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Updated 10/7/2013
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ANTIVIRALS .............................................................................................................................. 36
ANTIMALARIALS/ANTIPROTOZOALS ...................................................................................... 37
ANTIHELMINTICS ..................................................................................................................... 37
AMEBICIDES ............................................................................................................................. 37
ANALGESICS ............................................................................................................................... 38
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) ................................................... 38
NARCOTIC ANALGESICS ......................................................................................................... 39
RESPIRATORY DRUGS ............................................................................................................... 41
ALLERGIES ............................................................................................................................... 41
NASAL SPRAYS ........................................................................................................................ 42
ANTIHISTAMINE/ANTITUSSIVES ............................................................................................. 42
DECONGESTANT/ANTIHISTAMINES ....................................................................................... 42
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT ............................................................ 43
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES ...................................................... 43
ORALLY INHALED DRUGS ....................................................................................................... 43
OTHER BRONCHODILATORS, ORAL ...................................................................................... 45
THEOPHYLLINES...................................................................................................................... 45
LEUKOTRIENE RECEPTOR ANTAGONISTS ........................................................................... 45
MUCOLYTICS ............................................................................................................................ 45
DERMATOLOGICS ....................................................................................................................... 46
TOPICAL STEROIDS ................................................................................................................. 46
TOPICAL EMOLLIENTS ............................................................................................................ 48
TOPICAL IMMUNOMODULATORS ........................................................................................... 49
PSORIASIS ................................................................................................................................ 49
ANTI-INFECTIVES (TOPICAL) .................................................................................................. 49
BURN PREPARATIONS ............................................................................................................ 49
ANTIFUNGALS (TOPICAL) ........................................................................................................ 49
ACNE ......................................................................................................................................... 51
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS ................................................................... 52
SCABICIDES & PEDICULOCIDES ............................................................................................ 53
TOPICAL ENZYMES .................................................................................................................. 53
OTHER AGENTS ....................................................................................................................... 53
BLOOD MODIFIERS ..................................................................................................................... 53
ANTICOAGULANTS................................................................................................................... 53
ANTI-PLATELET DRUGS .......................................................................................................... 54
HEMORRHEOLOGIC AGENTS ................................................................................................. 54
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vi
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viii
HealthPlus encourages the consideration of OTC products. In general, OTC products are not
covered for the Commercial/PPO/HealthPlus Senior Program (non-Part D) lines of business,
with the exception of insulin, insulin syringes, AEROCHAMBER, and sterile saline for
nebulization. There are some additional exceptions, including generic Claritin and Claritin-D
OTC products, Zaditor OTC and generic Nicotine Patches. These products are a covered
benefit, with a written prescription, unless specifically excluded from the members benefit. If an
OTC product is a covered product, it will be included in the category/drug listing. Specifically for
the HealthPlus Partners program, a small list of OTC products is included for coverage as
mandated by the State of Michigan. Please refer to the HealthPlus Partners (Medicaid) OTC
summary list (Appendix B) on page 110.
ix
DEFINITIONS
1. FORMULARY: A list of medications and medical devices recommended for use under
the HealthPlus prescription drug benefit.
2. OPEN FORMULARY: A Drug Formulary that is voluntary. The HealthPlus Drug
Formulary is currently an open or voluntary Formulary, with some restrictions for drugs
included in special programs, such as the Prior Authorization program. Prescriptions for
drugs not listed in the HealthPlus Drug Formulary are still a covered benefit to the patient
as stipulated in the individual group subscriber contract, with exceptions as noted.
3. CLOSED FORMULARY: A Drug Formulary that is mandatory. In a mandatory
Formulary, prescriptions for products not listed in the Formulary are not a covered benefit
for the patient. Patients are still at liberty to use out-of-pocket expenses for nonformulary drug products.
4. PHARMACY & THERAPEUTICS COMMITTEE: An interdisciplinary committee
comprised of HealthPlus staff and community physicians and pharmacists who are
primarily responsible for the maintenance of the HealthPlus Drug Formulary, including the
evaluation and selection of drug products. The Pharmacy & Therapeutics Committee
meets at least five times annually.
5. FORMULARY (Preferred) DRUGS: Drugs included in copay tier 1 or 2 in the HealthPlus
Drug Formulary or updates to the Formulary.
6. NON-FORMULARY (Non-Preferred) DRUGS: Drug products not recommended by the
Pharmacy & Therapeutics Committee and included in copay tier 3. Non-formulary drugs
are still a covered benefit, in an Open Formulary, with the exception of specific
limitations. See Prescription Benefit Limitations (Appendix E, page 197).
7. MAXIMUM ALLOWABLE COST (MAC): The maximum allowable cost that HealthPlus
reimburses to a pharmacy for generic medications.
8. EXCLUDED DRUGS: Drugs that are excluded from the drug benefit. Excluded drugs
that are not reimbursable to the pharmacy include (but are not limited to): products for
cosmetic use, experimental drugs and medical foods. Also, prescriptions written by a
dentist that are not included on the DENTAL FORMULARY (see page xv) are excluded.
Exclusions may also vary depending on the members benefit. See Prescription Benefit
Limitations (Appendix E, page 197) for specific limitations.
9. PRIOR AUTHORIZATION DRUGS: Drugs for which specific criteria must be met for
coverage. Criteria is usually based on appropriate selection of recommended first-line
alternatives prior to selection of the prior authorization drug. A sample prior authorization
request form is included as Appendix C, page 111.
10. STEP THERAPY: Drugs for which a first step medication is required before coverage of
the second step drug. Step therapy is a process that may be used for administering
established Prior Authorization criteria.
11. COPAYMENT: A fee charged to the member for each prescription filled. Copayments
vary depending on the members benefit level.
xi
Generic substitution is not required for some products that may have an A rating, due to a
narrow therapeutic index. These include:
Coumadin
Depakene
Depakote
Dilantin
Lanoxin
Premarin
Synthroid
Tegretol
Theo-Dur
Narrow therapeutic index drugs are reviewed on a case by case basis for addition to the MAC
list. If a HealthPlus pharmacy submits the claim for the brand name drug, the brand name drug
is covered, and reimbursement is based on the price of the brand name drug and applicable
discounts. If a HealthPlus pharmacy submits the claim for a generic product, and the drug is
included on the MAC list, reimbursement is based on the MAC price.
PRIOR AUTHORIZATION PROGRAM
HealthPlus requires prior authorization for selected drug products based on clinical, safety, or
cost reasons. A copy of the Pharmacy Prior Authorization Form and the Prior Authorization
Criteria for medications that require prior authorization at the time of publication are included as
Appendix C and D (pages 111 and 112). Please note that the criteria documents include criteria
for Commercial/PPO/HealthPlus Senior Program (non-Part D) lines of business, HealthPlus
Partners (Medicaid) criteria, and criteria for specialty/injectable medications. For PPO,
requirements for Prior Authorization may or may not apply based on the benefit purchased by
the employer.
HealthPlus uses automated Step Therapy for some medications that require prior authorization.
This means that there are established first step drugs that must be used before the second
step drug is covered. If the pharmacy submits a claim for a second step drug, and the member
has already tried and failed the first step drug (based on a system look-back for previous
claims), the claim for the second drug will automatically be approved and paid.
For the Signature PPO Closed Formulary, an Exceptions Process is available for review of
medical necessity for coverage of non-formulary medications.The Exceptions Process also
applies to drugs that are excluded as specified by the employer.
To prescribe a medication that requires prior authorization or to submit a request for the
Exceptions Process:
The physician or office staff may complete the Pharmacy Prior Authorization form.
Fax the form to the HealthPlus Pharmacy Department:
FAX (810) 720-2757 (FLINT)
FAX (989) 797-4181 (SAGINAW)
If the patient presents a prescription to the pharmacy and prior authorization or an
exception has not been obtained, the pharmacy should contact the prescribing physician
and suggest preferred alternatives or instruct the physician to complete the Pharmacy
xii
Prior Authorization Form. For medications included in the specialty injectable program,
the physician may initiate the request for medication through the specialty vendor. The
specialty vendor will then contact HealthPlus.
7-Day Starter Dose:
To ensure that members are never in a situation where they are unable to obtain their
medication, a 7-day starter dose may be dispensed by the pharmacy when an on-line edit is
received for a medication or quantity that requires prior authorization. This override is a onetime override and is subject to audit.
If the prescribing physician is unavailable for consult, the pharmacy may dispense up to a
7-day starter dose to initiate care for the member.
Place a 06 in the denial clarification field (field 420) and enter up to a 7 for the days
supply.
Emergency Override:
Pharmacies may also override non-participating physician edits that may apply when a
prescription is written for an emergency situation. Entering 03 in the level of service field (field
418) will allow an override for emergency prescriptions only. This override is intended to be a
one-time override and is subject to audit.
If you would like an updated list of medications that require prior authorization, or if you have
questions about this program, please call the Prior Authorization line at:
Flint local phone (810) 720-2758
Note: These overrides do not apply to the Signature PPO Closed Formulary Benefit.
PHARMACY AUDIT PROGRAM
HealthPlus (or its designee) performs pharmacy audits to help ensure consistent and accurate
electronic submission of prescription claims by the pharmacy network. Prescription claim audit
activities may include a review of utilization by pharmacies, physicians, and members. The
pharmacy audit program includes desk (paper) audits, on-site audits, and an appeals process.
DRUG RECALL SURVEILLANCE PROGRAM
When a particular drug product is recalled or withdrawn from the market due to safety reasons,
HealthPlus reviews prescription utilization to identify members receiving that drug. HealthPlus
notifies members and physicians affected by the recall, as appropriate.
DOSE OPTIMIZATION PROGRAM
HealthPlus administers a Dose Optimization Program to target medications that are
recommended for once daily dosing and/or support maximum dose recommendations through
quantity limits. By optimizing the dose and decreasing the frequency, patient compliance
increases and prescription costs decrease.
xiii
System edits apply for the targeted medications when prescribed more often than once daily or
above the quantity limits. Physicians may submit the standard HealthPlus Pharmacy Prior
Authorization form, with information that includes a current diagnosis and medical necessity for
the dosage regimen.
Some of the categories included in the Dose Optimization Program are: proton pump inhibitors,
HMG CoA reductase inhibitors, COX-II inhibitors, angiotensin II receptor antagonists, selected
narcotic analgesics, selected antipsychotics, selected urinary incontinence drugs and selected
sleeping medications. For more information regarding the Dose Optimization Program, please
contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877-710-0993.
DRUG UTILIZATION REVIEW (DUR)
HealthPlus administers a comprehensive DUR program to help ensure the quality and safety of
prescribing and dispensing medications to members. The program includes point-of-service
quality and safety edits to the pharmacist when a prescription is being filled, and retrospective
analysis of claims data (with integration of medical and pharmacy data) to identify opportunities
for educational intervention and improve quality and outcomes. For more information regarding
the DUR program, please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or
toll-free at 1-877-710-0993.
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP)
HealthPlus offers services through a Controlled Substances Pharmacy Program to support the
appropriate management of pain, ensure patient safety of narcotic use, and monitor for and
prevent potential fraud and abuse of narcotics. For more information about the CSPP program,
please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877710-0993.
Most chronic medications are covered through the 90-day programs. Compounded medications
and injectable medications, with the exception of injectable diabetes medications, glucagon, EpiPen and Imitrex, are NOT covered through the 90-day programs.
To receive a 90-day supply in the Ask for 90 Rx Program, HealthPlus requires that the member
has already received a 30-day supply of the same drug and same strength within the last year
(to help assure the member is stabilized on the drug and dose before receiving a 90-day
supply). The prescription claims processing system looks for previous pharmacy claims billed to
HealthPlus for the member.
NOTE: Based on their benefit, the member may be enrolled in the Mandatory 90-Day
Medication Program. For most chronic medications, members are required to receive a 90-day
supply each time they fill their prescription at a participating local retail pharmacy or through mail
order with Express Scripts.
SPECIALTY PHARMACY PROGRAM
HealthPlus administers a specialty pharmacy program for injectable medications; including
medications administered in the physicians office and self-administered medications. For more
information about the specialty pharmacy program, please contact the HealthPlus Customer
Service Department at 1-800-332-9161. For PPO, please contact HealthPlus PPO Customer
Service at 1-888-212-1512.
NOTE: Based on their benefit, the member may be enrolled in the Mandatory Specialty
Program. For specific self-injected medications, the member is required to receive the
medication from a HealthPlus-contracted specialty pharmacy (the specialty pharmacy will mail
the medication to the physicians office or the members home). This program applies to selfinjected medications for Rheumatoid Arthritis, Hepatitis C, Multiple Sclerosis, Infertility,
Endometriosis (for HealthPlus Partners), and other targeted categories.
HEALTHPLUS DENTAL FORMULARY
The HealthPlus Dental Formulary is a restricted list of pharmaceutical agents covered when
prescribed by dentists. This list was established by the Medical Affairs Committee and Board of
Directors with recommendations by the Pharmacy & Therapeutics Committee. In the opinion of
the Medical Affairs Committee, these medications are of established value in the treatment or
prophylaxis of dental conditions, and present a broad range of choices to meet the usual clinical
problems. These products are covered when written by a dental provider treating a patient with
a HealthPlus drug benefit. Products that are not listed on the Dental Formulary are not a
covered benefit when prescribed by a dentist. Medications listed in the Dental Formulary are
available as either oral solids or oral liquids, whichever fits the clinical situation as determined by
the prescriber. Products listed with Y for YES in the GEQ column in the Formulary, must be
filled with a generic equivalent; for these generic medications, a tier 1 copay applies. In cases
of medical necessity, generic substitution may be overridden by the use of the Dispense as
Written (DAW) notation, with prior authorization required for these instances. A copy of the
HEALTHPLUS DENTAL FORMULARY is printed on the next page.
xv
MYCOSTATIN*
Antivirals
acyclovir
valacyclovir
ZOVIRAX*
VALTREX*
Antibiotics
Cephalosporins
cephalexin HCL
cefadroxil
cefuroxime
erythromycin
ERYTHROMYCIN*
Penicillins
amoxicillin
amoxicillin-clavulanate potassium
penicillin V potassium
AMOXIL*
AUGMENTIN*
PENVEEK*
Tetracyclines
doxycycline hyclate
tetracycline HCL
VIBRAMYCIN*, VIBRATABS*
(NOT DORYX, ORACEA)
Miscellaneous Antibiotics
clindamycin HCL
CLEOCIN 150mg*
Miscellaneous Anti-Infectives
metronidazole
FLAGYL*
Skeletal Muscle Relaxants
diazepam
ibuprofen
indomethacin
naproxen
VALIUM*
Nonsteroidal Anti-Inflammatory Agents
RX MOTRIN*
INDOCIN*
NAPROSYN*
Narcotic Analgesics
acetaminophen/codeine
acetaminophen 500/hydrocodone 5
acetaminophen 750/hydrocodone 7.5
acetaminophen 325/oxycodone 5
aspirin/caffeine/dihydrocodeine
aspirin/codeine
aspirin 325/oxycodone 5
butalbital/aspirin/caffeine/codeine
acetaminophen 325/hydrocodone 10
acetaminophen 325/hydrocodone 7.5
acetaminophen 325/hydrocodone 5
ibuprofen 200/hydrocodone 7.5
TYLENOL W/CODEINE*
VICODIN* 5/500
VICODIN ES* 7.5/750
PERCOCET*
SYNALGOS-DC*
EMPIRIN W/CODEINE*
PERCODAN*
FIORINAL W/CODEINE*
NORCO*
NORCO*
NORCO*
VICOPROFEN*
Systemic Corticosteroids
methylprednisolone
chlorhexidine gluconate
PERIDEX*
Miscellaneous
lidocaine viscous solution/ointment
LIDOCAINE*
NOTE: Behavior health medications (ex. diazepam) are carved out for HealthPlus Partners Medicaid and HealthPlus
MIChild/MIChild CSHCS.
*generic available
xvi
xvii
HealthPlus offers a Smoking Cessation program to members. The program includes: a free quit
kit, prescription coverage, phone/web coaching and reimbursement for community classes.
To enroll in the Smoking Cessation program, contact the Health & Lifestyle Management
Department at 1-866-810-4540.
xviii
FORMULARY KEY
Abbreviation
AG
DL
DME
DO
GEQ
GF
GM
HMO
M
M-NC
M-SUPP
MAND 90
MAND SPEC
MDCH
NA
NC
NF-NC
NF-PA
PA
PARTNERS
POS
PPO
QL
SP
SPEC
TPA
Description
Age Restriction
Duration Limit
Available through Durable Medical Equipment benefit only, with a copay as applicable.
Dose Optimization
Generically Available
Female Gender Restriction
Male Gender Restriction
Health Maintenance Organization
Medical injectable or infused drugs (not self-administered)
Medical benefit only, not processed by Pharmacy
HealthPlus Senior Program (non-Part D) Plan
Mandatory 90-Day Program (specific medications must be filled in a 90-day supply)
Mandatory Specialty Drug Program (specific medications must be obtained through a contracted
specialty pharmacy)
Michigan Department of Community Health (carve-out for specific medications)
Not Applicable
Not Covered, Excluded
Non-Formulary, Not Covered (for Signature PPO Closed formulary)
Non-Formulary, Prior Authorization Required (for Signature PPO Closed formulary)
Prior Authorization and/or Step Therapy Required
HealthPlus Partners Medicaid
Point of Service Plan
Preferred Provider Organization
Quantity Limit
Specialty Pharmacy Product with Limited Distribution (through a specific specialty pharmacy)
Specialty Drugs, self-injected or self-administered
Third Party Administrator
xix
BRAND NAME
ACIPHEX
AXID
CARAFATE
CARAFATE SUSP
CYTOTEC
DEXILANT
ESOMEPRAZOLE
STRONTIUM
GEQ
Y
Y
Y
FIRSTLANSOPRAZOLE
FIRSTOMEPRAZOLE
NEXIUM
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
GASTROINTESTINAL DRUGS
ANTI-ULCER AGENTS
PA, DO
PA, DO
PA, DO
SIGNATURE
PPO CLOSED
FORMULARY
PA, DO
PA, DO
PA, DO
NF-NC
1
1
2
1
NF-NC
PA, DO
PA, DO
PA, DO
NF-NC
LANSOPRAZOLE
PA, DO
PA, DO
PA, DO
NF-NC
OMEPRAZOLE
ESOMEPRAZOLE
OMEPRAZOLECLARITHROMYCINAMOXICILLIN
FAMOTIDINE
3
3
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
NF-NC
NF-NC
RABEPRAZOLE
NIZATIDINE
SUCRALFATE
SUCRALFATE
MISOPROSTOL
DEXLANSOPRAZOLE
2
1
1
2
1
3
ESOMEPRAZOLE
STRONTIUM
FAMOTIDINE
PREVACID
LANSOPRAZOLE
NF-NC
PREVACID
SOLUTAB
PRILOSEC 20MG
PRILOSEC 40MG
LANSOPRAZOLE
OMEPRAZOLE
OMEPRAZOLE
3
1
1
PA, DO
PA, DO
PA, DO
Y
Y
NF-NC
1
NF-NC
3
1
3
1
1
PA, DO
PA, DO
PA, DO
Y
Y
Y
Y
OMEPRAZOLE
MAGNESIUM
PANTOPRAZOLE
PANTOPRAZOLE
CIMETIDINE
RANITIDINE
PA, DO
PA, DO
PA, DO
NF-NC
NF-NC
NF-NC
1
1
th
th
PARTNERS
MAND
SPEC
NF-NC
NF-NC
OMECLAMOX-PAK
PEPCID RPD
PEPCID TABS,
SUSP
PRILOSEC DR
SUSP
PROTONIX TABS
PROTONIX PAK
TAGAMET
ZANTAC
MAND 90
MAND
SPEC
3
3
20
BRAND NAME
ZANTAC
EFFERDOSE
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
RANITIDINE
NF-NC
OMEPRAZOLE/SODIUM
BICARBONATE
NF-NC
ZEGERID SUSP
OMEPRAZOLE/SODIUM
BICARBONATE
APRISO
ASACOL
ASACOL HD
MESALAMINE
MESALAMINE
MESALAMINE
2
2
2
2
2
2
SULFASALAZINE
MESALAMINE
1
2
1
2 DO
BALSALAZIDE
DISODIUM
HYDROCORTISONE
ACETATE
NF-NC
MESALAMINE
OLSALAZINE
BUDESONIDE
BALSALAZIDE
DISODIUM
MESALAMINE
MESALAMINE
MESALAMINE
2
3
1
2
NF-NC
MESALAMINE
BUDESONIDE
2
3
AMYLASE/ LIPASE/
PROTEASE
ZEGERID 40MG
CAPS
AZULFIDINE,
ENTAB
CANASA
COLAZAL
CORTIFOAM
DELZICOL
DIPENTUM
ENTOCORT EC
GIAZO
LIALDA
PENTASA
ROWASA ENEMA
SF ROWASA
ENEMA
*UCERIS
CREON
th
3
3
2
1
th
PA, DO
PA, DO
PA, DO
INFLAMMATORY BOWEL DISEASE
DO
PA
DO
PA
DO
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
Y
Y
Y
Y
Y
1
PA
PA
PA
PA
PA
PA
DIGESTIVE ENZYMES
PA
PA
PA
NF-NC
NF-NC
2
1
Y
Y
2
NF-NC
21
BRAND NAME
GEQ
PANCREAZE
PERTZYE
ULTRASE
ULTRASE MT
ULTRESA
VIOKASE
ZENPEP 5,000
GENERIC NAME
ZENPEP 10,000,
15,000 AND 20,000
AMYLASE/ LIPASE/
PROTEASE
AMITIZA
LUBIPROSTONE
HYDROCORTISONE
SUPP
CROFELEMER
CROMOLYN SODIUM
ALOSETRON
PRAMOXINE
HYDROCORTISONE/
PRAMOXINE
ANUSOL HC
FULYZAQ
GASTROCROM
LOTRONEX
PROCTOFOAM
Y
Y
Y
PROCTOFOAM HC
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
TIER
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
3
HEMORRHOIDS AND OTHER GASTROINTESTINALS
PA
2
1
3
1
2
1
MAND
SPEC
PARTNERS
MAND
SPEC
2
1
NF-NC
1
NF-NC
1
2
ANTIEMETICS
ANTIVERT 12.5,
25MG
ANTIVERT 50MG
1
2
ANZEMET
MECLIZINE
MECLIZINE
DOLASETRON
MESYLATE
COMPAZINE
SYRUP
PROCHLORPERAZINE
th
th
1
2
PA
NF-NC
2
22
BRAND NAME
COMPAZINE TABS,
SUPP
DICLEGIS
EMEND
PHENERGAN
SANCUSO
TIGAN
TRANSDERMSCOP
ZOFRAN, ODT
ZUPLENZ
REGLAN
GEQ
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PROCHLORPERAZINE
DOXYLAMINE/
PYRIDOXINE
APREPITANT
PROMETHAZINE
GRANISETRON
TRIMETHOBENZAMIDE
3
3
1
3
1
SCOPOLAMINE
ONDANSETRON
ONDANSETRON
2
1
3
METOCLOPRAMIDE
AG
AG
AG
AG
AG
AG
NF-NC
NF-NC
1 AG
NF-NC
1 AG
PA
2
1
NF-NC
PA
PA
PROMOTILITY AGENTS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ANTIDIARRHEALS
IMODIUM
LOPERAMIDE
LOMOTIL
MOTOFEN
DIPHENOXYLATE/
ATROPINE
DIFENOXIN/ ATROPINE
1
3
1
NF-NC
ANASPAZ
BENTYL
Y
Y
HYOSCYAMINE
DICYCLOMINE
1
1
CANTIL
CYSTOSPAZ M
MEPENZOLATE
BROMIDE
HYOSCYAMINE
3
3
DONNATAL TAB,
ELIXIR
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
NF-NC
DONNATAL ER
LEVSIN
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
HYOSCYAMINE
3
1
NF-NC
1
ANTISPASMODICS
th
th
1
1
PA
NF-NC
NF-NC
23
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
LIBRAX
NULEV
Y
Y
CLIDINIUM BROMIDE/
CHLORDIAZEPOXIDE
HYOSCYAMINE
1
1
1
1
PAMINE
METHSCOPOLAMINE
BROMIDE
PAMINE FORTE
METHSCOPOLAMINE
BROMIDE
METHSCOPOLAMINE
COMBO
NF-NC
PROPANTHELINE
HYOSCYAMINE
2
1
2
1
HYOSCYAMINE
PAMINE FQ
PRO-BANTHINE
7.5MG
SYMAX FASTABS
SYMAX DUOTAB
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
LAXATIVES/CATHARTICS
COLYTE
PEG3350/NA
SULF/BICARB/CL/KCL
GOLYTELY
#LACTULOSE
SOLN
PEG3350/NA
SULF/BICARB/CL/KCL
LACTULOSE
MOVIPREP
PEG3350/SOD
SUL/NACL/ASB/CL/KCL
PA
NF-NC
OSMOPREP
PA
NF-NC
PREPOPIK
NA PICOSUL/MAG-OX/
CITRIC ACID
NF-NC
SUCLEAR
PEG3350/NA SULF/
BICARB/KCL
NF-NC
SUPREP
SODIUM
/POTASSIUM/MAG
SULFATES
NF-NC
th
th
24
BRAND NAME
GEQ
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
CARDIOVASCULAR AGENTS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
NF-NC
1
2
1
2
Y
Y
TIER
MAND
SPEC
PARTNERS
MAND
SPEC
NITRATES
ISOSORBIDE
DINITRATE/
HYDRALAZINE
ISOSORBIDE
DINITRATE
BIDIL
DILATRATE-SR
IMDUR
ISORDIL 10MG
ISOSORBIDE
DINITRATE
ISORDIL 40MG
MONOKET
NITRO-BID OINT
NITRO-DUR
PATCHES 0.1, 0.2,
0.4, 0.6MG/HR
NITRO-DUR
PATCHES 0.3,
0.8MG/HR
NITROLINGUAL
SPRAY
NITROSTAT
PAPAVERINE
ISOSORBIDE
MONONITRATE
ISOSORBIDE
DINITRATE
ISOSORBIDE
MONONITRATE
NITROGLYCERIN
NITROGLYCERIN
TRANSDERMAL
NITROGLYCERIN
TRANSDERMAL
RECTIV OINT
PA
NITROGLYCERIN
NITROGLYCERIN
SUBLINGUAL
PAPAVERINE
3
1
NF-NC
1
Y
Y
NITROGLYCERIN
NF-NC
1
1
1
1
Y
Y
Y
Y
ANTIARRHYTHMICS
BETAPACE, AF
CALAN
CORDARONE
LANOXIN
th
Y
Y
Y
Y
SOTALOL
VERAPAMIL
AMIODARONE
DIGOXIN
1
1
1
1
th
25
BRAND NAME
MULTAQ
NORPACE
NORPACE CR
PACERONE
PRONESTYL
RANEXA
RYTHMOL, SR
SECTRAL
TAMBOCOR
TIKOSYN
GEQ
Y
Y
Y
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
2
1
2
1
DISOPYRAMIDE
AMIODARONE
PROCAINAMIDE
RANOLAZINE
PROPAFENONE
ACEBUTOLOL
FLECAINIDE
DOFETILIDE
3
1
3
2
1
1
1
3
NF-NC
DIGOXIN
GENERIC NAME
DRONEDARONE
HYDROCHLORIDE
DISOPYRAMIDE
TIER
PPO
PARTNERS
MEDICAID
1
NF-NC
PA
2
1
1
1
NF-NC
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
CARDIAC GLYCOSIDES
LANOXIN
DIURETICS
ALDACTAZIDE
25/25
ALDACTAZIDE
50/50
ALDACTONE
CHLORTHALIDON
E
DEMADEX
DYAZIDE
DYRENIUM
INSPRA
LASIX
LOZOL
MAXZIDE
ZAROXOLYN
ACCUPRIL
th
SPIRONOLACTONE/
HCTZ
SPIRONOLACTONE/
HCTZ
SPIRONOLACTONE
3
1
NF-NC
1
Y
Y
1
1
1
1
1
1
NF-NC
3
1
1
1
1
1
1
1
1
1
1
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
CHLORTHALIDONE
TORSEMIDE
TRIAMTERENE/ HCTZ
TRIAMTERENE
EPLERENONE
FUROSEMIDE
INDAPAMIDE
TRIAMTERENE/ HCTZ
METOLAZONE
QUINAPRIL
1
th
26
BRAND NAME
GEQ
ACCURETIC
ACEON
ALTACE
CAPOTEN
EPANED
SOLUTION
LOTENSIN
LOTENSIN HCT
Y
Y
Y
Y
LOTREL
MAVIK
MONOPRIL
MONOPRIL HCT
PRINIVIL
PRINZIDE
Y
Y
Y
Y
Y
Y
TARKA
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
Y
Y
Y
Y
QUINAPRIL/ HCTZ
PERINDOPRIL
RAMIPRIL
CAPTOPRIL
1
1
1
1
1
1
1
1
3
1
1
NF-NC
1
1
Y
Y
Y
1
1
1
1
1
1
1
1
1
1
1
1
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
ENALAPRIL
BENAZEPRIL
BENAZEPRIL/ HCTZ
AMLODIPINE/
BENAZEPRIL
TRANDOLAPRIL
FOSINOPRIL
FOSINOPRIL/ HCTZ
LISINOPRIL
LISINOPRIL/ HCTZ
TRANDOLAPRIL/
VERAPAMIL
MOEXIPRIL/ HCTZ
MOEXIPRIL
ENALAPRIL/ HCTZ
ENALAPRIL
LISINOPRIL/ HCTZ
2
1
1
1
1
1
2
1
1
1
1
1
Y
Y
Y
Y
Y
Y
ZESTRIL
LISINOPRIL
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs)
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
Y
Y
Y
Y
CANDESARTAN
CANDESARTAN
IRBESARTAN/ HCTZ
IRBESARTAN
AMLODIPINE/
OLMESARTAN
OLMESARTAN
OLMESARTAN/ HCTZ
1
1
1
1
1 DO
1
1
1 DO
Y
Y
Y
Y
2
2 DO
2
Y
Y
Y
AZOR
BENICAR
BENICAR HCT
th
Y
Y
th
2
2
2
DO
DO
DO
DO
DO
DO
DO
DO
DO
MAND
SPEC
PARTNERS
MAND
SPEC
27
BRAND NAME
COZAAR
DIOVAN
DIOVAN HCT
GEQ
Y
GENERIC NAME
TIER
EXFORGE
LOSARTAN
VALSARTAN
VALSARTAN/ HCTZ
AZILSARTAN
MEDOXOMIL
AZILSARTAN
MEDOXOMIL/
CHLORTHALIDONE
AMLODIPINE/
VALSARTAN
EXFORGE HCT
HYZAAR
MICARDIS
MICARDIS HCT
TEVETEN
AMLODIPINE/
VALSARTAN/HCTZ
LOSARTAN/ HCTZ
TELMISARTAN
TELMISARTAN/ HCTZ
EPROSARTAN
EDARBI
EDARBYCLOR
TEVETEN HCT
EPROSARTAN/ HCTZ
OLMESARTAN MED/
AMLODIPINE/HCTZ
TELMISARTAN/
AMLODIPINE
ALISKIREN/
VALSARTAN
TRIBENZOR
TWYNSTA
VALTURNA
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
DO
1
2 DO
1
MAND 90
Y
Y
Y
PA, DO
PA, DO
NF-NC
PA, DO
PA, DO
NF-NC
2
1
3
3
1
PA, DO
PA
DO
PA, DO
PA
DO
PA, DO
PA
DO
2
1
NF-NC
NF-NC
1 DO
Y
Y
Y
Y
Y
PA
PA
PA
NF-NC
NF-NC
2
1
1
3
1
2
1
1
NF-NC
1
Y
Y
Y
Y
Y
1
2
1
DO
DO
PA, DO
PA, DO
2
3
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
VASODILATORS
APRESOLINE
HYDRALAZINE
1
CALCIUM CHANNEL BLOCKERS
ADALAT CC
AMTURNIDE
CALAN, SR
CARDENE
CARDENE SR
CARDIZEM
th
Y
Y
Y
NIFEDIPINE
ALISKIREN/
AMLODIPINE/HCTZ
VERAPAMIL
NICARDIPINE
NICARDIPINE
DILTIAZEM
th
28
BRAND NAME
CARDIZEM CD 120,
180, 240, 300, 360
CARDIZEM LA
120MG
CARDIZEM LA 180,
240, 300, 360
420MG
CARTIA XT
COVERA HS
DILACOR XR
DYNACIRC CR
ISOPTIN SR
LOTREL
NIMOTOP
NORVASC
PROCARDIA, XL
SULAR 8.5, 17,
25.5, 34
TEKAMLO
VERELAN, PM
GEQ
Y
GENERIC NAME
TIER
DILTIAZEM
Y
Y
Y
Y
Y
Y
Y
PPO
PARTNERS
MEDICAID
DILTIAZEM
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
1
1
NF-NC
1
NF-NC
1
Y
Y
Y
Y
Y
Y
DILTIAZEM
DILTIAZEM
VERAPAMIL
DILTIAZEM
ISRADIPINE
VERAPAMIL
AMLODIPINE/
BENAZEPRIL
NIMODIPINE
AMLODIPINE
NIFEDIPINE
1
1
3
1
3
1
1
1
1
1
1
1
1
1
NISOLDIPINE
ALISKIREN/
AMLODIPINE
VERAPAMIL
2
1
2
1
Y
Y
TIMOLOL
NEBIVOLOL
CARVEDILOL
CARVEDILOL
NADOLOL
NADOLOL/
BENDROFLUMETHIAZIDE
METOPROLOL/HCTZ
PROPRANOLOL
BETAXOLOL
1
2
1
3
1
1
2 DO
1
NF-NC
Y
Y
Y
Y
Y
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
BETA-BLOCKERS
BLOCADREN
BYSTOLIC
COREG
COREG CR
CORGARD
CORZIDE
DUTOPROL
INDERAL LA
KERLONE
th
Y
Y
Y
Y
th
1
3
1
1
DO
DO
DO
PA
PA
PA
1
NF-NC
1
1
Y
Y
Y
Y
29
BRAND NAME
LEVATOL
LOPRESSOR
LOPRESSOR HCT
NORMODYNE
SECTRAL
GEQ
Y
Y
Y
Y
TENORETIC
TENORMIN
Y
Y
TOPROL XL
TRANDATE
ZEBETA
ZIAC
Y
Y
Y
Y
GENERIC NAME
PENBUTOLOL
METOPROLOL
METOPROLOL/ HCTZ
LABETALOL
ACEBUTOLOL
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
1
1
1
MAND 90
Y
Y
Y
Y
Y
1
1
1
1
Y
Y
1
1
1
1
1
1
1
1
Y
Y
Y
Y
1
NF-NC
1
Y
Y
Y
2
1
TIER
3
1
1
1
1
ATENOLOL/
CHLORTHALIDONE
ATENOLOL
METOPROLOL
SUCCINATE
LABETALOL
BISOPROLOL
BISOPROLOL/ HCTZ
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
Y
ALPHA BLOCKERS
CARDURA
CARDURA XL
FLOMAX
JALYN
MINIPRESS
Y
Y
DOXAZOSIN
DOXAZOSIN
TAMSULOSIN
1
3
1
DUTASTERIDE/
TAMSULOSIN
PRAZOSIN
2
1
PA
PA
PULMONARY ANTIHYPERTENSIVES
*ADCIRCA
*REVATIO
*TRACLEER
TYVASO
ALDOMET
ALDOMET 125
ALDORIL-D
CATAPRES, TTS
DIBENZYLINE
th
TADALAFIL
SILDENAFIL CITRATE
BOSENTAN
TREPROSTINIL/NEBULI
ZER KIT
3
1
2
METHYLDOPA
METHYLDOPA
METHYLDOPA/ HCTZ
CLONIDINE
PHENOXYBENZAMINE
1
2
3
1
3
th
PA
PA
SP
PA
PA
SP
PA
PA
SP
SP
SP
SP
MISCELLANEOUS ANTIHYPERTENSIVES
NF-NC
1 PA
4 SP
NF-NC
1
2
NF-NC
Y
Y
1
NF-NC
30
BRAND NAME
INSPRA
NEXICLON XR
TEKTURNA
TEKTURNA HCT
TENEX
GEQ
Y
VALTURNA
GENERIC NAME
TIER
EPLERENONE
CLONIDINE
ALISKIREN
ALISKIREN/ HCTZ
GUANFACINE
ALISKIREN/
VALSARTAN
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
3
2
2
1
SIGNATURE
PPO CLOSED
FORMULARY
1
NF-NC
2
2
1
MAND 90
Y
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
NF-NC
NF-NC
Y
Y
Y
ANTIHYPERLIPIDEMICS
ADVICOR
ALTOPREV
ANTARA
CADUET
COLESTID
COLESTID 7.5
CRESTOR
FENOGLIDE
FIBRICOR
Y
Y
Y
*JUXTAPID
*KYNAMRO
LESCOL
LESCOL XL
LIPITOR
LIPOFEN
Y
Y
LIPTRUZET
LIVALO
LOFIBRA
LOPID
LOVAZA
th
Y
Y
NIACIN/LOVASTATIN
LOVASTATIN
FENOFIBRATE
AMLODIPINE/
ATORVASTATIN
COLESTIPOL
COLESTIPOL
ROSUVASTATIN
FENOFIBRATE
FENOFIBRIC ACID
LOMITAPIDE
MESYLATE
MIPOMERSEN
FLUVASTATIN
FLUVASTATIN
ATORVASTATIN
FENOFIBRATE
EZETIMIBE/
ATORVASTATIN
PITAVASTATIN
CALCIUM
FENOFIBRATE
GEMFIBROZIL
OMEGA-3-ACID ETHYL
ESTERS
th
3
3
1
PA, DO
PA, DO
1
1
3
2
3
1
DO
PA, DO
PA, DO
PA, DO
PA, DO
1
DO
DO
1 DO
1
NF-NC
2 PA, DO
NF-NC
1
Y
Y
Y
Y
Y
Y
PA, DO
PA
PA, DO
PA
PA, DO
PA
PA, SP
PA, SP
PA, SP
NF-NC
3
1
3
1
3
PA, SP
DO
PA, DO
DO
PA
PA, SP
DO
PA, DO
DO
PA
PA, SP
DO
PA, DO
DO
PA
NF-NC
1
NF-NC
1 DO
NF-NC
Y
Y
Y
Y
DO
DO
DO
2 DO
3
1
1
PA, DO
PA, DO
PA, DO
NF-NC
1
1
Y
Y
Y
PA
PA
PA
NF-NC
31
BRAND NAME
GEQ
MEVACOR
NIASPAN
PRAVACHOL
PREVALITE
QUESTRAN BULK
SIMCOR
TRICOR
TRIGLIDE
TRILIPIX
TIER
PPO
DO
PARTNERS
MEDICAID
DO
DO
DO
DO
LOVASTATIN
NIACIN
PRAVASTATIN
CHOLESTYRAMINE/
ASPARTAME
CHOLESTYRAMINE
POWDER
NIACIN/ SIMVASTATIN
FENOFIBRATE
FENOFIBRATE
1
2
1
FENOFIBRIC ACID
1
3
PA
PA
2
2
2
1
DO
DO
ICOSAPENT ETHYL
EZETIMIBE/
SIMVASTATIN
COLESEVELAM
EZETIMIBE
SIMVASTATIN
VASCEPA
VYTORIN
WELCHOL
ZETIA
ZOCOR
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
DO
1
1
2
1
3
DO
DO
DO
PA
PA
PA
PA
DO
PA
PA
PA
PA
DO
DO
DO
ANTIMICROBIALS AND INFECTIOUS DISEASE
SIGNATURE
PPO CLOSED
FORMULARY
1 DO
2
1 DO
MAND 90
Y
Y
Y
1
2 DO
1
NF-NC
Y
Y
Y
Y
NF-NC
2 DO
2
2 PA
1 DO
Y
Y
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
PENICILLINS
AMOXIL
AUGMENTIN
CHEW TABS, 12531.25 SUSP
AUGMENTIN XR
AUGMENTIN, ES,
250-62.5 SUSP
MOXATAG 775 MG
ER
CECLOR
CEDAX
CEFTIN TABS
th
AMOXICILLIN
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN
TRIHYDRATE
NF-NC
CEFACLOR
CEFTIBUTEN
CEFUROXIME
1
3
1
th
PA
PA
CEPHALOSPORINS
PA
NF-NC
1
NF-NC
1
32
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
BRAND NAME
GEQ
KEFLEX
SPECTRACEF
SUPRAX
Y
Y
CEPHALEXIN
CEFDITOREN
CEFIXIME
1
1
3
DOXYCYCLINE
DOXYCYCLINE/SALICY
/OCT/ZINC OX
NF-NC
Y
Y
1
1
3
1
3
1
3
1
PA
1
1
NF-NC
1
NF-NC
PA
1
NF-NC
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
MINOCYCLINE
MINOCYCLINE KIT
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
MINOCYCLINE
MINOCYCLINE
TETRACYCLINE
TETRACYCLINE
DOXYCYCLINE
3
1
1
1
NF-NC
Y
Y
Y
Y
DOXYCYCLINE
DOXYCYCLINE
PPO
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
NF-NC
TETRACYCLINES
AVIDOXY DK
DORYX 100MG
DORYX 150MG
DORYX 200MG
MINOCIN
MINOCIN PAC
MONODOX
ORACEA
PERIOSTAT
SOLODYN 45, 90,
135
SOLODYN 55,65,
80, 105, 115
SUMYCIN SUSP
TETRACYCLINE
VIBRAMYCIN
VIBRAMYCIN
SUSP
VIBRAMYCIN
SYRUP
Y
Y
PA
PA
PA
1
1
1
NF-NC
MACROLIDES
BIAXIN, XL
DIFICID
E.E.S.
th
CLARITHROMYCIN
FIDAXOMICIN
ERYTHROMYCIN
ETHYLSUCCINATE
1
th
1
PA
PA
PA
NF-NC
1
33
BRAND NAME
E.E.S. GRANULES
E-MYCIN
ERYPED CHEW
TABS
ERY-TAB
ERYTHROCIN
KETEK
PCE
ZITHROMAX
GEQ
ZMAX
GENERIC NAME
TIER
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN BASE
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN BASE
ERYTHROMYCIN
STEARATE
TELITHROMYCIN
ERYTHROMYCIN BASE
AZITHROMYCIN
AZITHROMYCIN
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
3
3
NF-NC
NF-NC
1
2
1
2
1
3
3
1
1
NF-NC
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
3
SULFONAMIDES
BACTRIM DS,
SEPTRA DS
BACTRIM, SEPTRA
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
SULFAMETHOXAZOLE/
TRIMETHOPRIM
1
QUINOLONES
AVELOX
CIPRO
CIPRO SUSP
FACTIVE
LEVAQUIN
NOROXIN
PROQUIN XR
MOXIFLOXACIN
CIPROFLOXACIN
2
1
CIPROFLOXACIN
GEMIFLOXACIN
MESYLATE
LEVOFLOXACIN
NORFLOXACIN
CIPROFLOXACIN
2
3
1
3
2
PA
2
1
2
PA
PA
PA
NF-NC
1
NF-NC
NF-NC
MISCELLANEOUS ANTIBIOTICS
CLEOCIN 75, 150,
300MG
FLAGYL 250, 500
FLAGYL 375MG
FLAGYL ER
th
Y
Y
CLINDAMYCIN
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
1
1
3
3
th
PA
1
1
NF-NC
NF-NC
34
BRAND NAME
FUROXONE
HIPREX
MACROBID
MACRODANTIN
25MG
MACRODANTIN 50,
100MG
MONUROL
VANCOCIN
XIFAXAN
ZYVOX
GEQ
Y
Y
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
FURAZOLIDONE
METHENAMINE
NITROFURANTOIN
3
1
1
AG
AG
AG
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
1 AG
NITROFURANTOIN
AG
AG
AG
2 AG
NITROFURANTOIN
FOSFOMYCIN
TROMETHAMINE
VANCOMYCIN, ORAL
RIFAXIMIN
LINEZOLID
AG
AG
AG
1 AG
GENERIC NAME
PPO
PARTNERS
MEDICAID
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
1
NF-NC
2
3
1
3
2
URINARY ANTI-INFECTIVES (UTI)
BACTRIM DS,
SEPTRA DS
BACTRIM, SEPTRA
CIPRO
Y
Y
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
SULFAMETHOXAZOLE/
TRIMETHOPRIM
CIPROFLOXACIN
CIPRO SUSP
MACROBID
CIPROFLOXACIN
NITROFURANTOIN
2
1
AG
AG
AG
2
1 AG
NITROFURANTOIN
AG
AG
AG
2 AG
1
1
AG
AG
AG
1 AG
MACRODANTIN
25MG
MACRODANTIN 50,
100MG
TRIMETHOPRIM
Y
Y
UTA
VIBRAMYCIN
Y
Y
NITROFURANTOIN
TRIMETHOPRIM
METHENAMINE/METH
BLUE/SALICYLATE
METHENAMINE/METH
BLUE/SALICYLATE/NA
PHOS/HYOSCY
DOXYCYCLINE
ANCOBON
FLUCYTOSINE
URELLE
1
1
1
1
1
1
1
1
ORAL ANTIFUNGALS
th
th
35
BRAND NAME
GEQ
DIFLUCAN
FULVICIN U/F
GRIFULVIN-V
GRIS-PEG
LAMISIL
MYCELEX
TROCHES
NOXAFIL
ONMEL
ORAVIG
SPORANOX CAPS
SPORANOX SOLN
VFEND TABS
Y
Y
INH
MYAMBUTOL
MYCOBUTIN
PRIFTIN
PYRAZINAMIDE
RIFADIN
Y
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
FLUCONAZOLE
GRISEOFULVIN,
ULTRAMICROSIZE
GRISEOFULVIN
GRISEOFULVIN,
ULTRAMICROSIZE
TERBINAFINE
CLOTRIMAZOLE
TROCHES
POSACONAZOLE
ITRACONAZOLE
MICONAZOLE
ITRACONAZOLE
ITRACONAZOLE
VORICONAZOLE
2
1
2
1
1
1
1
1
1
3
3
3
1
3
1
1
NF-NC
NF-NC
NF-NC
ISONIAZID
ETHAMBUTOL
RIFABUTIN
RIFAPENTINE
PYRAZINAMIDE
RIFAMPIN
1
1
3
3
1
1
1
1
NF-NC
NF-NC
RIFAMPIN/ ISONIAZID
RIFAMPIN/ INH/
PYRAZINAMIDE
NF-NC
NF-NC
CYCLOSERINE
BEDAQUILINE
FUMARATE
ETHIONAMIDE
3
3
NF-NC
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
1
ANTITUBERCULOSIS AGENTS
Y
Y
RIFAMATE
RIFATER
SEROMYCIN
PULVULES
*SIRTURO
TRECATOR
1
1
ANTIVIRALS
AMANTADINE
th
AMANTADINE
1
th
36
BRAND NAME
GEQ
GENERIC NAME
TIER
FAMVIR
FLUMADINE TABS
RELENZA
TAMIFLU
VALTREX
ZOVIRAX CREAM
ZOVIRAX OINT
Y
Y
FAMCICLOVIR
RIMANTADINE
ZANAMIVIR
OSELTAMIVIR
VALACYCLOVIR
ACYCLOVIR
ACYCLOVIR
1
1
2
2
1
2
1
ARALEN
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
2
2
1
2
1
ANTIMALARIALS/ANTIPROTOZOALS
COARTEM
DARAPRIM
MALARONE
MEPRON
CHLOROQUINE
ARTEMETHER/
LUMEFANTRINE
PYRIMETHAMINE
ATOVAQUONE/
PROGUANIL
ATOVAQUONE
3
2
NF-NC
2
1
3
1
NF-NC
NEBUPENT
PENTAMIDINE
ISETHIONATE
NF-NC
PLAQUENIL
PRIMAQUINE
TINDAMAX
HYDROXYCHOLOROQUINE
PRIMAQUINE
TINIDAZOLE
1
2
1
1
2
1
Y
Y
ANTIHELMINTICS
ALBENZA
ALINIA
BILTRICIDE
STROMECTOL
ALBENDAZOLE
NITAZOXANIDE
PRAZIQUANTEL
IVERMECTIN
NF-NC
NF-NC
3
3
2
3
2
NF-NC
AMEBICIDES
ARALEN
ERY-TAB
FLAGYL
FLAGYL ER
th
Y
Y
Y
CHLOROQUINE
ERYTHROMYCIN BASE
METRONIDAZOLE
METRONIDAZOLE
th
1
1
1
3
PA
1
1
1
NF-NC
37
BRAND NAME
GEQ
YODOXIN
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
IODOQUINOL
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANALGESICS
DOLOBID
DIFLUNISAL
ANAPROX, DS
ANSAID
Y
Y
ARTHROTEC
CATAFLAM
CELEBREX
CLINORIL
DAYPRO
FELDENE
Y
Y
NAPROXEN SODIUM
FLURBIPROFEN
DICLOFENAC/
MISOPROSTOL
DICLOFENAC
CELECOXIB
SULINDAC
OXAPROZIN
PIROXICAM
FLECTOR
INDOCIN SUSP
INDOMETHACIN
MOBIC
MOTRIN
NAPRELAN CR
NAPROSYN
PONSTEL
RELAFEN
TORADOL
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
VIMOVO
VOLTAREN GEL
VOLTAREN XR
ZIPSOR
th
1
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
DICLOFENAC
EPOLAMINE
INDOMETHACIN
INDOMETHACIN
MELOXICAM
IBUPROFEN
NAPROXEN SODIUM
NAPROXEN
MEFENAMIC ACID
NABUMETONE
KETOROLAC
ESOMEPRAZOLE/
NAPROXEN
DICLOFENAC
DICLOFENAC,
EXTENDED RELEASE
DICLOFENAC
POTASSIUM
th
1
1
1
1
2
1
1
1
1
1
1
PA
DO
PA
DO
PA
NF-NC
PA, DO
1
2 DO
1
1
1
3
3
1
1
1
3
1
1
1
1
PA
AG
AG
DO
PA
AG
AG
DO
PA
AG
AG
DO
NF-NC
NF-NC
1 AG
1 DO
PA
PA
PA
1
NF-NC
AG
AG
AG
1
1
1
1 AG
3
3
PA
PA
PA
PA
PA
NF-NC
NF-NC
1
3
1
PA
PA
PA
NF-NC
38
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
NARCOTIC ANALGESICS
SIGNATURE
PPO CLOSED
FORMULARY
FENTANYL SL
FENTANYL CITRATE
3
1
PA
PA
PA
PA
PA
PA
NF-NC
1 PA
PA
PA
PA
NF-NC
BUTRANS
CODEINE
CONZIP
DEMEROL
DILAUDID
DILAUDID 5 LIQUID
DOLOPHINE
3
2
3
1
1
1
1
PA
PA
PA
Y
Y
Y
Y
MORPHINE SULFATE
BUPRENORPHINE
PATCH
CODEINE
TRAMADOL
MEPERIDINE
HYDROMORPHONE
HYDROMORPHONE
METHADONE
NF-NC
2
NF-NC
1
1
1
1
DURAGESIC
PATCH
PA, QL
PA, QL
PA
NF-NC
NF-NC
NF-NC
FENTANYL
MORPHINE SULFATE/
NALTREXONE
HYDROMORPHONE
FENTANYL CITRATE
BUTALBITAL/
ACETAMINOPHEN/
CAFFEINE
BUTALBITAL/
ACETAMINOPHEN/
CAFFEINE
BUTALBITAL/ ASPIRIN/
CAFFEINE/ CODEINE
HYDROCODONE/
IBUUPROFEN
ABSTRAL
ACTIQ
AVINZA
EMBEDA
EXALGO
FENTORA
FIORICET 50-32540
FIORICET 50-30040
FIORINAL
W/CODEINE #3
IBUDONE
KADIAN 10. 20, 30,
50, 60, 80, 100MG
KADIAN 40, 70,
200MG
*KADIAN 130,
150MG
th
3
3
3
PA, QL
PA
PA, QL
PA
NF-NC
MORPHINE SULFATE
MORPHINE SULFATE
NF-NC
MORPHINE SULFATE
NF-NC
th
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
39
BRAND NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
FENTANYL
ACETAMINOPHEN/
HYDROCODONE
METHADONE
3
1
1
1
1
1
1
NF-NC
MORPHINE
MORPHINE SULFATE
TAPENTADOL
HYDROCHLORIDE
TAPENTADOL
HYDROCHLORIDE
OXYMORPHONE
FENTANYL CITRATE
OXYMORPHONE
3
3
3
1
NF-NC
NF-NC
NF-NC
1
OXYMORPHONE
GEQ
LAZANDA
LORCET, PLUS
METHADONE
MORPHINE
TABLETS
MS CONTIN
Y
Y
Y
Y
NUCYNTA
NUCYNTA ER
NUMORPHAN
ONSOLIS
OPANA
OXYMORPHONE
ER (NON-CRUSH
RESISTANT)
OPANA ER
(CRUSH
RESISTANT)
ORAMORPH SR
ORBIVAN CF
OXYCONTIN
PERCOCET
PERCODAN
Y
Y
REPREXAIN
RYBIX ODT
RYZOLT
*SUBSYS
th
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
NF-NC
QL
QL
QL
1 QL
1
PA
PA
PA
PA, QL
PA, QL
PA, QL
1 PA, QL
OXYMORPHONE
MORPHINE,
SUSTAINED RELEASE
BUTALBITAL/
ACETAMINOPHEN
OXYCODONE
ACETAMINOPHEN/
OXYCODONE
ASPIRIN/ OXYCODONE
IBUPROFEN/
HYDROCODONE
PA, QL
PA, QL
PA, QL
NF-NC
TRAMADOL
TRAMADOL ER
FENTANYL SL SPRAY
th
2
3
2
1
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
QL
QL
PA, QL
NF-NC
NF-NC
QL
QL
QL
1 QL
1
1
PA
PA
NF-NC
1
PA
PA
PA
NF-NC
40
BRAND NAME
GEQ
TYLENOL
W/CODEINE
TYLOX
ULTRACET
ULTRAM
Y
Y
ULTRAM ER
VICODIN 5/500
VICODIN ES
7.5/750
VICODIN HP 10/660
VICODIN 5/300
VICODIN ES
7.5/300
VICODIN HP 10/300
VICOPROFEN
XODOL
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
ACETAMINOPHEN/
CODEINE
ACETAMINOPHEN/
OXYCODONE
TRAMADOL/
ACETAMINOPHEN
TRAMADOL
TRAMADOL SUST.
RELEASE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
IBUPROFEN/
HYDROCODONE
HYDROCODONE BIT/
ACETAMINOPHEN
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
QL
QL
QL
1 QL
QL
QL
QL
1 QL
1
1
QL
QL
QL
1 QL
1
PARTNERS
MAND
SPEC
1
1
QL
QL
QL
1 QL
QL
QL
QL
1 QL
QL
QL
QL
1 QL
PA, QL
PA, QL
PA, QL
1 PA, QL
PA, QL
PA, QL
PA, QL
1 PA, QL
PA, QL
PA, QL
PA, QL
1 PA, QL
1
1
MAND 90
MAND
SPEC
1
QL
QL
RESPIRATORY DRUGS
QL
1 QL
ALLERGIES
ACCOLATE
ALAVERT OTC
ALLEGRA OTC
BENADRYL
CLARINEX
TABS/REDITABS
CLARITIN OTC
PHENERGAN
th
Y
Y
Y
Y
ZAFIRLUKAST
LORATADINE
FEXOFENADINE
DIPHENHYDRAMINE
1
1
1
1
Y
Y
Y
DESLORATIDINE
LORATADINE
PROMETHAZINE
1
1
1
th
1
NC
NC
1
NC
NC
DO
DO
DO
AG
AG
AG
NC
NC
1 AG
41
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
BRAND NAME
GEQ
GENERIC NAME
TIER
SINGULAIR
TAVIST
XYZAL TABS
ZYRTEC OTC
Y
Y
Y
Y
MONTELUKAST
CLEMASTINE
LEVOCETIRIZINE
CETIRIZINE
1
1
1
1
ASTELIN
ASTEPRO
ATROVENT NASAL
SPRAY
1
2
1
2
VERAMYST
AZELASTINE
AZELASTINE
IPRATROPIUM
BROMIDE
BECLOMETHASONE,
AQUEOUS
AZELASTINE/
FLUTICASONE
FLUTICASONE
TRIAMCINOLONE,
AQUEOUS
MOMETASONE
CICLESONIDE
OLOPATADINE
BECLOMETHASONE
DIPROPIONATE
BUDESONIDE
FLUTICASONE
FUROATE
ZETONNA
CICLESONIDE
BECONASE AQ
DYMISTA
FLONASE
NASACORT AQ
NASONEX
OMNARIS
PATANASE
Y
Y
QNASL
RHINOCORT AQUA
TUSSIONEX
PENNKINETIC
VITUZ
ALLEGRA-D 12
HOUR OTC
th
HYDROCODONE/
CHLORPHEN POLIS
HYDROCODONE/
CHLORPHENIRAMINE
FEXOFENADINE/
PSEUDOEPHEDRINE
th
NC
PPO
1
1
1
NC
NC
NASAL SPRAYS
PA
PA
PA
NF-NC
3
1
PA
PA
PA
NF-NC
PARTNERS
MAND
SPEC
1
3
3
3
PA
PA
PA
PA
PA
PA
1
NF-NC
NF-NC
NF-NC
3
3
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
ANTIHISTAMINE/ANTITUSSIVES
NF-NC
NC
NF-NC
PA
PA
NC
DECONGESTANT/ANTIHISTAMINES
NF-NC
MAND 90
Y
MAND
SPEC
NC
NC
NC
42
BRAND NAME
ALLEGRA-D 24
HOUR OTC
GEQ
GENERIC NAME
FEXOFENADINE/
PSEUDOEPHEDRINE
PSEUDOEPHEDRINE/
DESLORATADINE
LORATIDINE/
PSEUDOEPHEDRINE
PHENYLEPHRINE/
CHLORPHENIRAMINE
PSEUDOEPHEDRINE/
CHLORPHENIRAMINE
CLARINEX-D
CLARITIN-D OTC
DECONAMINE
SYRUP
DECONAMINE
TABS
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
NC
NC
PA
PA
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
NC
NC
1
1
NC
NC
SEMPREX-D
ENTEX LA
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
ENTEX LQ
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
ZOTEX GP
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
BROMFED-DM
TESSALON
PERLES
NC
3
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT
GUAIFENESIN/
PHENYLEPHRINE
BROMPHENIRAMINE/
PSEUDOEPHEDRINE/
DEXTROMETHORPHA
N
BENZONATATE
PARTNERS
MAND
SPEC
NC
PSEUDOEPHEDRINE/
ACRIVAS
ZOTEX
MAND 90
MAND
SPEC
NC
1
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES
NC
NF-NC
1
1
ALBUTEROL SULFATE
FLUTICASONE/
SALMETEROL
CICLESONIDE
th
2
3
2
NF-NC
43
BRAND NAME
GEQ
ARCAPTA
ASMANEX
ATROVENT HFA
BREO ELLIPTA
BROVANA
COMBIVENT
COMBIVENT
RESPIMAT
CROMOLYN SOLN
DULERA
DUONEB
FLOVENT HFA
FORADIL
ISOETHARINE
MAXAIR
PROAIR HFA
PROVENTIL HFA
PULMICORT
0.25MG/2ML AND
0.5MG/2ML
RESPULE
PULMICORT
1MG/2ML
RESPULE AND
FLEXHALER
PULMOZYME
th
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
INDACATEROL
MOMETASONE
FUROATE
IPRATROPIUM
BROMIDE
FLUTICASONE/
VILANTEROL
ARFORMOTEROL
ALBUTEROL/
IPRATROPIUM
ALBUTEROL/
IPRATROPIUM
3
2
NF-NC
CROMOLYN SODIUM
MOMETASONE/
FORMOTEROL HFA
IPRATROPIUM/
ALBUTEROL SULFATE
FLUTICASONE
1
2
1
2
FORMOTEROL
FUMARATE
ISOETHARINE
PIRBUTEROL
ALBUTEROL
ALBUTEROL
2
1
3
3
3
2
1
NF-NC
NF-NC
NF-NC
BUDESONIDE
BUDESONIDE
DORNASE ALFA
2
2
2
2
th
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
QL
PA
PA
QL
PA
PA
QL
PA
PA
2 QL
44
BRAND NAME
GEQ
QVAR
SEREVENT
DISKUS
SPIRIVA
SYMBICORT
TUDORZA
PRESSAIR
VENTOLIN HFA
XOPENEX HFA
XOPENEX NEB
SOLN
GENERIC NAME
BECLOMETHASONE
DIPROPIONATE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
SALMETEROL
TIOTROPIUM BROMIDE
BUDESONIDE/
FORMOTEROL
2
2
2
2
ACLIDINIUM BROMIDE
ALBUTEROL
LEVALBUTEROL
2
2
3
2
2
NF-NC
LEVALBUTEROL
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
OTHER BRONCHODILATORS, ORAL
DALIRESP
METAPROTERENOL SYRUP
VENTOLIN
VOSPIRE ER
Y
Y
Y
ROFLUMILAST
METAPROTERENOL,
10MG/5ML
ALBUTEROL
ALBUTEROL
1
1
1
1
1
1
AMINOPHYLLINE
ELIXOPHYLLIN
ELIXIR
THEO-24 SR
THEOPHYLLINE
AMINOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
2
2
1
2
2
1
Y
Y
Y
ACCOLATE
SINGULAIR
ZYFLO, CR
Y
Y
ZAFIRLUKAST
MONTELUKAST
ZILEUTON
1
1
3
1
1
NF-NC
Y
Y
DORNASE ALFA
THEOPHYLLINES
PULMOZYME
th
th
PA
PA
MUCOLYTICS
PA
45
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
DERMATOLOGICS
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
TOPICAL STEROIDS
ACLOVATE
APEXICON OINT
APEXICON E
CLOBEX SPRAY
CLODERM
CORDRAN
4MCG/SQ CM
TAPE
CORDRAN, SP
CUTIVATE
CUTIVATE 0.05%
LOTION
DERMASMOOTHE-FS
0.01% OIL
DESONATE GEL
DESOWEN
DESOWEN
COMBO
DIPROSONE
ELOCON
HALOG
KENALOG
KENALOG
AEROSOL SPRAY
LOCOID, CREAM,
OINT, SOL.
th
Y
Y
ALCLOMETASONE
DIFLORASONE
DIACETATE
DIFLORASONE
DIACETATE
CLOBETASOL
PROPIONATE
CLOCORTOLONE
PIVALATE
FLURANDRENOLIDE
FLURANDRENOLIDE
FLUTICASONE
PROPIONATE
FLUTICASONE
PROPIONATE
FLUOCINOLONE
ACETONIDE
DESONIDE
DESONIDE
DESONIDE/EMOLLIENT
COMBO
BETAMETHASONE
DIPROPIONATE
MOMETASONE
FUROATE
HALCINONIDE
TRIAMCINOLONE
TRIAMCINOLONE
ACETONIDE
HYDROCORTISONE
BUTYRATE 0.1%
th
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
2
3
PA
PA
PA
2
NF-NC
1
3
1
PA
PA
PA
1
NF-NC
1
PA
PA
PA
NF-NC
1
2
1
1
2
1
3
1
PA
PA
PA
NF-NC
1
46
BRAND NAME
LOCOID LOTION,
LIPOCREAM
LUXIQ
GEQ
MOMEXIN
NUCORT
OLUX
OLUX-E
Y
Y
PANDEL
PEDIADERM HC
2% KIT
PEDIADERM TA
SYNALAR KIT
TEMOVATE
TOPICORT BRAND
ONLY PRODUCTS
TOPICORT
GENERIC
PRODUCTS
U-CORT 1%-10%
CREAM
Y
Y
ULTRAVATE PAC
VANOXIDE-HC
0.5%-5% LOTION
VANOS
VERDESO
WESTCORT
th
GENERIC NAME
TIER
HYDROCORTISONE
BUTYRATE/ EMOLL
BETAMETHASONE
MOMETASONE
FUROATE/AMMONIUM
LAC
HYDROCORTISONE/
ALOE VERA
CLOBETASOL
PROPIONATE
CLOBETASOL EMOLL
HYDROCORTISONE
PROBUTATE
HYDROCORTISONE/
EMOLLIENT
TRIAMCINOLONE/
EMOLLIENT
FLUOCINOLONE SOLN/
CLEANSER
CLOBETASOL
PROPIONATE
3
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NF-NC
PA
NF-NC
NF-NC
1
1
1
1
PA
PA
PA
NF-NC
PA
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
1
PA
PA
PA
NF-NC
DESOXIMETASONE
DESOXIMETASONE
HYDROCORTISONE/
UREA
HALOBETASOL PROP/
AMMONIUM LAC
HYDROCORTISONE/
BENZOYL PEROXIDE
FLUOCINONIDE
DESONIDE
HYDROCORTISONE
VALERATE
th
PA
PA
PA
NF-NC
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
NF-NC
PARTNERS
MAND
SPEC
MAND 90
MAND
SPEC
47
BRAND NAME
GEQ
AMLACTIN 12%
GENERIC NAME
TIER
AMMONIUM LACTATE
DL-E AC/ GRAPE/
HYALURONIC ACID
UREA
EMOLLIENT COMBO
UREA
UREA
EMOLLIENT COMBO
EMOLLIENT COMBO
UREA
UREA
UREA/LACTIC AC/ZN
UNDECYLENATE
UREA/ LACTIC ACID/
SALICYL ACID
AMMONIUM LACTATE
EMOLLIENT COMBO
PROMISEB
ATOPICLAIR
CARMOL
EPICERAM
GORDONS UREA
HYDRO 35, 40
HYLATOPIC
HYLATOPIC PLUS
KERAFOAM
KERALAC
KEROL AD
KEROL 50%
SUSPENSION
LAC-HYDRIN
NEOSALUS
Y
Y
3
1
3
3
1
3
3
3
1
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
TOPICAL EMOLLIENTS
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
PA
PA
PA
1
1
NF-NC
NF-NC
1
NF-NC
NF-NC
NF-NC
1
1
1
1
3
PA
1
1
NF-NC
EMOLLIENT COMBO
PA
NF-NC
PROMISEB
COMPLETE
EMOLLIENT COMBO
PA
NF-NC
TROPAZONE
EMOLLIENT COMBO
PA
NF-NC
UREA
1
3
1
1
PA
Y
Y
UREA
UREA
UREA
NF-NC
1
1
UREA
UREA
UREA
UREA
3
1
3
1
PA
NF-NC
PA
1
NF-NC
UMECTA
SUSPENSION
UMECTA
EMULSION
URAMAXIN
URAMAXIN GT
URAMAXIN GT KIT
UREA
UTOPIC
X-VIATE
th
Y
Y
th
PARTNERS
MAND
SPEC
Y
Y
MAND 90
MAND
SPEC
48
BRAND NAME
ZENIEVA
GEQ
Y
GENERIC NAME
TIER
EMOLLIENT COMBO
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
TOPICAL IMMUNOMODULATORS
ELIDEL
PIMECROLIMUS
PA
QL
QL
QL
1
1 QL
1 QL
1 QL
PSORIASIS
ANTHRALIN
ANTHRALIN
CALCIPOTRIENE
DOVONEX CRM
DOVONEX SOLN
Y
Y
Y
CALCIPOTRIENE
CALCIPOTRIENE
CALCIPOTRIENE
1
1
1
FABIOR FOAM
METHOTREXATE
SORIATANE
TAZAROTENE
METHOTREXATE TABS
ACITRETIN
3
1
3
BETAMET DIPROP/
CALCIPOTRIENE
TAZAROTENE
ANTHRALIN SHAMPOO
3
3
3
TACLONEX OINT,
SCALP SUSP
TAZORAC
ZITHRANOL
QL
QL
QL
QL
QL
QL
NF-NC
1
NF-NC
QL
QL
QL
NF-NC
NF-NC
NF-NC
PA
NF-NC
1
ANTI-INFECTIVES (TOPICAL)
ALTABAX
BACTROBAN OINT
BACTROBAN CRM
BACTROBAN
NASAL OINT
CORTISPORIN
GARAMYCIN
SULFAMYLON
RETAPAMULIN
MUPIROCIN
3
1
MUPIROCIN
MUPIROCIN
HYDROCORTISONE/
NEOMYCIN/POLYMYXIN/ BACITRACIN
GENTAMICIN
MAFENIDE ACETATE
PA
PA
1
PA, QL
PA, QL
PA, QL
2
1
3
2 PA, QL
2
1
NF-NC
BURN PREPARATIONS
SILVADENE
SILVER SULFADIAZINE
1
ANTIFUNGALS (TOPICAL)
CICLODAN KIT
th
CICLOPIROX OLAMINE
CREAM/ CLEANSER
th
PA
PA
PA
NF-NC
49
BRAND NAME
GEQ
Y
Y
Y
Y
Y
Y
Y
GENERIC NAME
CICLOPIROX SOLN 8%/
LACQUER REMOVAL
PADS
OXICONAZOLE NITRATE
NYSTATIN/EMOLLIENT
CICLOPIROX
METRONIDAZOLE/
CLEANSER
VUSION
XOLEGEL/
COREPAK
KETOCONAZOLE
th
SERTACONAZOLE
NITRATE
SULCONAZOLE
NITRATE
KETOCONAZOLE
KETOCONAZOLE
FOAM/ CLEANSER
TERBINAFINE
CICLOPIROX OLAMINE
CLOTRIMAZOLE 1%
CLOTRIMAZOLE/
BETAMETHASONE
BUTENAFINE
METRONIDAZOLE
METRONIDAZOLE
NYSTATIN
NAFTIFINE
KETOCONAZOLE
TERBINAFINE/
HYDROXYCHITOSAN
SELENIUM SULFIDE
MICONAZOLE
NITRATE/ZINC OXIDE
TERBINEX
TERSI
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
th
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
3
1
PA
PA
PA
NF-NC
1
3
3
1
1
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
1
3
1
1
1
3
1
3
3
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
1
NF-NC
1
1
1
NF-NC
1
NF-NC
NF-NC
NC
NF-NC
3
3
3
PA
PA
PA
PA
PA
PA
NC
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
50
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
PA
NF-NC
DAPSONE
TRETINOIN
AZELAIC ACID
CLINDAMYCIN/
BENZOYL PEROXIDE
ERYTHROMYCIN/
BENZOYL PEROXIDE
ERYTHROMYCIN
BASE/ BENZOYL
PEROXIDE
3
3
3
PA
PA, AG
PA
PA, AG
PA
PA, AG
NF-NC
NF-NC
NF-NC
BENZOYL PEROXIDE
BENZIQ WASH
BREVOXYL
CLEOCIN-T
CLINDACIN PAC
CLINDAGEL
DESQUAM X
DIFFERIN 0.1%
CREAM, GEL
DIFFERIN 0.1%
LOTION
DIFFERIN 0.3%
GEL
Y
Y
Y
BENZOYL PEROXIDE
BENZOYL PEROXIDE
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
BENZOYL PEROXIDE
1
1
1
3
3
1
1
1
1
NF-NC
NF-NC
1
ADAPALENE
ADAPALENE
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
DUAC
ADAPALENE
CLINDAMYCIN
PHOSPHATE-BENZOYL
PEROXIDE
ADAPALENE/BENZOYL
PEROXIDE
AZELAIC ACID
BENZOYL PEROXIDE/
SULFUR
BRAND NAME
GEQ
CLINDAMYCIN/
BENZOYL PEROXIDE
ACANYA
ACZONE 5% GEL
ATRALIN
AZELEX
BENZACLIN 1%-5%
GEL
BENZAMYCIN GEL
BENZAMYCINPAK
BENZEFOAM
ULTRA
EPIDUO
FINACEA
NUOX GEL
th
GENERIC NAME
th
PPO
ACNE
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
PA
PA
PA
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
3
PA
PA
PA
NF-NC
NF-NC
PA
PA
PA
NF-NC
51
BRAND NAME
PACNEX
PACNEX MX
RETIN A
RETIN A MICRO
0.04%
RETIN A MICRO
0.1%
GEQ
Y
Y
Y
AG
AG
AG
1
1
1 AG
PA, AG
PA, AG
PA, AG
NF-NC
AG
AG
AG
1 AG
BENZOYL PEROXIDE
SULFACETAMD/
SULFR/ SKNCLNSR10
TRETINOIN
BENZOYL PEROXIDE
BENZOYL PEROXIDE/
HC/SKIN CLNSR NO. 14
CLINDAMYCIN/
TRETINOIN
BENZOYL PEROXIDE/
HYALURONT
CLINDAMYCIN/
TRETINOIN
SULFANILAMIDE
CLINDAMYCIN
CLINDAMYCIN
FLUCONAZOLE
METRONIDAZOLE
METRONIDAZOLE
3
1
1
3
NF-NC
Y
Y
METRONIDAZOLE
NYSTATIN
1
1
VELTIN
ZACARE KIT
ZIANA
th
PPO
SIGNATURE
PPO CLOSED
FORMULARY
1
1
1
VANOXIDE HC
AVC CREAM
CLEOCIN VAGINAL
CREAM
CLEOCIN VAGINAL
OVULE
DIFLUCAN
FLAGYL
FLAGYL ER
METROGELVAGINAL 0.75%
MYCOSTATIN
TIER
PARTNERS
MEDICAID
BENZOYL PEROXIDE
BENZOYL PEROXIDE
TRETINOIN
TRETINOIN
MICROSPHERES
TRETINOIN
MICROSPHERES
RIAX
ROSANIL
TRETIN X
TRIAZ
CLEANER/PADS/
FOAMING CLOTHS
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
Y
Y
th
3
3
PARTNERS
MAND
SPEC
NF-NC
PA, AG
PA, AG
PA, AG
NF-NC
NF-NC
PA
PA
PA
NF-NC
PA, AG
PA, AG
PA, AG
NF-NC
PA
PA
PA
NF-NC
MAND 90
MAND
SPEC
PA, AG
PA, AG
PA, AG
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS
PA
NF-NC
1
1
NF-NC
1
1
52
BRAND NAME
NYSTATIN
VAGINAL TABS
TERAZOL
GEQ
GENERIC NAME
TIER
Y
Y
NYSTATIN
TERCONAZOLE
1
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
SCABICIDES & PEDICULOCIDES
EURAX
OVIDE
SKLICE
ULESFIA
CROTAMITON
MALATHION
IVERMECTIN
BENZYL ALCOHOL
NF-NC
1
NF-NC
NF-NC
3
1
3
3
TOPICAL ENZYMES
GRANULEX
OPTASE
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
2
OTHER AGENTS
ALDARA
CONDYLOX GEL
CONDYLOX
SOLUTION
MIRVASO
PANRETIN
PROTOPIC
SOLARAZE
TARGRETIN
VECTICAL
ZYCLARA
IMIQUIMOD
PODOFILOX
1
3
1
NF-NC
PODOFILOX
BRIMONIDINE
ALITRETINOIN
TACROLIMUS
DICLOFENAC SODIUM
BEXAROTENE
CALCITRIOL
IMIQUIMOD
1
3
2
3
2
2
3
3
1
NF-NC
PA
PA
QL
QL
PA
PA
BLOOD MODIFIERS
PA
QL
PA
2
NF-NC
2
2
NF-NC
NF-NC
ANTICOAGULANTS
BRILINTA
COUMADIN
ELIQUIS
th
TICAGRELOR
WARFARIN
3
1
PA, DO
PA, DO
PA, DO
NF-NC
1
APIXABAN
PA, DO
PA, DO
PA, DO
NF-NC
th
53
BRAND NAME
PRADAXA 150mg
XARELTO 10mg
GENERIC NAME
DALTEPARIN
SODIUM,PORCINE
ENOXAPARIN
DABIGATRAN
ETEXILATE MESYLATE
DABIGATRAN
ETEXILATE MESYLATE
RIVAROXABAN
XARELTO 15mg ,
20mg
RIVAROXABAN
FRAGMIN
LOVENOX
GEQ
PRADAXA 75mg
AGGRENOX
AGRYLIN
EFFIENT
PERSANTINE
PLAVIX
PLETAL
Y
Y
Y
ASPIRIN/
DIPYRIDAMOLE
ANEGRELIDE
PRASUGREL
HYDROCHLORIDE
DIPYRIDAMOLE
CLOPIDOGREL
CILOSTAZOLE
TRENTAL
PENTOXIFYLLINE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
3
1
NF-NC
1
2
2
2
PA
QL
PA
QL
PA
QL
PA, DO
PA, DO
PA, DO
ANTI-PLATELET DRUGS
3
1
2
1
1
1
AG
AG
AG
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
2 PA
2 QL
2 PA, DO
NF-NC
1
Y
Y
2
1 AG
1
1
Y
Y
Y
HEMORRHEOLOGIC AGENTS
1
COLONY STIMULATING FACTORS
LEUKINE
250MCG/ML
*LEUKINE
500MCG/ML
*NEUPOGEN
SARGRAMOSTIM
4 SPEC
SARGRAMOSTIM
FILGRASTIM
2
2
4 SPEC
4 SPEC
ERYTHROCYTE STIMULATORS
ARANESP
EPOGEN
PROCRIT
#AMICAR
th
DARBEPOETIN ALFA IN
POLYSORBATE
EPOETIN ALFA
EPOETIN ALFA
3
2
2
AMINOCAPROIC ACID
th
PA
PA
PA
PA
PA
PA
HEMOSTATICS
PA
PA
PA
NF-NC
4 SPEC PA
4 SPEC PA
1
54
BRAND NAME
GEQ
#AMICAR 1,000MG
GENERIC NAME
TIER
AMINOCAPROIC ACID
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
NF-NC
1
2
1
NF-NC
MAND
SPEC
PARTNERS
MAND
SPEC
EENT DRUGS
GLAUCOMA AGENTS
ALPHAGAN P
0.15%
ALPHAGAN P 0.1%
ATROPINE
AZOPT
BETAGAN
BETIMOL
BETOPIC 0.5%
BETOPTIC S
COSOPT
Y
Y
Y
th
3
1
2
1
3
PA
PA
PA
PA
Y
Y
Y
Y
Y
Y
1
3
1
NF-NC
1
NF-NC
Y
Y
Y
CYCLOPENTOLATE
CYCLOPENTOLATE
ACETAZOLAMIDE
APRACLONIDINE
APRACLONIDINE
2
1
1
1
3
2
1
1
1
NF-NC
Y
Y
CARBACHOL
CARBACHOL
NF-NC
HOMATROPINE
HOMATROPINE
TIMOLOL
BIMATOPROST
BIMATOPROST
3
3
2
3
ISOPTO
CARBACHOL 8%
ISOPTO
HOMATROPINE 5%
ISOPTO
HOMATROPINE 2%
ISTALOL
LUMIGAN 0.01%
LUMIGAN 0.03%
BETAXOLOL
BETAXOLOL
TIMOLOL/ DORZOLAM
DORZOLAMIDE/TIMOL
OL
COSOPT PF
CYCLOGYL 0.5%,
CYCLOGYL 1%, 2%
DIAMOXSEQUELS
IOPIDINE 0.5%
IOPIDINE 1%
ISOPTO
CARBACHOL1%,
2%, 4%
BRIMONIDINE
TARTRATE
BRIMONIDINE
TARTRATE
ATROPINE SULFATE
BRINZOLAMIDE
LEVOBUNOLOL
TIMOLOL
th
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
2 PA
NF-NC
Y
Y
55
BRAND NAME
GEQ
METIPRANOLOL
MYDRIACYL
NEPTAZANE
Y
Y
Y
PHOSPHOLINE
IODIDE SOLN
PILOCAR
PILOPINE HS
PROPINE
SIMBRINZA
TIMOPTIC
TIMOPTIC
OCUDOSE
TIMOPTIC XE
TRAVATAN Z
TRUSOPT
XALATAN
ZIOPTAN
Y
Y
Y
ALREX
DECADRON
FLAREX
FML
FML FORTE
FML S.O.P.
LOTEMAX
MAXIDEX
PRED FORTE
PRED MILD
th
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
Y
METIPRANOLOL
TROPICAMIDE
METHAZOLAMIDE
1
1
1
1
1
1
ECHOTHIOPHATE
PILOCARPINE
PILOCARPINE
DIPIVEFRIN
BRINZOLAMIDE/
BIMONIDINE
TARTRATE
TIMOLOL
2
1
2
3
2
1
2
NF-NC
Y
Y
Y
3
1
NF-NC
Y
Y
TIMOLOL
TIMOLOL
TRAVOPROST
DORZOLAMIDE
LATANOPROST
TAFLUPROST
1
3
1
1
3
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
PREDNISOLONE
PREDNISOLONE
th
PA
PA
PA
PA, DO
PA, DO
PA, DO
TOPICAL OPHTHALMIC STEROIDS
1
1
NF-NC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
3
3
3
3
3
2
3
2
1
2
1
NF-NC
MAND
SPEC
2
PA
NF-NC
2
1
2
56
BRAND NAME
GEQ
VEXOL
GENERIC NAME
TIER
RIMEXOLONE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ZYLET
DOXYCYCLINE/
EYELID CLNS NO.2&3
AZITHROMYCIN
BESIFLOXACIN
HYDROCHLORIDE
SULFACETAMIDE
SODIUM
CIPROFLOXACIN
CIPROFLOXACIN
ERYTHROMYCIN
GENTAMICIN
ERYTHROMYCIN
LEVOFLOXACIN
NATAMYCIN
POLYMYXIN/
BACITRACIN/
NEOMYCIN
OFLOXACIN
POLYMYXIN/
BACITRACIN
POLYMYXIN/
TRIMETHOPRIM
LEVOFLOXACIN
TOBRAMYCIN
TOBRAMYCIN
MOXIFLOXACIN
TRIFLURIDINE
TOBRAMYCIN/
LOTEPRED ETAB
BLEPHAMIDE
SULFACETAMIDE/
PREDNISOLONE
ALODOX
AZASITE
BESIVANCE
BLEPH-10
CILOXAN GEL
CILOXAN SOLN
ERYTHROMYCIN
GARAMYCIN
ILOTYCIN
IQUIX
NATACYN
NEOSPORIN
OCUFLOX
Y
Y
POLYSPORIN
POLYTRIM
QUIXIN
TOBREX OINT
TOBREX SOLN
VIGAMOX
VIROPTIC
Y
Y
th
Y
Y
Y
Y
Y
Y
3
3
NF-NC
NF-NC
NF-NC
1
3
1
1
1
1
3
3
1
NF-NC
1
1
1
1
1
1
2
1
2
1
1
1
2
1
2
1
NF-NC
3
TOPICAL OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY
2
th
1
1
1
1
NF-NC
NF-NC
57
BRAND NAME
BLEPHAMIDE
S.O.P.
GEQ
CORTISPORIN
MAXITROL
RESTASIS
TOBRADEX SUSP
TOBRADEX OINT
TOBRADEX ST
ALOCRIL
ALOMIDE
BEPREVE
ELESTAT
EMADINE
LASTACAFT
OPTIVAR
PATADAY
PATANOL
ZADITOR OTC
GENERIC NAME
SULFACETAMIDE/
PREDNISOLONE
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN/
BACITRACIN
DEXAMETHASONE/
NEOMYCIN/
POLYMYXIN
CYCLOSPORINE
DEXAMETHASONE/
TOBRAMYCIN
DEXAMETHASONE/
TOBRAMYCIN
TOBRAMYCIN/
DEXAMETHASONE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
2
1
2 QL
QL
QL
PA, QL
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
TOPICAL OPHTHALMIC VASOCONSTRICTORS/ANTIHISTAMINES
NEDOCROMIL SODIUM
LODOXAMIDE
TROMETHAMINE
BEPOTASTINE
BESILATE
EPINASTINE
EMEDASTINE
DIFUMARATE
ALCAFTADINE
AZELASTINE
OLOPATADINE
OLOPATADINE
KETOTIFEN
PA
PA
PA
NC
PA
PA
PA
NC
3
1
PA
PA
PA
NC
1
3
3
1
3
2
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
NC
NC
NC
NC
NC
1
KETOROLAC
TROMETHAMINE
KETOROLAC
TROMETHAMINE
1
3
th
1
PA
NF-NC
58
BRAND NAME
GEQ
GENERIC NAME
TIER
BROMDAY
ILEVRO
NEVANAC
PROLENSA
BROMFENAC SODIUM
NEPAFENAC
NEPAFENAC
BROMFENAC SODIUM
AURALGAN
BENZOCAINEANTIPYRINE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
3
3
2
3
PARTNERS
MEDICAID
PA
PA
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
NF-NC
2
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
OTIC AGENTS
CETRAXAL
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN
CORTISPORIN-TC
DOMEBORO
TREAGAN OTIC
TRIOXIN
VOSOL
Y
Y
VOSOL HC
CIPROFLOXACIN
CIPROFLOXACIN HCL/
HC
CIPROFLOXACIN/
DEXAMETH
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
ACETIC ACID
ANTIPYRINEBENZOCAINEPOLYCOSANOL
CHLOROXYLENOL/
BENZOC/HYDROCORT
ACETIC ACID
ACETIC ACID/
HYDROCORTISONE
NF-NC
NF-NC
PA
3
2
NF-NC
2
PA
1
PA
3
1
NF-NC
1
1
1
1
1
1
BEHAVIORAL HEALTH
DEPRESSION
NOTE: FOR HEALTHPLUS MICHILD/MICHILD CSHCS, MEDICATIONS FOR ADD/ADHD WRITTEN BY THE PCP OR PLAN SPECIALIST ARE COVERED BY HEALTHPLUS.
ALL OTHER BEHAVIORAL HEALTH MEDICATIONS ARE COVERED BY COMMUNITY MENTAL HEALTH (CMH).
AMITRIPTYLINE
ANAFRANIL
th
Y
Y
AMITRIPTYLINE
CLOMIPRAMINE
1
1
th
AG
AG
MDCH
MDCH
1 AG
1
59
BRAND NAME
APLENZIN
BRISDELLE
CELEXA
CYMBALTA
EFFEXOR XR
EMSAM PATCH
GEQ
Y
Y
FORFIVO XL
LEXAPRO
LUVOX CR
NARDIL
NORPRAMIN
Y
Y
Y
OLEPTRO ER
PAMELOR
PARNATE
PAXIL, CR
PEXEVA
Y
Y
Y
PRISTIQ
PROZAC
PROZAC WEEKLY
REMERON
SARAFEM
DOXEPIN
SURMONTIL
TOFRANIL, PM
VIIBRYD
VIVACTIL
WELLBUTRIN, SR
th
Y
Y
Y
Y
Y
Y
Y
Y
GENERIC NAME
TIER
BUPROPION
PAROXETINE
CITALOPRAM
DULOXETINE
VENLAFAXINE
SELEGILINE
3
3
1
2
1
3
BUPROPION
ESCITALOPRAM
FLUVOXAMINE
MALEATE
PHENELZINE
DESIPRAMINE
TRAZODONE
HYDROCHLORIDE
EXTENDED RELEASE
NORTRIPTYLINE
TRANYLCYPROMINE
PAROXETINE
PAROXETINE
3
1
DESVENLAFAXINE
SUCCINATE
FLUOXETINE
FLUOXETINE
MIRTAZAPINE
FLUOXETINE
DOXEPIN
TRIMIPRAMINE
MALEATE
IMIPRAMINE PAMOATE
VILAZODONE
PROTRIPTYLINE
BUPROPION
th
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PPO
PA
PA
DO
PA
DO
DO
1
1
1
PA, DO
PA, DO
3
1
1
1
3
PA
2
1
1
1
3
1
1
1
3
1
1
PA, DO
DO
DO
PA
PA
AG
PA, DO
PA
AG
PA, DO
PARTNERS
MEDICAID
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
NF-NC
1
2 PA
1
NF-NC
MDCH
MDCH
NF-NC
1 DO
MDCH
MDCH
MDCH
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2 DO
MDCH
MDCH
MDCH
MDCH
MDCH
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
1
1
1
NF-NC
1
1
1
NF-NC
1
1
1 AG
NF-NC
1
1
60
BRAND NAME
WELLBUTRIN XL
ZOLOFT
GEQ
Y
Y
GENERIC NAME
TIER
BUPROPION
SERTRALINE
1
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
DO
PPO
DO
PARTNERS
MEDICAID
MDCH
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
1 DO
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANXIETY
NOTE: FOR HEALTHPLUS MICHILD/MICHILD CSHCS, MEDICATIONS FOR ADD/ADHD WRITTEN BY THE PCP OR PLAN SPECIALIST ARE COVERED BY HEALTHPLUS.
ALL OTHER BEHAVIORAL HEALTH MEDICATIONS ARE COVERED BY COMMUNITY MENTAL HEALTH (CMH).
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
1
1
1
NF-NC
1
1
AG
1 AG
MDCH
MDCH
ATIVAN
BUSPAR
MILTOWN
NIRAVAM
SILENOR
TRANXENE T
VALIUM
Y
Y
Y
Y
VISTARIL
XANAX
ALPRAZOLAM
XANAX XR
ALPRAZOLAM
AMBIEN, CR
Y
Y
Y
ZOLPIDEM
LORAZEPAM
DIPHENHYDRAMINE
1
1
1
DO
ZOLPIDEM TARTRATE
ZOLPIDEM SL
3
3
PA, DO
PA, DO
PA, DO
PA, DO
ESZOPICLONE
PA, DO
PA, DO
TEMAZEPAM
DO
RAMELTEON
PA, DO
Y
Y
LORAZEPAM
BUSPIRONE
MEPROBAMATE
ALPRAZOLAM
DOXEPIN
CLORAZEPATE
DIAZEPAM
HYDROXYZINE
PAMOATE
1
1
1
1
3
1
1
1
PA, DO
PA, DO
AG
AG
1
INSOMNIA
NOTE: FOR HEALTHPLUS MICHILD/MICHILD CSHCS, MEDICATIONS FOR ADD/ADHD WRITTEN BY THE PCP OR PLAN SPECIALIST ARE COVERED BY HEALTHPLUS.
ALL OTHER BEHAVIORAL HEALTH MEDICATIONS ARE COVERED BY COMMUNITY MENTAL HEALTH (CMH).
ATIVAN
BENADRYL
EDLUAR
INTERMEZZO
LUNESTA
RESTORIL
ROZEREM
SOMNOTE
CHLORAL HYDRATE
SONATA
ZOLPIMIST
ZALEPLON
ZOLPIDEM TARTRATE
1
3
th
th
DO
PA, DO
DO
PA, DO
PA, DO
MDCH
MDCH
1 DO
MDCH
MDCH
MDCH
NF-NC
NF-NC
MDCH
MDCH
NF-NC
MDCH
MDCH
MDCH
1
NF-NC
1
1
NF-NC
61
RISPERIDONE
MICROSPHERES
SAPHRIS
ASENAPINE
QUETIAPINE
FUMARATE
MDCH
MDCH
MDCH
SEROQUEL XR
QUETIAPINE
FUMARATE
MDCH
SYMBYAX
OLANZAPINE/
FLUOXETINE
MDCH
OLANZAPINE
MDCH
SEROQUEL
ZYPREXA, ZYDIS
th
th
SP
DO
SP
62
MDCH
METHYLPHENIDATE
MDCH
NF-NC
1
2
1
MDCH
MDCH
MDCH
1
2 PA
1
NF-NC
1
1
1
2 PA
VYVANSE
METHYLPHENIDATE
ARMODAFINIL
MODAFINIL
METHYLPHENIDATE
ORAL SUSP
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE
ATOMOXETINE
LISDEXAMFETAMINE
DIMESYLATE
*XYREM
SODIUM OXYBATE
METADATE ER
METHYLIN CHEW
TAB
METHYLIN SOLN
5MG/5ML
NUVIGIL
PROVIGIL
QUILLIVANT XR
RITALIN
RITALIN LA
RITALIN SR
STRATTERA
th
Y
Y
Y
Y
Y
th
PA, DO
PA, DO
3
1
1
1
3
PA
PA
PA
PA
MDCH
MDCH
MDCH
MDCH
MDCH
PA
PA
MDCH
NF-NC
PA, DO
PA, DO
MDCH
NF-NC
63
BRAND NAME
ZENZEDI 2.5,
7.5MG
GEQ
GENERIC NAME
DEXTROAMPHETAMINE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MDCH
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANTICONVULSANTS
BANZEL
CARBATROL
CELONTIN
DEPAKENE
DEPAKOTE
DIASTAT
DIASTAT ACUDIAL
DILANTIN 100MG
CAPS
DILANTIN 30
KEPSEAL
DILANTIN 50
INFATAB
FANATREX
FELBATOL
GABITRIL
GABITRIL12,16MG
KEPPRA
KEPPRA XR
KLONOPIN
LAMICTAL 5, 25MG
DISPER TABLET
LAMICTAL/XR
LAMICTAL ODT
LAMICTAL/XR
STARTER KIT
LYRICA
MYSOLINE
NEURONTIN
th
Y
Y
Y
Y
RUFINAMIDE
CARBAMAZEPINE
METHSUXIMIDE
VALPROIC ACID
DIVALPROEX SODIUM
DIAZEPAM
DIAZEPAM
2
1
2
1
1
1
3
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2
1
2
1
1
1
NF-NC
PHENYTOIN
MDCH
MDCH
NF-NC
PHENYTOIN
Y
Y
Y
PHENYTOIN
GABAPENTIN
FELBAMATE
TIAGABINE
TIAGABINE
LEVETIRACETAM
LEVETIRACETAM
CLONAZEPAM
1
2
1
1
2
1
1
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
2
1
1
2
1
1
1
LAMOTRIGINE
MDCH
LAMOTRIGINE
LAMOTRIGINE
1
2
MDCH
MDCH
1
2
LAMOTRIGINE
PREGABALIN
PRIMIDONE
GABAPENTIN
2
2
1
1
MDCH
MDCH
MDCH
MDCH
2
2
1
1
Y
Y
Y
Y
Y
th
QL
64
BRAND NAME
ONFI TABLETS
ONFI
SUSPENSION
OXTELLAR XR
PEGANONE
PHENOBARBITAL
POTIGA
SABRIL
TEGRETOL, XR
TEGRETOL XR
100MG
TOPAMAX
TRILEPTAL
TROKENDI XR
VIMPAT
ZARONTIN
ZONEGRAN
GEQ
Y
Y
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
CLOBAZAM
PARTNERS
MEDICAID
MDCH
CLOBAZAM
OXCARBAZEPINE
ETHOTOIN
PHENOBARBITAL
EZOGABINE
VIGABATRIN
CARBAMAZEPINE
3
3
2
1
3
2
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
NF-NC
NF-NC
2
1
NF-NC
2
1
CARBAMAZEPINE
TOPIRAMATE
OXCARBAZEPINE
TOPIRAMATE
LACOSAMIDE
ETHOSUXIMIDE
ZONISAMIDE
1
1
1
3
2
1
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
1
1
NF-NC
2
1
1
QL
PA, QL
1 QL
NF-NC
GENERIC NAME
TIER
PPO
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
MIGRAINE MEDICATIONS
AMERGE
AXERT
CAFERGOT
CAMBIA
FIORINAL
FROVA
IMITREX
INJECTION
IMITREX SPRAY
IMITREX TABLET
PROPRANOLOL
Y
Y
Y
th
QL
PA, QL
QL
PA, QL
NARATRIPTAN
ALMOTRIPTAN
ERGOTAMINE/
CAFFEINE
DICLOFENAC
POTASSIUM
BUTALBITAL/ ASA/
CAFFEINE
1
3
FROVATRIPTAN
SUMATRIPTAN
INJECTION
SUMATRIPTAN NASAL
SPRAY
SUMATRIPTAN TABLET
PROPRANOLOL
PA, QL
PA, QL
PA, QL
NF-NC
QL
QL
QL
1 QL
1
1
1
QL
QL
QL
QL
QL
QL
1QL
1 QL
NF-NC
3
3
PA
PA
PA
th
NF-NC
1
65
BRAND NAME
GEQ
INDERAL LA
MAXALT, MLT
MIGRANAL NASAL
SPRAY
Y
Y
PRODRIN
RELPAX
SUMAVEL
DOSEPRO
TREXIMET
ZOMIG NASAL
SPRAY
ZOMIG, ZMT
AMRIX
BACLOFEN
COMFORT PACTIZANIDINE
DANTRIUM
FLEXERIL
FEXMID
LORZONE
NORFLEX
PARAFON FORTE
DSC
ROBAXIN
SKELAXIN
SOMA
ZANAFLEX
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
1
QL
QL
QL
1
1 QL
PA, QL
PA, QL
PA, QL
NF-NC
1
2
QL
QL
PA, QL
1
2 QL
PA, QL
PA, QL
PA, QL
NF-NC
PA, QL
PA, QL
PA, QL
NF-NC
PROPRANOLOL SR
RIZATRIPTAN
DIHYDROERGOTAMINE
ACETAMINOPHENISOMETHEPTENECAFFEINE
ELETRIPTAN
SUMATRIPTAN
INJECTION
SUMATRIPTAN/
NAPROXEN
ZOLMITRIPTAN NASAL
SPRAY
ZOLMITRIPTAN
CYCLOBENZAPRINE
BACLOFEN
3
1
TIZANIDINE COMBO
DANTROLENE
CYCLOBENZAPRINE
CYCLOBENZAPRINE
CHLORZOXAZONE
ORPHENADRINE
3
1
1
1
3
1
Y
Y
Y
Y
CHLORZOXAZONE
METHOCARBAMOL
METAXALONE
CARISOPRODOL
1
1
1
1
TIZANIDINE
Y
Y
Y
3
1
QL
QL
QL
QL
QL
QL
SKELETAL MUSCLE RELAXANTS
PA, AG
AG
PA, AG
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
1 QL
NF-NC
1
NF-NC
AG
AG
AG
1
1 AG
AG
AG
AG
AG
AG
AG
1
NF-NC
1 AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
NC
1 AG
1 AG
1 AG
NF-NC
1
PYRIDOSTIGMINE
1
th
66
BRAND NAME
GEQ
MESTINON 180
GENERIC NAME
TIER
PYRIDOSTIGMINE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
PARCOPA
PARLODEL
REQUIP
REQUIP XL
Y
Y
Y
Y
SINEMET, CR
STALEVO
TASMAR
ZELAPAR
APOMORPHINE
RASAGILINE
BENZTROPINE
ENTACAPONE
CARBIDOPA
PRAMIPEXOLE
PRAMIPEXOLE DI-HCL
ROTIGOTINE
CARBIDOPA/
LEVODOPA
BROMOCRIPTINE
ROPINIROLE
ROPINIROLE
LEVODAPA/
CARBIDOPA
CARBIDOPA/
LEVODOPA/
ENTACAPONE
TOLCAPONE
SELEGILINE
3
2
1
1
3
1
3
3
PA
PA
PA
MDCH
NF-NC
2
1
1
NF-NC
1
NF-NC
NF-NC
1
1
1
1
1
1
1
1
2
3
3
2
NF-NC
NF-NC
ALZHEIMER'S DISEASE
ARICEPT
EXELON
CAPSULES
EXELON SOLN
AND PATCH
NAMENDA
NAMENDA XR
RAZADYNE ER
th
DONEPEZIL
RIVASTIGMINE
2
2
3
1
2
2
NF-NC
RIVASTIGMINE
MEMANTINE
MEMANTINE
GALANTAMINE
th
67
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
HORMONES
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
2
1
1
2
2
1
1
TRIAMCINOLONE
BETAMETHASONE
HYDROCORTISONE
CORTISONE ACETATE
METHYLPREDNISOLONE
Y
Y
PREDNISOLONE
PREDNISOLONE
1
1
1
1
Y
Y
ORAL CONTRACEPTIVES, GF
APRI
ARANELLE
AVIANE
BEYAZ
CAMILA
CRYSELLE
DESOGEN
ENPRESSE
th
ETHINYL ESTRADIOL
30MCG
DESOGESTREL
0.15MG
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
20MCG
LEVONORGESTREL
0.1MG
DROSPIR/ETH
ESTRA/LEVOMEF OL
CA
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
30MCG
DESOGESTREL
0.15MG
ETHINYL ESTRADIOL
LEVONORGESTREL
th
NF-PA
PA
PA
PA
68
BRAND NAME
GEQ
ERRIN
ESTROSTEP FE
FEMCON FE
GENERESS FE
GENERIC NAME
NORETHINDRONE
0.35MG
NORETH A-ET
ESTRA/FE FUMARATE
NORETH-ETHINYL
ESTRADIOL/IRON
NORETH-ETHINYL
ESTRADIOL/IRON
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
TIER
PA
PPO
PA
PARTNERS
MEDICAID
PA
JOLIVETTE
NORETHINDRONE
0.35MG
KARIVA
ETHINYL ESTRADIOL
DESOGESTREL
LESSINA
LEVORA
ETHINYL ESTRADION
20MCG
LEVONORGESTREL
0.1MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
LO/OVRAL
LOESTRIN FE 1/20
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
LOESTRIN 21
1.5/30
LOESTRIN 21 1/20
th
th
MAND
SPEC
PARTNERS
MAND
SPEC
69
BRAND NAME
GEQ
LOESTRIN 24 FE
LO MINASTRIN FE
LOSEASONIQUE
LOW-OGESTREL
LYBREL
MICROGESTIN FE
1.5/30
MICROGESTIN FE
1/20
MIRCETTE
MODICON
MONONESSA
NATAZIA
th
GENERIC NAME
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
10MCG
NORETHINDRONE
1MG
L-NORGEST-ETH
ESTR/ETHIN ESTRA
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
ETHINYL ESTRADIOL
LEVONORGESTREL
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
ETHINYL ESTRADIOL
20MCG/ FE/
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
DESOGESTREL
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ESTRADIOL
VALERATE/DIENOGEST
th
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
PA
PA
PA
NF-PA
PA
PA
PA
NF-PA
NF-PA
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
70
BRAND NAME
GEQ
NECON 0.5/35
NECON 1/35
NECON 1/50
NECON 10/11
GENERIC NAME
NORTREL 0.5/35
NORTREL 1/35
ETHINYL ESTRADIOL
NORETHINDRONE
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
NORTREL 7/7/7
ETHINYL ESTRADIOL
NORETHINDRONE
NECON 7/7/7
NORA-BE
NORDETTE
NORINYL 1/35
NORINYL 1+50
th
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
TIER
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
NORETHINDRONE
th
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PPO
PA
PARTNERS
MEDICAID
PA
MAND
SPEC
PARTNERS
MAND
SPEC
71
BRAND NAME
OGESTREL
ORTHO
MICRONOR
ORTHO TRICYCLEN
ORTHO TRICYCLEN LO
ORTHO-CYCLEN
ORTHO-NOVUM
1/35
ORTHO-NOVUM
1/50
ORTHO-NOVUM
7/7/7
GEQ
Y
Y
Y
Y
Y
ORTHO-CEPT
OVCON 35
OVCON 50
th
GENERIC NAME
ETHINYL ESTRADIOL
50MCG
NORGESTREL 0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
30MCG
DESOGESTREL
0.15MG
ETHINYL ESTRADIOL
35MCG
NORETHINDRONE
0.4MG
ETHINYL ESTRADIOL
50MCG
NORETHINDRONE
1MG
th
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
NF-PA
TIER
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
PPO
PA
PA
PARTNERS
MEDICAID
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
72
BRAND NAME
PORTIA
GEQ
SAFYRAL
SEASONALE
SEASONIQUE
SPRINTEC
TRINESSA
TRI-NORINYL
TRI-SPRINTEC
TRIVORA
YASMIN
YAZ
ZOVIA 1/35
ZOVIA 1/50
th
GENERIC NAME
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
DROSPIR/ETHESTRA/L
EVOMEFOL CA
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
L-NORGEST-ETH
ESTR/ETHIN ESTRA
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
LEVONORGESTREL
ETHINYL ESTRADIOL
30MCG
DROSPIRENONE 3MG
ETHINYL ESTRADIOL
20MCG
DROSPIRENONE 3MG
ETHINYL ESTRADIOL
35MG
ETHYNODIOL
DIACETATE 1MG
ETHINYL ESTRADIOL
50MCG
ETHYNODIOL
DIACETATE 1MG
th
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
3
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
73
BRAND NAME
GEQ
ESTRADIOL,
TRANSDERMAL
CONJUGATED
ESTROGENS
ESTRADIOL,
TRANSDERMAL
ESTRADIOL
CONJUGATED
ESTROGENS
ESTRADIOL
ESTRADIOL
ESTRADIOL,
TRANSDERMAL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTROGENS
ESTROPIPATE
ALORA
CENESTIN
ENJUVIA
ESTRACE TABS
ESTRACE
VAGINAL CREAM
ESTRADERM
ESTRASORB
ESTRING
ESTROGEL GEL
FEMRING
FEMTRACE
MENEST
OGEN
TIER
ETONOGESTREL
ETHINYL ESTRADIOL
ETHINYL ESTRADIOL
NORELGESTROMIN
NUVARING
ORTHO EVRA
PATCH
CLIMARA
DIVIGEL
GENERIC NAME
PA
PA
AG
PA
PA
NF-PA
AG
AG
2AG
AG
AG
PA, AG
NF-NC
1
3
AG
AG
AG
1 AG
NF-NC
3
1
AG
AG
AG
AG
PA, AG
AG
NF-NC
1 AG
Y
Y
PA
ESTROGENS, GF
AG
AG
AG
AG
AG
AG
AG
AG
AG
PREMARIN VAG
CREAM
VAGIFEM
CONJUGATED
ESTROGENS
ESTRADIOL
2
3
MAND
SPEC
PARTNERS
MAND
SPEC
2
3
3
3
3
3
3
1
CONJUGATED
ESTROGENS
th
MAND 90
NF-PA
SIGNATURE
PPO CLOSED
FORMULARY
PA
PREMARIN ORAL
th
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
NON-ORAL CONTRACEPTIVES, GF
AG
AG
Y
Y
Y
AG
AG
AG
2 AG
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
1 AG
PA, AG
2 AG
2
NF-NC
Y
Y
Y
Y
Y
Y
74
BRAND NAME
GEQ
VIVELLE-DOT
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
ESTRADIOL,
TRANSDERMAL
AG
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
AG
2 AG
1
1
Y
Y
1AG
1 AG
NF-NC
NF-NC
2 AG
NF-NC
NF-NC
AYGESTIN
PROMETRIUM
Y
Y
NORETHINDRONE
ACETATE
PROGESTERONE
1
1
PROVERA
MEDROXYPROGESTERONE/ MPA
PPO
AG
PROGESTINS
MAND
SPEC
PARTNERS
MAND
SPEC
COMBINATION ESTROGEN/ANDROGEN
ESTRATEST
ACTIVELLA
ESTERIFIED
ESTROGENS/
METHYLTESTOSTERO
NE
ESTRADIOL/
NORETHINDRONE
ACETATE
ANGELIQ
CLIMARA PRO
COMBIPATCH
FEMHRT 1MG5MCG
FEMHRT 0.5MG2.5MCG
PREFEST
PREMPHASE
th
ESTRADIOL/
DROSPIRENONE
ESTRADIOL/
LEVONORGESTREL
ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
ESTRADIOL/
NORGESTIMATE
CONJUGATED
ESTROGEN/ MPA
th
AG
AG
AG
COMBINATION ESTROGEN/PROGESTINS
AG
AG
AG
AG
AG
AG
AG
AG
PA, AG
75
BRAND NAME
GEQ
PREMPRO
DDAVP NASAL
SPRAY
DDAVP RHINAL
TUBE
Y
Y
GENERIC NAME
CONJUGATED
ESTROGEN/ MPA
TIER
2
DESMOPRESSIN
ACETATE
DESMOPRESSIN
ACETATE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
AG
AG
PA, AG
DDAVP-DESMOPRESSIN ACETATE
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ANDROGENS, GM
NF-NC
ANDROID
ANDROXY
TESTOSTERONE
TESTOSTERONE,
TRANSDERMAL
METHYLTESTOSTERONE
FLUOXYMESTERONE
2
3
2
NF-NC
Y
Y
AXIRON
TESTOSTERONE
NF-NC
FORTESTA
TESTOSTERONE
METHYLTESTOSTERONE
OXANDROLONE
NF-NC
3
1
NF-NC
1
Y
Y
TESTOSTERONE
METHYLTESTOSTERONE
NF-NC
NF-NC
ANDRODERM
ANDROGEL
METHITEST
OXANDRIN
TESTIM
TESTRED
3
INFERTILITY
UROFOLLITROPIN
(FSH)
*BRAVELLE
*CETROTIDE
*CLOMID
*FOLLISTIM AQ
*GONAL-F
th
CETRORELIX
ACETATE
CLOMIPHENE
FOLLITROPIN
BETA,RECOMB
FOLLITROPIN
ALPHA,RECOMB
th
PA
PA
NC
NC
3
1
PA
PA
PA
PA
NC
NC
NC
NC
Y
Y
PA
PA
NC
NC
PA
PA
NC
NC
76
BRAND NAME
*LUPRON DEPOT
3.75 KIT
GEQ
*NOVAREL
*OVIDREL
*PREGNYL
*REPRONEX
*LUPRON DEPOT
3.75 KIT
SYNAREL NASAL
SPRAY
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
LEUPROLIDE ACETATE
GONADOTROPIN,
CHORIONIC,HUMAN
HCG
ALPHA,RECOMBINANT
GONADOTROPIN,
CHORIONIC,HUMAN
MENOTROPINS
LEUPROLIDE ACETATE
NAFARELIN ACETATE
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NC
NC
PA
PA
NC
NC
PA
PA
NC
NC
3
3
PA
PA
NC
NC
NC
NC
Y
Y
PA
4 SPEC
PA
PA
ENDOMETRIOSIS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
OSTEOPOROSIS
SELECTIVE ESTROGEN RECEPTOR MODULATOR
EVISTA
RALOXIFENE
OSPHENA
OSPEMIFENE
PA
NF-NC
BISPHOSPHONATES
ACTONEL
ATELVIA
BINOSTO
BONIVA
DIDRONEL
*FORTEO
FORTICAL
FOSAMAX
FOSAMAX PLUS D
MIACALCIN NASAL
th
Y
Y
NF-NC
3
1
1
3
3
1
NF-NC
1
1
NF-NC
NF-NC
1
RISEDRONATE
RISEDRONATE
SODIUM
ALENDRONATE
IBANDRONATE
ETIDRONATE
TERIPARATIDE
CALCITONIN
ALENDRONATE
ALENDRONATE/
VITAMIN D3
CALCITONIN
3
1
th
PA
PA
NF-NC
1
Y
Y
Y
Y
Y
Y
Y
Y
77
BRAND NAME
GEQ
ARMOUR
THYROID
CYTOMEL
GENERIC NAME
MAND 90
1 AG
1
1
1
1
Y
Y
1
1
2
1
1
2
Y
Y
Y
LEVOTHROID
LEVOXYL
METHIMAZOLE
PROPYLTHIOURACIL
Y
Y
LEVOTHYROXINE
SODIUM
LEVOTHYROXINE
SODIUM
METHIMAZOLE
PROPYLTHIOURACIL
SYNTHROID
TAPAZOLE
THYROLAR
Y
Y
TIROSINT
ZEMPLAR
SIGNATURE
PPO CLOSED
FORMULARY
TIER
THYROID,
DESSICATED
LIOTHYRONINE
SODIUM
LEVOTHYROXINE
SODIUM
METHIMAZOLE
LIOTRIX
LEVOTHYROXINE
SODIUM
PARICALCITOL
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
THYROID DISORDERS
AG
AG
AG
PA
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
2
3
2
DIABETES
INSULINS
APIDRA
APIDRA
SOLOSTAR
HUMALOG
HUMALOG MIX
HUMULIN
INSULINS
LANTUS
LANTUS
SOLOSTAR
LEVEMIR
LEVEMIR
FLEXPEN
th
INSULIN GLULISINE
PA
PA
PA
NF-NC
INSULIN GLULISINE
INSULIN LISPRO
INSULIN
3
2
2
PA
PA
PA
NF-NC
2
2
INSULIN
INSULIN GLARGINE
2
2
2
2
Y
Y
INSULIN GLARGINE
INSULIN DETEMIR
2
2
2
2
Y
Y
INSULIN DETEMIR
th
78
BRAND NAME
NOVOLIN
INSULINS
NOVOLOG
INSULINS
NOVOLOG MIX
INSULIN
SYRINGES
GEQ
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
INSULIN
PA
INSULIN ASPART
INSULIN
3
3
PA
PA
PA
PA
NEEDLES/SYRINGES
SYRINGES
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
PA
PA
NF-NC
PA
PA
NF-NC
NF-NC
1
1 AG
1
Y
Y
Y
1 AG
1 AG
Y
Y
1 AG
Y
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
SULFONYLUREAS
AMARYL
DIABETA
GLUCOTROL, XL
GLYNASE
PRESTAB
MICRONASE
Y
Y
Y
GLIMEPIRIDE
GLYBURIDE
GLIPIZIDE
1
1
1
Y
Y
GLYBURIDE
GLYBURIDE
1
1
DIABINESE
FORTAMET
GLUCOPHAGE, XR
Y
Y
Y
CHLORPROPAMIDE
METFORMIN
METFORMIN
1
1
1
AG
GLUCOVANCE
GLUMETZA
GLYBURIDE/
METFORMIN
METFORMIN
1
3
AG
PA
INVOKANA
CANAGLIFLOZIN
NF-NC
*KORLYM
MIFEPRISTONE
REPAGLINIDE/
METFORMIN
REPAGLINIDE
NATEGLINIDE
NF-NC
3
1
1
NF-NC
1
1
Y
Y
Y
NF-NC
PRANDIMET
PRANDIN
STARLIX
Y
Y
AG
AG
AG
AG
AG
AG
AG
AG
AG
ORAL ANTIHYPERGLYCEMICS
AG
AG
1
1
AG
AG
PA
1 AG
NF-NC
DPP-4 INHIBITORS
JANUMET, XR
th
SITAGLIPTIN /
METFORMIN
3
th
PA
PA
PA
79
BRAND NAME
GEQ
JANUVIA
JENTADUETO
JUVISYNC
KAZANO
KOMBIGLYZE XR
NESINA
ONGLYZA
OSENI
TRADJENTA
ACTOPLUS MET
ACTOPLUS MET
XR
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
DUETACT
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
SITAGLIPTIN
LINAGLIPTIN/
METFORMIN
SITAGLIPTIN/
SIMVASTATIN
ALOGLIPTIN/
METFORMIN
SAXAGLIPTIN/
METFORMIN
ALOGLIPTIN/
BENZOATE
PA, DO
SAXAGLIPTIN
ALOGLIPTIN/
PIOGLITAZONE
LINAGLIPTIN
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
PA, DO
PA, DO
NF-NC
2
3
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
PA, DO
PA, DO
PA, DO
NF-NC
PA, DO
PA, DO
PA, DO
NF-NC
PA
DO
NF-NC
2 DO
Y
Y
3
1
NF-NC
1
Y
Y
NF-NC
3
3
NF-NC
NF-NC
Y
Y
3
2
PIOGLITAZONE/
METFORMIN
PIOGLITAZONE/
METFORMIN
PIOGLITAZONE
ROSIGLITAZONE/
METFORMIN
ROSIGLITAZONE/
GLIMEPIRIDE
ROSIGLITAZONE
PIOGLITAZONE/
GLIMEPIRIDE
PA
PA
DO
DO
THIAZOLIDINEDIONES
MAND
SPEC
PARTNERS
MAND
SPEC
MISCELLANEOUS
BYDUREON
BYETTA
FREESTYLE
LITE/INSULINX,
th
EXENATIDE
EXTENDED RELEASE
EXENATIDE
2
2
TEST STRIPS
0
th
2
2
DO
DO
DO
0 DO
80
BRAND NAME
PRECISION XTRA
GLUCOSE TEST
STRIPS (no copay
at a pharmacy)
ALL OTHER TEST
STRIPS (covered at
DME only with a
copay as applicable)
GLYSET
LANCETS
PRECOSE
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
TEST STRIPS
MIGLITOL
LANCETS
ACARBOSE
DME
NF-NC
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
3
2
1
NF-NC
NF-NC
2
1
Y
Y
Y
PPO
PARTNERS
MEDICAID
NF-NC
NF-NC
SYMLIN
PRAMLINTIDE
ACETATE
SYMLINPEN
VICTOZA
PRAMLINTIDE
ACETATE
LIRAGLUTIDE
2
2
2
2
MAND
SPEC
PARTNERS
MAND
SPEC
GLUCAGON
GLUCAGON
GLUCAGON
2
ANTI-GOUT DRUGS
COLCRYS
INDOCIN SUSP
INDOMETHACIN
PROBENECID
ULORIC
ZYLOPRIM
Y
Y
Y
COLCHICINE 0.6MG
INDOMETHACIN
INDOMETHACIN
PROBENECID
FEBUXOSTAT
ALLOPURINOL
2
2
1
1
2
1
AG
AG
AG
AG
AG
AG
DO, PA
DO, PA
DO, PA
2
2 AG
1 AG
1
NF-NC
1
Y
Y
SUPPLEMENTS
ANTI-ANEMIA DRUGS
FOLIC ACID
FOLIC ACID
1
PRENATAL VITAMINS
ATABEX EC
BAL-CARE DHA
ESSENTIAL
th
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
th
81
BRAND NAME
B-NEXA
CITRANATAL
ASSURE
CITRANATAL BCALM
CITRANATAL
HARMONY
COMPLETE-RF
PRENATAL
CONCEPT OB,
DHA
DUET DHA
BALANCED
GESTICARE DHA
HEMENATAL OB
MIS + DHA
HEMOCYTE-F
TABLET
NATALVIT
NATELLE ONE
NESTABS
NESTABS DHA
NEXA SELECT
OB COMPLETE,
PREMIER, ONE,
400, DHA
OBSTETRIX EC
PREFERA OB
PREFERA-OB ONE
PREFERA-OB
PLUS DHA
PRENATA
PRENATAL
COMPLETE
th
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITMAINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
3
PA
PA
NF-NC
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
PREP
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
PA
NF-NC
PA
PA
PA
PA
PA
1
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
1
3
3
PA
PA
PA
NF-NC
1
NF-NC
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
th
1
3
3
3
3
3
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
82
BRAND NAME
PRENATAL PLUS
GEQ
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
VITAMINS, PRENATAL
PRENATE ELITE,
DHA, ESSENTIAL
VITAMINS, PRENATAL
PA
NF-NC
PRENATE MINI
VITAMINS, PRENATAL
PA
NF-NC
PRENEXA
PREQUE 10
SELECT-OB
SELECT-OB + DHA
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
3
3
3
PA
PA
PA
PA
NF-NC
NF-NC
NF-NC
NF-NC
VITAFOL-OB
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
VITAMINS, PRENATAL
VITAFOL-ONE
VITAMINS, PRENATAL
PA
NF-NC
VITAFOL-PLUS
VITAMED MD ONE
RX/QUATREFOLIC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMED MD PLUS
VITAMED MD
REDICHEW
RX/QUATREFOLIC
VIVA CT
PRENATAL
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
POTASSIUM
KLOR-CON
POTASSIUM
CHLORIDE
POTASSIUM
PHOSPHATE
POTASSIUM
CHLORIDE
SSKI SOLUTION
POTASSIUM IODIDE
NEURIN-SL
CYANOCOBALAMIN/ME
COBALAMIN
K-PHOS ORIGINAL
MICRO-K
VITAMIN B
2
2
VITAMIN D
ROCALTROL
th
CALCITRIOL
1
th
83
BRAND NAME
GEQ
FLUORABON
DROPS
GENERIC NAME
TIER
SODIUM FLUORIDE
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
VITAMINS WITH FLUORIDE
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
3
TOPICAL FLUORIDE
PREVIDENT 5000
BOOSTER GEL
PREVIDENT 5000
PLUS CREAM
PREVIDENT
DENTAL RINSE
PREVIDENT GEL
PREVIDENT 5000
SENSITIVE 1.1%5%
SODIUM FLUORIDE
SODIUM FLUORIDE
Y
Y
SODIUM FLUORIDE
SODIUM FLUORIDE
1
1
1
1
SODIUM FLUORIDE
1
VITAMIN K
MEPHYTON
PHYTONADIONE
2
MISCELLANEOUS AGENTS
HEAVY METAL ANTAGONISTS
CUPRIMINE
PENICILLAMINE
NF-NC
DESFERAL
*EXJADE
DEFEROXAMINE
MESYLATE
DEFERASIROX
1
2
1
2
QUININE SULFATE
QUININE SULFATE
QUININE SULFATE
1
ALKALINIZING AGENTS
UROCIT-K 5,
10MEQ
UROCIT-K 15MEQ
POTASSIUM CITRATE
POTASSIUM CITRATE
1
3
1
NF-NC
AMINO ACID DERIVATIVES
#CARNITOR
LEVOCARNITINE
1
GALLSTONE SOLUBILIZERS
ACTIGALL
th
URSODIOL
1
th
84
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
SMOKING CESSATION PRODUCTS
VARENICLINE
TARTRATE
DL
NICOTINE
POLACRILEX
NICOTINE
POLACRILEX
NICOTINE PATCH
Y
NICOTROL NS
ZYBAN
ANTABUSE
METHADONE
REVIA
CHANTIX
NICORETTE GUM
OTC
DL
DL
SIGNATURE
PPO CLOSED
FORMULARY
PARTNERS
MAND
SPEC
2 DL
NC
NC
NF-NC
NC
NF-NC
PA, DL
PA, DL
PA, DL
NF-NC
DL
DL
DL
1 DL
NF-NC
3
1
NF-NC
NICOTINE INHALER
NICOTINE NASAL
SPRAY
BUPROPION
Y
Y
Y
DISULFIRAM
METHADONE
NALTREXONE
1
1
1
MDCH
MDCH
MDCH
1
1
1
BUPRENORPHINE/
NALOXONE
MDCH
BUPRENORPHINE/
NALOXONE
MDCH
MDCH
ZUBSOLV
BUPRENORPHINE
BUPRENORPHINE/
NALOXONE
MDCH
ERECTILE DYSFUNCTION (ED)
CAVERJECT
ALPROSTADIL
GM, QL
TADALAFIL
NICOTINE
LOZENGE OTC
NICOTINE PATCH,
RX
NICOTINE PATCH
OTC
NICOTROL
INHALER
MAND 90
MAND
SPEC
NC
1
SUBSTANCE ABUSE DETERRENTS
NOTE: FOR HEALTHPLUS MICHILD/MICHILD CSHCS, MEDICATIONS FOR ADD/ADHD WRITTEN BY THE PCP OR PLAN SPECIALIST ARE COVERED BY HEALTHPLUS.
ALL OTHER BEHAVIORAL HEALTH MEDICATIONS ARE COVERED BY COMMUNITY MENTAL HEALTH (CMH).
SUBOXONE
SUBOXONE SL
SUBUTEX
th
th
GM, QL
AG,
GM,
PA, QL
NF-NC
NC
NC
NC
NC
85
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
TADALAFIL
PA, QL
PA, QL
NC
NC
EDEX
ALPROSTADIL
GM, QL
NC
NC
LEVITRA
VARDENAFIL
GM, QL
AG,
GM,
PA, QL
NC
NC
MUSE
ALPROSTADIL
GM, QL
NC
NC
STAXYN
VARDENAFIL
NC
NC
VIAGRA
SILDENAFIL
NC
NC
AZASAN
AZATHIOPRINE
CELLCEPT
MYCOPHENOLATE
MOFETIL
GENGRAF
IMURAN
MYFORTIC
Y
Y
CYCLOSPORINE
AZATHIOPRINE
MYCOPHENOLATE
1
1
2
1
1
2
Y
Y
Y
NEORAL
PROGRAF
RAPAMUNE
SANDIMMUNE
Y
Y
CYCLOSPORINE
TACROLIMUS
SIROLIMUS
CYCLOSPORINE
1
1
2
1
1
1
2
1
Y
Y
Y
Y
EVEROLIMUS
EVEROLIMUS
BRAND NAME
GEQ
ZORTRESS
0.25MG
*ZORTRESS 0.5,
0.75MG
GENERIC NAME
GM, QL
AG,
GM,
AG, GM, PA, QL
PA, QL
AG,
GM,
AG, GM, PA, QL
PA, QL
IMMUNE SUPPRESSANTS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
RHEUMATOLOGIC MEDCATIONS
ARAVA
*CIMZIA
*ENBREL
th
LEFLUNOMIDE
CERTOLIZUMAB
PEGOL
ETANERCEPT
1
3
2
th
1
PA
PA
PA
PA
PA
PA
NF-NC
4 SPEC PA
86
BRAND NAME
GEQ
GENERIC NAME
TIER
*HUMIRA
*#KINERET
*ORENCIA SQ
RAYOS
RIDAURA
*SIMPONI
ADALIMUMAB
ANAKINRA
ABATACEPT
PREDNISONE
AURANOFIN
GOLIMUMAB
2
3
3
3
2
3
*XELJANZ
TOFACITINIB
LIDOCAINE
LIDOCAINE
LIDOCAINE/
TETRACAINE
LIDODERM 5%
PATCH
LIDORX GEL
PLIAGLIS
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
PA
PA
PPO
PA
PA
PA
PA
PARTNERS
MEDICAID
PA
PA
PA
PA
PA
PA
PA
SPEC,
SPEC, PA
PA
SPEC, PA
LOCAL ANESTHETICS
PA
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
4 SPEC PA
NF-NC
NF-NC
NF-NC
2
NF-NC
MAND 90
NF-NC
MAND
SPEC
Y
Y
Y
PARTNERS
MAND
SPEC
Y
Y
Y
1 PA
NF-NC
NF-NC
3
POTASSIUM REMOVING RESINS
KAYEXALATE
SODIUM
POLYSTYRENE
SULFONATE
1
UROLOGY
AVODART
CARDURA
CARDURA XL
DETROL
DETROL LA
DITROPAN XL
ELMIRON
ENABLEX
FLOMAX
th
DUTASTERIDE
DOXAZOSIN
DOXAZOSIN
TOLTERODINE
TARTRATE
TOLTERODINE
TARTRATE
OXYBUTYNIN
PENTOSAN
POLYSULFATE
SOLIFENACIN
SUCCINATE
TAMSULOSIN
2
1
3
2
1
NF-NC
2 DO
1 DO
Y
Y
2
1
DO
DO
DO
DO
DO
DO
2
3
1
th
2
DO
DO
DO
NF-NC
1
Y
Y
87
BRAND NAME
GEQ
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
NF-NC
JALYN
GENERIC NAME
OXYBUTYNIN
CHLORIDE
DUTASTERIDE/
TAMSULOSIN
MYRBETRIQ
OXYTROL PATCH
PROSCAR
PYRIDIUM
RAPAFLO
SANCTURA
SANCTURA XR
3
3
1
1
3
1
1
DO
DO
DO
PA
PA
PA
PA
Y
Y
MIRABEGRON
OXYBUTYNIN
FINASTERIDE
PHENAZOPYRIDINE
SILODOSIN
TROSPIUM CHLORIDE
TROSPIUM CHLORIDE
TOVIAZ
URECHOLINE
2
1
DO
FESOTERODINE
FUMARATE
BETHANECHOL
UROXATRAL
GELNIQUE
Y
Y
VESICARE
METHERGINE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
3
2
ALFUZOSIN
DARIFENACIN
HYDROBROMIDE
METHYLERGONOVINE
MAND
SPEC
PARTNERS
MAND
SPEC
MAND 90
2
NF-NC
NF-NC
1
1
NF-NC
1
1
DO
DO
DO
OXYTOCICS
DO
DO
Y
Y
Y
Y
Y
Y
2 DO
1
2 DO
1
HEPATITIS C PRODUCTS
*COPEGUS
RIBAVIRIN
*INCIVEK
TELAPREVIR
PA
PA
PA
4 SPEC PA
*PEGASYS,
PROCLICK
PA
PA
PA
4 SPEC PA
*PEG-INTRON
PEGINTERFERON
ALFA-2A
PEGINTERFERON
ALFA-2B
PA
PA
PA
NF-NC
REBETOL ORAL
SOLUTION
*REBETOL
*RIBAPAK
RIBASPHERE
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
NF-NC
1
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
th
Y
Y
3
1
3
1
th
88
BRAND NAME
*RIBATAB
*VICTRELIS
VIRAZOLE
AMITIZA
LINZESS
LOTRONEX
GEQ
Y
GENERIC NAME
TIER
RIBAVIRIN
BOCEPREVIR
RIBAVIRIN
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
1
PA
PA
PA
4 SPEC PA
2
NF-NC
3
IRRITABLE BOWEL SYNDROME/CHRONIC CONSTIPATION
LUBIPROSTONE
LINACLOTIDE
ALOSETRON
2
3
2
MAND 90
MAND
SPEC
Y
Y
PARTNERS
MAND
SPEC
Y
Y
PA
2
NF-NC
NF-NC
MDCH
MDCH
PA
2 PA
2
NF-NC
MDCH
NF-NC
PA
NF-NC
FIBROMYALGIA
CYMBALTA
LYRICA
SAVELLA
DULOXETINE
PREGABALIN
MILNACIPRAN
2
2
3
PA
QL
PA
*#KALYDECO
IVACAFTOR
PA
*TOBI SOLUTION/
PODHALER
TOBRAMYCIN
PA
PA
MULTIPLE SCLEROSIS
3
3
2
3
PA, SP
PA
PA
PA
PA, SP
PA
PA
PA
PA, SP
PA
PA
PA
NF-NC
NF-NC
4 SPEC PA
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
*COPAXONE
DALFAMPRIDINE
TERIFLUNOMIDE
INTERFERON BETA-1A
INTERFERON BETA-1B
GLATIRAMER
ACETATE
PA
PA
PA
4 SPEC PA
*EXTAVIA
INTERFERON BETA-1B
PA
PA
PA
NF-NC
*GILENYA
PA, DO
PA, DO
PA, DO
NF-NC
*REBIF
FINGOLIMOD
INTERFERON BETA1A/ALBUMIN
PA
PA
PA
4 SPEC PA
*TECFIDERA
DIMETHYL FUMERATE
NF-NC
GRALISE
GABAPENTIN
PA
PA
PA
NF-NC
HORIZANT
GABAPENTIN
ENACARBIL
PA, DO
PA, DO
PA, DO
NF-NC
*AMPYRA
*AUBAGIO
*AVONEX
*BETASERON
th
th
PA
PA
CYSTIC FIBROSIS
PA
PA
PA
PA
NEUROLOGICAL MISCELLANEOUS
89
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
NUEDEXTA
DEXTROMETHORPHAN/QUINIDINE
PA
*XENAZINE
TETRABENAZINE
FOSRENOL
PHOSLO
RENAGEL
LANTHANUM
CARBONATE
CALCIUM ACETATE
SEVELAMER
2
1
2
BRAND NAME
GEQ
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NF-NC
PA
PA
PA
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
MAND
SPEC
PARTNERS
MAND
SPEC
2
NF-NC
2
2
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NF-NC
2
1
2
*#COMETRIQ
DROXIA
SEVELAMER
CARBONATE
2
2
ONCOLOGY-ONCOLOGY DRUGS ARE ON FORMULARY UNLESS LISTED OTHERWISE
CABOZANTINIB
2
2
HYDROXYUREA
2
2
*#ICLUSIG
*JAKAFI
*#XALKORI
*XTANDI
PONATINIB
RUXOLITINIB
CRIZOTINIB
ENZALUTAMIDE
2
3
2
2
*#ZELBORAF
VEMURAFENIB
RENVELA
MAND 90
PA
PA
PA
GROWTH HORMONES
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
4 SPEC PA
2
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
HIV ALL HIV SELF-ADMINISTERED DRUGS ARE ON FORMULARY
*EGRIFTA
*GENOTROPIN
*HUMATROPE
*NORDITROPIN
*NUTROPIN
*OMNITROPE
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
#FUZEON
ENFUVIRTIDE
PA
PA
PA
2 PA
#TRUVADA
EMTRICITABINE/TENO
FOVIR DISOPROXIL
FUMARATE
PA, DO
PA, DO
MDCH
2 PA, DO
th
th
90
BRAND NAME
GEQ
BOTOX, DYSPORT,
XEOMIN
IMMUNE
GLOBULIN
ORENCIA IV
REMICADE
RITUXAN
SYNAGIS
TYSABRI
FOLIC ACID
(FEMALE ONLY)
IRON
SUPPLEMENTS
(AGES 6 MONTHS
TO 1 YEAR)
ORAL FLUORIDE
(AGES 6 MONTHS
TO 6 YEARS)
OTC ASPIRIN
(AGES 45-79
YEARS)
OTC NICOTINE
PATCHES
th
HMO
POS
TPA
SIGNATURE
M-SUPP RDS
PARTNERS
PPO CLOSED
GENERIC NAME
TIER
MICHILD
PPO
MEDICAID
FORMULARY
MEDICAL PRIOR AUTHORIZATION DRUGS WITH A MEDICAL BENEFIT COPAY
BOTULISM TOXIN
TYPE A
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
M-NC PA
PA
PA
M-NC PA
M
PA
IVIG
M-NC PA
M
PA
PA
PA
ABATACEPT
M-NC PA
M
PA
PA
PA
INFLIXIMAB
M-NC PA
M
PA
PA
PA
RITUXIMAB
M-NC PA
M
PA
PA
PA
PALIVIZUMAB
M-NC PA
M
PA
PA
PA
NATALIZUMAB
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM COVERED AT A ZERO COPAY WITH PRESCRIPTION
Y
NA
NA
NA
NA
NA
th
91
Addition of
Oral Agent
OR
Very Symptomatic
Severe
Hyperglycemia
Ketoacidosis
Possible Type 1
Pregnancy
Elevated A1c
Rapid
Short
Intermediate
Long
Acting
Acting
Acting
Acting
lispro
regular
NPH
glargine
aspart
70/30
detemir
glulisine
(See the American Diabetes Association Position Statements,
Insulin Administration, and Continuous Subcutaneous
Insulin Infusion, for further discussion on this subject.)
Addition
of
Insulin
Glycemic
goals not
achieved
Addition of
Third Agent **
Glycemic
goals not
achieved
Intensify
Insulin
Therapy
Insulin Options
Basal insulin once or twice daily
Basal insulin + 1 (mealtime) rapidacting injection
Intermediate twice daily
Basal insulin + 2 (mealtime) rapidacting injections
Continuous insulin infusion pump
- Add on therapy is indicated if glycemic goals are not reached/maintained after 36 months treatment
- Insulin therapy is eventually required due to progressive nature of T2DM
- Glycemic goals: A1C < 7%, or individualize to a goal < 8% based on complex
patient factors.
- More stringent goals (i.e. <6.5%) for patients if results can be achieved without
risk of hypoglycemia
- Check A1C every 3 months as therapy is changing or if goal is not met; once
goal is met, may check every 6 months
- Preprandial Plasma Glucose goal of 70-130 mg/dL
- Peak Postprandial Plasma Glucose goal of <180
** Initiation of insulin therapy is preferred over the use of three oral agents
Biguanides
Insulin
Amaryl* (glimepiride)
Diabinese* (chlorpropamide)
Glucotrol*/Glucotrol XL* (glipizide)
Glynase* (glyburide)
Micronase* (glyburide)
Orinase* (tolbutamide)
Tolinase* (tolazamide)
Glucophage* (metformin)
Glucophage XR*, Fortamet* (metformin ER)
Humulin
Humalog (lispro)
Lantus (insulin glargine)
Levemir (insulin detemir)
Alpha-Glucosidase Inhibitors
Precose* (acarbose)
GLP-1 Receptor Agonists
Byetta (exenatide)
Bydureon (exenatide once-weekly)
Victoza (liraglutide)
Thiazolidinediones
Avandia (rosiglitazone)
Actos (pioglitazone)*
Combination Products
Misc
Symlin (pramlintide)
Welchol (colesevelam)
Starlix* (nateglinide)
*available in generic
#
The FDA limits the use of rosiglitazone-containing products through a restricted distribution Risk Evaluation and Mitigation
Strategy (REMS) program effective 11/2011.
References:
Diabetes Care ,vol 35, supplement 1, January 2012
Diabetes Care, June 2012. vol. 35, no. 6. 1364-1379 (Position Statement)
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults. Institute for Clinical Systems Improvement, July 2010
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013;36:S11-66.
92
Stage 1
Hypertension
Stage 2
Hypertension
CCB
ALDO ANT
x
x
x
x
* Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling
indication is managed in parallel with the BP.
Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; Aldo ANT, aldosterone antagonist; BB,
beta-blocker; CCB, calcium channel blocker.
Formulary Drugs
Diuretics
Beta-Blockers
ACE Inhibitors
ARBs
Calcium Channel
Blockers
Aldactone*,
Bumex*,
Demadex*, Dyazide*,
Hydro-Diuril*,
Hygroton*
Inspra*, Lasix*,
Lozol*,Maxide*,
Zaroxolyn*
Blocadren*, Bystolic,
Coreg*, Corgard*,
Inderal*, Inderal LA*,
Kerlone*,
Lopressor*,
Normodyne*,
Sectral*, Tenormin*,
Toprol XL*,
Trandate*,
Visken*, Zebeta*,
Accupril*,
Aceon*, Altace*
Capoten*,
Lotensin*,
Mavik*
Monopril*,
Univasc*
Vasotec*,
Zestril*
Benicar (HCT)
Cozaar*/Hyzaar*
Diovan (HCT)*
Avapro*
Avalide*
Atacand HCT*
Adalat CC*
Cardene*
DynaCirc*
Nimotop*
Norvasc*
Plendil*
Procardia XL*
Sular*
Cardizem (CD)*
Cartia XT*
Calan SR*
Isoptin SR*
Tekturna (HCT)
Combination Agents
Azor
(amlodipine/olmesartan)
Exforge
(Diovan/Norvasc)
Lotrel*
(Lotensin/Norvasc)
* Generic available
Adapted from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII), May 2003**
Drugs for Hypertension. Treatment Guidelines from the Medical Letter, Vol. 10, Issue 113, January 2012
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013;36:S11-66
93
Stage A
At high risk for HF but
without structural heart
disease or symptoms
of HF
Class I
Stage B
Structural heart disease but
without signs or symptoms
of HF
Patients with:
- Previous MI
- LV remodeling
including LVH and
low ejection fraction
- Asymptomatic
valvular disease
Patients with:
- Hypertension
- Atherosclerotic disease
- Diabetes mellitus
- Obesity
- Metabolic syndrome
- Family history of
cardiomyopathy
- Exposure of cardiotoxins
Patients with:
- Known structural
heart disease
- Shortness of breath,
fatigue, and reduced
exercise tolerance
Class IV
Stage D
Refractory HF requiring
specialized
interventions
Goals
- All goals under Stages A and B
- Dietary salt restriction
Goals
All goals under Stage A
Goals
- Control hypertension
- Encourage smoking cessation
- Control lipid disorders
- Encourage regular exercise
- Discourage alcohol, illicit drugs
- Control metabolic syndrome
- Control blood sugar
- Treat thyroid disorders
Drugs
- ACEI or ARB^
- Beta-Blockers
Devices in Selected
Patients
- Implantable
Defibrillators
Drugs
- ACEI or ARB^
Goals
Appropriate measures under
Stages A, B, and C
Drugs
- Diuretics for fluid retention
- Use ACEI or ARB^
- Use Beta-Blockers
Drugs in select patients
- Aldosterone antagonist
- ARB
- Digitalis #
- Hydralazine/Nitrates
Options
- End-of-life care
options/hospice
- Extraordinary measures
* Heart transplant
* Chronic inotropes
* Permanent mechanical
support
* Experimental surgery
or drugs
FORMULARY AGENTS
Cardiovascular Medications Indicated for Treatment of Various Stages of HF
ACE Inhibitors
Stage B
Stage C
Capoten* (captopril)
Post MI
HF
Vasotec* (enalapril)
Asymptomatic LVSD HF
Monopril* (fosinopril)
HF
Zestril* (lisinopril)
Post MI
HF
Accupril* (quinapril)
HF
Altace* (ramipril)
Post MI
Post MI
Mavik* (trandolapril)
Post MI
Post MI
ARBs
Cozaar* (losartan potassium)
Benicar (olmesartan)
Diovan (valsartan)
Post MI
Post MI, HF
Avapro* (irbesartan)
Coreg* (carvedilol)
Toprol XL* (metoprolol)
Zebeta* (bisoprolol)
Aldosterone Antagonists for HF
Aldactone* (spironolactone)
Inspra* (eplerenone)
Common Diuretics for HF
Lasix* (furosemide)
Bumex* (bumatanide)
Zaroxolyn* (metolazone)
Microzide* (hydrochlorothiazide)
Aldactone* (spironoloactone)
References:
2009 Focused Update American College of Cardiology/American Heart Association Guideline Update for the Diagnosis and
Management of Chronic Heart Failure in Adults. Circulation 2009;119;1977-2016.
Review Date: 7/2013
94
Simple Analgesics:
(e.g., aspirin, Excedrin)
Simple Analgesics:
(e.g., aspirin, Excedrin,)
Moderate to Severe
Intensity/Disability (MIDAS
Scale Grade III & IV) or
Non-Responsive to NSAIDs
Anti-migraine (triptan)
2
therapy
Stronger analgesics may be
used if anti-migraine therapy
is contraindicated
Considerations:
I. Ergotamine products may be used in patients that respond poorly to NSAIDs and triptans
(note: CYP3A4 inhibitor interaction possible).
II. Avoid the long-term prescribing of opiates and barbiturates.
3
Initiate pharmacologic management for prophylactic treatment (low dose, titrate slow)
95
HYPERLIPIDEMIA
PHARMACOLOGIC TREATMENT RECOMMENDATIONS
Risk Category
No CHD with 0-1 risk factors
No CHD with > 2 risk factors
With CHD or CHD risk equivalents
Formulary Agents
Generic Mevacor*
(lovastatin)
Generic Pravachol*
(pravastatin)
Generic Zocor*
(simvastatin)
Crestor**
(rosuvastatin)
Generic Lipitor*
(atorvastatin)
+
Zetia (ezetimibe)
Vytorin
(ezetimibe/simvastatin)
Liptruzet
(ezetimibe/atorvastatin)
Simcor
(ER niacin + simvastatin)
*
+
DOSE
10 mg
20 mg
40 mg
10 mg
20 mg
40 mg
80 mg
5 mg
10 mg
20 mg
40 mg
80 mg#
5 mg
10 mg
20 mg
40 mg
10 mg
20 mg
40 mg
80 mg
10 mg
10/10
10/20
10/40
10/80#
10/10
10/20
10/40
10/80
500/20
750/20
1000/20
21%
24%
30%
22%
32%
34%
37%
26%
30%
38%
28- 41%
36- 47%
28- 45%
45- 52%
31- 55%
43- 63%
27- 39%
30-43%
50%
41- 60%
20%
46%
52%
56%
60%
53%
54%
56%
61%
--11.9%
Generic available
Prior authorization is required for Zetia monotherapy or
dose >10 mg/d
2.
3.
4.
5.
Treatment Recommendations
Therapeutic lifestyle changes remain an essential
modality in clinical management (i.e., cholesterollowering diet).
If pharmacologic therapy is indicated, consider
HMG CoA reductase inhibitors, niacin, bile acid
sequestrants, and fenofibrates when appropriate.
When prescribing an HMG CoA reductase inhibitor,
consider the percent reduction required, the potency
of the medication, and appropriate dosing for the
medication.
Non-HDL (VLDL + LDL-C) goal: if TG200 mg/dL
then non-HDL-C goal is [LCL-C goal + 30mg/dL]
Diabetics statin regardless of LDL if overt CVD or
age>40 with 1+ CVD risk factors; goal of therapy is
LDL <100
96
1)
2)
3)
4)
5)
6)
7)
8)
9)
FIRST STEP:
NON-OPIOIDS:
1) NSAIDs
2) Acetaminophen
3) Tramadol
+ ADJUNCTS^
Note:
NSAIDs may cause GI
bleeding/pain/ulcer
Tramadol may be
preferred for neurological
pain
SECOND STEP:
THIRD STEP:
OPIOIDS:
1) Codeine with
acetaminophen/aspirin
OPIOIDS:
1) Long-acting opioids (e.g.,
Morphine SR, Kadian, fentanyl,
extended release oxycodone,
methadone)
2) Hydrocodone or
oxycodone with
acetaminophen/aspirin
+ NON-OPIOIDS
+ NON-OPIOIDS
+ ADJUNCTS
+ ADJUNCTS^
Note:
Potential risk for
acetaminophen toxicity or
opioid addiction
Short-acting opioids
require frequent dosing
Note:
There are no dosage limits for
opioids and opioids should be
titrated to response
Adjuncts should be utilized to
minimize opioid dosage increases
Monitor potential addiction
Reference: 1. Assessment and Management of Chronic Pain. Institute for Clinical Systems Improvement. November 2011
2. Opioid Treatment Guidelines. The Journal of Pain. Vol 10, No 2. February 2009
3. WHO Pain Relief Ladder
Revised date: 7/2013
97
Drug Name
HalfLife
(hr)
2-4h
Recommended
Starting Dose
Aspirin
Diflunisal
(Dolobid)
Choline
magnesium
trisalicylate
(Trilisate)
Ibuprofen
(Motrin, Advil)
Naproxen
(Naprosyn)
Naproxen
sodium
(Anaprox)
Oxaprozin
(Daypro)
Ketoprofen
(Orudis)
Flurbiprofen
(Ansaid)
Indomethacin
(Indocin)
Diclofenac
(Voltaren)
Etodolac
(Lodine)
Ketorolac
(Toradol)
3-12h
8-12h
650mg q4-6h
500mg q12h
4000mg
1500mg
8-12h
1000mg q12h
4000mg
3-4h
400mg q6-8h
3200mg
13h
250mg q12h
1000mg
275mg q12h
1100mg
4250h
2-3h
1200mg q24h
1800mg
200mg q6h
ER-Extended Release
IR-Immediate Release
5-6h
50mg q8-12h
200mg ER
300mg IR
300mg
4-5h
25mg q8-12h
200mg
2h
25mg q6-8h
200mg
7h
200mg q6-8h
1200mg
4-7h
10mg q6h
40mg
Sulindac
(Clinoril)
14h
150mg q12h
400mg
Piroxicam
(Feldene)
Meloxicam
(Mobic)
Nabumetone
(Relafen)
Meclofenamate
(Meclomen)
Celecoxib
(Celebrex)
45h
20mg q24h
20mg
20h
7.5mg q24h
15mg
2035h
2-4h
1000mg q24h
2000mg
50mg q4-6h
400mg
9-10h
200mg q24h
400mg
Acetaminophen
Salicylates
Propionic
Acid
Acetic Acid
Oxicams
Naphthylalkanone
Fenamate
Cox-2
Inhibitors
325-650mg q46h
Maximum
Recommended
Dose (mg/day)
4000mg
3,4
Note:
98
Usual
Starting Dose
Usual Dosing
Frequency
(hr)
Notes
30mg
4 6h
Fentanyl
(Actiq)
Oral lozenge
Hydrocodone
200mcg
Opioid Agonist
NA
(see Table 3)
30mg
2 4h
5 10mg
15 minutes
and may
repeat
4 6h
8mg
2 3h
2mg
4 6h
300mg
3 4h
50mg
3 4h
(alone or in combination
with APAP or ASA)
Hydromorphone
(Dilaudid)
Meperidine
(12 16h
normeperidine)
Morphine
30mg
2 3.5h
10 30mg
4h
Oxycodone (alone or
in combination with
APAP or ASA)
Tramadol
(Ultram)
20mg
2 3h
5mg
6h
150mg
6 7h
50mg
4-6h
25mcg patch =
45-134mg/24h
PO morphine
4mg acute
1mg chronic
20mg acute
3mg chronic
17h
25 mcg
72h
12 16h
2mg
6 8h
15 30h
2.5mg
6 8h
Morphine
Oramorph SR
MS Contin
Kadian
30mg
2 3.5h
15 30mg
Oxycodone
(Oxycontin)
20mg
2 3h
10mg
12h
(Oramorph)
(MS Contin)
24h
(Kadian)
12h
Long-Acting Opioids
Fentanyl
(Duragesic)
topical patch
Levorphanol
Methadone
* Examples of CYP 2D6 inhibitors: SSRIs, ketoconazole, cimetidine, amiodarone, Haldol, Benadryl.
99
If pain is constant or recurring, consider dosing around-the-clock. Most patients with malignant pain
require fixed-schedule dosing to manage the constant pain and prevent the pain from worsening.
Determine the total 24-hour dose of the current opioid. Using the estimated equianalgesic dose, calculate
the equivalent dose of the new opioid. The starting conversion dose of the new opioid should be 50%75% of the equianalgesic dose to prevent overshooting the analgesic needs.
As needed breakthrough or rescue doses (non-opioid medications analgesics or short-acting opioids) are
helpful in titration to the optimal dose. When using short-acting for breakthrough, give opioid doses
equivalent to approximately 10% of the daily opioid dose as needed.
While treating breakthrough pain with short-acting opioids, consider using the same ingredient as the longacting opioid. Then, the total daily dose of the short-acting opioids can be calculated into the appropriate
dose for the long-acting opioids.
Dose adjustment may need to be considered in elderly or patients with renal or liver impairment.
There is no maximum dose for most opioids. Titrate the current therapy to patients response or tolerance
before switching to a different agent.
The accurate assessment of opiate allergy is necessary to distinguish a true allergy from a side effect.
These opioids are NOT recommended for chronic pain: Meperidine (Demerol, poor oral absorption, short
half-life, and neurotoxic metabolite), opioid agonist/antagonist (pentazocine, nalbuphine).
A sudden stop or reduction in a dose of opioid after prolonged use may result in withdrawal symptoms
(e.g., sweating, restlessness, anxiety, stomach or leg cramps, unable to sleep, increased heart rate or
blood pressure, hot or cold flashes). Death may occur. Without treatment, most symptoms may disappear
in 5 to 14 days; some symptoms (e.g., insomnia, irritability, and muscle aches) may last 2 to 6 months.
After 72 hours of withdrawal, it is unlikely that withdrawal symptoms will worsen.
100
6,8
TABLE 4. Suggested Maximum Daily Opioid Doses for Primary Care Clinicians
Opioid
Morphine
Methadone
Oxycodone
Fentanyl (transdermal)
Oxymorphone
13
Dose
200 mg/day
40 mg/day
120 mg/day
100mcg/hour
30mg/day
*Higher doses require close, careful documentation and may prompt consultation with a pain specialist.
Hydrocodone
Products
Example
Vicodin 5/300 6 tabs /
day
Endocet 10/325 6 tabs /
day
Norco 10/325
12 tabs / day
Oxycodone
Total daily dose
Morphine
Equivalent dose per DAY
20 mg
30 mg
60 mg
90 mg
80 mg
120 mg
101
Acetaminophen
(Tylenol) mg/tab
Other Ingredient(s)
Anexsia
325 mg
hydrocodone 5 mg
Anexsia
325 mg
hydrocodone 7.5 mg
12
Endocet 5-325
325 mg
oxycodone 5 mg
12
Endocet 10-325
325 mg
oxycodone 10 mg
12
Endocet 7.5-325
325 mg
oxycodone 7.5 mg
12
Fioricet w/ codeine
325 mg
12
Norco
325 mg
butalbital/caffeine/ codeine
30 mg
hydrocodone 5 mg
12
Norco
325mg
hydrocodone 7.5 mg
12
Norco
325 mg
hydrocodone 10 mg
12
Percocet
325 mg
oxycodone 5 or 10mg
12
Percocet 2.5-325
325 mg
oxycodone 2.5 mg
12
Roxicet
325 mg
oxycodone 5 mg
12
Tylenol #2
300 mg
codeine 15 mg
13
10
Tylenol #3
300 mg
codeine 30 mg
13
10
Tylenol #4
300 mg
codeine 60 mg
13
10
Ultracet
325 mg
tramadol 37.5 mg
VIcodin
300 mg
hydrocodone 5 mg
12
*8
9
*8
Vicodin ES
300 mg
hydrocodone 7.5 mg
*6
*6
Vicodin HP
300 mg
hydrocodone 10 mg
*6
*6
102
Class
Antidepressants
Drug
Amitriptyline(Elavil)
Doxepin (Sinequan)
Imipramine (Tofranil)
Venlafaxine (Effexor XR)
Duloxetine (Cymbalta)
Initial Dose
10 25 mg PO qHS
25 mg PO qHS
50 75 mg PO qHS
37.5 150 mg PO QD
60 mg QD
Anticonvulsants
Carbamazepine
(Tegretol)
Gabapentin (Neurontin)
Clonazepam (Klonopin)
Pregabalin (Lyrica)
Lorazepam (Ativan)
Dexamethasone
Baclofen
Methylphenidate (Ritalin)
4 mg PO TID-QID
5 mg PO TID
5 mg PO QAM
Pamidronate (Aredia)
60-90 mg IV infusion
monthly
Others
100 mg PO TID
0.25 mg PO BID
75 mg BID
1 mg PO BID
Note
Useful for neuropathic pain, or
pain complicated by
depression or insomnia. SSRI
or SNRI may also be helpful.
Black Box Warning: SNRIs
increase suicidal behavior in
young adults
Monitor serum level, liver
function, CBC for Tegretol.
Comprehensive (including est.
GFR) for all.
Anxiety. Increased sedation.
Potential addiction.
Advanced, malignant pain.
Lacerating neuropathic pain.
Reserve use, opioid-induced
daily sedation in intolerant pt.
Malignant, bone pain
Long-term use of opioids in patients with chronic, non-malignant pain is controversial. Patients treated for
prolonged periods with opiate drugs for non-malignant pain fail to demonstrate the need for escalating doses in
order to achieve pain relief. Therefore, monitoring for dependence or addiction is important.
2,3
2,3
You may obtain a complete list of controlled substances filled for a patient in Michigan by requesting a
Patient Controlled Substance Prescription report from the Michigan Automated Prescription System
(MAPS). (Request Form for MAPS report is attached). Information is available at
http://www.michigan.gov/mdch/0,1607,7-132-27417_27648---,00.html
If opioid misuse or dependence is identified and the patient no longer needs opioids, treatment options include:
9
clonidine, naltrexone, methadone, or buprenorphine/naloxone (Suboxone). (Table 8)
103
104
Drug
Formulary
Status
Dosage
ANTICONVULSANTS
Gabapentin*
(Neurontin)
Formulary
Pregabalin*
(Lyrica)
Formulary
50 mg 75 mg twice daily-three
times daily to start. Up to 200 mg
three times daily.
Lamotrigine
(Lamictal)
Formulary
Oxcarbazepine
(Trileptal)
Formulary
Carbamazepine*
(Tegretol)
Formulary
Topiramate
(Topamax)
Formulary
Duloxetine *
(Cymbalta)
Formulary, PA
required
Venlafaxine
(Effexor)
Formulary
Formulary
10 to 25 mg at bedtime; increase
by 10 to 25 mg per week up to 75
to 100 mg at bedtime or a
therapeutic drug level.
Formulary
25 mg in the morning or at
bedtime; increase by 25 mg per
week up to 100 mg per day or a
therapeutic drug level.
Non-formulary
PA Required
Over-theCounter
ANTIDEPRESSANTS
(SNRIs)
Tricyclics**
Amitriptyline (Elavil),
Imipramine (Tofranil)
Desipramine
(Norpramin)
Nortriptyline (Pamelor)
TOPICAL MEDICATIONS
Lidocaine 5% Patch*
(Lidoderm)
Capsaicin
(Capzasin-HP,
Capzasin-P, DiabetAid
Pain and Tingling Relief,
SalonpasHot, Zostrix)
105
Drug
Formulary
Status
AS-NEEDED MEDS
Tramadol (Ultram);
(Ultram ER)
Formulary
Ultracet
Formulary
Oxycodone
w/ Acetaminophen
(Endocet)
w/Ibuprofen
(Combunox)
with Aspirin
(Percodan)
Formulary
Dosage
*Approved by the U.S. Food and Drug Administration for treatment of neuropathic pain
**Not recommended in patients > 65 years of age
1 FDA alert: Increased risk of suicidal behavior or ideation.
2 Black box warning: Increased suicidal behavior in young adults
3 Two black box warnings on carbamazepine: Aplastic anemia and agranulocytosis have been reported in association with the use of
carbamazepine. The genetic testing is recommended prior to initiation of therapy in most patients of Asian ancestry for the presence
of the HLA-B*1502 allele genetic marker to decrease the risk of developing Stevens-Johnson syndrome (SJS) and/or toxic epidermal
necrolysis (TEN). Drugs labeled initial drug of choice based on a combination of evidence for efficacy from randomized controlled
trials and safety profile. It does not imply superiority.
References:
1. World Health Organization. Cancer Pain Relief 1996
2. http://www.oqp.med.va.gov/cpg/cpg.htm
3. http://www.guideline.gov/summary/summary.aspx?doc_id=4218&nbr=3226&string=opioid+and+%22pain+management%22
4. http://cancertrials.nci.nih.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/page3/print
5. Pain Relief Connection Vol 1 #6, June 18, 2002. Pain Topics and Pain Relief Connections are services of MGH Cares About
Pain Relief
http://www.massgeneral.org/painrelief/mghpain_equichart.htm
http://www.guideline.gov/summary/summary.aspx?doc_id=3365&nbr=2591&string=opioid+and+%22pain+management%22
http://www.vapbm.org/archive/methadonedosing.pdf#search='methadone%20dose%20conversion
NEJM. 2002 Sept. (347): 817-823
Drug and Alcohol Dependence 2003 (70): S59-77
http://www.rsdfoundation.org/en/en_opoid_treatment_protocol.html
Refer to HealthPlus Clinical Practice Guideline for additional information on diagnosis and management of acute low back
pain, substance abuse disorders, major depression, smoking cessation and pharmacologic step protocol for migraine
treatment.
13. Assessment and Management of Chronic Pain. 5th Ed. Institute for Clinical Systems Improvement. pp. 106-107. November
2011
6.
7.
8.
9.
10.
11.
12.
106
Evaluation
Type
Tool Name
Chronic Pain
Evaluation
Description
A sample pain evaluation form for chart documentation.
(HPM Sample)
PDI
Wong-Baker Faces
Helpful for assessing persons with moderate to severe dementia who have lost
much of their ability to use language to describe pain.
DAST-10
DIRE
Pain
Assessment
SISAP
5-Point
AUDIT
Alcohol Use
CAGE
A 4-question self-test to help patients become aware of alcohol abuse. This test
specifically focuses on alcohol use, and not on the use of other drugs.
TWEAK Test
107
PHQ-2
Depression
Screening
PHQ-9
MDQ
Zung
108
APPENDIX A
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY
Completed forms will be reviewed by the Pharmacy & Therapeutics Committee. The need for
the drug, alternative therapy available, efficacy, safety and cost-effectiveness will be considered.
It is essential that this form be completed for proper evaluation.
1. Generic Names: ___________________________________________________________
2. Brand Name & Manufacturer: _________________________________________________
3. Dosage Form(s) & Strength(s): ________________________________________________
4. Specific pharmacologic action and indications for use:
_________________________________________________________________________
_________________________________________________________________________
5. Comparable drugs currently on the Formulary: ____________________________________
_________________________________________________________________________
6. If the requested drug is used, which of the drugs above may be deleted from the Formulary?
_________________________________________________________________________
7. List the therapeutic advantages of the requested drugs over those already listed on the
Formulary. Supply references to support these advantages:
_________________________________________________________________________
_________________________________________________________________________
8. Estimate the anticipated cost impact if the requested drug is added to the Formulary:
_________________________________________________________________________
________________________________
DATE
___________________________________
PRINT NAME
_________________________________________________________________________
SIGNATURE
Send to: HealthPlus
ATTN: Pharmacy Department
2050 S Linden Road; PO Box 1700
Flint, MI 48501-1700
FAX: 810-720-2757
E-MAIL: rx@healthplus.org
109
APPENDIX B
HEALTHPLUS PARTNERS (MEDICAID) OVER-THE-COUNTER (OTC) MEDICATIONS
Michigan Medicaid regulations include a requirement for coverage of selected over-the-counter
(OTC) medications as part of the prescription benefit. OTC products covered by Michigan
Medicaid are covered for members in the HealthPlus Partners program only, with a written
prescription. If the OTC product is available as a generic, the generic product is covered. A
summary list (alphabetic by brand name) of covered OTC products is included below:
Allegra (fexofenadine)
Allegra-D (fexofenadine/pseudoephedrine)
Artificial Tears solution
Aspirin tablets (regular, buffered and enteric-coated), suppositories
Bacitracin ointment
Benadryl (diphenhydramine) capsules, elixir
Calcium carbonate tablets, suspension
Chlor-Trimeton (chlorpheniramine) tablets, syrup
Claritin (loratadine) tablets, reditabs, syrup
Claritin-D (loratadine/pseudoephedrine)
Colace (docusate sodium) capsules, liquid
Condoms, latex
Dulcolax (bisacodyl) tablets, suppositories
Ferrous gluconate
Ferrous sulfate tablets, solution
Gyne-Lotrimin (vaginal cream, suppositories)
Hydrocortisone cream, ointment
Imodium caplet
Imodium AD (loperamide) liquid
Maalox (aluminum/magnesium hydrox) suspension
Metamucil (psyllium) powder
Monistat-7 (miconazole) vaginal cream, suppositories
Motrin (ibuprofen) tablets, suspension, chewables
Neosporin (bacitracin/neomycin/polymixin) ointment
Nicotine patch, inhaler, nasal spray, gum/lozenges
Nix (permethrin cream rinse)
Pepto-Bismol caplet, chewable, suspension
Peri-Colace (docusate sodium w/ casanthranol) capsules
Prevacid 24 Hour (lansoprazole) capsules
Tavist (clemastine) tablets, syrup
Tylenol (acetaminophen) tablets, drops, elixir, suppositories
Zaditor (ketotifen)
Zyrtec (cetirizine) tablets, chewable, liquid gels, solution
Note: This is a summary list and does not include all covered OTC products.
110
STATUS
APPENDIX C
Patient Name:
Height:
Weight:
DAW
BMI:
Exception Request
Medically Urgent
Exception Request
DEA#:
Office Phone: (_____)
Pharmacy Name (optional):
I represent to the best of my knowledge and belief that the information provided is true, complete, and
fully disclosed. A person may be committing insurance fraud if false or deceptive information with the
intent to defraud is provided.
Physicians Name (please print) ____________________ Physicians Signature
Office Contact Person:
Request Date:
Non-Urgent Request:
Urgent Request:
CPhT Review Time
RPh Review Time
Med Dir Review Time
Comments:
Approved
Partial Approval
Denied
Approved by:
Reason for Denial:
Effective Date:
Faxed to Indigent Program:
If you would like to discuss this case with a physician reviewer, please call (800) 332-9161.
**THIS DOCUMENT MAY BE PHOTOCOPIED, or you may request additional copies by calling the HealthPlus
Pharmacy Department at the telephone number(s) listed above.
Rev June 2013
111
QTY
LIMIT
ADD Medications
Vyvanse
(lisdexamfetamine dimesylate)
Strattera (atomoxetine)
CRITERIA
1. The patient must have a chart documented trial or Rx claims
for generic Adderall or Adderall XR in the past 120 days.
Focalin XR
(dexmethylphenidate)
Daytrana
(methylphenidate patch)
Quillivant XR (methylphenidate
suspension)
Intuniv (guanfacine)
Allergy Medications
Clarinex (desloratadine)
Clarinex-D
(desloratadine/pseudoephedrine)
Limited to
a qty of 30
units per
month
1. The patient must have documented failure or Rx claims for
generic OTC Claritin D or OTC generic Claritin in combination
with OTC generic pseudoephedrine in the past year.
NOTE: For Clarinex-D, prior authorization is only required for
patients over 12 years of age. Generic Claritin and Claritin-D
OTC products are covered with a prescription; OTC
pseudoephedrine is not a covered benefit.
112
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Qty is
limited to
60 units
per 30
days
Qty is
limited to
30 units
per 30
days
All acetaminophen-containing
narcotic analgesics
CRITERIA
113
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Analgesics, continued
Oxycontin (oxycodone)
Vicodin 5/300
(hydrocodone/acetaminophen)
Vicodin ES 7.5/300
(hydrocodone/acetaminophen)
Vicodin HP 10/300
(hydrocodone/acetaminophen)
Qty is
limited to
30 units
per 30
days
Vicodin
5/300 limit
8 tabs/day
VIcodin
ES
7.5/300 &
Vicodin
HP 10/300
limit 6
tabs/day
All ARBs
except
Cozaar
(not
combos)
are limited
to a qty of
30 units
per month
Qty is
limited to
30 units
per 30
days
CRITERIA
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than twice daily dosing. Criteria for quantities that exceed
70 per month:
1. The patient must have documented failure or Rx claims for
OxyContin twice daily therapy plus short-acting pain
medications for breakthrough, OR
2. The patient has received an oncology or HIV-related
pharmacy claims during the past 365 days, OR
3. The patient has received a prescription claim from an
oncologist or infectious disease physician in the past 365
days (system-automated so care will not be interrupted),
OR
4. Documented blood plasma levels indicate the drug is not
lasting 12 hours, OR
5. For all other medical necessities, physician will be referred to
the HealthPlus Pain Management Guideline for
recommendation of alternatives.
Requires prior authorization for indications other than cancer.
System will automatically approve if written by an oncologist or if
there are previous claims for chemotherapy-related medications.
1. The patient must have documented failure or Rx claims with
generic Dilaudid (hydromorphone) and generic Duragesic
(fentanyl).
1. Physician must provide chart documentation that shows that a
product with 325mg acetaminophen (i.e. generic Norco) is
contraindicated in this patient but that a product with 300mg
acetaminophen is not contraindicated
Note: Acetaminophen is not recommended for patients with liver
disease.
114
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
Antibiotics
Oracea
(doxycycline monohydrate)
Dificid (fidaxomicin)
Moxatag ER
(amoxicillin trihydrate)
Factive
(gemifloxacin mesylate)
Tobi Solution/Podhaler
Anticoagulant
Brilinta (ticagrelor)
Qty is
limited to
60 units
per 30
days
Eliquis (apixaban)
Qty is
limited to
60 units
per 30
days
115
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Anticoagulant, continued
Pradaxa 150mg (dabigatran)
Xarelto (rivaroxaban)
Antidepressants
Luvox CR
(fluvoxamine ext. release)
Pexeva (paroxetine mesylate)
Viibryd (vilazodone)
Prozac Weekly (fluoxetine)
Qty for
10mg is
limited to
35 units
Limited to
a qty of
30 units
per month
CRITERIA
Limited to
a qty of
30 units
per month
116
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
Antidepressants, continued
Wellbutrin XL
(bupropion, ext. release)
Antiemetic
Zuplenz (ondansetron)
Antineoplastic
Jakafi (ruxolitinib)
Antipsychotics, Atypical
Latuda (lurasidone)
Abilify (aripiprazole)
Zyprexa/Zydis (olanzapine)
Limited to
a qty of
30 units
per month
117
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Limited to
6 doses
per day
Limited to
a qty of
30 units
per month
Cardizem LA
(diltiazem, long-acting)
Lovaza
(omega-3-acid ethyl esters)
Vascepa (icosapent ethyl)
Cholesterol Medications
On Formulary with PA:
Crestor (rosuvastatin)
Zyflo/CR (zileuton)
Beta Blockers
Bystolic (nebivolol)
CRITERIA
Limited to
a qty of
30 units
per month
118
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Cholesterol Medications,
continued
Fenoglide (fenofibrate)
Lipofen (fenofibrate)
Triglide (fenofibrate)
On Formulary with PA:
Zetia (ezetimibe)
CRITERIA
1. The patient must have documented failure or Rx claim for a
formulary fenofibrate (i.e., generic Lofibra) in the past year
with at least one documented dosage increase.
Contraceptives
All Brand Contraceptives
Beyaz
LoEstrin 24 Fe 1/20
Natazia
Ovcon-50
Safyral
NuvaRing
Ortho Evra
Ortho Tri-Cyclen Lo
Cough and Cold
Vituz
Dermatologicals
Altabax (retapamulin)
Lidoderm (lidocaine)
Vusion
(miconazole nitrate/zinc oxide)
Zyclara (imiquimod)
10 grams
(10, 1gm)
tubes per
month
119
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
Dermatologicals, continued
All Branded Topical Antifungal
Agents
Ciclodan Kit (ciclopirox olamine
cream/cleanser)
CNL Nail Kit (ciclopirox/lacquer
removal pads)
Ertaczo
(sertaconazole nitrate)
Exelderm (sulconazole nitrate)
Ketodan Kit (ketoconazole
foam/cleanser)
Lamisil Soln
(terbinafine soln)
Mentax (butenafine)
Naftin (naftifine)
Oxistat (oxiconazole nitrate)
Pediaderm AF
(nystatin/emollient)
Terbinex
(terbinafine/hydroxychitosan)
Tersi (selenium sulfide)
Xolegel/Corepak
(ketoconazole)
All Branded Topical
Clindamycin Products
Clindagel 1% Gel (clindamycin)
120
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Dermatologicals, continued
All Brand Tretinoin Products
Atralin (tretinoin)
Retin A Micro 0.04% (tretinoin)
Tretin-X (tretinoin)
Veltin (tretinoin/clindamycin)
Ziana (tretinoin/clindamycin)
All Brand Topical Steroids
Clobex Spray (clobetasol
propionate)
Synalar TS
(fluocinolone/cleanser)
Ultravate PAC Kit (halobetasol
propionate/ammonium lactate)
Vanos Cream (fluocinonide)
Kenalog Aerosol Spray
(triamcinolone acetonide)
Pandel Cream (hydrocortisone
probutate)
Pediaderm TA (triamcinolone)
Topicort Spray
(desoximetasone)
Cloderm Cream (clocortolone
pivalate)
Cordran Lotion (flurandrenolide)
Cordran SP Cream
(flurandrenolide)
Locoid Lotion, Lipocream
(hydrocortisone butyrate)
Desonate Gel (desonide)
Desowen Combo
(desonide/emollient)
Pediaderm HC (hydrocortisone)
Vanoxide-HC Lotion
(hydrocortisone/benzoyl peroxide)
Verdeso Foam (desonide)
Protopic (tacrolimus)
Dovonex (calcipotriene)
Taclonex
(betamethasone/calcipotriene)
Vectical (calcitriol)
CRITERIA
1. The patient must have documented failure or Rx claim for a
generic tretinoin product (e.g., Retin-A, Avita) in the past 90
days.
NOTE: Age restriction for all topical tretinoin products for age >
25 based on a diagnosis of acne.
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g.,
Temovate, Ultravate, Diprolene) in the past 60 days.
Safety
limited to
a qty of <
100g per
7 days
Safety
limited to
a qty of <
200g per
7 days
121
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Diabetes
Glumetza (metformin)
Janumet, XR
(sitagliptin/metformin)
Juvisync (sitagliptin/simvastatin)
Kazano (alogliptin/metformin)
Kombiglyze XR
(saxagliptin/metformin)
Oseni (alogliptin/pioglitazone)
Januvia (sitagliptin)
Nesina (alogliptin benzoate)
Onglyza (saxagliptin)
Tradjenta (linagliptin)
Apidra
Novolin Insulins (insulin)
Novolog Insulins (insulin aspart)
Novolog Mix (insulin)
Glucose Test Strips
Freestyle Lite
Freestyle Insulinx
Precision Xtra
Erectile Dysfunction
On Formulary:
Cialis 10, 20MG (tadalafil)
Viagra (sildenafil)
Non-Formulary:
Caverject, Edex, Muse
(alprostadil)
ED meds are covered when
written by PCP or in-plan
urologist. Males Only. Limit 6
units per 30 days (for all ED drugs
combined).
CRITERIA
1. The patient must have documented failure or Rx claims in the
past year for generic Glucophage AND generic Glucophage
XR.
1. The patient must have documented failure or Rx claims with a
preferred formulary DPP-4 inhibitor (i.e. Tradjenta,
Jentadueto).
Limited to
a qty of
30 units
per month
Limited to
a qty of
30 units
per month
Limited
qty of 150
units per
30 days
or 450
units per
90 days
All ED
meds are
limited to
a qty of 6
units per
month
122
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Genitourinary Medications
Detrol LA
(tolterodine, long-acting)
Ditropan XL
(oxybutynin, sust. release)
Enablex
Myrbetriq (mirabegron)
(darifenacin hydrobromide)
Toviaz (fesoterodine)
Vesicare (solifenacin)
Cialis 2.5, 5MG (tadalafil)
Rapaflo (silodosin)
QTY
LIMIT
All ED
meds are
limited to
a qty of 6
units per
month
Limited to
a qty of
30 units
per month
Limited to
30 tablets
per month
for
indication
of BPH
**No addl
qty of
drugs for
ED
approved
when
receiving
Cialis
daily for
BPH
CRITERIA
1. The patient must have documented failure or Rx claims for
both sildenafil (Viagra) AND tadalafil (Cialis) in the past 180
days.
2. If the patient <35, the patient must have a documented
diagnosis of ED OR a history of ED with contributing OR
concomitant disease state. The prescription must be written
by a PCP or in plan urologist (this does not apply to PPO
members).
3. Prior Authorization is also required if patient has a history of
nitrate use.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
123
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Limited to
a qty of
30 units
per month
CRITERIA
1.
2.
3.
4.
Infertility
All medications for infertility
(subject to the members benefit).
Confirmation of Coverage:
1. The patients benefit includes coverage for infertility, AND
2. There is an appropriate referral, if applicable, AND
3. The service/procedure is a covered benefit.
Migraine Medications
Axert (almotriptan)
Frova (frovatriptan)
Treximet
(sumatriptan/naproxen)
All
triptans
combined
are
limited to
a qty of 9
tablets
per month
124
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY LIMIT
CRITERIA
Migraine Medications,
continued
Imitrex Injection (sumatriptan
injection)
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
Migranal (dihydroergotamine)
including generics
Muscle Relaxants
Amrix (cyclobenzaprine ext
release)
Miscellaneous
Cardura XL
(doxazosin mesylate ext. release)
All nasal
triptan
products
are limited
to a
quantity of
6 per
month
8 units (ml)
per month
125
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY LIMIT
Miscellaneous, continued
Lyrica (pregabalin)
Nuvigil (armodafinil)
Cymbalta (duloxetine)
Quantity
limit of
540mls
every 30
days
CRITERIA
DOSE OPTIMIZATION ONLY
Quantity limits/dose optimization:
1. The 25, 50, 75, 100, 150 and 200mg capsules are limited to
a quantity of 90 per month.
2. The 225 and 300mg capsules are limited to a quantity of 60
per month.
1. The patient has a documented diagnosis of narcolepsy, or
excessive daytime sleepiness associated with obstructive
sleep apnea/hypopnea syndrome (OSAHS) or shift work
sleep disorder (SWSD).
1. The patient is 16 years of age or older AND
2. The patient has documented sleep study results resulting in
a diagnosis of narcolepsy and has one of the following:
a. Episodes of cataplexy demonstrated by chart
documentation, OR
b. Excessive daytime sleepiness with symptoms that limit
the ability to perform normal daily activities demonstrated
by chart documentation and:
i. Provigil or Nuvigil therapy has been ineffective or
contraindicated AND
ii. Methylphenidate, amphetamine salts, or
dextroamphetamine therapy has been ineffective or
contraindicated AND
3. The patient is not being treated with a sedative hypnotic
agent AND
4. The patient does not have a succinic semialdehyde
dehydrogenase deficiency AND
5. The patient does not have a history of substance abuse.
1. The patient must have a documented diagnosis of pulmonary
arterial hypertension.
2. If the patient has a history of nitrate use, the physician must
submit a written request on his/her letterhead stating that the
patient is no longer using nitrates.
1. The patient must have a documented diagnosis of
fibromyalgia, OR
2. Documentation of all of the following:
a. Widespread pain for at least 3 months, AND
b. Pain on both sides of the body, above and below the
waist, AND
c. Abnormal tenderness in at least 11 of the 18
anatomically-defined body sites.
1. Specific to diagnosis of fibromyalgia, the patient must have
documented failure, contraindication to, or prescription
claims for Lyrica.
NOTE: To minimize disruption with use of Cymbalta for a
diagnosis of depression, the claims processing system will
automatically approve the claim if there are prescription
claims for an antidepressant in the last year.
126
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY LIMIT
CRITERIA
Uloric (febuxostat)
Limited to
a qty of 30
units per
month
Neurological Miscellaneous
Horizant (gabapentin enacarbil)
Limited to
a qty of 30
units per
30 days.
Gralise (gabapentin)
Nuedexta
(dextromethorphan/quinidine)
NSAIDs
Arthrotec
(diclofenac/misoprostol)
Naprelan CR (naproxen
sodium)
Limited to
a qty of 60
units per
30 days.
All Cox-2
drugs and
Mobic are
limited to a
qty of 30
units per
month
127
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY LIMIT
CRITERIA
Vimovo
(esomeprazole/naproxen)
Rayos
Voltaren Gel
(diclofenac sodium)
128
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY LIMIT
Ophthalmic Products
All Brand Topical Ophthalmic
Antihistamines
On Formulary with PA:
Patanol (olopatadine)
Non-Formulary with PA:
Alocril (nedocromil sodium)
Alomide
(lodoxamide tromethamide)
Bepreve
(bepotastine besilate)
Emadine
(emedastine difumarate)
Lastacaft (alcaftadine)
Pataday (olopatadine)
Restasis (cyclosporine)
Betimol (timolol)
Istalol (timolol maleate)
All Brand Topical Ophthalmic
Prostaglandin Analogs
On Formulary with PA:
Lumigan 0.01%
(bimatoprost)
Non-Formulary with PA:
Lumigan 0.03%
(bimatoprost)
Travatan Z (travoprost)
Zioptan (tafluprost)
Proton Pump Inhibitors
On Formulary with PA:
Aciphex (rabeprazole)
Esomeprazole Strontium
(esomeprazole strontium)
Non-Formulary with PA:
Dexilant (dexlansoprazole)
First-Lansoprazole
(lansoprazole)
First-Omeprazole (omeprazole)
Nexium (esomeprazole)
Prevacid Solutab (lansoprazole)
Prilosec DR Susp (omeprazole
magnesium)
Protonix Pak (pantoprazole)
Zegerid Susp
(omeprazole/sodium bicarbonate)
CRITERIA
1. The patient must have documented failure or Rx claim for
generic OTC Zaditor in the past 90 days (covered with
written prescription).
2. If the patient fails treatment with generic OTC Zaditor, then
Patanol is the second-line formulary alternative with prior
authorization required.
3. The patient must have documented failure or Rx claims for
the formulary alternatives (OTC Zaditor and Patanol) before
a non-formulary drug will be approved.
Qty is
limited to 2
units per
day
Zioptan is
limited to a
qty of 1 unit
per day
Brand PPIs
are limited
to a qty of
30
tabs/caps
per month
129
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY LIMIT
CRITERIA
Quantity is
limited to
30 per
month
Ambien/CR (zolpidem)
Restoril (temazepam)
Sonata (zaleplon)
Smoking Cessation
All prescription nicotine patches
Chantix (varenicline)
Limited to a
qty of 30
units per
month
130
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
1. The patient is an adult 18 years of age; AND
2
2. The patient has a body mass index (BMI) of >30kg/m , OR
2
3. The patient has a body mass index (BMI) of >27kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
4. The patient has a body mass index (BMI) of >27kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis, pregnancy, and/or lacation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician-supervised diet and exercise program
consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet and a
regular exercise program. AND
5. If the medication is a brand name product, the patient must
have tried a generically available product (i.e. phentermine,
diethylpropion) in the past year.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total
coverage.
131
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
1. The compounded product contains at least one FDA-approved
prescription ingredient; AND
2. Each prescription drug or active ingredient in the compounded
product is approved by the Food & Drug Administration (FDA) for
medical use in the United States; AND
3. The active prescription medication component(s) are in therapeutic
amounts; AND
4. The compounded product is not a copy of any commercially available
FDA-approved drug product; AND
5. The use for which the compounded product is being prescribed is
supported by FDA approval of the active ingredient(s), or is supported
by two or more articles from peer reviewed journals demonstrating
the safety and efficacy of the prescribed therapy for that diagnosis
and method or route of delivery; AND
6. If any prescription ingredient in the compounded product is included
in the HealthPlus Prior Authorization program, the patient must meet
the criteria designated for that prescription ingredient.
Based on limitations or exclusions in the subscriber certificate,
coverage will NOT be provided for compounds under the following
circumstances:
1. Any compound that does not contain a FDA-approved prescription
ingredient otherwise covered by the plan; OR
2. Any compound that contains a non-FDA approved or non-HealthPlus
covered prescription ingredient.
3. Compounded formulations that contain any bulk powders that are not
FDA approved or HealthPlus approved; OR
4. Compounded formulations that are being used for cosmetic purposes;
OR
5. Compounded formulations that are using prescription ingredients for
non-FDA approved indications or purposes that are not supported by
peer-reviewed literature; OR
6. Compounded formulations that may be considered investigational or
experimental; OR
7. Compounded formulations that use drugs withdrawn or removed from
the market for safety reasons; OR
8. Prescription ingredient(s) compounded for the purpose of
convenience only.
a. Exceptions include:
i. Compounded medications for those patients that cannot
swallow or have trouble swallowing and require
administration with an oral liquid, or administration by topical,
rectal or other appropriate non-oral routes;
ii. Compounded medications for those patients who have
sensitivity to dyes, preservatives, or fillers in commercial
products and require allergy-free medications as documented
in the medical record;
iii. Compounded medications for children who require
prescription medications for which there are no liquid
formulations available.
132
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
1. The benefit covers generic products when a generically
equivalent product is available.
2. In general, prior authorization is required for all brand name
drugs (when the drug is available and covered as a generic
medication). The physician may submit a prior authorization
request form for the brand name drug (when a generic
equivalent is available), but this must be substantiated by
medical necessity. If medical necessity is based on a trial and
failure of the generic medication, a prescription claim for the
generic drug must be present or chart notes documenting the
failure must be provided.
3. If a physician submits a prior authorization request form for
coverage of a brand name drug (when a generic equivalent is
available), the request is reviewed through the same process
as all other drugs that require prior authorization.
4. The member may still choose to receive a brand product
without medical necessity, but would be responsible for
additional costs based on their benefit (i.e., the difference in
cost between the brand and generic product plus their usual
copayment; or, a higher copayment).
1. The physician must provide documentation of the clinical
rationale for requesting a dosage, quantity, or duration of
medication greater than the criteria specified in the formulary.
2. If the dosage exceeds the manufacturer product
labeling/prescribing information, the physician must submit
documentation of two articles from peer reviewed journals
demonstrating the safety and efficacy of the prescribed
therapy.
Quantity Limit QL
Specific request for a dose,
quantity or duration that exceeds
the established limits
QTY
LIMIT
CRITERIA
1. Formulary drugs/alternatives are not appropriate, are
contraindicated or are unsafe for the patient based on specific
documented patient circumstances, OR
2. The patient has a documented trial and failure (or prescription
claims) for all of the formulary drugs/alternatives.
133
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Name
Concern
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Alternative Treatment
Hot flashes: non-pharmacological therapy, Zoloft, Paxil,
Effexor
2
Bone density: Calcium with vitamin D , Fosamax,
1
1
Boniva , Evista
1,2
2
Antihistamine: Claritin , Zytrec
1
Antiemetic: Antivert, Zofran
Cough: Dextromethorphan
Depends on site of infection, culture, and sensitivity.
1
Bactrim, Vibramycin, Azithromycin, Fluoroquinolone
Levothyroxine (LT4): Synthroid, Levoxyl
Carisoprodol (Soma)
Glyburide-Metformin
(Glucovance)
Chlorpropamide (Diabinese)
Cyclobenzaprine (Flexeril)
Orphenadrine (Norflex)
Chlorzoxazone (Parafon
Forte)
Methocarbamol (Robaxin)
Skelaxin (Metaxalone)
134
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Name
Amitriptyline (Elavil)
Concern
Alternative Treatment
Trimethobenzamide (Tigan)
Ketorolac (Toradol)
GI bleeding
Imipramine (Tofranil)
2
Indomethacin
Dipyridamole (Persantine)
1
2
Drug may require prior authorization or may have limited coverage depending on members benefit plan
Available OTC
135
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Acne
Clindagel
(clindamycin phosphate)
All Brand Topical Adapalene
and Dapsone Products
Aczone 5% Gel (dapsone)
Differin 0.1% Lotion
(adapalene)
Differin 0.3% Gel (adapalene)
Epiduo 0.1%-2.5% Gel
(adapalene/benzoyl peroxide)
All Branded Benzoyl Peroxide
Combination Products
Acanya 1.2%-2.5%
(clindamycin/benzoyl peroxide)
Benzamycin Pak 3%-5% Gel
(erythromycin base/benzoyl
peroxide)
Duac (clindamycin/benzoyl
peroxide)
Clarinex-D
(desloratadine/pseudoephedrine)
CRITERIA
136
QTY
LIMIT
Allergy Medications,
continued
All Brand Nasal Steroids
Beconase AQ
(beclomethasone dipropionate)
Nasonex
(mometasone furoate)
Omnaris (ciclesonide)
Qnasl (beclomethasone
dipropionate)
Rhinocort Aqua (budesonide)
Veramyst (fluticasone furoate)
Zetonna (ciclesonide)
All Brand Nasal Steroids,
Combination Products
Dymista (azelastine/fluticasone
propionate)
Analgesics
On Formulary with PA:
Actiq (fentanyl citrate oral
transmucosal)
Non-Formulary with PA:
Abstral (fentanyl sl)
Fentora
(fentanyl citrate buccal tablet)
Lazanda (fentanyl nasal spray)
Onsolis (fentanyl soluble film)
Subsys (fentanyl sublingual
spray)
All acetaminophen-containing
narcotic analgesics
CRITERIA
1. The patient must have documented failure or Rx claims for two
generic nasal steroids (i.e., Flonase, flunisolide) in the past
year.
Qty limit
of 1
patch per
72 hours
OxyContin (oxycodone)
Qty limit
60 in 30
days
137
QTY
LIMIT
Qty is
limited to
30 units
per 30
days
CRITERIA
1. The patient must have a current documented diagnosis of
active cancer.
NOTE: System will automatically approve if written by an
oncologist or if there are previous claims for chemotherapyrelated medications.
For indications other than cancer:
1. The patient must have documented failure or prescription
claims for at least two formulary alternatives (including generic
MS Contin and short-acting narcotic analgesic) within the last
3 months OR
2. Based on chart documentation, all formulary alternatives are
inappropriate.
NOTE: System will automatically approve if written by an
oncologist or if there are prescription claims for chemotherapyrelated medications.
New Starts Only
Qty is
limited to
60 units
per 30
days
Qty is
limited to
30 units
per 30
days
Vicodin 5/300
(hydrocodone/acetaminophen)
Vicodin ES 7.5/300
(hydrocodone/acetaminophen)
Vicodin HP 10/300
(hydrocodone/acetaminophen)
Vicodin
5/300
limit 8
tabs/day
VIcodin
ES
7.5/300 &
Vicodin
HP
10/300
limit 6
tabs/day
138
QTY
LIMIT
All ARBs
except
Cozaar
(not
combos)
are
limited to
a qty of
30 units
per
month
Qty is
limited to
30 units
per 30
days
CRITERIA
1. The patient must have documented failure or Rx claims for all
formulary ARBs or ARB combination products (i.e.,
Benicar/HCT, or Diovan/HCT).
NOTE: If patient is a first time ARB user, patient should have
documented failure or Rx claims for at least one generically
available ACE inhibitor previous to ARB therapy.
Antibiotics
Oracea
(doxycycline monohydrate)
Moxatag ER (amoxicillin
trihydrate)
Dificid (fidaxomicin)
Avelox (moxifloxacin)
Factive (gemifloxacin)
Flagyl ER (metronidazole)
Tobi Solution/Podhaler
139
Eliquis (apixaban)
QTY
LIMIT
Qty is
limited to
60 units
per 30
days
Qty is
limited to
60 units
per 30
days
Antiemetic
Zuplenz (ondansetron)
Xarelto (rivaroxaban)
CRITERIA
Qty for
10mg is
limited to
35 units
140
QTY
LIMIT
Anti-Nausea
Anzemet
(dolasetron mesylate)
Antineoplastic
Jakafi (ruxolitinib)
Asthma/COPD
Combivent Respimat
(albuterol/ ipratropium)
Proventil HFA (albuterol)
ProAir HFA (albuterol)
CRITERIA
Limited to
6 doses
per day
Xopenex/HFA (levalbuterol)
Zyflo/CR (zileuton)
141
QTY
LIMIT
Beta Blockers
Levatol (penbutolol)
Coreg CR (carvedilol
phosphate controlled release)
Bystolic (nebivolol)
Limited
to a qty
of 30
units per
month
Limited
to a qty
of 30
units per
month
CRITERIA
1. The patient must have documented failure or Rx claims
with at least three generically available beta blockers (e.g.,
Inderal, Tenormin, Lopressor, Corgard).
1. The patient must have documented failure on immediate
release carvedilol of equivalent dose and attempted at least
one dose increase (6.25/day IR = 10mg/day ER when
converting).
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
Cardizem LA
(diltiazem, long-acting)
Cholesterol Medications
On Formulary with PA:
Crestor (rosuvastatin)
Non-Formulary with PA:
Advicor (lovastatin/niacin)
Altoprev (lovastatin SR)
Lescol XL (fluvastatin)
Livalo (pitavastatin calcium)
Liptruzet
(ezetimibe/atorvastatin)
All HMGs
are
limited to
a qty of
30 units
per
month
Limited to
a qty of
30 units
per
month
Welchol (colesevelam)
Lovaza
(omega-3-acid ethyl esters)
Vascepa (icosapent ethyl)
Fenoglide (fenofibrate)
Lipofen (fenofibrate)
Triglide (fenofibrate)
142
QTY
LIMIT
Cholesterol Medications,
continued
On Formulary:
Zetia (ezetimibe)
CRITERIA
AUTHORIZATION IS ONLY REQUIRED FOR THE
FOLLOWING:
1. If the patient has not had an Rx claim for an HMG statin
medication in the previous year. Criteria for authorization for
monotherapy include a documented contraindication for both
hydrophilic (Pravachol, Lescol) and lipophilic (Zocor, Lipitor)
statins, elevated liver enzymes, etc.
2. A dose >10mg per day requires documentation to support
safety and efficacy.
Contraceptives
All Brand Oral Contraceptives
Beyaz
LoEstrin 24 Fe 1/20
Natazia
NuvaRing
Ortho Evra
Ortho Tri-Cyclen Lo
Ovcon-50
Safyral
Dermatologicals
On Formulary with PA:
Elidel (pimecrolimus)
Protopic (tacrolimus)
Dovonex (calcipotriene)
Taclonex
(betamethasone/calcipotriene)
Safety
limited to
a qty of <
100g per
7 days
Vectical (calcitriol)
Safety
limited to
a qty of <
200g per
7 days
Zyclara (imiquimod)
143
QTY
LIMIT
Dermatologicals, continued
All Branded Topical Antifungal
Agents
Ciclodan Kit (ciclopirox olamine
cream/cleanser)CNL Nail Kit
(ciclopirox/lacquer removal pads)
Ertaczo
(sertaconazole nitrate)
Exelderm (sulconazole nitrate)
Ketodan Kit (ketoconazole
foam/cleanser)Lamisil Soln
(terbinafine soln)
Mentax (butenafine)
Naftin (naftifine)
Oxistat (oxiconazole nitrate)
Pediaderm AF
(nystatin/emollient)
Terbinex
(terbinafine/hydroxychitosan)
Tersi (selenium sulfide)
Xolegel/Corepak
(ketoconazole)
Vusion
(miconazole nitrate/zinc oxide)
Altabax (retapamulin)
CRITERIA
1. The patient must have documented failure and Rx claims for
four generic antifungals (e.g., Loprox, Nizoral, Spectazole
and Grifulvin V).
10 grams
(10, 1gm)
tubes per
month
144
QTY
LIMIT
CRITERIA
Dermatologicals, continued
All Brand Topical Steroids
Cloderm Cream (clocortolone
pivalate)
Cordran Lotion
(flurandrenolide)
Cordran SP Cream
(flurandrenolide)
Locoid Lotion, Lipocream
(hydrocortisone butyrate)
Momexin (mometasone
furoat/ammonium lac)
Janumet, XR
(sitagliptin/metformin)
Juvisync
(sitagliptin/simvastatin)
Kazano (alogliptin/metformin)
Kombiglyze XR
(saxagliptin/metformin)
Oseni (alogliptin/pioglitazone)
Januvia (sitagliptin)
Nesina (alogliptin benzoate)
Onglyza (saxagliptin)
Limited to
a qty of 30
units per
month
145
Limited to
a qty of 30
units per
month
Limited
qty of 150
units per
30 days or
450 units
per 90
days
Endometriosis
Lupron Depot 3.75 Kit
(leuprolide acetate)
1. Confirmation of diagnosis.
NOTE: Not covered for infertility (infertility services are
excluded).
1. The patient must have documented failure or Rx claims for
both generically available estrogen products (i.e., Estrace,
Ogen).
Hormone Replacement
Cenestin
(estrogens, conj synthetic)
Premarin
(conjugated estrogens)
Premphase (conj
estrogens/medroxypro)
Prempro
(conj estrogens/medroxypro)
Enjuvia
(conjugated estrogen, synthetic)
Migraine Medications
Formulary with PA:
Relpax (eletriptan)
For Relpax:
1. The patient must have documented failure or Rx claims for all
generic triptans (i.e., Amerge, Imitrex, Maxalt, Zomig); OR
2. Generic alternatives must be inappropriate with chart
documentation provided.
For Non-Formulary Products:
1. The patient must have documented failure or Rx claims for all
formulary alternatives (i.e., Amerge, Imitrex, Maxalt, Relpax
and Zomig); OR
2. Formulary alternatives must be inappropriate with chart
documentation provided.
CRITERIA FOR MORE THAN NINE TABLETS PER MONTH
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than nine tablets per month.
2. Patient has had documented failure of all options for migraine
prophylaxis and still requires more than nine tablets per
month.
146
QTY
LIMIT
Migraine Medications,
continued
Cambia (diclofenac potassium)
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
Sumavel (sumatriptan
injection)
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
Migranal (dihydroergotamine)
including generics
CRITERIA
All nasal
triptan
products
are limited
to a
quantity of
6 per
month
8 units
(ml) per
month
147
QTY
LIMIT
CRITERIA
Muscle Relaxants
Amrix (cyclobenzaprine ext
release)
Miscellaneous
Cantil (mepenzolate bromide)
Cardura XL (doxazosin
mesylate ext. release)
Ranexa (ranolazine)
Nitroglycerin Patches
Thyrolar (liotrix)
Amitiza (lubiprostone)
Uloric (febuxostat)
Limited to
a qty of 30
units per
month
148
QTY
LIMIT
Neurological Miscellaneous
Gralise (gabapentin)
CRITERIA
1. The patient must have a documented diagnosis of
postherpetic neuralgia, AND
2. The patient must have documented failure and Rx claims with
generic Neurontin, AND
3. The patient must have documented failure or Rx claims with a
generic tricyclic antidepressant.
Horizant (gabapentin
enacarbil)
Limited to
a qty of 30
units per
30 days.
Nuedexta
(dextromethorphan/quinidine)
Limited to
a qty of 60
units per
30 days.
NSAIDs
On Formulary with PA:
Celebrex (celecoxib)
Cox-2
drugs and
Mobic are
limited to
a qty of 30
units per
month
149
QTY
LIMIT
CRITERIA
NSAIDs, continued
Flector (diclofenac epolamine
transdermal patch)
Vimovo
(esomeprazole/naproxen)
Rayos
Voltaren Gel
(diclofenac sodium)
150
QTY
LIMIT
Ophthalmics
All Brand Topical Ophthalmic
Antihistamines
On Formulary with PA:
Patanol (olopatadine)
CRITERIA
Qty is
limited to
2 units per
day
Lotemax
(loteprednol etabonate)
Betimol (timolol)
Istalol (timolol maleate)
Zioptan is
limited to
a qty of 1
unit per
day
151
QTY
LIMIT
Osteoporosis
Actonel (risedronate sodium)
Evista (raloxifene)
Forteo (teriparatide)
Otic Products
Cipro HC (ciprofloxacin)
Coly-mycin S (colistin/
hc ace/neo sulfate/
thonzonium bromide)
Cortisporin-TC (colistin/
hc ace/neo sulfate/
thonzonium bromide)
Proton Pump Inhibitors
On Formulary with PA:
Aciphex (rabeprazole)
Esomeprazole Strontium
(esomeprazole strontium)
Non-Formulary with PA:
Dexilant (dexlansoprazole)
First-Lansoprazole
(lansoprazole)
First-Omeprazole (omeprazole)
Nexium (esomeprazole)
Prevacid Solutab
(lansoprazole)
Prilosec DR Susp
(omeprazole magnesium)
Protonix Pak (pantoprazole)
Zegerid Susp
(omeprazole/sodium
bicarbonate)
Smoking Cessation
All prescription nicotine patches
(OTC patches are covered
without prior authorization)
CRITERIA
Brand
PPIs are
limited to
a qty of
30
tabs/caps
per
month
For Aciphex:
1. The patient must have documented failure or Rx claims for all
generic proton pump inhibitors (generic omeprazole,
lansoprazole, pantoprazole).
Limited to
1 course
of
therapy
per year
Chantix (varenicline)
152
QTY
LIMIT
Limited to
a qty of
30 units
per
month
Urology
Gelnique (oxybutynin chloride)
Oxytrol Patch (oxybutynin)
Rapaflo (silodosin)
Detrol LA
(tolterodine, long-acting)
Ditropan XL
(oxybutynin, sust. release)
Enablex
(darifenacin hydrobromide)
Myrbetriq (mirabegron)
Toviaz (fesoterodine)
Vesicare (solifenacin)
Vitamins
All Brand Prenatal Vitamins
Atabex
Bal-Care DHA Essential
B-Nexa
Citranatal Assure
Citranatal B-Calm
Citranatal Harmony
Duet DHA Balanced
Gesticare DHA
Natalvit
Natelle One
Nexa Select
OB Complete
Obtrex
Obstetrix DHA
Prefera OB
Prenata
Prenate Elite, DHA, Essential
Prenexa
Preque 10
Select OB
Vitafol-Plus
Vitafol-One
Vitamed MD One
Rx/Quatrefolic
Vitamed MD Plus
CRITERIA
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
Limited to
a qty of
30 units
per
month
153
QTY
LIMIT
CRITERIA
1. The patient is an adult 18 years of age; AND
2
2. The patient has a body mass index (BMI) of >30kg/m , OR
2
3. The patient has a body mass index (BMI) of >27kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
4. The patient has a body mass index (BMI) of >27kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis, pregnancy, and/or lactation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician supervised diet and exercise
program consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet, and a
regular exercise program. AND
5. If the medication is a brand name product, the patient must
have tried a generically available product (i.e. phentermine,
diethylpropion) in the past year.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total
coverage.
154
QTY
LIMIT
CRITERIA
1. The compounded product contains at least one FDA-approved
prescription ingredient; AND
2. Each prescription drug or active ingredient in the compounded
product is approved by the Food & Drug Administration (FDA) for
medical use in the United States; AND
3. The active prescription medication component(s) are in therapeutic
amounts; AND
4. The compounded product is not a copy of any commercially available
FDA-approved drug product; AND
5. The use for which the compounded product is being prescribed is
supported by FDA approval of the active ingredient(s), or is supported
by two or more articles from peer reviewed journals demonstrating
the safety and efficacy of the prescribed therapy for that diagnosis
and method or route of delivery; AND
6. If any prescription ingredient in the compounded product is included
in the HealthPlus Prior Authorization program, the patient must meet
the criteria designated for that prescription ingredient.
Based on limitations or exclusions in the subscriber certificate,
coverage will NOT be provided for compounds under the following
circumstances:
1. Any compound that does not contain a FDA-approved prescription
ingredient otherwise covered by the plan; OR
2. Any compound that contains a non-FDA approved or non-HealthPlus
covered prescription ingredient.
3. Compounded formulations that contain any bulk powders that are not
FDA approved or HealthPlus approved; OR
4. Compounded formulations that are being used for cosmetic purposes;
OR
5. Compounded formulations that are using prescription ingredients for
non-FDA approved indications or purposes that are not supported by
peer-reviewed literature; OR
6. Compounded formulations that may be considered investigational or
experimental; OR
7. Compounded formulations that use drugs withdrawn or removed from
the market for safety reasons; OR
8. Prescription ingredient(s) compounded for the purpose of
convenience only.
a. Exceptions include:
i. Compounded medications for those patients that cannot
swallow or have trouble swallowing and require
administration with an oral liquid, or administration by topical,
rectal or other appropriate non-oral routes;
ii. Compounded medications for those patients who have
sensitivity to dyes, preservatives, or fillers in commercial
products and require allergy-free medications as documented
in the medical record;
iii. Compounded medications for children who require
prescription medications for which there are no liquid
formulations available.
155
QTY
LIMIT
CRITERIA
Quantity Limit QL
Specific request for a dose,
quantity or duration that exceeds
the established limits
156
Name
Concern
Alternative Treatment
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Thyroid USP
(Armour Thyroid, Desiccated)
Glyburide (Micronase)
Glyburide-Metformin
(Glucovance)
Chlorpropamide (Diabinese)
Hydroxyzine (Vistaril, Atarax)
Cyclobenzaprine (Flexeril)
Orphenadrine (Norflex)
Chlorzoxazone (Parafon Forte)
Methocarbamol (Robaxin)
Skelaxin (Metaxalone)
Trimethobenzamide (Tigan)
Ketorolac (Toradol)
Indomethacin
Dipyridamole (Persantine)
Drug may require prior authorization or may have limited coverage depending on members benefit plan, 2 Available OTC
157
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Criteria
1. The patient must be over 18 years old; AND
2. The patient must have a previous Rx claim
for a HMG-CoA reductase inhibitor (i.e.
statin); AND
3. The patient must have clinical and/or
laboratory determined presence of
homozygous familial hypercholesterolemia.
Acceptable documentation includes*:
a. Chart documentation confirming the
presence of xanthomas before the age
of 10, an untreated LDL of >500mg/dL, a
treated LDL of 300mg/dL, or a treated
non-HDL 330mg/dL; OR
b. Genetic testing showing 2 mutated
alleles at the LDL-Receptor, ApoB,
PCSK9, or ARH adaptor protein gene
locus; AND
4. If the patient is female and of childbearing
potential, a negative pregnancy test must
be completed just prior to initiating therapy;
AND
5. The patient must have ALT, AST, alkaline
phosphate, total bilirubin, INR, and SCr
testing obtained just prior to initiating
therapy; AND
6. The results from liver function tests must
be normal (no clinically significant or
unexplainable abnormalities); AND
7. The dose must be appropriate based on
manufacturer recommendations.
Duration of Approval
Approval of prior
authorization requests is
limited to 12 months.
Notes
Recent lab results (within
3 months) are required
for each renewal.
158
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antihyperlipidemics,
continued
Kynamro (mipomersen)
1.
2.
3.
4.
5.
6.
Criteria
The patient must be over 18 years old;
AND
The patient must have a previous Rx claim
for a HMG-CoA reductase inhibitor (i.e.
statin); AND
The patient must have clinical and/or
laboratory determined presence of
homozygous familial hypercholesterolemia.
Acceptable documentation includes*:
a. Chart documentation confirming the
presence of xanthomas before the age
of 10, an untreated LDL of >500mg/dL,
a treated LDL of 300mg/dL, or a
treated non-HDL 330mg/dL; OR
b. Genetic testing showing 2 mutated
alleles LDL-Receptor, ApoB, PCSK9, or
ARH adaptor protein gene locus; AND
The patient must have ALT, AST, alkaline
phosphate, total bilirubin, INR, and SCr
testing obtained just prior to initiating
therapy; AND
The results from liver function tests must
be normal (no clinically significant or
unexplainable abnormalities); AND
The dose must be appropriate based on
manufacture recommendations
Duration of Approval
Approval of prior
authorization requests is
limited to 12 months.
Notes
Recent lab values (within
3 months) are required
for each renewal.
Discontinuation of
treatment should be
considered if patient
does not have a
sufficient response to
warrant the potential risk
of liver toxicity after 6
months.
159
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals
Fuzeon (enfuvirtide)
Criteria
1. For new starts, patient must have a
diagnosis of HIV-1; AND
2. Fuzeon must be used in combination with
other anti-retroviral agents; AND
3. Patient must be anti-retroviral treatmentexperienced; AND
4. Evidence of HIV-1 replication despite
ongoing anti-retroviral therapy; AND
5. Patient or caregiver is able to demonstrate
appropriate techniques for administration of
Fuzeon.
Incivek (telaprevir)
Duration of Approval
Long-term
Notes
Is included in the
Mandatory Specialty
Program.
Utilization will be monitored
to prevent deviation from
recommended dosing
guidelines.
160
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals, continued
Victrelis (boceprevir)
Infergen
(interferon alfacon-1)
Criteria
1. Patient must have a documented diagnosis
of Hepatitis C (HCV) genotype 1, AND
2. Patient has concurrent therapy with both
ribavirin and pegylated interferon, AND
3. Patient has not received HCV treatment
with a protease inhibitor in the past, AND
4. Viral loads (HCV-RNA test) must be drawn
at 12, 24, and 36 weeks after starting
therapy. Treatment is considered futile and
prior authorization will be rescinded if
HCV-RNA level is >100IU/ml after 12 or
24 weeks.
5. Initial duration of approval is for 14 weeks.
Authorization is renewed for an additional
18 weeks (or an additional 30 weeks if
patient has documented cirrhosis) provided
HCV-RNA levels at week 12 are not
indicative of treatment futility.
New Starts Only
1. The patient must be >18 years of age, AND
2. A diagnosis of hepatitis C, AND
3. Documented failure of, or intolerance to,
interferon alfa (Intron A, Roferon A, or
Pegasys).
(Treatment failure is defined as an increase in
aminotransferase or viral RNA levels while on,
or after, interferon alfa-2b therapy.)
Duration of Approval
Notes
161
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals, continued
Intron A
(interferon alpha-2b)
Roferon A
(interferon alpha-2a)
Criteria
1. For diagnosis of hairy cell leukemia, malignant
melanoma, follicular lymphoma, AIDS related
Kaposi's Sarcoma and CML, patients must be
>18 years of age; OR
2. For the diagnosis of condylomata acuminata,
documented failure of, or intolerance to,
traditional treatment modalities (e.g., podofilox,
imiquimod, acid-therapy, or surgical options); OR
3. For the diagnosis of chronic hepatitis B, patients
must have documented liver disease and
hepatitis B viral replication; OR
4. For the diagnosis of chronic hepatitis C, allow 6month initial authorization and 6-month renewal
permitted if the patient has Genotype 1 HCV; or
has initial viral load >2 million copies/mL.
Duration of Approval
Approvals for diagnosis of
condylomata acuminata
should be approved for 4
months.
Notes
162
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals, continued
Synagis (palivizumab)
Criteria
Duration of Approval
Notes
163
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Criteria
1. Creatinine clearance is > 35 ml/min; AND
2. Documented failure of, or intolerance to, an
oral bisphosphonate agent; AND
3. Patient has a diagnosis of osteoporosis or is
postmenopausal with osteopenia as
indicated by a t-score <-1; OR
4. Diagnosis of Pagets disease; OR
5. Patient is considered high-risk (e.g., recent
low-trauma hip fracture) and Reclast is
indicated for secondary fracture
prophylaxis.
Duration of Approval
Approved for 1 year
Dose optimization not to
exceed 5mg once a year
(with the exception of
Pagets disease)
Notes
Retreatment may be
necessary for patients with
Pagets disease who have
relapsed, so there is no
defined dosing frequency.
When treating Pagets
disease, patients should
receive 1500 mg elemental
calcium daily in divided
doses (750 mg two times a
day, or 500 mg three times
a day) and 800 IU vitamin
D daily, particularly in the 2
weeks following
administration to prevent
hypocalcemia.
164
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Enzymes
Ceredase (alglucerase)
Cerezyme (imiglucerase)
VPRIV
(velaglucerase alfa)
Criteria
1. The patient must have a diagnosis of Type
1 (non-neuronopathic or adult) Gaucher's
disease with evidence of at least 1 of the
following:
- Moderate to severe anemia OR
- Thrombocytopenia OR
- Bone disease OR
- Hepatomegaly OR
- Splenomegaly
Duration of Approval
Long-term
Evaluate initially at 3 month
intervals for maintenance
dose reductions/
development of sensitivity
Fabrazyme (agalsidase)
Myozyme
(alglucosidase alfa)
Notes
Recommended dose:
Ceredase and Cerezyme
Initial dosage may begin at
2.5 units/kg of body weight
infused 3 times a week up
to as much as 60 units/kg
administered as frequently
as once a week or as
infrequently as every 4
weeks.
Precaution: Patients may
develop antibodies to
Ceredase
VPRIV
Dose 60units/kg IVPB
every other week.
Recommended dose:
1mg/kg infused once every
2 weeks
Pt should receive
antipyretics prior to infusion
Precaution:
Most patients will develop
IgG antibodies to
Fabrazyme; physicians
should periodically monitor
IgE levels/Fabrazyme
sensitivity
Recommended dose:
20 mg/kg body weight
infused every 2 weeks
Precaution:
Risk of hypersensitivity and
sudden cardiac death
165
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Erythrocyte Stimulating
Agents
Aranesp (darbepoetin alfa)
Epogen (epoetin alfa)
Procrit (epoetin alfa)
Growth Factor,
Recombinant Insulin-like
Increlex (mecasermin [rDNA
origin] injection)
Criteria
1. The patient must have a diagnosis of
anemia associated with
a. chronic renal failure, OR
b. cancer treated with chemotherapy, OR
c. zidovudine-treated HIV infection, OR
d. hepatitis C, OR
e. chronic disease, OR
f. prematurity, OR
g. myelodysplastic syndrome, OR
h. rheumatoid arthritis, AND
2. Hgb level is < 11g/dL.
OR
1. Treatment is needed to reduce the need for
allogenic blood transfusion prior to surgery
for anemic patients (Hgb >10 to < 13g/dL)
who are at high risk for perioperative blood
loss from elective, non-cardiac, nonvascular surgery.
1. Patient has a diagnosis of primary
IGF-1 deficiency or GH gene deletion, AND
2. Increlex is prescribed by or after
consultation with a pediatric endocrinologist,
AND
3. Patient is 2 years to 18 years of age, AND
4. Epiphyses are open, AND
5. Patients bone age is < 16 years for
males or < 14 years for females
Duration of Approval
1 year
Notes
For each of the conditions
listed (except for allogenic
blood transfusion), therapy
is to be discontinued when
Hgb level > 11g/dL OR
after 8 weeks of therapy if
there has been no
response as measured by
hemoglobin levels.
166
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APPENDIX D
Brand (generic) Name
Growth Hormones
On Formulary with PA:
Norditropin Products
(somatropin)
Non-Formulary with PA:
All other somatropin products
Egrifta
Genotropin
Humatrope
Omnitrope
Nutropin
Nutropin AQ
Nutropin AQ NuSpin
Saizen
Serostim
Tev-Tropin
Zorbtive
Criteria
Pediatric patients:
1. Diagnosis of chronic renal failure and growth
retardation; OR
2. Diagnosis of hypothalamic-pituitary lesions or
panhypopituitarism; OR
3. Diagnosis of growth hormone (GH) deficiency; AND
Patient must meet 3 of the 4 following criteria for
documentation of growth failure:
a. Height is >2 standard deviations below the mean
for age and sex (less than 5th percentile for age);
AND
b. Growth velocity is subnormal (age specific growth
rate at less than the 25th percentile); AND
c. Bone age is delayed; AND
d. Documented failure of at least one GH stimulation
tests (defined as a peak growth hormone level of
less than 10mcg/L after GH stimulation by insulin,
arginine, clonidine, glucagon, or levodopa). GH
stimulation tests not required with diagnosis of
Turner Syndrome, Noonan Syndrome, or PraderWilli Syndrome; OR
4. Diagnosis of Idiopathic Short Stature (ISS); AND
a. Height is >2 standard deviations below the mean
for age and sex (less than 5th percentile for age);
AND
b. Documentation that epiphyses are not closed.
Adult patients:
1. Diagnosis of HIV and an unintentional weight loss of
10% over 12 months, 7.5% over 6 months or a BMI
<20mg/kg; OR
2. Diagnosis of hypothalamic-pituitary lesions or
panhypopituitarism; OR
3. Documented GH deficiency; OR
4. Diagnosis of Short Bowel Syndrome; AND
5. Patient is currently receiving specialized nutrition
support directed by a healthcare professional (Total
Parenteral Nutrition (TPN), Peripheral Parenteral
Nutrition (PPN), or high-complex carbohydrate, low-fat
diet)
Both Pediatric and Adult patients:
1. Patient must have documented failure of, or
intolerance to Norditropin before a non-preferred
recombinant human growth hormone product will be
approved.
Duration of Approval
Approved for 1 year
Documentation required for
pediatric renewal:
1. Growth rate has exceeded
2.5cm/year
Notes
Contraindicated for:
-Diabetic retinopathy
-Epiphyseal closure
-Respiratory insufficiency
-Sleep Apnea
-Product specific
hypersensitivities (Cresol,
Benzyl Alcohol,Glycerin)
-Active neoplastic disease
-Intracranial hypertension
167
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APPENDIX D
Brand (generic) Name
Hormones
Lupron Depot (leuprolide)
Criteria
1. The patient must have a diagnosis of uterine
fibroid tumors, endometriosis, ovarian
cancer or prostate cancer; AND
2. The patient must be 18 years of age or
older.
Lupron Depot-Ped
(leuprolide)
Duration of Approval
Notes
168
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APPENDIX D
Brand (generic) Name
Immunomodulators
Actemra (tocilizumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be
initiated before treatment with Actemra; AND
3. Patient has no active infection (including
bacterial sepsis, tuberculosis, invasive fungal
and other opportunistic infections; AND
3
4. Patient has ANC >2000/mm AND Platelets
3
>100,000/mm AND ALT or AST <1.5x upper
limits of normal; AND
5. Patient is not also receiving TNF antagonists, or
other biologics (Enbrel, Humira, Remicade,
Simponi, Cimzia, Kineret, Rituxan, Orencia), or
live vaccines and diagnostic specific criteria are
met.
Duration of Approval
Notes
The dose of Actemra is
4mg/kg IV every 4 weeks;
may increase to 8 mg/kg IV
based on clinical response
(Max: 800mg per infusion).
Infuse over 60 minutes with
infusion set.
Rheumatoid Arthritis:
6. Diagnosis of moderate to severe rheumatoid
arthritis; AND
7. Patient has documented failure of, or intolerance
to, both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
8. The patient is not physically able to administer or
is not an appropriate candidate for a
subcutaneously administered biologic agent
(e.g., Humira, Enbrel); AND
9. Documented failure of, intolerance or
contraindication to, two other disease modifying
antirheumatic drugs (DMARDS) (e.g.,
methotrexate, sulfasalazine, azathioprine, or
hydroxychloroquine).
Juvenile Idiopathic Arthritis (JIA)/Juvenile
Rheumatoid Arthritis (JRA) / polyarticular
juvenile idiopathic arthritis (PJIA):
6. Patient is > 2 years old; AND
7. Patient has a diagnosis of active systemic
JIA/JRA/PJIA. AND
8. Patient has documented failure of, or
intolerance to, both formulary subcutaneous
biologic agents (e.g., Humira and Enbrel).
169
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Amevive (alefacept)
Criteria
1. Documentation of a negative TB test before
initiating therapy; AND
Duration of Approval
Approval for 6 months
Notes
Amevive has not been
studied for use in pediatric
populations; geriatric
populations have not been
large enough to establish
safety or efficacy data.
Data on retreatment
beyond 2 cycles are
limited.
Psoriasis:
170
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Berinert (C1 esterase
inhibitor)
Cinryze (C1 esterase
inhibitor)
Firazyr (icatibant)
Criteria
1. The patient must have a diagnosis of
hereditary angiodema or C1 inhibitor
deficiency
2. The prescription must be written by an
allergist, immunologist, or hematologist
3. For Firazyr, the patient must be 18 years of
age or older.
Cimzia
(certolizumab pegol)
Duration of Approval
Notes
171
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APPENDIX D
Brand (generic) Name
Immunomodulators ,
continued
Enbrel (etanercept)
1.
2.
3.
4.
Criteria
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Enbrel; AND
Patient has no active infection (including
influenza, systemic fungal or bacterial
infections, or acute hepatitis B or C viral
infections); AND
Patient is not also receiving Orencia,
Kineret, Humira, Remicade or other antiTNF therapy; AND diagnosis specific
criteria are met.
Duration of Approval
Approved for 1 year
Dose Optimization not to
exceed 50mg twice a week
Notes
Patients with a latex allergy
or sensitivity should not
handle the prefilled syringe
or autoinjector syringe
since the needle cap(s)
contain latex.
Arthritis:
5. Diagnosis of rheumatoid arthritis (RA),
juvenile RA (JRA), juvenile idiopathic
arthritis (JIA), or psoriatic arthritis (JRA/JIA
approved for ages 2-17).
Psoriasis:
5. Diagnosis of plaque psoriasis; AND
6. Prescription is written by a dermatologist;
AND
7. Documented failure of, intolerance or
contraindication to, at least 2 traditional
therapies (e.g., PUVA, UVB, methotrexate,
or cyclosporine).
Spondylitis:
5. Diagnosis of ankylosing spondylitis or
juvenile spondyloarthropathy.
172
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Humira (adalimumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be
initiated before treatment with Humira; AND
3. Patient has no active infection (including
influenza, systemic fungal or bacterial infections,
or acute hepatitis B or C viral infections); AND
4. Patient is not also receiving Orencia, Kineret,
Enbrel, Remicade or other anti-TNF therapy;
AND diagnosis specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
Patients with a latex allergy
or sensitivity should not
handle the needle cover of
the syringe as it contains
latex.
173
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Humira (adalimumab),
continued
Criteria
Duration of Approval
Notes
Psoriasis:
5. Diagnosis of chronic moderate to severe plaque
psoriasis; AND
6. Documented failure of, intolerance or
contraindication to, at least 2 traditional therapies
(e.g. PUVA, UVB, methotrexate, or
cyclosporine); AND
7. Prescription is written by a dermatologist.
8. The dose of Humira is 80 mg subcutaneously
followed by 40 mg every other week starting 1
week after the initial dose.
Rheumatoid Arthritis:
5. Diagnosis of rheumatoid arthritis; AND
6. The dose of Humira is 40mg every other week.
Ulcerative Colitis:
5. Diagnosis of moderate-to-severe ulcerative
colitis; AND
6. Documented failure of, intolerance or
contraindication to, conventional therapy
(azathioprine, mesalamine, mercaptopurine,
sulfasalazine, methotrexate, corticosteroids);
AND
7. The dose of Humira is 160mg on day 1, 80mg on
day 15 and then 40mg every other week
thereafter.
Documentation of clinical remission must be
submitted to continue therapy beyond 12 weeks.
174
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Criteria
Primary Immunodeficiencies [X-linked
(congenital) agamma-globulinemia, X-linked
(congenital) immunodeficiency with hyper-IgM,
Hypogammaglobulinemia, Common variable
immunodeficiency, and Combined
immunodeficiency syndromes including:
Wiskott-aldrich syndrome; severe combined
immunodeficiency syndrome (SCIDs)]
Duration of Approval
1 year
Notes
1 year
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Criteria
Idiopathic Thrombocytopenia Purpura (ITP)
Acute ITP
1. Platelet count <50,000/ul and rapid rise in
platelet count is necessary prior to surgery,
or to avoid/defer splenectomy, or patient is
at risk for acute bleeding.
Chronic ITP
1. Platelet count is low < 30,000/ul, -and2. Age 10 years of age, -and3. Duration of illness > 6 months, -and4. Documented failure of, intolerance, or
contraindication to at least 3 of the
following: corticosteroids, rituximab,
danazol, colchicine, dapsone,
cyclophosphamide, azathioprine,
mycophenolate, cyclosporine,
chemotherapy -or5. Splenectomy
ITP in pregnancy
rd
1. Platelets <30,000/ul in 3 trimester, -or2. Previously delivered infants with
autoimmune thrombocytopenia and platelet
counts <75,000/ul during current
pregnancy, -and3. Documented failure of, intolerance, or
contraindication to corticosteroids, -or4. Splenectomy
Kawasaki syndrome/Mucocutaneous Lymph
Node Syndrome (MCLS)
1. Therapy is started within 10 days of fever, and2. Concurrent aspirin administration.
Duration of Approval
Acute ITP
1 week
Notes
Chronic ITP
1 year
ITP in pregnancy
1year
1 week
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Duration of Approval
4 months
Criteria
Allogeneic (genetically similar donor) bone
marrow transplant
1. Therapy is started within the first 100 days
post transplant, -or2. Patient is 100 days post transplant, -and3. IgG levels < 400 mg/dl (exception made for
patients who underwent transplantation for
multiple myeloma or malignant
macroglobulinemia because total IgG
concentration is affected by their underlying
paraproteinemia, -or4. Patient has history of CMV or RSV.
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
1 year
1 year
Notes
177
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Criteria
Acute and Chronic Inflammatory
Demyelinating Polyneuropathy
(CIDP)/Guillian-Barre Syndrome (GBS)
For Chronic CIDP:
1. Documented failure of, intolerance, or
contraindication to prednisone or
azathioprine, -or2. Documented plasma exchange.
Duration of Approval
Not limited
For GBS
1. Patient must initiate within first four weeks of
illness.
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
1 month
(to account for relapse)
1 year
Gamunex-C
Hizentra
Notes
178
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Criteria
Myasthenia Gravis (MG) and Lambert-Eaton
(LE) Myasthenia
MG:
1. Documented failure of, intolerance, or
contraindication to at least 2 of the
following: anticholinesterases (eg.,
Mestinon, Prostigmin), corticosteroids,
cyclosporine, cyclophosphamide, or
azathioprine.
LE :
1. Documented failure of, intolerance, or
contraindication to anticholinesterases (eg.
Mestinon,Prostigmin), -or2. Documented plasma exchange.
Duration of Approval
1 week
6 months
Not limited
Notes
179
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Criteria
Autoimmune mucocutaneous blistering
diseases, including Pemphigus vulgaris,
Pemphigus foliaceus, Bullous pemphigoid,
Mucous membrane pemphigoid,
Epidermyolysis bullosa
1. Documented failure of, intolerance, or
contraindication to atleast 2 of the following:
corticosteroids. methotrexate, azathioprine,
or cyclophosphamide, -or2. Documentation of rapidly progressive
disease in which a clinical response could
not be affected quickly enough using
prerequisite therapies.
Duration of Approval
6 months
Not limited
Not limited
Not limited
Fetal/neonatal alloimmune
thrombocytopenia (FAIT/NAIT)
1. Diagnosis is required
Gamunex-C
Hizentra
Not limited
Not limited
Not limited
Notes
180
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Kineret (anakinra)
1.
2.
3.
4.
5.
Criteria
The patient must be > 18 years of age;
AND
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Kineret; AND
Patient has no active infection (including
influenza, systemic fungal or bacterial
infections, or acute hepatitis B or C viral
infections); AND
Patient is not also receiving Orencia,
Enbrel, Remicade or other anti-TNF
therapy; AND diagnosis specific criteria are
met.
Duration of Approval
Approved for 1 year
Notes
Patients with a latex allergy
or sensitivity should not
handle the Kineret needle
cover as it contains latex.
Kineret should not be given
by intravenous
administration or
intramuscular
administration.
Rheumatoid Arthritis:
6. Diagnosis of rheumatoid arthritis; AND
7. Documented failure of, or intolerance to,
methotrexate; AND
8. Documented failure of, or intolerance to,
another disease modifying antirheumatic
drug (DMARD) (e.g., azathioprine,
leflunomide, cyclosporine, penicillamine,
sulfasalazine); AND
9. Patient has documented failure of, or
intolerance to Humira and Enbrel; AND
10. The dose of Kineret is 100mg administered
subcutaneously once daily.
181
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Orencia (abatacept)
Criteria
1. A negative TB test before initiating therapy;
OR
2. Treatment for latent TB infections must be
initiated before treatment with Orencia;
AND
3. Patient has no active infection (including
influenza, systemic fungal or bacterial
infections, or acute hepatitis B or C viral
infections); AND
4. Patient is not also receiving Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF
therapy; AND
5. For infused Orencia, the patient has
documented failure of, intolerance to, or is
not physically able to administer the
subcutaneous formulation of Orencia; AND
diagnosis specific criteria are met.
Arthritis:
6. Diagnosis of moderate to severe rheumatoid
arthritis; OR
7. Diagnosis of moderate to severe
polyarticular juvenile rheumatoid arthritis
(JRA)/juvenile idiopathic arthritis (JIA);
(JRA/JIA approved for > 6 years of age).
8. Patient has documented failure of,
intolerance or contraindication to, two other
disease modifying antirheumatic drugs
(DMARDS) (e.g., methotrexate,
sulfasalazine, azathioprine, or
hydroxychloroquine); AND
9. Patient has documented failure of, or
intolerance to both formulary subcutaneous
biologic agents (e.g., Humira and Enbrel).
Duration of Approval
Approved for 1 year
Notes
182
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade (infliximab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be
initiated before treatment with Remicade; AND
3. Patient has no active infection (including
influenza, systemic fungal or bacterial infections,
or acute hepatitis B or C viral infections); AND
4. Patient is not also receiving Orencia, Kineret,
Enbrel, or Humira or other anti-TNF therapy;
AND
5. The dose of Remicade is not to exceed 10mg/kg;
AND diagnosis specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
183
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade (infliximab)
continued
Criteria
Duration of Approval
Notes
Psoriasis:
6. Prescription is written by a dermatologist; AND
7. Patient has diagnosis of chronic, severe (i.e.,
extensive and/or disabling) plaque psoriasis;
AND
8. Documented failure of, or intolerance to, at least
2 traditional therapies (e.g., PUVA, UVB,
methotrexate, or cyclosporine); AND
9. Patient has documented failure of, or intolerance
to both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
10. The patient is not physically able to administer
or is not an appropriate candidate for a
formulary subcutaneously administered biologic
agent (e.g., Humira, Enbrel).
Rheumatoid Arthritis:
6. Diagnosis of rheumatoid arthritis; AND
7. Patient has documented failure of, or intolerance
to, two other disease modifying antirheumatic
drugs(DMARDS) (e.g., methotrexate,
sulfasalazine, azathioprine, or
hydroxychloroquine); AND
8. Patient has documented failure of, or intolerance
to both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
9. The patient is not physically able to administer or
is not an appropriate candidate for a formulary
subcutaneously administered biologic agent
(e.g., Humira, Enbrel).
184
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade (infliximab),
continued
Criteria
Duration of Approval
Notes
Ulcerative Colitis:
6. Patient has moderately to severely active
ulcerative colitis and required high dose systemic
corticosteroid use; OR
7. Patient has documented inadequate response to
conventional therapy (e.g., mesalamine (5-ASA),
azathioprine, mercaptopurine); AND
8. Patient has documented failure of, or intolerance
to formulary subcutaneous biologic agents
(e.g., Humira); OR
9. The patient is not physically able to administer or
is not an appropriate candidate for a formulary
subcutaneously administered biologic agent
(e.g., Humira).
Uveitis:
6. Diagnosis of Uveitis Associated with Behcets
Syndrome
185
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Rituxan (rituximab)
Criteria
1. Prescription is written by an oncologist or
hematologist; OR
2. The patient has a diagnosis of moderate to
severe rheumatoid arthritis; AND
3. Patient has no active infection (including
influenza, systemic fungal or bacterial
infections, or acute hepatitis B or C viral
infections); AND
4. Patient is not also receiving Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF
therapy; AND
5. Patient has documented failure of, or
intolerance to both formulary subcutaneous
biologic agents (e.g., Humira and Enbrel);
OR
6. The patient is not physically able to
administer or is not an appropriate
candidate for a formulary subcutaneous
biologic agent (e.g., Humira, Enbrel); AND
7. Documented failure of, or intolerance to, two
other disease modifying antirheumatic
drugs (DMARDS) (e.g., methotrexate,
sulfasalazine, azathioprine, or
hydroxychloroquine).
Duration of Approval
For a diagnosis of RA:
Since safety and efficacy of
re-treatment have not been
established in controlled
trials and a limited number of
patients have received two
to five courses (two infusions
per course) of treatment in
an uncontrolled setting, the
duration of approval for RA
should be limited to 5
courses (3 months) with reevaluation based on
individual response.
Notes
The dose for use in RA is 2
x 1000mg IV infusions
separated by 2 weeks.
Glucocorticoids,
administered as
methylprednisolone 100mg
IV or its equivalent, given
30 minutes prior to each
infusion, are recommended
to reduce the incidence
and severity of infusion
reactions.
186
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Simponi (golimumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be
initiated before treatment with Simponi; AND
3. Patient has no active infection (including
influenza, systemic fungal or bacterial infections,
or acute hepatitis B or C viral infections); AND
4. Patient is not also receiving Orencia, Kineret,
Enbrel, Remicade or other anti-TNF therapy;
AND diagnosis specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
Patients with a latex allergy
or sensitivity should not
handle the prefilled syringe
or autoinjector syringe
since the needle cover
contains latex.
187
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Stelara (ustekinumab)
Criteria
1. A negative TB test before initiating therapy;
OR
2. Treatment for latent TB infections must be
initiated before treatment with Stelara; AND
3. Patient has no active infection (including
bacterial, fungal or viral); AND diagnostic
specific criteria are met
Psoriasis:
4. Diagnosis of moderate to severe plaque
psoriasis; AND
5. Prescription is written by a dermatologist;
AND
6. Documented failure of, intolerance or
contraindication to, at least two traditional
therapies (e.g., PUVA, UVB, methotrexate,
or cyclosporine); AND
7. Patient has documented failure of, or
intolerance to Humira and Enbrel.
Duration of Approval
Notes
WT <100 kg - 45 mg
subcutaneously initially and
4 weeks later, followed by
45 mg every 12 weeks.
WT >100 kg 90 mg
subcutaneously initially and
4 weeks later, followed by
90 mcg every 12 weeks.
188
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Tysabri (natalizumab)
Criteria
Duration of Approval
Notes
189
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APPENDIX D
Brand (generic) Name
Immunomodulators
Xgeva (denosumab)
Criteria
1. Patient has a diagnosis of bone metastases
secondary to solid tumor.
Duration of Approval
1 year
Notes
Dose: 120 mg every 4
weeks subcutaneously.
Administer calcium and Vit
D PRN to treat or prevent
hypocalcemia
Not indicated in patients
with multiple myeloma.
Immunomodulators,
continued
Cryopyrin-Associated
Periodic Syndromes
Arcalyst (rilonacept)
Recommended dose:
Adults 18 yrs or older:
Loading dose: 320mg Sub Q
Maintenance dose:160mg
SubQ once weekly
Pediatric patients 12 to 17 yrs
old:
Loading dose:4.4mg/kg(to
max of 320mg) SQ
Maintenance dose: 2.2mg/kg
SubQ once weekly
*Dose should not be given
more than once per week
Precautions:
Arcalyst should not be
administered if patient has
active or chronic infection.
Patient should receive all
recommended vaccinations
prior to receiving Arcalyst.
190
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APPENDIX D
Brand (generic) Name
Cryopyrin-Associated
Periodic Syndromes
Ilaris (canakinumab)
Criteria
1. Patient has no active or chronic infection
(including influenza, systemic fungal or
bacterial infections, or acute hepatitis B or C
viral infections); AND
2. Diagnosis specific criteria are met
Cryopyrin-Associated Periodic Syndromes
(CAPS), including Familial Cold
Autoinflammatory Syndrome (FCAS) and
Muckle-Wells Syndrome (MWS)
3. Patient is > 4 years old; AND
4. Patient has a diagnosis of CAPS, FCAS, or
MWS.
Duration of Approval
Long Term
Notes
Recommended dose:
Adults, Adolescents, and
Children >= 4 years of age
and > 40kg: 150mg SC
every 8 weeks.
Adults, Adolescents, and
Children >=4 years of age
and 15-40kg: 2mg/kg SC
every 8 weeks. Response
is inadequate in children in
this weight range, may
consider dose increase to
3mg/kg SC every 8 weeks.
191
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APPENDIX D
Brand (generic) Name
Multiple Sclerosis,
Adjunctive Agents
Non-Formulary
Ampyra (dalfampridine)
Criteria
1. The patient must have a diagnosis of Multiple
Sclerosis; AND
2. The patient is ambulatory; AND
3. The patient has no history of a seizure
disorder; AND
4. The patient must have a CrCl>50mL/min;
AND
5. The patient must be receiving concurrent
therapy with a disease modifying agent (i.e.,
Avonex, Betaseron, Copaxone); AND
6. The prescription is written by a neurologist;
AND
7. For renewal, the patient has a documented
20% or greater improvement from baseline
in a timed 25 foot
walk.
1. Patient has a diagnosis of multiple sclerosis;
OR
2. Patient has had signs and symptoms of
Clinically Isolated Syndrome (CIS)
suggestive of MS
Duration of Approval
6 months
Notes
Quantity is limited to 60 units
per 30 days.
Long-term
192
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
All Multiple Sclerosis,
Disease-Modifying Agents
Non-Formulary with PA,
continued
Gilenya (fingolimod)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Criteria
The patient must have documented diagnosis of a relapsing
form of multiple sclerosis;
There is documentation of the following within the last 6
months:
a. CBC, Liver Function Tests, and
b. Ophthalmologic Evaluation; and
Physician must submit documentation that the first dose is
administered in a setting with resources to appropriately
manage symptomatic bradycardia. Setting allows for hourly
patient monitoring of pulse and blood pressure for 6 hours for
signs and symptoms of bradycardia, including an
electrocardiogram prior to dosing, and at the end of the
observation period.
Patient has not had a recent (within the last six months)
occurrence of MI, unstable angina, stroke, TIA, decompensated
HF requiring hospitalization, or Class II/IV HF.
Patient does not have a history or presence of Mobitz Type II
2nd degree or 3rd degree AV block or sick sinus syndrome,
unless patient has a pacemaker.
Patient has a QTc interval >/500ms.
Patient is not receiving treatment with a Class 1a or Class III
antiarrhythmic drug.
Patients receiving concurrent therapy with drugs that slow heart
rate (e.g., beta blockers, heart-rate lowering calcium channel
blockers such as diltiazem or verapamil, or digoxin) must
receive overnight continuous ECG monitoring with
administration of first dose.
Patient has had treatment failure, contraindication, or
intolerance to Copaxone (glatiramer acetate); AND
Patient is intolerant to both Avonex (interferon beta 1a) and
Rebif (interferon beta 1a) (i.e. severe or intolerable injection site
reactions or side effects); OR
Patient has had treatment failure, contraindication, or allergy to
interferon therapy.
Duration of Approval
Notes
Quantity is limited
to 30 units per
month.
Patient should not
receive Gilenya
concomitantly with
another
immunomodulator
therapy for
multiple sclerosis
(e.g. Avonex,
Rebif, Betaseron,
Extavia,
Copaxone, or
Tysabri).
193
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Neurological
Xenazine (tetrabenazine)
Criteria
1. The patient must have a diagnosis of chorea associated with
Huntingtons disease; AND
2. The patient must have documented failure of, intolerance to, or
contraindication to at least two of the following: amantadine, an
antipsychotic (fluphenazine, haloperidol, risperidone,
ziprasidone, quetiapine or olanzapine), riluzole, or a
benzodiazepine, AND
3. Prescription must be prescribed by a neurologist, AND
4. For doses greater than 50 mg/day, CYP2D6 genotyping is
required.
Duration of Approval
3 months
Notes
Patients who do
not express
CYP2D6 (i.e.,
poor metabolizers
of CYP2D6)
require a daily
dose of 37.550
mg, in 3 divided
doses.
Patients who do
express CYP2D6
(i.e., intermediate
or extensive
metabolizers of
CYP2D6) require
a daily dose of at
least 50 mg100mg in 3
divided doses.
Neuromuscular Blocking
Agent
Botox
Dysport
Xeomin
(botulism toxin type A)
Parkinsons
Apokyn (apomorphine)
Approved 3 months
Long-term
Pulmonary
Cayston
(aztreonam for inhalation)
194
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Pulmonary, continued
Xolair (omalizumab)
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Criteria
Patient is over 12 years of age; AND
Patient has a diagnosis of moderate to severe allergic asthma;
AND
A positive skin test or in vitro reactivity to a perennial
aeroallergen; AND
Failure of, or intolerance to, maximum dose of oral inhaled
steroids (medication compliance should be taken into
consideration); AND/OR
Patient required long-term (>3months) oral steroids previously
and had at least 1 ED or hospital admission during the last 6
months.
Diagnosis of moderate to severe rheumatoid arthritis; AND
A negative TB test before initiating therapy; OR
Treatment for latent TB infections must be initiated before
treatment with Xeljanz; AND
Patient has no active infection (including bacterial sepsis,
tuberculosis, invasive fungal and other opportunistic infections);
AND
3
Patient has a lymphocyte count >500 cells/mm , ANC > 1000
3
cells/mm , and hemoglobin level >9g/dL; AND
Patient is not also receiving TNF antagonists, or other biologics
(e.g. Enbrel, Humira, Remicade, Simponi, Cimzia, Kineret,
Rituxan, Orencia); AND
Patient has documented failure of, intolerance or
contraindication to, two other disease- modifying antirheumatic
drugs (DMARDS) (e.g., methotrexate, sulfasalazine,
azathioprine, or hydroxychloroquine); AND
Patient has documented failure of, or intolerance to, both
formulary subcutaneous biologic agents (e.g., Humira and
Enbrel); OR
The patient is not physically able to administer or is not an
appropriate candidate for a subcutaneously administered
biologic agent (e.g., Humira, Enbrel).
Duration of Approval
Approved 3 months to
determine patient
response.
Notes
The warnings for
Xolair include
malignancy and
anaphylaxis.
Renewals may be
authorized long-term.
195
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX 1
AGE
IgA
IgG
IgM
AGE
IgG1
IgG2
IgG3
IgG4
1 - 2 mo
1 - 53
251 - 906
20 - 87
cord
435 - 1084
143 - 453
27 - 146
1 - 47
2 - 3 mo
3 - 47
206 - 601
17 - 105
0 - 3 mo
218 - 496
40 - 167
4 - 23
1 - 33
3 - 4 mo
4 - 73
176 - 581
24 - 101
3 - 6 mo
143 - 394
23 - 147
4 - 100
1 - 14
4 - 5 mo
8 - 84
172 - 814
33 - 108
6 - 9 mo
190 - 388
37 - 60
12 - 62
1-1
5 - 6 mo
8 - 68
215 - 704
35 - 102
9 mo - 3 yr
286 - 680
30 - 327
13 - 82
1 - 65
6 - 8 mo
11 - 90
217 - 904
34 - 125
3 - 5 yr
381 - 884
70 - 443
17 - 90
1 - 116
8 mo 1 yr
16 - 84
294 - 1069
41 - 149
5 - 7 yr
292 - 816
83 - 513
8 - 111
1 - 121
1 - 2 yr
43 - 173
7 - 9 yr
442 - 802
113 - 480
15 - 133
1 - 84
2 - 3 yr
48 - 168
9 - 11 yr
456 - 938
163 - 513
26 - 113
1 - 121
3 - 4 yr
47 - 200
11 - 13 yr
456 - 952
147 - 493
12 - 179
1 - 168
4 - 6 yr
43 - 196
13 - 15 yr
347 - 993
140 - 440
23 - 117
1 - 183
6 - 9 yr
48 - 207
15 yr & up
422 - 1292
117 - 747
41 - 129
1 - 291
9 - 11 yr
52 - 242
11 yr & up
56 - 352
196
197
199
A
ABATACEPT........................................................................... 87, 91
ABILIFY........................................................................................62
ABSTRAL .....................................................................................39
ACANYA ......................................................................................51
ACARBOSE ..................................................................................81
ACCOLATE............................................................................. 41, 45
ACCUNEB ....................................................................................43
ACCUPRIL....................................................................................26
ACCURETIC .................................................................................27
ACEBUTOLOL ........................................................................ 26, 30
ACEON ........................................................................................27
ACETAMINOPHEN/ CODEINE .....................................................41
ACETAMINOPHEN/ HYDROCODONE .................................... 40, 41
ACETAMINOPHEN/ OXYCODONE ......................................... 40, 41
ACETAMINOPHEN-ISOMETHEPTENE-CAFFEINE .........................66
ACETAZOLAMIDE ........................................................................55
ACETIC ACID ...............................................................................59
ACETIC ACID/ HYDROCORTISONE ...............................................59
ACETONIDE .................................................................................46
ACIPHEX......................................................................................20
ACITRETIN...................................................................................49
ACLIDINIUM BROMIDE ...............................................................45
ACLOVATE ..................................................................................46
ACTIGALL ....................................................................................84
ACTIQ .........................................................................................39
ACTIVELLA 1.0-0.5 ......................................................................75
ACTONEL ....................................................................................77
ACTOPLUS MET ..........................................................................80
ACTOPLUS MET XR .....................................................................80
ACTOS .........................................................................................80
ACULAR LS ..................................................................................58
ACUVAIL .....................................................................................58
ACYCLOVIR .................................................................................37
ACZONE 5% GEL .........................................................................51
ADALAT CC .................................................................................28
ADALIMUMAB ............................................................................86
ADAPALENE ................................................................................51
ADAPALENE/BENZOYL PEROXIDE ...............................................51
ADCIRCA .....................................................................................30
ADDERALL XR..............................................................................63
ADOXA, PAK................................................................................33
ADVAIR .......................................................................................43
ADVICOR.....................................................................................31
AGGRENOX .................................................................................54
AGRYLIN .....................................................................................54
ALAVERT OTC .............................................................................41
ALBENDAZOLE ............................................................................37
ALBENZA .....................................................................................37
ALBUTEROL........................................................................... 44, 45
ALBUTEROL SULFATE ..................................................................43
ALBUTEROL/ IPRATROPIUM .......................................................44
ALCAFTADINE .............................................................................58
ALCLOMETASONE .......................................................................46
ALDACTAZIDE 25/25 ...................................................................26
ALDACTAZIDE 50/50 ...................................................................26
ALDACTONE ................................................................................26
ALDARA ......................................................................................53
ALDOMET ...................................................................................30
ALDOMET 125 ............................................................................30
ALDORIL-D ..................................................................................30
ALENDRONATE ...........................................................................77
ALENDRONATE/ VITAMIN D3 .....................................................77
ALFUZOSIN .................................................................................88
ALINIA .........................................................................................37
ALISKIREN ...................................................................................31
ALISKIREN/ ..................................................................... 28, 29, 31
ALISKIREN/ HCTZ ........................................................................31
ALITRETINOIN .............................................................................53
ALL OTHER TEST STRIPS (covered at DME only with a copay as
applicable) .............................................................................81
ALLEGRA OTC .............................................................................41
ALLEGRA-D .................................................................................43
ALLEGRA-D 12 HOUR ..................................................................42
ALLOPURINOL .............................................................................81
ALMOTRIPTAN............................................................................65
ALOCRIL ......................................................................................58
ALODOX ......................................................................................57
ALOGLIPTIN/ BENZOATE.............................................................80
ALOGLIPTIN/ METFORMIN .........................................................80
ALOGLIPTIN/ PIOGLITAZONE ......................................................80
ALOMIDE ....................................................................................58
ALORA ........................................................................................74
ALOSETRON .......................................................................... 22, 89
ALPHAGAN P ..............................................................................55
ALPRAZOLAM .............................................................................61
ALPROSTADIL........................................................................ 85, 86
ALREX .........................................................................................56
ALTABAX .....................................................................................49
ALTACE CAPS ..............................................................................27
ALTOPREV...................................................................................31
ALVESCO .....................................................................................43
AMANTADINE .............................................................................36
AMARYL ......................................................................................79
AMBIEN ......................................................................................61
AMERGE .....................................................................................65
AMICAR ......................................................................................54
AMICAR 1,000MG ......................................................................55
AMINOCAPROIC ACID ........................................................... 54, 55
AMINOPHYLLINE ........................................................................45
AMIODARONE ...................................................................... 25, 26
AMITIZA ................................................................................ 22, 89
AMITRIPTYLINE ...........................................................................59
AMLACTIN 12%...........................................................................48
AMLODIPINE...............................................................................29
AMLODIPINE/ .............................................................................28
AMLODIPINE/ ATORVASTATIN ...................................................31
AMLODIPINE/ BENAZEPRIL ................................................... 27, 29
AMLODIPINE/ OLMESARTAN......................................................27
AMLODIPINE/ VALSARTAN .........................................................28
AMMONIUM LACTATE ...............................................................48
AMOXICILLIN ..............................................................................32
AMOXICILLIN TRIHYDRATE .........................................................32
AMOXICILLIN/ CLAVULANATE ....................................................32
AMOXIL ......................................................................................32
200
ATACAND....................................................................................27
ATACAND HCT ............................................................................27
ATELVIA ......................................................................................77
ATENOLOL ..................................................................................30
ATENOLOL/ CHLORTHALIDONE ..................................................30
ATIVAN .......................................................................................61
ATOMOXETINE ...........................................................................63
ATOPICLAIR ................................................................................48
ATORVASTATIN ..........................................................................31
ATOVAQUONE ............................................................................37
ATOVAQUONE/ PROGUANIL ......................................................37
ATRALIN......................................................................................51
ATROPINE ...................................................................................55
ATROPINE SULFATE ....................................................................55
ATROVENT HFA ..........................................................................44
ATROVENT NASAL SPRAY ...........................................................42
AUBAGIO ....................................................................................89
AUGMENTIN CHEW TABS, 125-31.25 SUSP ................................32
AUGMENTIN XR ..........................................................................32
AUGMENTIN, ES .........................................................................32
AURALGAN .................................................................................59
AURANOFIN ................................................................................87
AVALIDE......................................................................................27
AVANDAMET ..............................................................................80
AVANDARYL ................................................................................80
AVANDIA ....................................................................................80
AVAPRO ......................................................................................27
AVC CREAM ................................................................................52
AVELOX.......................................................................................34
AVIANE .......................................................................................68
AVIDOXY DK................................................................................33
AVINZA .......................................................................................39
AVODART....................................................................................87
AVONEX ......................................................................................89
AXERT .........................................................................................65
AXID ............................................................................................20
AXIRON .......................................................................................76
AYGESTIN....................................................................................75
AZASAN ......................................................................................86
AZASITE ......................................................................................57
AZATHIOPRINE ...........................................................................86
AZELAIC ACID ..............................................................................51
AZELASTINE .......................................................................... 42, 58
AZELASTINE/ ...............................................................................42
AZELEX ........................................................................................51
AZILECT .......................................................................................67
AZILSARTAN MEDOXOMIL ..........................................................28
AZILSARTAN MEDOXOMIL/ ........................................................28
AZITHROMYCIN .................................................................... 34, 57
AZOPT .........................................................................................55
AZOR...........................................................................................27
AZULFIDINE, ENTAB ....................................................................21
B
BACLOFEN ..................................................................................66
BACTRIM DS, SEPTRA DS ...................................................... 34, 35
BACTRIM, SEPTRA ................................................................ 34, 35
BACTROBAN ...............................................................................49
BACTROBAN NASAL OINT ...........................................................49
BAL-CARE DHA ESSENTIAL ..........................................................81
201
C
CABOZANTINIB ...........................................................................90
CADUET ......................................................................................31
CAFERGOT ..................................................................................65
CALAN.........................................................................................25
CALAN SR ....................................................................................28
CALCIPOTRIENE ..........................................................................49
CALCITONIN................................................................................77
CALCITRIOL ........................................................................... 53, 83
CALCIUM ACETATE .....................................................................90
CAMBIA ......................................................................................65
CAMILA .......................................................................................68
CANAGLIFLOZIN..........................................................................79
CANASA ......................................................................................21
CANDESARTAN ...........................................................................27
CANTIL ........................................................................................23
CAPOTEN ....................................................................................27
CAPTOPRIL..................................................................................27
CARAFATE ...................................................................................20
CARAFATE SUSP..........................................................................20
CARBACHOL................................................................................55
CARBAMAZEPINE.................................................................. 64, 65
CARBATROL ................................................................................64
CARBIDOPA ................................................................................67
CARBIDOPA/ LEVODOPA ............................................................67
CARBIDOPA/ LEVODOPA/ ENTACAPONE....................................67
CARDENE ....................................................................................28
202
CARDENE SR ...............................................................................28
CARDIZEM ..................................................................................28
CARDIZEM CD 120, 180, 240, 300 ..............................................29
CARDIZEM LA .............................................................................29
CARDURA ............................................................................. 30, 87
CARDURA XL ......................................................................... 30, 87
CARISOPRODOL ..........................................................................66
CARMOL .....................................................................................48
CARNITOR ...................................................................................84
CARTIA XT ...................................................................................29
CARVEDILOL ...............................................................................29
CATAFLAM ..................................................................................38
CATAPRES-TTS ............................................................................30
CAVERJECT..................................................................................85
CECLOR .......................................................................................32
CEDAX .........................................................................................32
CEFACLOR ...................................................................................32
CEFDITOREN ...............................................................................33
CEFIXIME ....................................................................................33
CEFTIBUTEN................................................................................32
CEFTIN ........................................................................................32
CEFUROXIME ..............................................................................32
CELEBREX....................................................................................38
CELECOXIB ..................................................................................38
CELESTONE .................................................................................68
CELEXA .......................................................................................60
CELLCEPT ....................................................................................86
CELONTIN ...................................................................................64
CENESTIN....................................................................................74
CEPHALEXIN ...............................................................................33
CERTOLIZUMAB PEGOL ..............................................................86
CETIRIZINE ..................................................................................42
CETRAXAL ...................................................................................59
CETRORELIX ACETATE .................................................................76
CETROTIDE .................................................................................76
CHANTIX .....................................................................................85
CHLORAL HYDRATE.....................................................................61
CHLOROQUINE ...........................................................................37
CHLOROXYLENOL/ ......................................................................59
CHLORPROPAMIDE.....................................................................79
CHLORTHALIDONE......................................................................26
CHLORZOXAZONE .......................................................................66
CHOLESTYRAMINE POWDER ......................................................32
CHOLESTYRAMINE/ ....................................................................32
CIALIS..........................................................................................85
CIALIS 2.5, 5MG ..........................................................................85
CICLESONIDE ........................................................................ 42, 43
CICLODAN KIT .............................................................................49
CICLOPIROX ................................................................................50
CICLOPIROX OLAMINE ................................................................50
CICLOPIROX OLAMINE CREAM/ CLEANSER ................................49
CICLOPIROX SOLN 8%/ LACQUER REMOVAL PADS.....................50
CILOSTAZOLE ..............................................................................54
CILOXAN GEL ..............................................................................57
CILOXAN SOLN............................................................................57
CIMETIDINE ................................................................................20
CIMZIA ........................................................................................86
CIPRO.................................................................................... 34, 35
CIPRO HC ....................................................................................59
CIPRO SUSP .......................................................................... 34, 35
CIPRODEX ...................................................................................59
203
COMETRIQ..................................................................................90
COMFORT PAC-TIZANIDINE ........................................................66
COMPAZINE SYRUP ....................................................................22
COMPAZINE TABS , SUPP ...........................................................23
COMPLETE-RF PRENATAL ...........................................................82
COMTAN.....................................................................................67
CONCEPT OB, DHA .....................................................................82
CONCERTA ..................................................................................63
CONDYLOX GEL...........................................................................53
CONDYLOX SOLUTION ................................................................53
CONJUGATED ESTROGEN/ MPA ........................................... 75, 76
CONJUGATED ESTROGENS .........................................................74
CONZIP .......................................................................................39
COPAXONE .................................................................................89
COPEGUS ....................................................................................88
CORDARONE...............................................................................25
CORDRAN 4MCG/SQ CM TAPE ...................................................46
CORDRAN, SP .............................................................................46
COREG ........................................................................................29
COREG CR ...................................................................................29
CORGARD ...................................................................................29
CORTEF TABS ..............................................................................68
CORTIFOAM................................................................................21
CORTISONE .................................................................................68
CORTISONE ACETATE .................................................................68
CORTISPORIN ................................................................. 49, 58, 59
CORTISPORIN-TC ........................................................................59
CORZIDE .....................................................................................29
COSOPT ......................................................................................55
COSOPT PF..................................................................................55
COUMADIN.................................................................................53
COVERA HS .................................................................................29
COZAAR ......................................................................................28
CREON ........................................................................................21
CRESTOR .....................................................................................31
CROFELEMER ..............................................................................22
CROMOLYN SODIUM ............................................................ 22, 44
CROMOLYN SOLN .......................................................................44
CROTAMITON .............................................................................53
CRYSELLE ....................................................................................68
CUPRIMINE .................................................................................84
CUTIVATE ...................................................................................46
CUTIVATE 0.05% LOTION............................................................46
CYANOCOBALAMIN/MECOBALAMIN .........................................83
CYCLOBENZAPRINE.....................................................................66
CYCLOGYL 0.5%, .........................................................................55
CYCLOGYL 1% .............................................................................55
CYCLOPENTOLATE ......................................................................55
CYCLOSERINE ..............................................................................36
CYCLOSPORINE ..................................................................... 58, 86
CYMBALTA ............................................................................ 60, 89
CYSTOSPAZ, M ............................................................................23
CYTOMEL ....................................................................................78
CYTOTEC .....................................................................................20
D
DABIGATRAN ETEXILATE MESYLATE ...........................................54
DALFAMPRIDINE ........................................................................89
DALIRESP ....................................................................................45
DALTEPARIN SODIUM,PORCINE .................................................54
DANTRIUM .................................................................................66
DANTROLENE .............................................................................66
DAPSONE ....................................................................................51
DARAPRIM ..................................................................................37
DARBEPOETIN ALFA IN POLYSORBATE .......................................54
DARIFENACIN HYDROBROMIDE .................................................88
DAYPRO ......................................................................................38
DAYTRANA..................................................................................63
DDAVP NASAL SPRAY .................................................................76
DDAVP RHINAL TUBE..................................................................76
DECADRON .................................................................................56
DECONAMINE SYRUP .................................................................43
DECONAMINE TABS ....................................................................43
DEFERASIROX .............................................................................84
DEFEROXAMINE MESYLATE ........................................................84
DELZICOL ....................................................................................21
DEMADEX ...................................................................................26
DEMEROL ...................................................................................39
DEPAKENE ..................................................................................64
DEPAKOTE ..................................................................................64
DERMA-SMOOTHE-FS 0.01% OIL................................................46
DESFERAL ...................................................................................84
DESIPRAMINE .............................................................................60
DESLORATIDINE ..........................................................................41
DESMOPRESSIN ACETATE ...........................................................76
DESOGEN ....................................................................................68
DESONATE GEL ...........................................................................46
DESONIDE ............................................................................. 46, 47
DESONIDE/EMOLLIENT COMBO .................................................46
DESOWEN...................................................................................46
DESOWEN COMBO .....................................................................46
DESOXIMETASONE .....................................................................47
DESOXYN ....................................................................................63
DESQUAM X ...............................................................................51
DESVENLAFAXINE SUCCINATE ....................................................60
DETROL .......................................................................................87
DETROL LA ..................................................................................87
DEXAMETHASONE ......................................................................56
DEXAMETHASONE/ NEOMYCIN/ POLYMYXIN ............................58
DEXAMETHASONE/ TOBRAMYCIN .............................................58
DEXILANT....................................................................................20
DEXLANSOPRAZOLE....................................................................20
DEXMETHYLPHENIDATE .............................................................63
DEXMETHYLPHENI-DATE ............................................................63
DEXTROAMPHET-AMINE ............................................................64
DIABETA .....................................................................................79
DIABINESE ..................................................................................79
DIAMOX SEQUELS ......................................................................55
DIASTAT ......................................................................................64
DIAZEPAM ............................................................................ 61, 64
DIBENZYLINE ..............................................................................30
DICLOFENAC ...............................................................................38
DICLOFENAC EPOLAMINE ...........................................................38
DICLOFENAC POTASSIUM ...........................................................65
DICLOFENAC SODIUM ................................................................53
DICLOFENAC, EXTENDED RELEASE .............................................38
DICLOFENAC/ MISOPROSTOL .....................................................38
DICLOFENAX POTASSIUM ...........................................................38
DICYCLOMINE .............................................................................23
DIDRONEL ...................................................................................77
DIFENOXIN/ ATROPINE...............................................................23
204
DUONEB .....................................................................................44
DURAGESIC PATCH .....................................................................39
DUTASTERIDE .............................................................................87
DUTASTERIDE/...................................................................... 30, 88
DUTOPROL .................................................................................29
DYAZIDE......................................................................................26
DYMISTA .....................................................................................42
DYNACIRC CR ..............................................................................29
DYRENIUM..................................................................................26
E
E.E.S. ...........................................................................................33
E.E.S. GRANULES ........................................................................34
ECHOTHIOPHATE ........................................................................56
EDARBI .......................................................................................28
EDARBYCLOR ..............................................................................28
EDEX ...........................................................................................86
EDLUAR ......................................................................................61
EFFEXOR XR ................................................................................60
EFFIENT ......................................................................................54
EGRIFTA ......................................................................................90
ELESTAT ......................................................................................58
ELETRIPTAN ................................................................................66
ELIDEL .........................................................................................49
ELIQUIS .......................................................................................53
ELIXOPHYLLIN ELIXIR ..................................................................45
ELMIRON ....................................................................................87
ELOCON ......................................................................................46
EMADINE ....................................................................................58
EMBEDA .....................................................................................39
EMEDASTINE DIFUMARATE ........................................................58
EMEND .......................................................................................23
EMOLLIENT COMBO ............................................................. 48, 49
EMSAM PATCH ...........................................................................60
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE ..............90
E-MYCIN .....................................................................................34
ENABLEX .....................................................................................87
ENALAPRIL ..................................................................................27
ENALAPRIL/ HCTZ .......................................................................27
ENBREL .......................................................................................86
ENFUVIRTIDE ..............................................................................90
ENJUVIA......................................................................................74
ENOXAPARIN ..............................................................................54
ENPRESSE ...................................................................................68
ENTACAPONE .............................................................................67
ENTEX ER ....................................................................................43
ENTEX LIQUID .............................................................................43
ENTOCORT EC .............................................................................21
ENZALUTAMIDE ..........................................................................90
EPANED SOLUTION.....................................................................27
EPICERAM...................................................................................48
EPIDUO .......................................................................................51
EPINASTINE ................................................................................58
EPLERENONE ........................................................................ 26, 31
EPOETIN ALFA.............................................................................54
EPOGEN ......................................................................................54
EPROSARTAN ..............................................................................28
EPROSARTAN/ HCTZ ...................................................................28
ERGOTAMINE/ CAFFEINE ...........................................................65
ERRIN..........................................................................................69
205
ERTACZO.....................................................................................50
ERYPRED .....................................................................................34
ERY-TAB ................................................................................ 34, 37
ERYTHROCIN ...............................................................................34
ERYTHROMYCIN .........................................................................57
ERYTHROMYCIN BASE .......................................................... 34, 37
ERYTHROMYCIN BASE/ BENZOYL PEROXIDE ..............................51
ERYTHROMYCIN ETHYLSUCCINATE ...................................... 33, 34
ERYTHROMYCIN STEARATE ........................................................34
ERYTHROMYCIN/ BENZOYL PEROXIDE .......................................51
ESCITALOPRAM ..........................................................................60
ESKALITH, CR ..............................................................................62
ESOMEPRAZOLE .........................................................................20
ESOMEPRAZOLE STRONTIUM ....................................................20
ESOMEPRAZOLE/ ........................................................................38
ESTRACE .....................................................................................74
ESTRACE VAGINAL CREAM .........................................................74
ESTRADERM ...............................................................................74
ESTRADIOL..................................................................................74
ESTRADIOL VALERATE/DIENOGEST ............................................70
ESTRADIOL, TRANSDERMAL ................................................. 74, 75
ESTRADIOL/ DROSPIRENONE .....................................................75
ESTRADIOL/ LEVONORGESTREL..................................................75
ESTRADIOL/ NORETHINDRONE ACETATE ...................................75
ESTRADIOL/ NORGESTIMATE .....................................................75
ESTRASORB.................................................................................74
ESTRATEST ..................................................................................75
ESTRING......................................................................................74
ESTROGEL GEL ............................................................................74
ESTROGENS ................................................................................74
ESTROPIPATE ..............................................................................74
ESTROSTEP FE .............................................................................69
ESZOPICLONE .............................................................................61
ETANERCEPT ...............................................................................86
ETHAMBUTOL.............................................................................36
ETHINYL ESTRADIOL ............................... 68, 69, 70, 71, 72, 73, 74
ETHINYL ESTRADIOL 20MCG .................................... 68, 69, 70, 73
ETHINYL ESTRADIOL 20MCG/ FE/ ...............................................70
ETHINYL ESTRADIOL 30MCG ........................ 68, 69, 70, 71, 72, 73
ETHINYL ESTRADIOL 35MCG ......................................................72
ETHINYL ESTRADIOL 35MG....................................... 70, 71, 72, 73
ETHINYL ESTRADIOL 50MCG ................................................ 72, 73
ETHINYL ESTRADIOL/ NORETHINDRONE ACETATE .....................75
ETHINYL ESTRADION 20MCG......................................................69
ETHIONAMIDE ............................................................................36
ETHOSUXIMIDE ..........................................................................65
ETHOTOIN ..................................................................................65
ETIDRONATE ...............................................................................77
ETONOGESTREL ..........................................................................74
EURAX ........................................................................................53
EVEROLIMUS ..............................................................................86
EVISTA ........................................................................................77
EXALGO ......................................................................................39
EXELDERM ..................................................................................50
EXELON .......................................................................................67
EXELON SOLN AND PATCH .........................................................67
EXENATIDE .................................................................................80
EXENATIDE EXTENDED RELEASE .................................................80
EXFORGE ....................................................................................28
EXFORGE HCT .............................................................................28
EXJADE........................................................................................84
EXTAVIA ......................................................................................89
EXTINA ........................................................................................50
EZETIMIBE ..................................................................................32
EZETIMIBE/ ATORVASTATIN .......................................................31
EZETIMIBE/ SIMVASTATIN ..........................................................32
EZOGABINE .................................................................................65
F
FABIOR FOAM ............................................................................49
FACTIVE ......................................................................................34
FAMCICLOVIR .............................................................................37
FAMOTIDINE...............................................................................20
FAMVIR.......................................................................................37
FANAPT.......................................................................................62
FANATREX ..................................................................................64
FAZACLO .....................................................................................62
FEBUXOSTAT ..............................................................................81
FELBAMATE ................................................................................64
FELBATOL ...................................................................................64
FELDENE .....................................................................................38
FEMCON FE ................................................................................69
FEMHRT ......................................................................................75
FEMHRT 0.5MG-2.5MCG ............................................................75
FEMRING ....................................................................................74
FEMTRACE ..................................................................................74
FENOFIBRATE ....................................................................... 31, 32
FENOFIBRIC ACID .................................................................. 31, 32
FENOGLIDE .................................................................................31
FENTANYL ............................................................................. 39, 40
FENTANYL CITRATE............................................................... 39, 40
FENTANYL SL ..............................................................................39
FENTANYL SL SPRAY ...................................................................40
FENTORA ....................................................................................39
FESOTERODINE FUMARATE........................................................88
FEXMID .......................................................................................66
FEXOFENADINE...........................................................................41
FEXOFENADINE/ .........................................................................42
FEXOFENADINE/ PSEUDOEPHEDRINE ........................................43
FIBRICOR ....................................................................................31
FIDAXOMICIN .............................................................................33
FILGRASTIM ................................................................................54
FINACEA .....................................................................................51
FINASTERIDE...............................................................................88
FINGOLIMOD ..............................................................................89
FIORICET .....................................................................................39
FIORICET 50-300-40....................................................................39
FIORINAL ....................................................................................65
FIORINAL W/CODEINE #3 ...........................................................39
FIRST-LANSOPRAZOLE ................................................................20
FIRST-OMEPRAZOLE ...................................................................20
FLAGYL............................................................................ 34, 37, 52
FLAGYL 375MG ...........................................................................34
FLAGYL ER....................................................................... 34, 37, 52
FLAREX........................................................................................56
FLECAINIDE .................................................................................26
FLECTOR .....................................................................................38
FLEXERIL .....................................................................................66
FLOMAX ................................................................................ 30, 87
FLONASE .....................................................................................42
FLOVENT HFA .............................................................................44
206
G
GABAPENTIN ........................................................................ 64, 89
GABAPENTIN ENACARBIL ...........................................................89
GABITRIL .....................................................................................64
GABITRIL12,16MG ......................................................................64
GALANTAMINE ...........................................................................67
GARAMYCIN ......................................................................... 49, 57
GASTROCROM ............................................................................22
GELNIQUE ...................................................................................87
GEMFIBROZIL .............................................................................31
GEMIFLOXACIN MESYLATE .........................................................34
GENERESS FE ..............................................................................69
GENGRAF ....................................................................................86
GENOTROPIN..............................................................................90
GENTAMICIN ........................................................................ 49, 57
GEODON .....................................................................................62
GESTICARE, DHA .........................................................................82
GIAZO .........................................................................................21
GILENYA......................................................................................89
GLATIRAMER ACETATE ...............................................................89
GLIMEPIRIDE ..............................................................................79
GLIPIZIDE ....................................................................................79
GLUCAGON .................................................................................81
GLUCOPHAGE XR ........................................................................79
GLUCOSE TEST STRIPS ................................................................80
GLUCOTROL XL ...........................................................................79
GLUCOVANCE .............................................................................79
GLUMETZA .................................................................................79
GLYBURIDE .................................................................................79
GLYBURIDE/ METFORMIN ..........................................................79
GLYNASE PRESTAB......................................................................79
GLYSET ........................................................................................81
GOLIMUMAB ..............................................................................87
GOLYTELY ...................................................................................24
GONADOTROPIN, CHORIONIC,HUMAN......................................77
GONAL-F .....................................................................................76
GORDO-UREA .............................................................................48
GRALISE ......................................................................................89
GRANISETRON ............................................................................23
GRANULEX ..................................................................................53
GRIFULVIN-V...............................................................................36
GRISEOFULVIN............................................................................36
GRISEOFULVIN, ULTRAMICROSIZE .............................................36
GRIS-PEG ....................................................................................36
GUAIFENESIN/ PHENYLEPHRINE.................................................43
GUANFACINE ........................................................................ 31, 63
H
HALCINONIDE .............................................................................46
HALDOL ......................................................................................62
HALOBETASOL PROP/ AMMONIUM LAC ....................................47
HALOG ........................................................................................46
HALOPERIDOL.............................................................................62
HCG ALPHA,RECOMBINANT .......................................................77
HEMENATAL OB MIS + DHA .......................................................82
HEMOCYTE-F TABLET .................................................................82
HIPREX ........................................................................................35
HOMATROPINE ..........................................................................55
HORIZANT...................................................................................89
HUMALOG ..................................................................................78
HUMALOG MIX ...........................................................................78
HUMATROPE ..............................................................................90
HUMIRA......................................................................................86
HUMULIN INSULINS....................................................................78
HYDRALAZINE .............................................................................28
HYDRO 40 ...................................................................................48
HYDROCODONE BIT/ ACETAMINOPHEN ....................................41
HYDROCODONE/ CHLORPHEN POLIS .........................................42
HYDROCODONE/ CHLORPHENIRAMINE .....................................42
207
I
IBANDRONATE............................................................................77
IBUDONE 10/200 ........................................................................39
IBUPROFEN.................................................................................38
IBUPROFEN/ HYDROCODONE .............................................. 40, 41
ICLUSIG .......................................................................................90
ICOSAPENT ETHYL ......................................................................32
ILEVRO ........................................................................................59
ILOPERIDONE..............................................................................62
ILOTYCIN.....................................................................................57
IMDUR ........................................................................................25
IMIPRAMINE PAMOATE .............................................................60
IMIQUIMOD ...............................................................................53
IMITREX KIT ................................................................................65
IMITREX SPRAY ...........................................................................65
IMITREX TABLET .........................................................................65
IMMUNE GLOBULIN ...................................................................91
IMODIUM ...................................................................................23
IMURAN......................................................................................86
INCIVEK.......................................................................................88
INDACATEROL.............................................................................44
INDAPAMIDE ..............................................................................26
INDERAL .....................................................................................65
INDERAL LA.................................................................................66
INDERAL, LA................................................................................29
INDOCIN .....................................................................................38
INDOCIN SUSP ............................................................................81
INDOMETHACIN ........................................................... 38, 81, See
INFLIXIMAB.................................................................................91
INH .............................................................................................36
INSPRA.................................................................................. 26, 31
INSULIN ................................................................................ 78, 79
INSULIN ASPART .........................................................................79
INSULIN DETEMIR .......................................................................78
INSULIN DETIMIR ........................................................................78
J
JAKAFI .........................................................................................90
JALYN .................................................................................... 30, 88
JANUMET....................................................................................79
JANUVIA .....................................................................................80
JENTADUETO ..............................................................................80
JOLIVETTE ...................................................................................69
JUVISYNC ....................................................................................80
JUXTAPID ....................................................................................31
K
KADIAN .......................................................................................39
KADIAN 10, 40, 70, 130, 150, 200MG .........................................39
KAPVAY.......................................................................................63
KARIVA .......................................................................................69
KAYEXALATE ...............................................................................87
KAZANO ......................................................................................80
KEFLEX ........................................................................................33
KENALOG ....................................................................................46
KENALOGAEROSOL SPRAY ..........................................................46
KEPPRA .......................................................................................64
KEPPRA XR ..................................................................................64
KERAFOAM .................................................................................48
KERALAC .....................................................................................48
208
KERLONE.....................................................................................29
KEROL 50% SUSPENSION ............................................................48
KEROL AD ...................................................................................48
KETEK..........................................................................................34
KETOCONAZOLE .........................................................................50
KETOCONAZOLE FOAM/ CLEANSER ...........................................50
KETODAN KIT ..............................................................................50
KETOROLAC ................................................................................38
KETOROLAC TROMETHAMINE ....................................................58
KETOTIFEN ..................................................................................58
KINERET ......................................................................................87
KLONOPIN ..................................................................................64
KLOR-CON ..................................................................................83
KOMBIGLYZE XR .........................................................................80
KORLYM ......................................................................................79
K-PHOS ORIGINAL.......................................................................83
KYNAMRO ..................................................................................31
L
LABETALOL .................................................................................30
LAC-HYDRIN................................................................................48
LACOSAMIDE ..............................................................................65
LACTULOSE .................................................................................24
LACTULOSE SOLN .......................................................................24
LAMICTAL 5, 25MG DISPER TABLET............................................64
LAMICTAL ODT ...........................................................................64
LAMICTAL XR, STARTER KIT ........................................................64
LAMICTAL/XR .............................................................................64
LAMISIL .......................................................................................36
LAMISIL SOLN .............................................................................50
LAMOTRIGINE ............................................................................64
LANCETS .....................................................................................81
LANOXIN 125MCG ................................................................ 25, 26
LANSOPRAZOLE ..........................................................................20
LANTHANUM CARBONATE .........................................................90
LANTUS .......................................................................................78
LANTUS SOLOSTAR .....................................................................78
LASIX ...........................................................................................26
LASTACAFT .................................................................................58
LATANOPROST............................................................................56
LATUDA ......................................................................................62
LAZANDA ....................................................................................40
LEFLUNOMIDE ............................................................................86
LESCOL........................................................................................31
LESCOL, XL ..................................................................................31
LESSINA ......................................................................................69
LEUKINE ......................................................................................54
LEUPROLIDE ACETATE ................................................................77
LEVALBUTEROL ...........................................................................45
LEVAQUIN...................................................................................34
LEVATOL .....................................................................................30
LEVEMIR .....................................................................................78
LEVEMIR FLEXPEN ......................................................................78
LEVETIRACETAM .........................................................................64
LEVITRA ......................................................................................86
LEVOBUNOLOL ...........................................................................55
LEVOCARNITINE..........................................................................84
LEVOCETIRIZINE..........................................................................42
LEVODAPA/ CARBIDOPA ............................................................67
LEVOFLOXACIN ..................................................................... 34, 57
LEVORA.......................................................................................69
LEVOTHROID ..............................................................................78
LEVOTHYROXINE SODIUM ..........................................................78
LEVOXYL .....................................................................................78
LEVSIN ........................................................................................23
LEXAPRO .....................................................................................60
LIALDA ........................................................................................21
LIBRAX ........................................................................................24
LIDOCAINE ..................................................................................87
LIDOCAINE/ TETRACAINE ...........................................................87
LIDODERM 5% PATCH ................................................................87
LIDORX GEL.................................................................................87
LINACLOTIDE ..............................................................................89
LINAGLIPTIN ...............................................................................80
LINAGLIPTIN/ ..............................................................................80
LINEZOLID ...................................................................................35
LINZESS .......................................................................................89
LIOTHYRONINE SODIUM ............................................................78
LIOTRIX .......................................................................................78
LIPITOR .......................................................................................31
LIPOFEN ......................................................................................31
LIPTRUZET ..................................................................................31
LIRAGLUTIDE ..............................................................................81
LISDEXAMFETAMINE DIMESYLATE .............................................63
LISINOPRIL ..................................................................................27
LISINOPRIL/ HCTZ .......................................................................27
LITHIUM .....................................................................................62
LITHOBID ....................................................................................62
LIVALO ........................................................................................31
L-NORGEST-ETH ESTR/ETHIN ESTRA..................................... 70, 73
LO MINASTRIN FE .......................................................................70
LO/OVRAL ...................................................................................69
LOCOID .......................................................................................46
LOCOID LOTN, LIPOCREAM ........................................................47
LODOSYN ....................................................................................67
LODOXAMIDE TROMETHAMINE .................................................58
LOESTRIN 21 1.5/30 ...................................................................69
LOESTRIN 21 1/20 ......................................................................69
LOESTRIN 24 FE ..........................................................................70
LOESTRIN FE 1/20 .......................................................................69
LOFIBRA ......................................................................................31
LOMITAPIDE MESYLATE .............................................................31
LOMOTIL.....................................................................................23
LOPERAMIDE ..............................................................................23
LOPID..........................................................................................31
LOPRESSOR .................................................................................30
LOPRESSOR HCT .........................................................................30
LOPROX ......................................................................................50
LORATADINE...............................................................................41
LORATIDINE/ PSEUDOEPHEDRINE ..............................................43
LORAZEPAM ...............................................................................61
LORCET, PLUS .............................................................................40
LORZONE ....................................................................................66
LOSARTAN ..................................................................................28
LOSARTAN/ HCTZ .......................................................................28
LOSEASONIQUE ..........................................................................70
LOTEMAX....................................................................................56
LOTENSIN ...................................................................................27
LOTENSIN HCT ............................................................................27
LOTEPREDNOL ETABONATE .......................................................56
LOTEPREDNOLETABONATE ........................................................56
209
M
MACROBID .................................................................................35
MACRODANTIN 25MG ...............................................................35
MACRODANTIN 50, 100MG........................................................35
MAFENIDE ACETATE ...................................................................49
MALARONE.................................................................................37
MALATHION ...............................................................................53
MAVIK ........................................................................................27
MAXAIR ......................................................................................44
MAXALT, MLT .............................................................................66
MAXIDEX ....................................................................................56
MAXITROL ..................................................................................58
MAXZIDE.....................................................................................26
MECLIZINE ..................................................................................22
MEDROL .....................................................................................68
MEDROXY-PROGESTERONE/ MPA..............................................75
MEFENAMIC ACID ......................................................................38
MELOXICAM ...............................................................................38
MEMANTINE...............................................................................67
MENEST ......................................................................................74
MENOTROPINS ...........................................................................77
MENTAX .....................................................................................50
MEPENZOLATE BROMIDE ...........................................................23
MEPERIDINE ...............................................................................39
MEPHYTON.................................................................................84
MEPROBAMATE .........................................................................61
MEPRON .....................................................................................37
MESALAMINE .............................................................................21
MESTINON ..................................................................................66
MESTINON 180 ...........................................................................67
MESTRANOL 50MCG ............................................................ 71, 72
METADATE CD ............................................................................63
METADATE ER ............................................................................63
METAPROTERENOL SYRUP .........................................................45
METAPROTERENOL, 10MG/5ML ................................................45
METAXALONE .............................................................................66
METFORMIN ...............................................................................79
METHADONE .................................................................. 39, 40, 85
METHAMPHETAMINE.................................................................63
METHAZOLAMIDE ......................................................................56
METHENAMINE ..........................................................................35
METHENAMINE/METH BLUE/SALICYLATE ..................................35
METHENAMINE/METH BLUE/SALICYLATE/NA PHOS/HYOSCY ...35
METHERGINE ..............................................................................88
METHIMAZOLE ...........................................................................78
METHITEST .................................................................................76
METHOCARBAMOL.....................................................................66
METHOTREXATE .........................................................................49
METHOTREXATE TABS ................................................................49
METHSCOPOLAMINE BROMIDE .................................................24
METHSCOPOLAMINE COMBO ....................................................24
METHSUXIMIDE..........................................................................64
METHYLDOPA .............................................................................30
METHYLDOPA/ HCTZ ..................................................................30
METHYLERGONOVINE ................................................................88
METHYLIN CHEW TAB ................................................................63
METHYLIN SOLN 5MG/5ML ........................................................63
METHYLPHENIDATE....................................................................63
METHYLPHENIDATE ORAL SUSP .................................................63
METHYLPHENIDATE PATCH ........................................................63
METHYLPHENIDATE, SUST. RELEASE ..........................................63
METHYLPREDNISOLONE .............................................................68
METHYLTESTOSTERONE .............................................................76
METIPRANOLOL..........................................................................56
METOCLOPRAMIDE ....................................................................23
METOLAZONE .............................................................................26
METOPROLOL .............................................................................30
METOPROLOL SUCCINATE ..........................................................30
METOPROLOL/ HCTZ ..................................................................30
METOPROLOL/HCTZ ...................................................................29
METROGEL 0.75%.......................................................................50
METROGEL-VAGINAL ............................................................ 50, 52
METRONIDAZOLE ..................................................... 34, 37, 50, 52
METRONIDAZOLE/ CLEANSER ....................................................50
MEVACOR ...................................................................................32
MIACALCIN NASAL ......................................................................77
MICARDIS ...................................................................................28
MICARDIS HCT ............................................................................28
MICONAZOLE .............................................................................36
MICONAZOLE NITRATE/ZINC OXIDE ...........................................50
MICROGESTIN FE 1.5/30 ............................................................70
MICROGESTIN FE 1/20 ...............................................................70
MICRO-K 10MEQ ........................................................................83
MICRONASE ................................................................................79
MIFEPRISTONE ...........................................................................79
MIGLITOL ....................................................................................81
MIGRANAL NASAL SPRAY ...........................................................66
MILNACIPRAN ...................................................................... 89, 90
MILTOWN ...................................................................................61
MINICYCLINE KIT ........................................................................33
MINIPRESS ..................................................................................30
MINOCIN ....................................................................................33
MINOCIN PAC .............................................................................33
MINOCYCLINE.............................................................................33
MIPOMERSEN.............................................................................31
MIRABEGRON .............................................................................88
MIRAPEX.....................................................................................67
MIRAPEX ER................................................................................67
MIRCETTE ...................................................................................70
MIRTAZAPINE .............................................................................60
210
MIRVASO ....................................................................................53
MISOPROSTOL ............................................................................20
MOBAN ......................................................................................62
MOBIC ........................................................................................38
MODAFINIL .................................................................................63
MODICON ...................................................................................70
MOEXIPRIL..................................................................................27
MOEXIPRIL/ HCTZ .......................................................................27
MOLINDONE ...............................................................................62
MOMETASONE ...........................................................................42
MOMETASONE FUROATE ..................................................... 44, 46
MOMETASONE FUROATE/AMMONIUM LAC .............................47
MOMETASONE/ .........................................................................44
MOMEXIN...................................................................................47
MONODOX .................................................................................33
MONOKET ..................................................................................25
MONONESSA ..............................................................................70
MONOPRIL .................................................................................27
MONOPRIL HCT ..........................................................................27
MONTELUKAST ..................................................................... 42, 45
MONUROL ..................................................................................35
MORPHINE .................................................................................40
MORPHINE SULFATE ............................................................ 39, 40
MORPHINE SULFATE/ .................................................................39
MORPHINE TABLETS ...................................................................40
MORPHINE, SUSTAINED RELEASE ...............................................40
MOTOFEN...................................................................................23
MOTRIN ......................................................................................38
MOVIPREP ..................................................................................24
MOXATAG 775 MG ER ................................................................32
MOXIFLOXACIN .................................................................... 34, 57
MS CONTIN.................................................................................40
MULTAQ .....................................................................................26
MUPIROCIN 2% ..........................................................................49
MUPIROCIN 2% CRM ..................................................................49
MUPIROCIN 2% OINT .................................................................49
MUSE ..........................................................................................86
MYAMBUTOL..............................................................................36
MYCELEX TROCHES.....................................................................36
MYCOBUTIN ...............................................................................36
MYCOPHENOLATE ......................................................................86
MYCOPHENOLATE MOFETIL .......................................................86
MYCOSTATIN ........................................................................ 50, 52
MYDRIACYL.................................................................................56
MYFORTIC...................................................................................86
MYRBETRIQ ................................................................................88
MYSOLINE...................................................................................64
N
NA PICOSUL/MAG-OX/ CITRIC ACID ...........................................24
NABUMETONE............................................................................38
NADOLOL....................................................................................29
NADOLOL/ BENDROFLUMETHIAZIDE .........................................29
NAFARELIN ACETATE ..................................................................77
NAFTIFINE...................................................................................50
NAFTIN .......................................................................................50
NALTREXONE ..............................................................................85
NAMENDA ..................................................................................67
NAMENDA XR ............................................................................67
NAPHOS MB-MH/NAPHOS, DI-BA ..............................................24
211
NIRAVAM....................................................................................61
NITAZOXANIDE ...........................................................................37
NITRO-BID OINT .........................................................................25
NITRO-DUR PATCHES 0.1, 0.2, 0.4, 0.6MG/HR ...........................25
NITRO-DUR PATCHES 0.3, 0.8MG/HR .........................................25
NITROFURANTOIN ......................................................................35
NITROGLYCERIN .........................................................................25
NITROGLYCERIN SUBLINGUAL ....................................................25
NITROGLYCERIN TRANSDERMAL ................................................25
NITROLINGUAL SPRAY ................................................................25
NITROSTAT .................................................................................25
NIZATIDINE .................................................................................20
NIZORAL .....................................................................................50
NORA-BE.....................................................................................71
NORDETTE ..................................................................................71
NORDITROPIN ............................................................................90
NORETH A-ET ESTRA/FE FUMARATE ..........................................69
NORETH-ETHINYL ESTRADIOL/IRON ...........................................69
NORETHINDRONE 0.35MG ....................................... 68, 69, 71, 72
NORETHINDRONE ACETATE .......................................................75
NORFLEX .....................................................................................66
NORFLOXACIN ............................................................................34
NORINYL 1/35.............................................................................71
NORINYL 1+50 ............................................................................71
NORMODYNE .............................................................................30
NOROXIN ....................................................................................34
NORPACE ....................................................................................26
NORPACE CR 100MG ..................................................................26
NORPRAMIN ...............................................................................60
NORTREL 0.5/35 .........................................................................71
NORTREL 1/35 ............................................................................71
NORTREL 7/7/7...........................................................................71
NORTRIPTYLINE ..........................................................................60
NORVASC ....................................................................................29
NOVAREL ....................................................................................77
NOVOLIN INSULINS ....................................................................79
NOVOLOG INSULINS ...................................................................79
NOVOLOG MIX ...........................................................................79
NOXAFIL .....................................................................................36
NUCORT......................................................................................47
NUCYNTA....................................................................................40
NUCYNTA ER...............................................................................40
NULEV.........................................................................................24
NUMORPHAN .............................................................................40
NUOX GEL ...................................................................................51
NUTROPIN ..................................................................................90
NUVARING ..................................................................................74
NUVIGIL ......................................................................................63
NYSTATIN ....................................................................... 50, 52, 53
NYSTATIN VAGINAL TABS ...........................................................53
NYSTATIN/EMOLLIENT ...............................................................50
O
OB COMPLETE, PREMIER, ONE, 400, DHA ..................................82
OBSTETRIX EC .............................................................................82
OCUFLOX ....................................................................................57
OFLOXACIN .................................................................................57
OGEN ..........................................................................................74
OGESTREL ...................................................................................72
OLANZAPINE ...............................................................................62
212
OXTELLAR XR ..............................................................................65
OXYBUTYNIN ........................................................................ 87, 88
OXYBUTYNIN CHLORIDE .............................................................87
OXYCODONE...............................................................................40
OXYCONTIN ................................................................................40
OXYMORPHONE .........................................................................40
OXYMORPHONE ER (NON-CRUSH RESISTANT) ...........................40
OXYTROL PATCH .........................................................................88
P
PACERONE ..................................................................................26
PACNEX ......................................................................................52
PACNEX MX ................................................................................52
PALIPERIDONE ............................................................................62
PALIVIZUMAB .............................................................................91
PAMELOR ...................................................................................60
PAMINE ......................................................................................24
PAMINE FORTE ...........................................................................24
PAMINE FQ .................................................................................24
PANCREAZE ................................................................................22
PANDEL.......................................................................................47
PANRETIN ...................................................................................53
PANTOPRAZOLE .........................................................................20
PAPAVERINE ...............................................................................25
PARAFON FORTE DSC .................................................................66
PARCOPA ....................................................................................67
PARICALCITOL.............................................................................78
PARLODEL ...................................................................................67
PARNATE ....................................................................................60
PAROXETINE ...............................................................................60
PATADAY ....................................................................................58
PATANASE ..................................................................................42
PATANOL ....................................................................................58
PAXIL, CR ....................................................................................60
PCE .............................................................................................34
PEDIADERM AF ...........................................................................50
PEDIADERM HC 2% KIT ...............................................................47
PEDIADERM TA ...........................................................................47
PEDIAPRED LIQUID .....................................................................68
PEG3350/NA SULF/ BICARB/KCL ................................................24
PEG3350/NA SULF/BICARB/CL/KCL ............................................24
PEG3350/SOD SUL/NACL/ASB/CL/KCL .......................................24
PEGANONE .................................................................................65
PEGASYS .....................................................................................88
PEGINTERFERON ALFA-2A ..........................................................88
PEGINTERFERON ALFA-2B ..........................................................88
PEG-INTRON ...............................................................................88
PENBUTOLOL ..............................................................................30
PENICILLAMINE ..........................................................................84
PENLAC .......................................................................................50
PENTAMIDINE ISETHIONATE ......................................................37
PENTASA.....................................................................................21
PENTOSAN POLYSULFATE ...........................................................87
PENTOXIFYLLINE .........................................................................54
PEPCID RPD ................................................................................20
PEPCID TABS ...............................................................................20
PERCOCET...................................................................................40
PERCODAN .................................................................................40
PERINDOPRIL ..............................................................................27
PERIOSTAT ..................................................................................33
PERSANTINE ...............................................................................54
PERTZYE ......................................................................................22
PEXEVA .......................................................................................60
PHENAZOPYRIDINE .....................................................................88
PHENELZINE................................................................................60
PHENERGAN ......................................................................... 23, 41
PHENOBARBITAL ........................................................................65
PHENOXYBENZAMINE ................................................................30
PHENYLEPHRINE/ CHLORPHENIRAMINE ....................................43
PHENYTOIN ................................................................................64
PHOSLO ......................................................................................90
PHOSPHOLINE IODIDE SOLN ......................................................56
PHYTONADIONE .........................................................................84
PILOCAR......................................................................................56
PILOCARPINE ..............................................................................56
PILOPINE HS ...............................................................................56
PIMECROLIMUS ..........................................................................49
PIMOZIDE ...................................................................................62
PIOGLITAZONE ...........................................................................80
PIOGLITAZONE/ ..........................................................................80
PIOGLITAZONE/ GLIMEPIRIDE ....................................................80
PIOGLITAZONE/ METFORMIN ....................................................80
PIRBUTEROL ...............................................................................44
PIROXICAM .................................................................................38
PITAVASTATIN CALCIUM ............................................................31
PLAQUENIL .................................................................................37
PLAVIX ........................................................................................54
PLETAL ........................................................................................54
PLIAGLIS .....................................................................................87
PODOFILOX.................................................................................53
POLYMYXIN/ BACITRACIN ..........................................................57
POLYMYXIN/ BACITRACIN/ NEOMYCIN ......................................57
POLYMYXIN/ TRIMETHOPRIM ....................................................57
POLYSPORIN ...............................................................................57
POLYTRIM ...................................................................................57
PONATINIB .................................................................................90
PONSTEL .....................................................................................38
PORTIA .......................................................................................73
POSACONAZOLE .........................................................................36
POTASSIUM CHLORIDE ...............................................................83
POTASSIUM CITRATE ..................................................................84
POTASSIUM PHOSPHATE............................................................83
POTIGA .......................................................................................65
PRADAXA ....................................................................................54
PRAMIPEXOLE ............................................................................67
PRAMIPEXOLE DI-HCL.................................................................67
PRAMLINTIDE ACETATE ..............................................................81
PRAMOXINE ...............................................................................22
PRANDIMET ................................................................................79
PRANDIN ....................................................................................79
PRASUGREL HYDROCHLORIDE....................................................54
PRAVACHOL................................................................................32
PRAVASTATIN .............................................................................32
PRAZIQUANTEL...........................................................................37
PRAZOSIN ...................................................................................30
PRECOSE .....................................................................................81
PRED FORTE................................................................................56
PRED MILD..................................................................................56
PREDNISOLONE .................................................................... 56, 68
PREDNISONE ..............................................................................87
PREFERA-OB ONE .......................................................................82
213
PROSCAR ....................................................................................88
PROTONIX ..................................................................................20
PROTONIX PAK ...........................................................................20
PROTOPIC ...................................................................................53
PROTRIPTYLINE...........................................................................60
PROVENTIL HFA ..........................................................................44
PROVERA ....................................................................................75
PROVIGIL ....................................................................................63
PROZAC ......................................................................................60
PROZAC WEEKLY ........................................................................60
PSEUDOEPHEDRINE/ ACRIVAS ...................................................43
PSEUDOEPHEDRINE/ CHLORPHENIRAMINE ...............................43
PSEUDOEPHEDRINE/ DESLORATADINE ......................................43
PULMICORT ................................................................................44
PULMICORT 0.25MG/2ML AND 0.5MG/2ML RESPULE ..............44
PULMICORT 1MG/2ML RESPULE, FLEXHALER AND TURBUHALER
..............................................................................................44
PULMOZYME ........................................................................ 44, 45
PYRAZINAMIDE ...........................................................................36
PYRIDIUM ...................................................................................88
PYRIDOSTIGMINE ................................................................. 66, 67
PYRIMETHAMINE........................................................................37
Q
QNASL ........................................................................................42
QUESTRAN BULK ........................................................................32
QUETIAPINE FUMARATE ............................................................62
QUILLIVANT XR ...........................................................................63
QUINAPRIL..................................................................................26
QUINAPRIL/ HCTZ .......................................................................27
QUININE SULFATE ......................................................................84
QUIXIN ........................................................................................57
QVAR ..........................................................................................45
R
RABEPRAZOLE ............................................................................20
RALOXIFENE ...............................................................................77
RAMELTEON ...............................................................................61
RAMIPRIL ....................................................................................27
RANEXA ......................................................................................26
RANITIDINE ........................................................................... 20, 21
RANOLAZINE...............................................................................26
RAPAFLO.....................................................................................88
RAPAMUNE ................................................................................86
RASAGILINE ................................................................................67
RAYOS.........................................................................................87
RAZADYNE ..................................................................................67
REBETOL .....................................................................................88
REBETOL ORAL SOLUTION ..........................................................88
REBIF ..........................................................................................89
RECTIV OINT ...............................................................................25
REGLAN ......................................................................................23
RELAFEN .....................................................................................38
RELENZA .....................................................................................37
RELPAX .......................................................................................66
REMERON ...................................................................................60
REMICADE ..................................................................................91
RENAGEL ....................................................................................90
RENVELA .....................................................................................90
214
REPAGLINIDE ..............................................................................79
REPAGLINIDE/METFORMIN ........................................................79
REPREXAIN .................................................................................40
REPRONEX ..................................................................................77
REQUIP .......................................................................................67
REQUIP XL...................................................................................67
RESTASIS .....................................................................................58
RESTORIL ....................................................................................61
RETAPAMULIN ............................................................................49
RETIN A .......................................................................................52
RETIN A MICRO...........................................................................52
RETIN A MICRO 0.1% ................................................................ See
REVATIO .....................................................................................30
REVIA ..........................................................................................85
RHINOCORT AQUA .....................................................................42
RIAX ............................................................................................52
RIBAPAK .....................................................................................88
RIBASPHERE................................................................................88
RIBATAB .....................................................................................88
RIBAVIRIN ............................................................................. 88, 89
RIDAURA.....................................................................................87
RIFABUTIN ..................................................................................36
RIFADIN ......................................................................................36
RIFAMATE ...................................................................................36
RIFAMPIN ...................................................................................36
RIFAMPIN/ INH/ PYRAZINAMIDE ................................................36
RIFAMPIN/ ISONIAZID ................................................................36
RIFAPENTINE ..............................................................................36
RIFATER ......................................................................................36
RIFAXIMIN ..................................................................................35
RIMANTADINE ............................................................................37
RIMEXOLONE..............................................................................57
RISEDRONATE .............................................................................77
RISEDRONATE SODIUM ..............................................................77
RISPERDAL ..................................................................................62
RISPERDAL CONSTA ....................................................................62
RISPERIDONE ..............................................................................62
RISPERIDONE MICROSPHERES....................................................62
RITALIN .......................................................................................63
RITALIN LA ..................................................................................63
RITALIN SR ..................................................................................63
RITUXAN .....................................................................................91
RITUXIMAB .................................................................................91
RIVAROXABAN ............................................................................54
RIVASTIGMINE ............................................................................67
RIZATRIPTAN ..............................................................................66
ROBAXIN.....................................................................................66
ROCALTROL ................................................................................83
ROFLUMILAST.............................................................................45
ROPINIROLE ................................................................................67
ROSADAN KIT .............................................................................50
ROSANIL .....................................................................................52
ROSIGLITAZONE..........................................................................80
ROSIGLITAZONE/ GLIMEPIRIDE ..................................................80
ROSIGLITAZONE/ METFORMIN ..................................................80
ROSUVASTATIN ..........................................................................31
ROTIGOTINE ...............................................................................67
ROWASA ENEMA ........................................................................21
ROZEREM ...................................................................................61
RUFINAMIDE ..............................................................................64
RUXOLITINIB ...............................................................................90
S
SABRIL ........................................................................................65
SAFYRAL .....................................................................................73
SALMETEROL ..............................................................................45
SANCTURA ..................................................................................88
SANCTURA, XR ............................................................................88
SANCUSO ....................................................................................23
SANDIMMUNE ............................................................................86
SAPHRIS ......................................................................................62
SARAFEM ....................................................................................60
SARGRAMOSTIM ........................................................................54
SAVELLA................................................................................ 89, 90
SAXAGLIPTIN HYDROCHLORIDE..................................................80
SAXAGLIPTIN/ .............................................................................80
SCOPOLAMINE ...........................................................................23
SEASONALE.................................................................................73
SEASONIQUE ..............................................................................73
SECTRAL................................................................................ 26, 30
SELECT-OB ..................................................................................83
SELECT-OB + DHA .......................................................................83
SELEGILINE ........................................................................... 60, 67
SELENIUM SULFIDE.....................................................................50
SEMPREX-D.................................................................................43
SEREVENT DISKUS ......................................................................45
SEROMYCIN PULVULES ...............................................................36
SEROQUEL ..................................................................................62
SEROQUEL, XR ............................................................................62
SERTACONAZOLE NITRATE .........................................................50
SERTRALINE ................................................................................61
SEVELAMER ................................................................................90
SEVELAMER CARBONATE ...........................................................90
SILDENAFIL .................................................................................86
SILDENAFIL CITRATE ...................................................................30
SILENOR ......................................................................................61
SILODOSIN ..................................................................................88
SILVADENE..................................................................................49
SILVER SULFADIAZINE .................................................................49
SIMBRINZA .................................................................................56
SIMCOR ......................................................................................32
SIMPONI .....................................................................................87
SIMVASTATIN .............................................................................32
SINEMET, CR ...............................................................................67
SINGULAIR ............................................................................ 42, 45
SIROLIMUS .................................................................................86
SIRTURO .....................................................................................36
SITAGLIPTIN PHOS/ METFORMIN ...............................................79
SITAGLIPTIN PHOSPHATE ...........................................................80
SITAGLIPTIN/ ..............................................................................80
SKELAXIN ....................................................................................66
SKLICE .........................................................................................53
SODIUM /POTASSIUM/MAG SULFATES .....................................24
SODIUM FLUORIDE .....................................................................84
SODIUM OXYBATE ......................................................................63
SODIUM POLYSTYRENE SULFONATE ..........................................87
SOLARAZE ...................................................................................53
SOLIFENACIN SUCCINATE ...........................................................87
215
SOLODYN ....................................................................................33
SOMA .........................................................................................66
SOMATROPIN .............................................................................90
SOMNOTE...................................................................................61
SONATA ......................................................................................61
SORIATANE .................................................................................49
SOTALOL .....................................................................................25
SPECTRACEF ...............................................................................33
SPIRIVA .......................................................................................45
SPIRONOLACTONE......................................................................26
SPIRONOLACTONE/ HCTZ ...........................................................26
SPORANOX CAPS ........................................................................36
SPORANOX SOLN ........................................................................36
SPRINTEC ....................................................................................73
STALEVO .....................................................................................67
STARLIX.......................................................................................79
STAXYN .......................................................................................86
STRATTERA .................................................................................63
STRIPS .........................................................................................80
STROMECTOL .............................................................................37
SUBOXONE .................................................................................85
SUBSYS .......................................................................................40
SUBUTEX ....................................................................................85
SUCLEAR .....................................................................................24
SUCRALFATE ...............................................................................20
SULAR 20, 30, 10 ........................................................................29
SULCONAZOLE NITRATE .............................................................50
SULFACETAMD/ SULFR/ SKNCLNSR10 ........................................52
SULFACETAMIDE SODIUM ..........................................................57
SULFACETAMIDE/ PREDNISOLONE ....................................... 57, 58
SULFAMETHOXAZOLE/ TRIMETHOPRIM .............................. 34, 35
SULFAMETHOXAZOLE/ TRIMETHOPRIM DS ......................... 34, 35
SULFAMYLON .............................................................................49
SULFANILAMIDE .........................................................................52
SULFASALAZINE ..........................................................................21
SULINDAC ...................................................................................38
SUMATRIPTAN INJECTION .................................................... 65, 66
SUMATRIPTAN NASAL SPRAY .....................................................65
SUMATRIPTAN TABLET ...............................................................65
SUMATRIPTAN/ NAPROXEN .......................................................66
SUMAVEL DOSEPRO ...................................................................66
SUMYCIN ....................................................................................33
SUPRAX.......................................................................................33
SUPREP .......................................................................................24
SURMONTIL ................................................................................60
SYMAX DUOTAB .........................................................................24
SYMAX, DUOTAB ........................................................................24
SYMBICORT ................................................................................45
SYMBYAX ....................................................................................62
SYMLIN .......................................................................................81
SYMLINPEN.................................................................................81
SYNAGIS......................................................................................91
SYNALAR TS ................................................................................47
SYNAREL NASAL SPRAY...............................................................77
SYNTHROID.................................................................................78
SYRINGES ....................................................................................79
T
TACLONEX OINT .........................................................................49
TACROLIMUS ........................................................................ 53, 86
216
TINIDAZOLE ................................................................................37
TIOTROPIUM BROMIDE ..............................................................45
TIROSINT ....................................................................................78
TIZANIDINE .................................................................................66
TIZANIDINE COMBO ...................................................................66
TOBI INHALATION /PODHALER...................................................89
TOBRADEX ..................................................................................58
TOBRADEX ST .............................................................................58
TOBRAMYCIN ....................................................................... 57, 89
TOBRAMYCIN/ ............................................................................58
TOBRAMYCIN/LOTEPRED ETAB ..................................................57
TOBREX OINT..............................................................................57
TOBREX SOLN .............................................................................57
TOFACITINIB ...............................................................................87
TOFRANIL PM .............................................................................60
TOLCAPONE ................................................................................67
TOLTERODINE TARTRATE ...........................................................87
TOPAMAX ...................................................................................65
TOPICORT ...................................................................................47
TOPICORT GENERIC PRODUCTS..................................................47
TOPIRAMATE ..............................................................................65
TOPROL XL ..................................................................................30
TORADOL ....................................................................................38
TORSEMIDE ................................................................................26
TOVIAZ........................................................................................88
TRACLEER ...................................................................................30
TRADJENTA .................................................................................80
TRAMADOL ..................................................................... 39, 40, 41
TRAMADOL ER ............................................................................40
TRAMADOL SUST. RELEASE ........................................................41
TRAMADOL/ ACETAMINOPHEN .................................................41
TRANDATE ..................................................................................30
TRANDOLAPRIL ...........................................................................27
TRANDOLAPRIL/ VERAPAMIL .....................................................27
TRANSDERM-SCOP .....................................................................23
TRANXENE T ...............................................................................61
TRANYLCYPROMINE ...................................................................60
TRAVATAN Z ...............................................................................56
TRAVOPROST ..............................................................................56
TRAZODONE HYDROCHLORIDE EXTENDED RELEASE ..................60
TREAGAN OTIC ...........................................................................59
TRECATOR ..................................................................................36
TRENTAL .....................................................................................54
TREPROSTINIL/NEBULIZER KIT....................................................30
TRETIN X .....................................................................................52
TRETINOIN ............................................................................ 51, 52
TRETINOIN MICROSPHERES........................................................52
TREXIMET ...................................................................................66
TRIAMCINOLONE .................................................................. 46, 68
TRIAMCINOLONE, AQUEOUS .....................................................42
TRIAMCINOLONE/ ......................................................................47
TRIAMTERENE ............................................................................26
TRIAMTERENE/ HCTZ..................................................................26
TRIAZ CLEANER/PADS.................................................................52
TRIBENZOR .................................................................................28
TRICOR .......................................................................................32
TRIFLURIDINE .............................................................................57
TRIGLIDE .....................................................................................32
TRILEPTAL ...................................................................................65
TRILIPIX.......................................................................................32
TRIMETHOBENZAMIDE...............................................................23
TRIMETHOPRIM..........................................................................35
TRIMIPRAMINE MALEATE ..........................................................60
TRINESSA ....................................................................................73
TRI-NORINYL ...............................................................................73
TRIOXIN ......................................................................................59
TRI-SPRINTEC..............................................................................73
TRIVORA .....................................................................................73
TROKENDI XR ..............................................................................65
TROPAZONE ...............................................................................48
TROPICAMIDE.............................................................................56
TROSPIUM CHLORIDE .................................................................88
TRUSOPT ....................................................................................56
TRUVADA....................................................................................90
TRYPSIN/ BALSAM PERU/ CASTOR OIL .......................................53
TUDORZA PRESSAIR....................................................................45
TUSSIONEX PENNKINETIC ...........................................................42
TWYNSTA ...................................................................................28
TYLENOL W/CODEINE .................................................................41
TYLOX .........................................................................................41
TYSABRI ......................................................................................91
TYVASO.......................................................................................30
U
UCERIS ........................................................................................21
U-CORT 1%-10% CREAM ............................................................47
ULESFIA ......................................................................................53
ULORIC .......................................................................................81
ULTRACET ...................................................................................41
ULTRAM......................................................................................41
ULTRAM ER.................................................................................41
ULTRASE .....................................................................................22
ULTRASE MT 12, 18 ....................................................................22
ULTRAVATE PAC .........................................................................47
ULTRESA .....................................................................................22
UMECTA .....................................................................................48
UMECTA EMULSION ...................................................................48
UNIRETIC ....................................................................................27
UNIVASC .....................................................................................27
URAMAXIN .................................................................................48
URAMAXIN GT ............................................................................48
URAMAXIN GT KIT ......................................................................48
UREA...........................................................................................48
UREA/ LACTIC ACID/ SALICYL ACID .............................................48
UREA/LACTIC AC/ZN UNDECYLENATE ........................................48
URECHOLINE...............................................................................88
URELLE........................................................................................35
UROCIT-K ....................................................................................84
UROCIT-K 15MEQ .......................................................................84
UROFOLLITROPIN (FSH) ..............................................................76
UROXATRAL ................................................................................88
URSODIOL...................................................................................84
UTA .............................................................................................35
UTOPIC .......................................................................................48
V
VAGIFEM ....................................................................................74
VALACYCLOVIR ...........................................................................37
VALIUM ......................................................................................61
VALPROIC ACID ...........................................................................64
217
VALSARTAN ................................................................................28
VALSARTAN/ HCTZ .....................................................................28
VALTREX .....................................................................................37
VALTURNA ............................................................................ 28, 31
VANCOCIN ..................................................................................35
VANCOMYCIN, ORAL ..................................................................35
VANOS ........................................................................................47
VANOXIDE HC .............................................................................52
VANOXIDE-HC 0.5%-5% LOTION.................................................47
VARDENAFIL ...............................................................................86
VARENICLINE TARTRATE.............................................................85
VASCEPA .....................................................................................32
VASERETIC ..................................................................................27
VASOTEC.....................................................................................27
VECTICAL ....................................................................................53
VELTIN ........................................................................................52
VENLAFAXINE .............................................................................60
VENTOLIN ...................................................................................45
VENTOLIN HFA............................................................................45
VERAMYST ..................................................................................42
VERAPAMIL .................................................................... 25, 28, 29
VERDESO ....................................................................................47
VERELAN .....................................................................................29
VESICARE ....................................................................................88
VEXOL .........................................................................................57
VFEND ........................................................................................36
VIAGRA .......................................................................................86
VIBRAMYCIN......................................................................... 33, 35
VIBRAMYCIN SUSP......................................................................33
VIBRAMYCIN SYRUP ...................................................................33
VICODIN .....................................................................................41
VICODIN 10/300 .........................................................................41
VICODIN 5/300 ...........................................................................41
VICODIN 7.5/300 ........................................................................41
VICODIN ES .................................................................................41
VICODIN HP ................................................................................41
VICOPROFEN ..............................................................................41
VICTOZA .....................................................................................81
VICTRELIS....................................................................................89
VIGABATRIN ...............................................................................65
VIGAMOX ...................................................................................57
VIIBRYD.......................................................................................60
VILAZODONE ..............................................................................60
VIMOVO .....................................................................................38
VIMPAT.......................................................................................65
VIOKASE 8...................................................................................22
VIRAZOLE ....................................................................................89
VIROPTIC ....................................................................................57
VISTARIL .....................................................................................61
VITAFOL-OB ................................................................................83
VITAFOL-ONE..............................................................................83
VITAFOL-PLUS.............................................................................83
VITAMED MD ONE RX/QUATREFOLIC ........................................83
VITAMED MD PLUS.....................................................................83
VITAMED MD REDICHEW RX/QUATREFOLIC ..............................83
VITAMINS, PRENATAL..................................................... 81, 82, 83
VITAMINS, PRENATAL PREP........................................................82
VITMAINS, PRENATAL.................................................................82
VITUZ ..........................................................................................42
VIVA CT PRENATAL .....................................................................83
VIVACTIL .....................................................................................60
VIVELLE-DOT...............................................................................75
VOLTAREN GEL ...........................................................................38
VOLTAREN XR .............................................................................38
VORICONAZOLE ..........................................................................36
VOSOL ........................................................................................59
VOSOL HC ...................................................................................59
VOSPIRE ER .................................................................................45
VUSION .......................................................................................50
VYTORIN .....................................................................................32
VYVANSE ....................................................................................63
W
WARFARIN ..................................................................................53
WELCHOL ...................................................................................32
WELLBUTRIN ..............................................................................60
WELLBUTRIN XL ..........................................................................61
WESTCORT .................................................................................47
X
XALATAN ....................................................................................56
XANAX ........................................................................................61
XANAX XR ...................................................................................61
XARELTO 10mg ...........................................................................54
XARELTO 15mg , 20mg ...............................................................54
XELJANZ ......................................................................................87
XIFAXAN .....................................................................................35
XODOL ........................................................................................41
XOLEGEL .....................................................................................50
XOPENEX NEB SOLN ...................................................................45
XOPENEX, HFA ............................................................................45
XTANDI .......................................................................................90
X-VIATE .......................................................................................48
XYREM ........................................................................................63
XYZAL ..........................................................................................42
Y
YASMIN ......................................................................................73
YAZ .............................................................................................73
YODOXIN ....................................................................................38
Z
ZACARE KIT .................................................................................52
ZADITOR OTC..............................................................................58
ZAFIRLUKAST ........................................................................ 41, 45
ZALEPLON ...................................................................................61
ZANAFLEX TABLETS ....................................................................66
ZANAMIVIR .................................................................................37
ZANTAC ......................................................................................20
ZANTAC EFFERDOSE ...................................................................21
ZARONTIN...................................................................................65
ZAROXOLYN ................................................................................26
ZEBETA .......................................................................................30
ZEGERID ......................................................................................21
ZEGERID SUSP.............................................................................21
ZELAPAR .....................................................................................67
ZEMPLAR ....................................................................................78
ZENIEVA......................................................................................49
218
ZENPEP .......................................................................................22
ZENZEDI 2.5, 7.5MG ...................................................................64
ZESTORETIC ................................................................................27
ZESTRIL .......................................................................................27
ZETIA ..........................................................................................32
ZETONNA ....................................................................................42
ZIAC ............................................................................................30
ZIANA .........................................................................................52
ZILEUTON ...................................................................................45
ZIOPTAN .....................................................................................56
ZIPRASIDONE MESYLATE ............................................................62
ZIPSOR ........................................................................................38
ZITHRANOL .................................................................................49
ZITHROMAX ................................................................................34
ZMAX ..........................................................................................34
ZOCOR ........................................................................................32
ZOFRAN ODT ..............................................................................23
ZOLMITRIPTAN ...........................................................................66
ZOLMITRIPTAN NASAL SPRAY ....................................................66
ZOLOFT .......................................................................................61
ZOLPIDEM...................................................................................61
ZOLPIDEM SL ..............................................................................61
ZOLPIDEM TARTRATE .................................................................61
ZOLPIMIST ..................................................................................61
ZOMIG NASAL SPRAY..................................................................66
ZOMIG, ZMT ...............................................................................66
ZONEGRAN .................................................................................65
ZONISAMIDE ...............................................................................65
ZORTRESS 0.25MG .....................................................................86
ZORTRESS 0.5, 0.75MG...............................................................86
ZOTEX .........................................................................................43
ZOTEX GP....................................................................................43
ZOVIA 1/35 .................................................................................73
ZOVIA 1/50 .................................................................................73
ZOVIRAX .....................................................................................37
ZOVIRAX CREAM.........................................................................37
ZUBSOLV.....................................................................................85
ZUPLENZ .....................................................................................23
ZYBAN .........................................................................................85
ZYCLARA .....................................................................................53
ZYFLO, CR ...................................................................................45
ZYLET ..........................................................................................57
ZYLOPRIM ...................................................................................81
ZYPREXA ZYDIS ...........................................................................62
ZYRTEC OTC ................................................................................42
ZYVOX .........................................................................................35
219