-12 /5ML Acetaminophen-Codeine #2 ORAL TABLET 300-15 Acetaminophen-Codeine #3 ORAL TABLET 300-30 Acetaminophen-Codeine #4 ORAL TABLET 300-60 ASCOM-CODEINE ORAL CASULE 50-325-40-30 Butalbital-AA-Caff-Cod ORAL CASULE 50-325-40-30 Butalbital-ASA-Caff-Codeine ORAL CASULE 50-325-40-30 *Hydrocodone Combinations*** Hydrocodone-Acetaminophen ORAL SOLUTION 7.5-325 /15ML, 7.5-500 /15ML QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (3720 ML per 31 day(s)) 6
Drug Name reference Details Coverage Details Hydrocodone-Acetaminophen ORAL TABLET 10-325, 10-500, 10-650, 10-660, 10-750, 2.5-500, 5-325, 5-500, 7.5-325, 7.5-500, 7.5-650, 7.5-750 Hydrocodone-Ibuprofen ORAL TABLET 7.5-200 QL (248 EA per 31 day(s)) QL (155 EA per 31 day(s)) HYDROGESIC ORAL CASULE 5-500 QL (248 EA per 31 day(s)) *Opioid Combinations*** ENDOCET ORAL TABLET 10-325, 5-325, 7.5-325, 7.5-500 QL (248 EA per 31 day(s)) ENDOCET ORAL TABLET 10-650 QL (186 EA per 31 day(s)) Oxycodone-Acetaminophen ORAL CASULE 5-500 Oxycodone-Acetaminophen ORAL TABLET 10-325, 5-325, 7.5-325, 7.5-500 Oxycodone-Acetaminophen ORAL TABLET 10-650 Oxycodone-Aspirin ORAL TABLET 4.8355-325 QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) ROXICET ORAL TABLET 5-325 QL (248 EA per 31 day(s)) *Opioid artial Agonists** *Opioid artial Agonists*** Buprenorphine HCl SUBLINGUAL TABLET SUBLINGUAL 2, 8 Butorphanol Tartrate NASAL SOLUTION 10 /ML entazocine-naloxone HCl ORAL TABLET 50-0.5 SUBOXONE SUBLINGUAL FILM 12-3, 2-0.5, 4-1, 8-2 *Androgens-Anabolic* *Anabolic Steroids** *Anabolic Steroids*** Oxandrolone ORAL TABLET 10, 2.5 A *Androgens** *Androgens*** A QL (3 ML per 31 day(s)) A 7
Drug Name reference Details Coverage Details Danazol ORAL CASULE 100, 200, 50 Methitest ORAL TABLET 10 TESTIM TRANSDERMAL GEL 50 /5GM Testosterone Cypionate INTRAMUSCULAR* OIL 100 /ML, 200 /ML Testosterone Enanthate INTRAMUSCULAR* OIL 200 /ML *Anorectal Agents* *Intrarectal Steroids** *Intrarectal Steroids*** Hydrocortisone RE ENEMA 100 /60ML *Rectal Steroids** *Rectal Steroids*** ROCTOSOL HC RE CREAM 2.5 % ROCTOZONE-HC RE CREAM 2.5 % *Antacids* *Antacids - Aluminum Salts** *Antacids - Aluminum Salts*** Aluminum Hydroxide Gel ORAL SUSENSION 320 /5ML *Antacids - Calcium Salts** *Antacids - Calcium Salts*** Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 *Antacids - Magnesium Salts** *Antacids - Magnesium Salts*** Magnesium Oxide ORAL TABLET 250, 400, 420 *Anthelmintics* *Anthelmintics** *Anthelmintics*** ALBENZA ORAL TABLET 200 A BILTRICIDE ORAL TABLET 600 A Reeses inworm Medicine ORAL SUSENSION 144 /ML A 8
Drug Name reference Details Coverage Details STROMECTOL ORAL TABLET 3 QL (10 EA per 31 day(s)) *Antianginal Agents* *Nitrates** *Nitrates*** Isosorbide Dinitrate ORAL TABLET 10, 20, 30, 5 Isosorbide Dinitrate ER ORAL TABLET EXTENDEDRELEASE* 40 Isosorbide Mononitrate ORAL TABLET 10, 20 Isosorbide Mononitrate ER ORAL TABLET EXTENDED RELEASE 24 HR* 120, 30, 60 NITRO-BID TRANSDERMAL OINTMENT 2 % Nitroglycerin TRANSDERMAL ATCH 24 HR 0.1 /HR, 0.2 /HR, 0.4 /HR, 0.6 /HR NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3, 0.4, 0.6 *Antianxiety Agents* *Antianxiety Agents - Misc.** *Antianxiety Agents - Misc.*** BusIRone HCl ORAL TABLET 10, 15, 30, 5, 7.5 HydrOXYzine HCl ORAL SOLUTION 10 /5ML HydrOXYzine HCl ORAL SYRU 10 /5ML HydrOXYzine HCl ORAL TABLET 10, 25, 50 HydrOXYzine amoate ORAL CASULE 100, 25, 50 Meprobamate ORAL TABLET 200, 400 *Benzodiazepines** *Benzodiazepines*** ALRAZolam ORAL TABLET 0.25, 0.5, 1, 2 QL (450 ML per 31 day(s)) QL (450 ML per 31 day(s)) 9
Drug Name reference Details Coverage Details ChlordiazeOXIDE HCl ORAL CASULE 10, 25, 5 Clorazepate Dipotassium ORAL TABLET 15, 3.75, 7.5 Diazepam INJECTION SOLUTION 5 /ML AL (Min 9 Years) Diazepam ORAL SOLUTION 1 /ML QL (1240 ML per 31 day(s)) Diazepam ORAL TABLET 10, 2, 5 LORazepam INJECTION SOLUTION 2 /ML, 4 /ML LORazepam ORAL TABLET 0.5, 1, 2 Oxazepam ORAL CASULE 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A** *Antiarrhythmics Type I-A*** Disopyramide hosphate ORAL CASULE 100, 150 rocainamide HCl INJECTION SOLUTION 100 /ML, 500 /ML QuiNIDine Gluconate INJECTION SOLUTION 80 /ML QuiNIDine Gluconate ER ORAL TABLET EXTENDEDRELEASE* 324 QuiNIDine Sulfate ORAL TABLET 300 *Antiarrhythmics Type I-B** *Antiarrhythmics Type I-B*** Lidocaine HCl (Cardiac) INTRAVENOUS* SOLUTION 20 /ML Mexiletine HCl ORAL CASULE 150, 200, 250 *Antiarrhythmics Type I-C** *Antiarrhythmics Type I-C*** Flecainide Acetate ORAL TABLET 100, 150, 50 ropafenone HCl ORAL TABLET 150, 225, 300 10
Drug Name reference Details Coverage Details *Antiarrhythmics Type Iii** *Antiarrhythmics Type Iii*** Amiodarone HCl INTRAVENOUS* SOLUTION 150 /3ML Amiodarone HCl ORAL TABLET 200, 400 ACERONE ORAL TABLET 200, 400 *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies** *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 *Anti-Inflammatory Agents** *Anti-Inflammatory Agents*** Cromolyn Sodium INHALATION NEBULIZATION SOLUTION 20 /2ML *Bronchodilators - Anticholinergics** *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT Ipratropium Bromide INHALATION SOLUTION 0.02 % TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators** *Leukotriene Receptor Antagonists*** Montelukast Sodium ORAL ACKET 4 Montelukast Sodium ORAL TABLET 10 Montelukast Sodium ORAL TABLET CHEWABLE 4, 5 Zafirlukast ORAL TABLET 10, 20 *Steroid Inhalants** *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH A QL (25.8 GM per 31 day(s)) QL (480 ML per 31 day(s)) QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) 11
Drug Name reference Details Coverage Details ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH Budesonide INHALATION SUSENSION 0.25 /2ML, 0.5 /2ML FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ULMICORT INHALATION SUSENSION 1 /2ML QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT *Sympathomimetics** *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT COMBIVENT INHALATION AEROSOL 18-103 MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT Ipratropium-Albuterol INHALATION SOLUTION 0.5-2.5 (3) /3ML QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) QL (120 ML per 31 day(s)); AL (Max 8 Years) QL (60 EA per 30 day(s)) QL (12 GM per 30 day(s)) QL (10.6 GM per 30 day(s)) QL (120 ML per 31 day(s)); AL (Max 8 Years) QL (8.7 GM per 30 day(s)) QL (17.4 GM per 30 day(s)) QL (60 EA per 30 day(s)) QL (12 GM per 30 day(s)) QL (29.4 GM per 31 day(s)) QL (4 GM per 20 day(s)) QL (13 GM per 30 day(s)) QL (720 ML per 31 day(s)) 12
Drug Name reference Details Coverage Details SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Beta Adrenergics*** Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (2.5 /3ML) 0.083% Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (5 /ML) 0.5% Albuterol Sulfate INHALATION NEBULIZATION SOLUTION 0.63 /3ML, 1.25 /3ML QL (10.2 GM per 30 day(s)) QL (720 ML per 31 day(s)) QL (60 ML per 30 day(s)) QL (300 ML per 31 day(s)) Albuterol Sulfate ORAL SYRU 2 /5ML QL (2480 ML per 31 day(s)) Albuterol Sulfate ORAL TABLET 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG Metaproterenol Sulfate ORAL SYRU 10 /5ML SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE Terbutaline Sulfate INJECTION SOLUTION 1 /ML Terbutaline Sulfate ORAL TABLET 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines** *Xanthines*** Aminophylline INTRAVENOUS* SOLUTION 25 /ML ELIXOHYLLIN ORAL ELIXIR 80 /15ML Theophylline ORAL SOLUTION 80 /15ML Theophylline ER ORAL TABLET EXTENDED RELEASE 12 HR* 100, 200, 300, 450 QL (60 EA per 30 day(s)) QL (60 EA per 30 day(s)) QL (36 GM per 31 day(s)) 13
Drug Name reference Details Coverage Details Theophylline ER ORAL TABLET EXTENDED RELEASE 24 HR* 400, 600 *Anticoagulants* *Coumarin Anticoagulants** *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Warfarin Sodium ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors** *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 QL (35 EA per 365 day(s)) *Heparins And Heparinoid-Like Agents** *Low Molecular Weight Heparins*** Enoxaparin Sodium INJECTION SOLUTION 300 /3ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 100 /ML, 150 /ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 120 /0.8ML, 80 /0.8ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 30 /0.3ML, 40 /0.4ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 60 /0.6ML *Synthetic Heparinoid-Like Agents*** Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 10 /0.8ML Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 2.5 /0.5ML Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 5 /0.4ML Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 7.5 /0.6ML *Anticonvulsants* *Anticonvulsants - Benzodiazepines** *Anticonvulsants - Benzodiazepines*** QL (24 ML per 31 day(s)) QL (28 ML per 31 day(s)) QL (22.4 ML per 31 day(s)) QL (8.4 ML per 31 day(s)) QL (16.8 ML per 31 day(s)) QL (11.2 ML per 31 day(s)) QL (16 ML per 31 day(s)) QL (5.6 ML per 31 day(s)) QL (8.4 ML per 31 day(s)) 14
Drug Name reference Details Coverage Details ClonazeAM ORAL TABLET 0.5, 1, 2 Diazepam RE GEL 10, 2.5, 20 QL (3 EA per 31 day(s)) *Anticonvulsants - Misc.** *Anticonvulsants - Misc.*** CarBAMazepine ORAL SUSENSION 100 /5ML QL (2480 ML per 31 day(s)) CarBAMazepine ORAL TABLET 200 QL (248 EA per 31 day(s)) CarBAMazepine ORAL TABLET CHEWABLE 100 QL (310 EA per 31 day(s)) EITOL ORAL TABLET 200 QL (248 EA per 31 day(s)) Gabapentin ORAL CASULE 100 QL (310 EA per 31 day(s)) Gabapentin ORAL CASULE 300 QL (372 EA per 31 day(s)) Gabapentin ORAL CASULE 400 QL (279 EA per 31 day(s)) Gabapentin ORAL SOLUTION 250 /5ML QL (2230 ML per 31 day(s)) Gabapentin ORAL TABLET 600, 800 LamoTRIgine ORAL TABLET 100, 150, 200 LamoTRIgine ORAL TABLET 25 QL (310 EA per 31 day(s)) LamoTRIgine ORAL TABLET CHEWABLE 25, 5 LevETIRAcetam INTRAVENOUS* SOLUTION 500 /5ML LevETIRAcetam ORAL SOLUTION 100 /ML LevETIRAcetam ORAL TABLET 1000, 500, 750 QL (310 EA per 31 day(s)) QL (1000 ML per 31 day(s)) LevETIRAcetam ORAL TABLET 250 QL (372 EA per 31 day(s)) OXcarbazepine ORAL SUSENSION 300 /5ML QL (1240 ML per 31 day(s)) OXcarbazepine ORAL TABLET 150 QL (310 EA per 31 day(s)) OXcarbazepine ORAL TABLET 300 QL (248 EA per 31 day(s)) OXcarbazepine ORAL TABLET 600 rimidone ORAL TABLET 250 QL (248 EA per 31 day(s)) rimidone ORAL TABLET 50 QL (310 EA per 31 day(s)) Topiramate ORAL CASULE SRINKLE 15, 25 QL (310 EA per 31 day(s)) 15
Drug Name reference Details Coverage Details Topiramate ORAL TABLET 100, 25, 50 QL (310 EA per 31 day(s)) Topiramate ORAL TABLET 200 QL (248 EA per 31 day(s)) Zonisamide ORAL CASULE 100 QL (186 EA per 31 day(s)) Zonisamide ORAL CASULE 25 QL (310 EA per 31 day(s)) Zonisamide ORAL CASULE 50 QL (372 EA per 31 day(s)) *Gaba Modulators** *Gaba Modulators*** GABITRIL ORAL TABLET 12, 16 TiaGABine HCl ORAL TABLET 2, 4 *Hydantoins** *Hydantoins*** DILANTIN ORAL CASULE 30 QL (310 EA per 31 day(s)) Fosphenytoin Sodium INJECTION SOLUTION 100 E/2ML EGANONE ORAL TABLET 250 QL (372 EA per 31 day(s)) henytoin ORAL SUSENSION 125 /5ML henytoin ORAL TABLET CHEWABLE 50 henytoin Sodium INJECTION SOLUTION 50 /ML henytoin Sodium Extended ORAL CASULE 100, 200, 300 *Succinimides** *Succinimides*** Ethosuximide ORAL CASULE 250 Ethosuximide ORAL SOLUTION 250 /5ML *Valproic Acid** *Valproic Acid*** Divalproex Sodium ORAL CASULE SRINKLE 125 Divalproex Sodium ORAL TABLET DELAYED RELEASE 125, 250 Divalproex Sodium ORAL TABLET DELAYED RELEASE 500 QL (930 ML per 31 day(s)) QL (372 EA per 31 day(s)) QL (930 ML per 31 day(s)) QL (310 EA per 31 day(s)) QL (310 EA per 31 day(s)) QL (279 EA per 31 day(s)) 16
Drug Name reference Details Coverage Details Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250 Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 QL (310 EA per 31 day(s)) QL (279 EA per 31 day(s)) Valproic Acid ORAL CASULE 250 QL (310 EA per 31 day(s)) Valproic Acid ORAL SOLUTION 250 /5ML QL (2790 ML per 31 day(s)) Valproic Acid ORAL SYRU 250 /5ML QL (2790 ML per 31 day(s)) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)** *Alpha-2 Receptor Antagonists (Tetracyclics)*** Mirtazapine ORAL TABLET 15, 30, 45, 7.5 Mirtazapine ORAL TABLET DISERSIBLE 15, 30, 45 *Antidepressants - Misc.** *Antidepressants - Misc.*** BUDERION SR ORAL TABLET EXTENDED RELEASE 12 HR* 150 BuROion HCl ORAL TABLET 100, 75 BuROion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100, 150, 200 BuROion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150, 300 Maprotiline HCl ORAL TABLET 25, 50, 75 *Modified Cyclics** *Modified Cyclics*** Nefazodone HCl ORAL TABLET 100, 150, 200, 250, 50 TraZODone HCl ORAL TABLET 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)** *Monoamine Oxidase Inhibitors (Maois)*** henelzine Sulfate ORAL TABLET 15 17
Drug Name reference Details Coverage Details Tranylcypromine Sulfate ORAL TABLET 10 *Selective Serotonin Reuptake Inhibitors (Ssris)** *Selective Serotonin Reuptake Inhibitors (Ssris)*** Citalopram Hydrobromide ORAL TABLET 10, 20, 40 Escitalopram Oxalate ORAL TABLET 10, 20, 5 FLUoxetine HCl ORAL CASULE 10, 20, 40 FLUoxetine HCl ORAL SOLUTION 20 /5ML FLUoxetine HCl ORAL TABLET 10, 20 FluvoxaMINE Maleate ORAL TABLET 100, 25, 50 ARoxetine HCl ORAL TABLET 10, 20, 30, 40 Sertraline HCl ORAL TABLET 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)** *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** Venlafaxine HCl ORAL TABLET 100, 25, 37.5, 50, 75 Venlafaxine HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 150, 37.5, 75 *Tricyclic Agents** *Tricyclic Agents*** Amitriptyline HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Amoxapine ORAL TABLET 100, 150, 25, 50 ClomiRAMINE HCl ORAL CASULE 25, 50, 75 QL (31 EA per 31 day(s)) 18
Drug Name reference Details Coverage Details Desipramine HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Doxepin HCl ORAL CASULE 10, 100, 25, 50, 75 Doxepin HCl ORAL CONCENTRATE 10 /ML Imipramine HCl ORAL TABLET 10, 25, 50 Nortriptyline HCl ORAL CASULE 10, 25, 50, 75 Nortriptyline HCl ORAL SOLUTION 10 /5ML rotriptyline HCl ORAL TABLET 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors** *Alpha-Glucosidase Inhibitors*** Acarbose ORAL TABLET 100, 25, 50 *Antidiabetic Combinations** *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000, 50-500 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000, 50-1000, 50-500 JENTADUETO ORAL TABLET 2.5-1000, 2.5-500, 2.5-850 *Sulfonylurea-Biguanide Combinations*** GlipiZIDE-MetFORMIN HCl ORAL TABLET 2.5-250, 2.5-500, 5-500 GlyBURIDE-MetFORMIN ORAL TABLET 1.25-250, 2.5-500, 5-500 *Sulfonylurea-Thiazolidinedione Combinations*** AVANDARYL ORAL TABLET 4-1, 4-2, 4-4, 8-2, 8-4 *Thiazolidinedione-Biguanide Combinations*** QL (2325 ML per 31 day(s)) ST ST ST; QL (31 EA per 31 day(s)) ST 19
Drug Name reference Details Coverage Details AVANDAMET ORAL TABLET 2-1000, 2-500, 4-1000, 4-500 ioglitazone HCl-Metformin HCl ORAL TABLET 15-500, 15-850 *Biguanides** *Biguanides*** MetFORMIN HCl ORAL TABLET 1000, 500, 850 MetFORMIN HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 500, 750 MetFORMIN HCl ER (OSM) ORAL TABLET EXTENDED RELEASE 24 HR* 500 RIOMET ORAL SOLUTION 500 /5ML QL (900 ML per 31 day(s)) *Diabetic Other** *Diabetic Other*** GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 GLUCAGON EMERGENCY INJECTION KIT 1 Glucose ORAL TABLET CHEWABLE 4 GM *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors** *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100, 25, 50 ST ST QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) TRADJENTA ORAL TABLET 5 ST; QL (31 EA per 31 Day(s)) *Incretin Mimetic Agents (Glp-1 Receptor Agonists)** *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 *Insulin Sensitizing Agents** *Thiazolidinediones*** AVANDIA ORAL TABLET 2, 4, 8 ST ST; QL (4 EA per 28 day(s)) ST 20
Drug Name reference Details Coverage Details ioglitazone HCl ORAL TABLET 15, 30, 45 *Insulin** *Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN 70/30 EN SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN N EN SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML *Sulfonylureas** ST QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) 21
Drug Name reference Details Coverage Details *Sulfonylureas*** ChlorproAMIDE ORAL TABLET 100, 250 Glimepiride ORAL TABLET 1, 2, 4 GlipiZIDE ORAL TABLET 10, 5 GlipiZIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GlyBURIDE ORAL TABLET 1.25, 2.5, 5 GlyBURIDE Micronized ORAL TABLET 1.5, 3, 6 *Antidiarrheals* *Antiperistaltic Agents** *Antiperistaltic Agents*** Diphenoxylate-Atropine ORAL LIQUID 2.5-0.025 /5ML Diphenoxylate-Atropine ORAL TABLET 2.5-0.025 LONOX ORAL TABLET 2.5-0.025 Loperamide HCl ORAL CASULE 2 *Antidotes* *Antidotes - Chelating Agents** *Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125, 250, 500 *Antidotes** *Antidotes*** Deferoxamine Mesylate INJECTION SOLUTION RECONSTITUTED 2 GM, 500 *Opioid Antagonists** *Opioid Antagonists*** Naltrexone HCl ORAL TABLET 50 *Antiemetics* A 22
Drug Name reference Details Coverage Details *5-Ht3 Receptor Antagonists** *5-Ht3 Receptor Antagonists*** Ondansetron ORAL TABLET DISERSIBLE 4, 8 Ondansetron HCl ORAL SOLUTION 4 /5ML Ondansetron HCl ORAL TABLET 4, 8 *Antiemetics - Anticholinergic** *Antiemetics - Anticholinergic*** Meclizine HCl ORAL TABLET 12.5, 25 Meclizine HCl ORAL TABLET CHEWABLE 25 Travel Sickness ORAL TABLET CHEWABLE 25 *Antifungals* *Antifungals** *Antifungals*** Griseofulvin Microsize ORAL SUSENSION 125 /5ML Griseofulvin Microsize ORAL TABLET 500 Griseofulvin Ultramicrosize ORAL TABLET 125, 250 Nystatin ORAL TABLET 500000 UNIT Terbinafine HCl ORAL TABLET 250 *Imidazole-Related Antifungals** *Imidazoles*** Ketoconazole ORAL TABLET 200 *Triazoles*** Fluconazole ORAL SUSENSION RECONSTITUTED 10 /ML, 40 /ML Fluconazole ORAL TABLET 100, 150, 200, 50 *Antihistamines* *Antihistamines - Alkylamines** *Antihistamines - Alkylamines*** QL (450 ML per 31 day(s)) 23
Drug Name reference Details Coverage Details Allergy ORAL TABLET 4 *Antihistamines - Ethanolamines** *Antihistamines - Ethanolamines*** Aler-Dryl ORAL TABLET 50 BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 /5ML DiphenhydrAMINE HCl ORAL CASULE 25, 50 DiphenhydrAMINE HCl ORAL TABLET 25 *Antihistamines - Non-Sedating** *Antihistamines - Non-Sedating*** ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 Allergy ORAL TABLET DISERSIBLE 10 Cetirizine HCl ORAL SYRU 1 /ML, 5 /5ML Cetirizine HCl ORAL TABLET 10, 5 Cetirizine HCl Childrens ORAL SOLUTION 1 /ML Childrens Loratadine ORAL SYRU 5 /5ML Fexofenadine HCl ORAL TABLET 180, 60 ; QL (300 ML per 31 day(s)) ; QL (300 ML per 31 day(s)) ; QL (310 ML per 31 day(s)) Loratadine ORAL TABLET 10 *Antihistamines - henothiazines** *Antihistamines - henothiazines*** romethazine HCl ORAL SYRU 6.25 /5ML romethazine HCl ORAL TABLET 12.5, 25, 50 romethazine HCl RE SUOSITORY 25 ROMETHEGAN RE SUOSITORY 25, 50 *Antihistamines - iperidines** *Antihistamines - iperidines*** 24
Drug Name reference Details Coverage Details Cyproheptadine HCl ORAL SYRU 2 /5ML Cyproheptadine HCl ORAL TABLET 4 *Antihyperlipidemics* *Antihyperlipidemics - Combinations** *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** VYTORIN ORAL TABLET 10-10, 10-20, 10-40, 10-80 *Bile Acid Sequestrants** *Bile Acid Sequestrants*** Cholestyramine ORAL ACKET 4 GM Cholestyramine ORAL OWDER 4 GM/DOSE Cholestyramine Light ORAL ACKET 4 GM Cholestyramine Light ORAL OWDER 4 GM/DOSE *Fibric Acid Derivatives** *Fibric Acid Derivatives*** Fenofibrate ORAL TABLET 160, 54 Fenofibrate Micronized ORAL CASULE 134, 200, 67 Gemfibrozil ORAL TABLET 600 *Hmg Coa Reductase Inhibitors** *Hmg Coa Reductase Inhibitors*** Atorvastatin Calcium ORAL TABLET 10, 20, 40, 80 Lovastatin ORAL TABLET 10, 20, 40 ravastatin Sodium ORAL TABLET 10, 20, 40, 80 Simvastatin ORAL TABLET 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors** *Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 A *Nicotinic Acid Derivatives** *Nicotinic Acid Derivatives*** QL (300 ML per 31 day(s)) A ST 25
Drug Name reference Details Coverage Details NIACOR ORAL TABLET 500 *Antihypertensives* *Ace Inhibitors** *Ace Inhibitors*** Benazepril HCl ORAL TABLET 10, 20, 40, 5 Captopril ORAL TABLET 100, 12.5, 25, 50 Enalapril Maleate ORAL TABLET 10, 2.5, 20, 5 Fosinopril Sodium ORAL TABLET 10, 20, 40 Lisinopril ORAL TABLET 10, 2.5, 20, 30, 40, 5 Quinapril HCl ORAL TABLET 10, 20, 40, 5 Ramipril ORAL CASULE 1.25, 10, 2.5, 5 *Angiotensin Ii Receptor Antagonists** *Angiotensin Ii Receptor Antagonists*** Losartan otassium ORAL TABLET 100, 25, 50 *Antiadrenergic Antihypertensives** *Antiadrenergics - Centrally Acting*** CloNIDine HCl ORAL TABLET 0.1, 0.2, 0.3 GuanFACINE HCl ORAL TABLET 1, 2 Methyldopa ORAL TABLET 250, 500 *Antiadrenergics - eripherally Acting*** Doxazosin Mesylate ORAL TABLET 1, 2, 4, 8 razosin HCl ORAL CASULE 1, 2, 5 Terazosin HCl ORAL CASULE 1, 10, 2, 5 *Antihypertensive Combinations** *Ace Inhibitors & Thiazide/Thiazide-Like*** QL (31 EA per 31 day(s)) 26
Drug Name reference Details Coverage Details Benazepril-Hydrochlorothiazide ORAL TABLET 10-12.5, 20-12.5, 20-25, 5-6.25 Captopril-Hydrochlorothiazide ORAL TABLET 25-15, 25-25, 50-15, 50-25 Enalapril-Hydrochlorothiazide ORAL TABLET 10-25, 5-12.5 Lisinopril-Hydrochlorothiazide ORAL TABLET 10-12.5, 20-12.5, 20-25 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** Losartan otassium-hctz ORAL TABLET 100-12.5, 100-25, 50-12.5 *Beta Blocker & Diuretic Combinations*** Atenolol-Chlorthalidone ORAL TABLET 100-25, 50-25 Bisoprolol-Hydrochlorothiazide ORAL TABLET 10-6.25, 2.5-6.25, 5-6.25 ropranolol-hctz ORAL TABLET 40-25, 80-25 *Vasodilators** *Vasodilators*** HydrALAZINE HCl INJECTION SOLUTION 20 /ML HydrALAZINE HCl ORAL TABLET 10, 100, 25, 50 Minoxidil ORAL TABLET 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.** *Anti-Infective Agents - Misc.*** MetroNIDAZOLE ORAL TABLET 250, 500 Trimethoprim ORAL TABLET 100 Vancomycin HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1000, 500, 750 Vancomycin HCl ORAL CASULE 125, 250 QL (31 EA per 31 day(s)) A 27
Drug Name reference Details Coverage Details *Anti-Infective Misc. - Combinations** *Anti-Infective Misc. - Combinations*** Erythromycin-Sulfisoxazole ORAL SUSENSION RECONSTITUTED 200-600 /5ML Sulfamethoxazole-TM DS ORAL TABLET 800-160 Sulfamethoxazole-Trimethoprim ORAL SUSENSION 200-40 /5ML Sulfamethoxazole-Trimethoprim ORAL TABLET 400-80 *Antiprotozoal Agents** *Antiprotozoal Agents*** MERON ORAL SUSENSION 750 /5ML *Leprostatics** *Leprostatics*** Dapsone ORAL TABLET 100, 25 *Lincosamides** *Lincosamides*** Clindamycin HCl ORAL CASULE 150, 300, 75 Clindamycin almitate HCl ORAL SOLUTION RECONSTITUTED 75 /5ML Clindamycin hosphate INJECTION SOLUTION 300 /2ML, 600 /4ML, 9 GM/60ML, 900 /6ML Clindamycin hosphate INTRAVENOUS* SOLUTION 300 /2ML *Antimalarials* *Antimalarial Combinations** *Antimalarial Combinations*** Atovaquone-roguanil HCl ORAL TABLET 250-100, 62.5-25 *Antimalarials** *Antimalarials*** DARARIM ORAL TABLET 25 Hydroxychloroquine Sulfate ORAL TABLET 200 QL (1200 ML per 31 day(s)) QL (2400 ML per 31 day(s)) 28
Drug Name reference Details Coverage Details Mefloquine HCl ORAL TABLET 250 rimaquine hosphate ORAL TABLET 26.3 *Antimyasthenic/Cholinergic Agents* *Antimyasthenic/Cholinergic Agents** *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 /5ML MESTINON ORAL TABLET EXTENDEDRELEASE* 180 ROSTIGMIN ORAL TABLET 15 yridostigmine Bromide ORAL TABLET 60 *Antimycobacterial Agents* *Antimycobacterial Agents** *Antimycobacterial Agents*** Ethambutol HCl ORAL TABLET 100, 400 Isoniazid INJECTION SOLUTION 100 /ML Isoniazid ORAL TABLET 100, 300 MYCOBUTIN ORAL CASULE 150 yrazinamide ORAL TABLET 500 Rifampin INTRAVENOUS* SOLUTION RECONSTITUTED 600 Rifampin ORAL CASULE 150, 300 *Antineoplastics And Adjunctive Therapies* *Alkylating Agents** *Alkylating Agents*** HEXALEN ORAL CASULE 50 A MYLERAN ORAL TABLET 2 A *Imidazotetrazines*** Temozolomide ORAL CASULE 100, 140, 180, 20, 250, 5 *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 A Cyclophosphamide ORAL TABLET 25, 50 A A 29
Drug Name reference Details Coverage Details LEUKERAN ORAL TABLET 2 A *Nitrosoureas*** Lomustine ORAL CASULE 10, 100, 40 *Antimetabolites** *Antimetabolites*** ADRUCIL INTRAVENOUS* SOLUTION 500 /10ML Fluorouracil INTRAVENOUS* SOLUTION 500 /10ML Gemcitabine HCl INTRAVENOUS* SOLUTION 1 GM/26.3ML, 2 GM/52.6ML, 200 /5.26ML Gemcitabine HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM, 2 GM, 200 Mercaptopurine ORAL TABLET 50 Methotrexate ORAL TABLET 2.5 Methotrexate Sodium INJECTION SOLUTION 25 /ML Methotrexate Sodium INJECTION SOLUTION RECONSTITUTED 1 GM Methotrexate Sodium (F) INJECTION SOLUTION 25 /ML TABLOID ORAL TABLET 40 A XELODA ORAL TABLET 150, 500 A *Antineoplastic - Angiogenesis Inhibitors** *Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS* SOLUTION 100 /4ML, 400 /16ML *Antineoplastic - Hedgehog athway Inhibitors** *Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 A *Antineoplastic - Hormonal And Related Agents** *Antiadrenals*** A A A A A A 30
Drug Name reference Details Coverage Details LYSODREN ORAL TABLET 500 A *Antiandrogens*** XTANDI ORAL CASULE 40 A *Antiestrogens*** Tamoxifen Citrate ORAL TABLET 10, 20 *Aromatase Inhibitors*** Anastrozole ORAL TABLET 1 Letrozole ORAL TABLET 2.5 *Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 A *Lhrh Analogs*** TRELSTAR DEOT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 TRELSTAR DEOT MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 3.75 TRELSTAR LA INTRAMUSCULAR* SUSENSION RECONSTITUTED 11.25 TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 11.25 TRELSTAR MIXJECT INTRAMUSCULAR* SUSENSION RECONSTITUTED 22.5 *rogestins-antineoplastic*** Megestrol Acetate ORAL SUSENSION 40 /ML Megestrol Acetate ORAL TABLET 20, 40 *Antineoplastic Enzyme Inhibitors** *Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 A *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 A *Antineoplastic - Mtor Kinase Inhibitors*** A A A A A QL (600 ML per 31 day(s)) 31
Drug Name reference Details Coverage Details AFINITOR ORAL TABLET 10, 2.5, 5, 7.5 *Antineoplastic - Multikinase Inhibitors*** STIVARGA ORAL TABLET 40 A SUTENT ORAL CASULE 12.5, 25, 50 *Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100, 500 A CARELSA ORAL TABLET 100, 300 GILOTRIF ORAL TABLET 20, 30, 40 GLEEVEC ORAL TABLET 100, 400 SRYCEL ORAL TABLET 100, 140, 20, 50, 70, 80 TARCEVA ORAL TABLET 100, 150, 25 TASIGNA ORAL CASULE 150, 200 TYKERB ORAL TABLET 250 A XALKORI ORAL CASULE 200, 250 *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10, 15, 20, 25, 5 *Antineoplastic Enzymes** *Antineoplastic Enzymes*** ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT *Antineoplastics Misc.** *Antineoplastics Misc.*** Hydroxyurea ORAL CASULE 500 A *Chemotherapy Rescue/Antidote Agents** *Folic Acid Antagonists Rescue Agents*** Leucovorin Calcium INJECTION SOLUTION RECONSTITUTED 100, 200, 350 A A A A; QL (31 EA per 31 day(s)) A A A A A A A 32
Drug Name reference Details Coverage Details Leucovorin Calcium INTRAVENOUS* SOLUTION 10 /ML Leucovorin Calcium ORAL TABLET 10, 15, 25, 5 *Mitotic Inhibitors** *Mitotic Inhibitors*** Etoposide ORAL CASULE 50 A *Antiparkinson Agents* *Antiparkinson Anticholinergics** *Antiparkinson Anticholinergics*** Benztropine Mesylate ORAL TABLET 0.5, 1, 2 Trihexyphenidyl HCl ORAL ELIXIR 0.4 /ML Trihexyphenidyl HCl ORAL TABLET 2, 5 *Antiparkinson Dopaminergics** *Antiparkinson Dopaminergics*** Amantadine HCl ORAL CASULE 100 Amantadine HCl ORAL SYRU 50 /5ML Amantadine HCl ORAL TABLET 100 Bromocriptine Mesylate ORAL CASULE 5 Bromocriptine Mesylate ORAL TABLET 2.5 *Levodopa Combinations*** Carbidopa-Levodopa ORAL TABLET 10-100, 25-100, 25-250 Carbidopa-Levodopa ER ORAL TABLET EXTENDEDRELEASE* 25-100, 50-200 *Nonergoline Dopamine Receptor Agonists*** ramipexole Dihydrochloride ORAL TABLET 0.125, 0.25, 0.5, 0.75, 1, 1.5 ROINIRole HCl ORAL TABLET 0.25, 0.5, 1, 2, 3, 4, 5 *Antiparkinson Monoamine Oxidase Inhibitors** ST 33
Drug Name reference Details Coverage Details *Antiparkinson Monoamine Oxidase Inhibitors*** Selegiline HCl ORAL CASULE 5 Selegiline HCl ORAL TABLET 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents** *Antimanic Agents*** Lithium Carbonate ORAL CASULE 150, 300, 600 Lithium Carbonate ORAL TABLET 300 Lithium Carbonate ER ORAL TABLET EXTENDEDRELEASE* 300, 450 Lithium Citrate ORAL SOLUTION 8 MEQ/5ML *Benzisoxazoles** *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 /0.75ML, 156 /ML, 234 /1.5ML, 39 /0.25ML, 78 /0.5ML RisperiDONE ORAL SOLUTION 1 /ML RisperiDONE ORAL TABLET 0.25, 0.5, 1, 2, 3, 4 RisperiDONE ORAL TABLET DISERSIBLE 0.25, 0.5, 1, 2, 3, 4 RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5, 1, 2, 3, 4 *Butyrophenones** *Butyrophenones*** Haloperidol ORAL TABLET 0.5, 1, 10, 2, 5 Haloperidol Decanoate INTRAMUSCULAR* SOLUTION 100 /ML, 50 /ML Haloperidol Lactate INJECTION SOLUTION 5 /ML Haloperidol Lactate ORAL CONCENTRATE 2 /ML A; QL (1 ML per 28 day(s)); AL (Min 18 Years) QL (496 ML per 31 day(s)); AL (Min 10 Years) QL (62 EA per 31 Day(s)); AL (Min 10 Years) QL (62 EA per 31 Day(s)); AL (Min 10 Years) QL (62 EA per 31 Day(s)); AL (Min 10 Years) AL (Min 3 Years) AL (Min 18 Years) AL (Min 3 Years) AL (Min 3 Years) 34
Drug Name reference Details Coverage Details *Dibenzapines** *Dibenzodiazepines*** CloZAine ORAL TABLET 100, 200, 25, 50 CloZAine ORAL TABLET DISERSIBLE 12.5 *Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10, 5 *Dibenzothiazepines*** QUEtiapine Fumarate ORAL TABLET 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** Loxapine Succinate ORAL CASULE 10, 25, 5, 50 *Thienbenzodiazepines*** OLANZapine ORAL TABLET 10, 15, 2.5, 20, 5, 7.5 *henothiazines** *henothiazines*** ChlorproMAZINE HCl ORAL TABLET 10, 100, 200, 25, 50 FluHENAZine Decanoate INJECTION SOLUTION 25 /ML FluHENAZine HCl ORAL CONCENTRATE 5 /ML FluHENAZine HCl ORAL ELIXIR 2.5 /5ML FluHENAZine HCl ORAL TABLET 1, 10, 2.5, 5 erphenazine ORAL TABLET 16, 2, 4, 8 AL (Min 18 Years) QL (31 EA per 31 day(s)); AL (Min 18 Years) ST; AL (Min 18 Years) AL (Min 10 Years) AL (Min 18 Years) QL (31 EA per 31 day(s)); AL (Min 13 Years) AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 day(s)) QL (2480 ML per 31 day(s)) AL (Min 12 Years) rochlorperazine RE SUOSITORY 25 AL (Min 2 Years) rochlorperazine Maleate ORAL TABLET 10, 5 Thioridazine HCl ORAL TABLET 10, 100, 25, 50 AL (Min 2 Years) AL (Min 2 Years) 35
Drug Name reference Details Coverage Details Trifluoperazine HCl ORAL TABLET 1, 10, 2, 5 *Thioxanthenes** *Thioxanthenes*** Thiothixene ORAL CASULE 1, 10, 2, 5 *Antiseptics & Disinfectants* *Chlorine Antiseptics** *Chlorine Antiseptics*** Chlorhexidine Gluconate EXTERNAL LIQUID 4 % *Antivirals* *Antiretrovirals** *Antiretroviral Combinations*** ATRILA ORAL TABLET 600-200-300 COMLERA ORAL TABLET 200-25-300 AL (Min 6 Years) AL (Min 12 Years) ; QL (480 ML per 31 day(s)) EZICOM ORAL TABLET 600-300 QL (31 EA per 31 day(s)) KALETRA ORAL SOLUTION 400-100 /5ML KALETRA ORAL TABLET 100-25, 200-50 Lamivudine-Zidovudine ORAL TABLET 150-300 STRIBILD ORAL TABLET 150-150-200-300 QL (31 EA per 31 day(s)) TRIZIVIR ORAL TABLET 300-150-300 QL (62 EA per 31 day(s)) TRUVADA ORAL TABLET 200-300 QL (31 EA per 31 day(s)) *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150, 300 *Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL TABLET 400 36
Drug Name reference Details Coverage Details ISENTRESS ORAL TABLET CHEWABLE 100, 25 TIVICAY ORAL TABLET 50 QL (62 EA per 31 day(s)) *Antiretrovirals - rotease Inhibitors*** ATIVUS ORAL CASULE 250 CRIXIVAN ORAL CASULE 200, 400 INVIRASE ORAL CASULE 200 INVIRASE ORAL TABLET 500 LEXIVA ORAL SUSENSION 50 /ML LEXIVA ORAL TABLET 700 QL (124 EA per 31 day(s)) NORVIR ORAL CASULE 100 NORVIR ORAL SOLUTION 80 /ML NORVIR ORAL TABLET 100 REZISTA ORAL SUSENSION 100 /ML REZISTA ORAL TABLET 150, 400, 600, 75, 800 REYATAZ ORAL CASULE 150, 200, 300 VIRACET ORAL TABLET 250, 625 *Antiretrovirals - Rti-Non-Nucleoside Analogues*** QL (62 EA per 31 day(s)) QL (310 EA per 31 day(s)) EDURANT ORAL TABLET 25 QL (31 EA per 31 day(s)) INTELENCE ORAL TABLET 100, 200, 25 Nevirapine ORAL SUSENSION 50 /5ML Nevirapine ORAL TABLET 200 RESCRITOR ORAL TABLET 100, 200 SUSTIVA ORAL CASULE 200, 50 SUSTIVA ORAL TABLET 600 *Antiretrovirals - Rti-Nucleoside Analogues-urines*** Abacavir Sulfate ORAL TABLET 300 37
Drug Name reference Details Coverage Details Didanosine ORAL CASULE DELAYED RELEASE 125, 200, 250, 400 VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM ZIAGEN ORAL SOLUTION 20 /ML *Antiretrovirals - Rti-Nucleoside Analogues-yrimidines*** EMTRIVA ORAL CASULE 200 QL (31 EA per 31 day(s)) EMTRIVA ORAL SOLUTION 10 /ML QL (170 ML per 31 day(s)) EIVIR ORAL SOLUTION 10 /ML EIVIR HBV ORAL SOLUTION 5 /ML EIVIR HBV ORAL TABLET 100 LamiVUDine ORAL TABLET 150, 300 *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** Stavudine ORAL CASULE 15, 20, 30, 40 Stavudine ORAL SOLUTION RECONSTITUTED 1 /ML Zidovudine ORAL CASULE 100 Zidovudine ORAL SYRU 50 /5ML QL (1860 ML per 31 day(s)) Zidovudine ORAL TABLET 300 *Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL TABLET 150, 200, 250, 300 *Hepatitis Agents** *Hepatitis B Agents*** BARACLUDE ORAL TABLET 0.5, 1 *Hepatitis C Agents*** INCIVEK ORAL TABLET 375 A; QL (504 EA per 365 day(s)) EGASYS SUBCUTANEOUS* KIT 180 MCG/0.5ML EGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML A A A 38
Drug Name reference Details Coverage Details EGASYS ROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML RIBASHERE ORAL TABLET 200 Ribavirin ORAL TABLET 200 *Herpes Agents** *Herpes Agents - urine Analogues*** Acyclovir ORAL CASULE 200 Acyclovir ORAL SUSENSION 200 /5ML QL (3500 ML per 31 day(s)) Acyclovir ORAL TABLET 400, 800 ValACYclovir HCl ORAL TABLET 1 GM, 500 *Influenza Agents** *Influenza Agents*** Rimantadine HCl ORAL TABLET 100 *Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 5 /BLISTER A QL (62 EA per 31 day(s)) QL (40 EA per 365 day(s)); AL (Min 7 Years) TAMIFLU ORAL CASULE 30 QL (40 EA per 365 day(s)) TAMIFLU ORAL CASULE 45, 75 QL (20 EA per 365 day(s)) TAMIFLU ORAL SUSENSION RECONSTITUTED 6 /ML *Assorted Classes* *Immunomodulators** *Antileprotics*** THALOMID ORAL CASULE 100, 150, 200, 50 *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CASULE 10, 15, 2.5, 20, 25, 5 *Immunosuppressive Agents** *Cyclosporine Analogs*** CycloSORINE ORAL CASULE 100, 25 CycloSORINE Modified ORAL CASULE 100, 25, 50 QL (360 ML per 365 day(s)); AL (Max 18 Years) A A 39
Drug Name reference Details Coverage Details CycloSORINE Modified ORAL SOLUTION 100 /ML GENGRAF ORAL CASULE 100, 25 GENGRAF ORAL SOLUTION 100 /ML SANDIMMUNE ORAL SOLUTION 100 /ML *Inosine Monophosphate Dehydrogenase Inhibitors*** CELLCET ORAL SUSENSION RECONSTITUTED 200 /ML Mycophenolate Mofetil ORAL CASULE 250 Mycophenolate Mofetil ORAL TABLET 500 *Macrolide Immunosuppressants*** HECORIA ORAL CASULE 0.5, 1, 5 Tacrolimus ORAL CASULE 0.5, 1, 5 *urine Analogs*** AzaTHIOprine ORAL TABLET 50 *otassium Removing Resins** *otassium Removing Resins*** Sodium olystyrene Sulfonate ORAL OWDER SS ORAL SUSENSION 15 GM/60ML *Beta Blockers* *Alpha-Beta Blockers** *Alpha-Beta Blockers*** Carvedilol ORAL TABLET 12.5, 25, 3.125, 6.25 Labetalol HCl INTRAVENOUS* SOLUTION 5 /ML Labetalol HCl ORAL TABLET 100, 200, 300 *Beta Blockers Cardio-Selective** *Beta Blockers Cardio-Selective*** QL (454 GM per 31 day(s)) 40
Drug Name reference Details Coverage Details Atenolol ORAL TABLET 100, 25, 50 Bisoprolol Fumarate ORAL TABLET 10, 5 Metoprolol Succinate ER ORAL TABLET EXTENDED RELEASE 24 HR* 100, 200, 25, 50 Metoprolol Tartrate INTRAVENOUS* SOLUTION 1 /ML Metoprolol Tartrate ORAL TABLET 100, 25, 50 *Beta Blockers Non-Selective** *Beta Blockers Non-Selective*** Nadolol ORAL TABLET 20, 40, 80 indolol ORAL TABLET 10, 5 ropranolol HCl INTRAVENOUS* SOLUTION 1 /ML ropranolol HCl ORAL TABLET 10, 20, 40, 60, 80 ropranolol HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 160, 60, 80 SORINE ORAL TABLET 120, 160, 240, 80 Sotalol HCl ORAL TABLET 120, 160, 240, 80 Sotalol HCl (AF) ORAL TABLET 120, 160, 80 Timolol Maleate ORAL TABLET 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers** *Calcium Channel Blockers*** AmLODIine Besylate ORAL TABLET 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300 41
Drug Name reference Details Coverage Details Dilt-XR ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240 Diltiazem HCl INTRAVENOUS* SOLUTION 125 /25ML, 25 /5ML, 50 /10ML Diltiazem HCl ORAL TABLET 120, 30, 60, 90 Diltiazem HCl ER ORAL CASULE EXTENDED RELEASE 12 HOUR 120, 60, 90 Diltiazem HCl ER Beads ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300, 360, 420 Diltiazem HCl ER Coated Beads ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300, 360 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180, 240, 300, 360, 420 NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30, 60, 90 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30, 60 NIFEdipine ORAL CASULE 10 NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 30, 60, 90 Verapamil HCl ORAL TABLET 120, 40, 80 Verapamil HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 100, 120, 180, 200, 240, 300, 360 Verapamil HCl ER ORAL TABLET EXTENDEDRELEASE* 120, 180, 240 *Cardiotonics* *Cardiac Glycosides** *Cardiac Glycosides*** 42
Drug Name reference Details Coverage Details Digoxin INJECTION SOLUTION 0.25 /ML Digoxin ORAL SOLUTION 0.05 /ML Digoxin ORAL TABLET 0.125, 0.25 *Cardiovascular Agents - Misc.* *ulmonary Hypertension - Endothelin Receptor Antagonists** *ulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10, 5 A *ulmonary Hypertension - hosphodiesterase Inhibitors** *ulmonary Hypertension - hosphodiesterase Inhibitors*** Sildenafil Citrate ORAL TABLET 20 A *Cephalosporins* *Cephalosporins - 1St Generation** *Cephalosporins - 1St Generation*** Cefadroxil ORAL CASULE 500 Cefadroxil ORAL SUSENSION RECONSTITUTED 250 /5ML, 500 /5ML Cefadroxil ORAL TABLET 1 GM Cephalexin ORAL CASULE 250, 500, 750 Cephalexin ORAL SUSENSION RECONSTITUTED 125 /5ML Cephalexin ORAL SUSENSION RECONSTITUTED 250 /5ML *Cephalosporins - 2Nd Generation** *Cephalosporins - 2Nd Generation*** Cefaclor ORAL CASULE 250, 500 Cefprozil ORAL SUSENSION RECONSTITUTED 125 /5ML, 250 /5ML Cefprozil ORAL TABLET 250, 500 Cefuroxime Axetil ORAL SUSENSION RECONSTITUTED 125 /5ML QL (300 ML per 31 day(s)) 43