Procare Health Plan-Formulary

What is a PDL?

• The Preferred Drug List (PDL) helps doctors select the most cost effective, quality drug for members

Who Chose These Drugs?

• These drugs were judged by our Pharmacy and Therapeutics (P&T) Committee to have the greatest use in member’s care

What Do I Do If A Drug Is Not Listed?

• If a drug not listed on the PDL but is required for a valid medical reason, you may request prior authorization and obtain coverage

• Please refer to the section on Prior Authorizations for more information

Do We Offer A Mail Order Option?

• We offer a mail order option that allows up to a 90 day supply of a chronic medication

• However, to be eligible the member must first receive a 30 day supply of the same medication

• These requirements reduce medication waste due to discontinued drugs or changes in prescription treatments

• Only chronic medications are eligible to be received through the mail order program

How is the PDL Organized?

• The PDL is organized by therapeutic classes

• The drugs listed are those that we and the P&T Committee recommend as first line agents

How Can I Find Out About Product Changes?

• Changes to the PDL will be communicated to prescribing doctors through the quarterly newsletter or similar communication

• Doctors may request additions or deletions to the PDL by sending a request to the Chairman, Pharmacy & Therapeutics Committee, Pro Care Health Plan, 3956 Mount Elliot, Detroit, MI 48207

What about Generic Drugs?

• We require using generics when available.

• Request for exceptions must clearly document specific reasons for medical necessity and appropriateness

• In some cases brand name drugs may be listed for reference purposes, however the generic equivalent will be dispensed to our member unless a specific medical necessity exist

What About Over the Counter (OTC) Drugs?

• In select situations we will cover OTC drugs such as prilosec OTC and the generic equivalent forms of others (e.g. loratadine)

• Please refer to the PDL for the OTC items covered under the plan

How Do I Receive Prior Authorization / Quantity Limit?

· Selected medications may require prior authorization or quantity limits

· Drugs requiring a prior authorization have the words (Prior Authorization) next to their listing

· Specific Prior Authorization criteria can be obtained by contacting Pro Care at 313-267-0300 (local) and 1-877-255-3055 (toll free)

• Examples of drugs that may require prior authorization are as follows:

o Brand name drugs when an equivalent generic drug is available

o Non-PDL drugs

o Drugs where the dosage or quantity exceed maximum dosages and/or quantities

o Drugs used for extended periods that may require other clinical review and assessment for dosage reduction or termination of therapy

• Most decisions are given within 48 hours of receipt of all information

• Doctors are notified of the determination by telephone, fax or other means

• For emergency prescription requests, a small supply of medication will be supplied (usually 72 hours) pending review

• The pharmacist must submit the appropriate emergency code in the prior authorization field when submitting the claim

• Upon review, if the request is denied, the following information will be supplied to the doctor and member:

o The reasons for denial in writing

o Information for the patient to file an appeal grievance or for the provider to file a complaint

Are there Quantity Limits?

• Quantity limits may be placed on certain drugs for various reasons i.e. as a safety precaution not to exceed FDA or medical literature recommended quantities

• Others may be to encourage more effective dosing (once a day versus twice a day)

• All products are covered to a maximum of a 30-day supply

Are Diabetic Supplies Available?

• Diabetic testing strips and meters are covered under the prescription drug benefit

• Please consult the PDL for the brands

Are Non-Covered Medications Available?

• Medications that are not covered under the prescription drug benefit include but are not limited to:

· Drugs for erectile dysfunction

· Drugs for cosmetic use

· Agents to promote hair growth

· OTC (Over the Counter) drugs, except as provided elsewhere in the PDL

· Weight loss agents

· Fertility Drugs

· Experimental Medications

**MEDICATIONS THAT ARE USED TO TREAT HIV AND DEPRESSION ARE AVAILABLE THROUGH MDCH PHARMACY BENEFIT MANAGER-FIRST HEALTH

What about Drugs That Are Covered By Other Insurance?

• In the event that a member receives a drug that is covered under another insurance, that claim must be billed to the primary insurance

What if I Need Help?

• Questions regarding pharmacy coverage can be directed to the Rx Options Pharmacy Help Desk at 1- 800-361-4542 or www.envisionrx.com or www.procarehp.com

How Can I Obtain Drugs Through the Specialty Pharmacy Program?

• Please contact us at 1-800-361-4542 with questions on how to obtain certain drugs through McKesson Specialty Pharmacy Program

What Is the Specialty Pharmacy Program?

• There are certain drugs for chronic diseases that require special methods for taking them

• Most of the time, they are given by injection either at home or at the doctor’s office

• These drugs also may require special storage conditions such as refrigeration and many times local retail pharmacies do not carry these medications

• Pro Care has contracted with McKesson Specialty Pharmacy to provide these drugs to you

• McKesson Specialty Pharmacy will provide these drugs to you through the mail and will deliver them to you when you need them

• In addition, there will be a nurse or pharmacist on staff 24 hours a day, 7 days a week to help answer any questions that you may have on how to use these drugs

How Can I Link to the Medicaid Formulary (Drug List)?

• www.michigan.fhsc.com

ANTICOAGULANTS

Warfarin Tab All Strengths

Dipyridamole 25,50,75 mg

Dipyridamole IV Soln 5mg/mL

Ticlid 250mg

Plavix (Prior Authorization) 75mg

Lovenox 30mg, 40mg, 60mg, 80mg,

120mg, 150mg, 300mg

Arixtra (Prior Authorization)2.5mg, 5 mg, 7.5mg, 10mg

Fragmin (Prior Authorization) 2500mg, 5000mg, 7500mg, 10000mg

PLATELET AGGREGATION INHIBITORS

Aspirin CR 800mg

Aspirin EC 975mg

Cilostazol 50,100 mg

MISCELLANEOUS

Pentoxifylline ext-rel 400mg

ALPHA BLOCKERS

Doxazosin 1,2,4,8 mg

Prazosin 1,2,5 mg

Terazosin 1,2,5,10 mg

ACE INHIBITORS

Captopril 12.5,25,50,100 mg

Enalapril 2.5,5,10,20 mg

Lisinopril 2.5,5,10,20,30,40 mg

Quinapril 5,10,20,40 mg

ANGIOTENSIN II RECEPTOR BLOCKERS

Diovan 40,80,160,320 mg

Micardis 20,40,80 mg

Note: Conventional NSAIDS section now under rheumatoid section on page 8

ANTIARRHYTHMICS/CARDIAC GLYCOSIDES

Amiodarone 200 mg

Digoxin 0.125,0.25 tab

Digoxin 0.05 mg/ml

Disopyramide ext-rel 150 mg

Disopyramide 100,150 mg

Mexiletine 150,200,250 mg

Procainamide 250,375 mg

Procainamide ext-rel (6 hr) 500,1000 mg

Quinidine sulfate 200,300 mg

Quinidine sulfate ext-rel 300 mg

Quinidine gluconate CR 324mg

Sotalol 80,120,160,240 mg

BETA BLOCKERS

CARDIOSELECTIVE

Acebutolol 200,400 mg

Atenolol 25,50,100 mg

Metoprolol 25,50, 100 mg

Betaxolol 10,20 mg

Bisoprolol 10,20mg

NONCARDIOSELECTIVE

Nadolol 20,40,80,120,160 mg

Pindolol 5,10 mg

Propranolol 10,20,40,60,80 mg

Timolol Maleate 5,10,20 mg

ALPHA-BETA

Labetalol 100,200,300 mg

CALCIUM CHANNEL BLOCKERS

DIHYDROPYRIDINE

Nifedipine 10,20 mg

Nifedipine ext-rel 30,60,90 mg

Amlodipioe 2.5,5,10 mg

NONDIHYDROPYRIDINE

Diltiazem 30,60,90,120 mg

Diltiazem SR 60,90,120,180,240 mg

Diltiazem ER 120,180,240,300,360 mg

Verapamil 40,80,120 mg

Verapamil CR 120,180,240 mg

Verapamil SR 120,180,240,360 mg

Nicardipine 20,30 mg

CHOLESTEROL LOWERING

Cholestyramine 4GM

Cholestyramine Light 4GM

Gemfibrozil 600mg

Clofibrate 500mg

Lovastatin 10,20,40 mg

Lipitor (Prior Authorization) 10,20,80,40 mg

DIURETICS/COMBINATION PRODUCTS

Atenolol/chlorthalidone 50/25,100/25 mg

Bisoprolol/hctz 2.5/6.25,5/6.25,10/6.25 mg

Bumetanide 0.5,1,2 mg

Captopril/hctz 25/15,25/25,50/15,50/25 mg

Chlorthalidone 25,50,100 mg

Enalapril/hctz 5/12.5,10/25

Furosemide 20,40,80 mg

Furosemide 10mg/mL Soln

Hydrochlorothiazide 12.5,25,50 mg

Spironolactone 25,50,100 mg

Triamterene/hctz cap 37.5/25,50/25 mg

Triamterene/hctz tab 37.5/25,75/50 mg

Lisinopril/HCTZ 10/12.5,20/12.5,20/25 mg

Torsemide 5,10,20,100 mg

Acetazolamide CR 500mg

Acetazolamide 125,250 mg

Methazolamide 25,50 mg

Indapamide Tab 1.25 ,2.5 mg

Methyclothiazide Tab 2.5,5 mg

Amiloride/HCTZ Tab 5-50 MG

Spironolactone/HCTZ Tab 25-25 MG

Micardis-HCT 80/25,80/12.5,40/12.5 mg

Diovan-HCT 160/25,160/12.5,80/12.5,320/12.5,320/25mg

NITRATES

Isosorbide dinitrate 5,10,20,30,40 mg

Isosorbide dinitrate CR 40mg

Isosorbide mononitrate 30,60,120 mg

Nitroglycerin ointment 2%

Nitroglycerin Cap CR 2.5,6.5,9 mg

Nitrglycerin patch 0.1,0.2.0.4.0.6 mg/hr

Nitroglycerin sublingual 0.3,0.4,0.6 mg

SYMPATHOLYTICS

Clonidine 0.1,0.2,0.3 mg

Guanabenz Ace 4,8 mg

Guanfacine 1,2 mg

Methyldopa/HCTZ 15/250,25/250 mg

Methyldopa 125,250,500 mg

Isoxsuprine 10,20 mg

Papaverine CR 150mg

MISCELLANEOUS

Hydralazine 10,25,50,100 mg

Minoxidil 2.5,10 mg

MIGRAINE

Preventative Therapy

Generic beta blockers

Generic calcium channel blockers

Treatment

Isometheptene/dichloralphenazone/aceta-minophen

Ergotamine w/Caffeine

Prior Authorization

Imitrex Nasal Spray 5,20 mg

Imitrex Tabs 25,50,100 mg

Imitrex Injection Kit

Relpax 20,40 mg

Zomig 2.5,5 mg

Zomig Nasal Spray 5mg

Zomig ZMT

ANALGESICS

NON-NARCOTIC COMBINATIONS

Butalbital/acetaminophen

Butalbital/caffeine/acetaminophen

Butalbital/caffeine/aspirin

Acetanminophen All Strengths

OPIOIDS

Acetaminophen/codeine #2,#3,#4

Hydrocodone/acetaminophen TAB 5/500, 7.5/750

Aspirin/codeine 325/30,325/60

Butalbital/ASA/Caffeine w/Codeine

Prior Authorization

Hydrocodone/acetaminophen 10/500, 7.5/500,7.5/650,10/650

Hydrocodone/acetaminophen Cap 5/500mg

Hydrocodone/acetaminophen Soln 7.5-500mg/15mL

Hydromorphone 2,4,8 mg

Hydromorphone LIQ 1mg/mL

Hydromorphone Suppos 3mg

Oxycodone 5,15,30 mg

Oxycodone Soln 5mg/5mL

Oxycodone Conc 20mg/mL

Oxycodone SR 12hr 80mg

Oxycodone/acetaminophen All Strengths

Oxycodone/aspirin Full Strength

PAIN-MODERATE TO SEVERE

AVINZA 30,60,90,120 mg-Prior Authorization

MISCELLANEOUS

Tramadol 50 mg

Propoxyphene 65 mg

Propoxyphene Compound 65mg

Propoxyphene/acetaminophen 65/650,100,/650 mg

Methadone 5,10,40 mg

ANTIVERTIGO/MOTION SICKNESS AGENTS

Promethazine 12.5,25,50 mg

Promethazine Syrup 6.25/5mL

Promethazine Supp 12.5,25,50 mg

Meclizine 12.5,25 mg

SEIZURES

Carbamazepine 100,200 mg

Carbamazepine Susp 100mg/5mL

Clonazepam 0.5,1,2 mg

Divalproex 125,250,500 mg

Ethosuximide 250 mg

Ethosuximide Syrup 250 mg/5mL

Gabapentin 100,300,400,600,800 mg

Phenobarbital All Strengths

Primidone 50,250 mg

Valproic acid 250 mg

Valproate Sodium Syrup 250mg/5 mL

Phenytoin Chew 50mg

Phenytoin Susp 125mg/5 mL

Phenytoin 100 mg

DERMATOLOGY

BACTERIAL INFECTIONS

Azelaic acid crm 20%

Metronidazole Crm 0.75%

Clindamycin soln, gel, lotion, swab 1%

Erythromycin soln,gel,pads 2%

Sulfacetamide/sulfur susp,emuls. 10-5%

Sulfacetamide/sulfur lotion 10-5%

Tetracycline oral

Silver sulfadiazine

Mupirocin Oint 2%

Gentamicin Crm 0.1%

Gentamicin Oint 0.1%

Benzoyl-Peroxide-Erythromycin Gel 5-3%

CORTICOSTEROIDS

Listed by potency: Group I is most potent; Group IV is least potent

GROUP I

Augmented betamethasone dipropionate ointment 0.05%

Clobetasol propionate Products 0.05%

GROUP II

Betamethasone dipropionate Crm 0.05%

Betamethasone dipropionate Oint 0.05%

Flucinonide Soln,Crm,Gel,Oint 0.05%

Flucinonide Emuls Base Crm 0.05%

Triamcinolone acetonide Crm 0.5%

Triamcinolone acetonide Oint 0.5%

Betamethasone valerate Ointment 0.1%

Desoximetasone Crm,Oint 0.25%

GROUP III

Betamethasone valerate Cream 0.1%

Betamethasone valerate Lotion 0.1%

Fluocinolone acetonide Crm 0.025%

Fluocinolone acetonide Oint 0.025%

Mometasone furoate Oint 0.1%

Triamcinolone acetonide Crm,Oint,Lot 0.1%

Triamcinolone acetonide Crm,Oint,Lot 0.025%

Betamethasone dipropionate Lot 0.05%

Desoximetasone Crm 0.05%

Hydrocortisone Valerate Oint 0.2%

Hydrocortisone Butyrate Soln 0.1%

GROUP IV

Hydrocortisone Crm,Lotion,Oint 1%

Hydrocortisone Crm,Lotion,Oint 2.5%

HC Acetate Crm,Lotion,Oint 2.5%

Desonide Crm 0.05%

Fluocinolone Crm,Soln 0.01%

PSORIASIS

Methotrexate (2.5 mg tablet only)

SCABIES AND PEDICULOSIS

Lindane shampoo,lotion 1%

Permethrin cream 5%

Permethrin cream rinse 1%

MISCELLANEOUS

Selenium sulfide shampoo 2.5%

Silver Sulfadiazine Crm 1%

Lidocaine Soln 4%

Lidocaine Cream 3%

Lidocaine Gel 2%

Lidocaine Onit 5%

Lidocaine-Hydrocortisone crm 3-0.5%

Elidel

Protoptic

ENDOCRINOLOGY

ADRENAL CORTICOSTEROIDS

Prednisolone sodium 5mg

Prednisolone sodium 5mg/5mL,15mg/5mL, 6.7mg/15mL

Prednisone 5,10,20 mg

Prednisone 5,10 mg dose pak

Fludrocortisone 0.1 mg

Methylprednisolone 4,6 mg

Dexamethasone 0.5,0.75,1.5, mg

Dexamethasone Elixir 0.5mg/5mL

Dexamethasoen Dose Pak 0.75 mg

Hydrocortisone

DIABETES MELLITUS

INSULIN

LANTUS- vials only

NOVOLIN 70/30- vials only

NOVOLIN N- vials only

NOVOLIN R- vials only

NOVOLOG –vials only

HUMULIN L -vials only

HUMULIN N-vials only

HUMULIN R-vials only

ORAL AGENTS

Glipizide 5,10 mg

Glipizide ER 2.5,5,10 mg

Glimepiride 1,2,4 mg

Glyburide 1.25,2.5,5 mg

Glyburide micronized 1.5,3,6 mg

Metformin 500,850,1000 mg

Metformin 24hr 500 mg

Glyburide/metformin 1.25/250,2.5/500,5/500 mg

Chlorpropamide 100,250 mg

Tolazamide 100,250,500 mg

Tolbutamide 500mg

ACTOS - Prior Authorization

DIABETIC SUPPLIES

Insulin Syringes

Lancets

Blood Glucose alibration Liquid

Limit (1) Glucometer per year

FREESTYLE

ASCENCIA BREEZE, BREEZE 2 & ASCENCIA CONTOUR

THYROID MODIFIERS

Levothyroxine all strengths

Methimazole 5,10 mg

Propylthioruacil 50mg

Thyroid tab 30mg (1/2 grain)

LEVOXYL

MISCELLANEOUS

Desmopressin 0.01% Nasal Spray

GASTROINTESTINAL DRUGS

ANTIEMETICS

Prochlorperazine 5,10 mg

Prochlorperazine Supp 25mg

Promethazine 12.5,25,50 mg

Promethazine Syrup 6.25/5mL

Promethazine Supp 12.5,25,50 mg

Meclizine 12.5,25 mg

Trimethobenzamide 100,200 mg

CHRON’S/INFLAMMATORY BOWEL DISEASE

hydrocortisone/pramoxine

DIARRHEA

diphenoxylate/atropine Tab,LIQ

Loperamide 2 mg

Loperamide LIQ 1mg/7.5 mL,1mg/5mL

Bismuth Subsalicyclate 262mg

Bismuth Subsalicyclate Sus 262/15mL

PANCREATIC ENZYMES

Pancreatin Tab 1200mg

Pancreatin Powder

Amylase-Lipase-Protease Tab 30000-8000-30000 Unit

Amylase-Lipase-Protease Tab 60000-16000-60000 Unit

Amy-Lip-Prot DR Particles Cap 20000-4500-25000 Uni

Amy-Lip-Prot DR Particles Cap 48000-16000-48000 U

PROMOTILITY AGENTS

Metoclopramide 5,10 mg

Metoclopramide Syrup 5mg/5mL

SPASM

Hyoscyamine Tab 0.125mg, SL 0.125mg,ODT 0.12

Hyoscyamine 0.125mg/5mL

Hyoscyamine SR 12hr 0.375mg tab and cap

Dicyclomine 20mg

Belladonna Alkaloids-Phenobarbital Tab 16.2 MG

Belladonna Alkaloids-Phenobarbital Elixir 16 MG/5M

Clidinium & Chlordiazepoxide Cap 2.5-5 MG

ULCERS AND REFLUX (GERD)

Cimetidine 200,300,400,800 mg

Cimetidine 300mg/mL Soln

Famotidine 20,40 mg

Famotidine Susp 40mg/mL

Famotidine ODT 20mg

Misoprostol 100,200 mcg

Ranitidine tablets 150,300 mg

Sucralfate 1GM

Nizatidine 150,300 mg

PRILOSEC OTC

MISCELLANEOUS

Sulfasalazine 500mg, EC tab 500mg

OTC Antacids

Docusate Sodium- all strengths

Docusate Casanthranol- all strengths

Lactulose Syrup 10GM/15mL

PEG-Electrolyte for Soln

ANTI-INFECTIVE AGENTS

CEPHALOSPORINS

First Generation

Cefadroxil 500mg, 1 GM

Cephalexin 250,500 mg cap

Cephalexin 250 mg tab

Cephalexin 125/5, 250/5 Susp

Cephradine 250,500 mg cap

Cephradine 250/5 Susp

Second Generation

Cefaclor 250,500 mg

Cefaclor 125/5, 187/5, 250/5, 375/5 Susp

Cefaclor Monohydrayte Tab 500mg

FLUOROQUINOLONES

Ciprofloxacin 100,250,500,750 mg

MACROLIDES

Clarithromycin (all strengths and forms)

Erythromycin Tab 500 MG

Erythromycin w/ Delayed Release Particles Cap 250

Erythromycin Stearate

Erythromycin Estolate Susp 125 /5

Erythromycin Ethylsuccinate Tab 400 MG

Erythromycin Ethylsuccinate Susp 200/5, 400/5

Azithromycin 250 mg

Prior Authorization

Azithromycin 500,600 mg

Azithromycin 100/5, 200/5,1GM Susp-

PENICILLINS

Amoxicillin 250,500 mg cap

Amoxicillin 500, 875 mg tab

Amoxicillin 125,200,250,400 mg chew tab

Amoxicillin 125/5, 200/5, 250/5, 400/5 Susp

Ampicillin 250, 500 mg

Ampicillin 125/5, 250/5 Susp

Dicloxacillin 250,500 mg

Penicillin VK 250,500 mg

Penicillin VK 125/5, 250/5 Soln

Amoxicillin/ potassium clavulanate (all strengths and forms)

SULFONAMIDES

Sulfisoxazole 500mg

TETRACYCLINES

Doxycycline hyclate 50,100 mg

Minocycline 50,75,100 mg

Tetracycline 250, 500 mg

URINARY ANTI-INFECTIVES

Nitrofurantoin macro 50,100 mg

Nitrofurantoin Monohydrate 100mg

Trimethoprim tablets

COMBINATION ANTIBIOTICS

Sulfamethoxazole/trimethoprim

Sulfisoxazole/erythromycin

MISCELLANEOUS ANTIBIOTICS

Metronidazole 250,500 mg

Metronidazole 375mg cap

Metronidazole SR 24 hr 750mg

Neomycin tab 500mg

Clindamycin 150,300 mg

ANTIFUNGALS

Topical

Ciclopirox Gel 0.77%

Ciclopirox Shampoo 1%

clotrimazole

Clotrimazole/betamethasone Crm,Lotion 1-0.05 %

Ketoconazole Crm,Shampoo 2%

Nystatin topical powder

Nystatin Crm,Oint 100000 Unit/GM

Nystatin/triamcinolone Crm, Oint 100000-0.1 Unit/GM-%

Iodoquinol-HC Cream 1%

Oral

Griseofulvin microsize 500mg tab

Griseofulvin microsize Powder

Griseofulvin ultramicrosize

Ketoconazole 200mg tab

Nystatin Susp 100000 Units/mL

Fluconazole 10mg/ml, 40mg/ml

Fluconazole 50,100,150,200 mg

ANTIVIRAL DRUGS

Topical

Acyclovir

Oral

Acyclovir 200mg cap

Acyclovir 400, 800 mg tab

Acyclovir 200/5 Soln

MISCELLANEOUS

AMEBICIDES

Mebendazole 100mg chew tab

ANTITUBERCULOSIS AGENTS

Ethambutol 100,400 mg

Isoniazid 100,300 mg

Pyrazinamide 500mg

Rifampin 150,300 mg

MALARIA AND OTHER PROTOZOAL INFECTIONS

Chloroquine phosphate 250,500 mg

Hydroxychloroquine 200mg

Quinine 200,325 mg cap

Quinine 260 mg tab

RHEUMATOID ARTHRITIS

GOUT AGENT

Allopurinol 100,300 mg

Colchicine 0.6mg

Colchicine/probenecid 0.5/500 mg

Probenecid 500mg

Sulfinpyrazone Cap 200mg

RHEUMATOID/

OSTEOARTHRITIS

Hydroxychloroquine 200mg

Methotrexate 2.5mg

ANALGESICS

(CONVENTIONAL NSAIDS )

Ibuprofen 100,200,400,600,800 mg

Ibuprofen Chew Tab 50,100 mg

Ibuprofen Susp 40mg/mL, 100mg/5mL

Etodolac 200,300,400,500 mg

Etodolac SR 400,500,600 mg

Diclofenac Del Rel 25,50,75 mg

Diclofenac SR 24hr 100 mg

Diclofenac Pot 50mg

Flurbiprofen 100mg

Indomethacin 25,50

Indomethacin CR 75mg

Naproxen 250,375,500

Naproxen EC 375,500 mg

Naproxen Susp 125mg/5mL

Naproxen Sodium 220,275,550

Naproxen Sodium SR 24hr 500mg

Oxaprozin 600mg

Piroxicam 10,20 mg

Salsalate 500,750 mg

Sulindac 150,200 mg

Ketoprofen 50,75 mg

Ketorolac 10mg

Celecoxib 100,200,400 mg

Tolmetin 200,400,600 mg

Diflunisal 250,500 mg

Meloxicam 7.5,15 mg

Nabumetone 500,750 mg

Meclofenamate 50,100 MG

CHO MAG TRIS 500,750,1000 mg

CHO MAG TRIS LIQ 500/5ML

SPASTICITY

Baclofen 10,20 mg

Cyclobenzaprine 5,10 mg

Methocarbamol 500,750 mg

Carisoprodol 350 mg

Tizanidine 2,4 mg

Chlorzoxasone 250,500 mg

Methocarbamol w/ ASA Tab 400-325 MG

OPHTHALMIC

OPHTHALMIC-ANTIBACTERIAL

Bacitracin Oint 500 Units/GM

Chloramphenical Oint 1%

Ciprofloxacin HCl Soln 0.3%

Erythromycin ophthalmic oint 5mg/GM

Gentamicin Soln 0.3%

Neomycin/polymixin B/bacitracin ointment

Neomycin/polymixin B/gramicidin solution

Polymyxin B/bacitracin

Polymyxin B/trimethoprim Soln

Sulfacetamide 10% drops

Sulfacetamide 10% ointment

Tobramycin Soln 0.3%

Tobramycin/Dexamthasone Susp

Tobramycin/Dexamthasone Oint

OPHTHALMIC-ANTI-INFLAMMATORIES

Dexamethasone Soln 0.1%

Dexamethasone Oint 0.05%

Fluorometholone Susp 0.1%

Neomycin/polymixin B/dexamethasone

Neo-Polymixin-HC Susp

Bacitracin-Polymixin-Neomycin-HC Oint 1%

Prednisolone acetate Susp 1%

Prednisolone phosphate Soln 1%

Prednisolone phosphate/sulfacetamide

OPHTHALMIC-ANTIVIRAL

Trifluridine Soln 1%

OPHTHALMIC-GLAUCOMA/OTHER

Acetazolamide

Dipivefrin 0.1%

Cromolyn Sodium Ophth Soln 4%

Brinzolamide Ophth Susp 1%

Levobunolol 0.25%,0.5%

Methazolamide

Pilocarpine 0.5,1,2,3,4,6 %

Timolol maleate 0.25%,0.5%

Timolol maleate Gel Forming 0.25%,0.5%

XALATAN

OPHTHALMIC-MISCELLANEOUS

Atropine Soln 1%

Atropine Oint 1%

Tropicamide Ophth Soln 1%

Naphazoline HCl Ophth Soln 0.1%

Phenylephrine 2.5%,10%

OTIC (EAR)

Acetic acid Soln 2%

Acetic acid/aluminum acetate

Acetic acid/hydrocortisone Soln

Benzocaine/antipyrine Soln

Hydrocortisone/neomycin/polymyxin B

CIPRO-HC

MISCELLANEOUS

Lidocaine viscous solution 2%

Epinephrine HCl Inj Device 1:1000

Hydrocortisone Acetate Suppos 25 MG

Chlorhexidine Gluconate Soln 0.12%

Triamcinolone in Orabase 0.1%

Hydrocortisone Enema 100mg/60mL

Hydrocortisone w/Pramoxine Crm

RESPIRATORY

ANTIHISTAMINE

DECONGESTANT COMBINATIONS

Brompheniramine & Pseudoephedrine Cap CR 6-60 MG

Brompheniramine & Pseudoephedrine Cap CR 12-120 MG

Carbinoxamine & Pseudoephedrine-All strengths and forms

Promethazine/phenylephrine

Pseudoephedrine/chlorpheniramine

Brompheniramine & Phenylpropanolamine Elixir 2-12.

Brompheniramine & Pseudoephedrine Elixir 1-15 MG/5

Chlorphen Tan & Phenyleph Tan Tab 9-25 MG

Chlorphen-Pyrilamine & PE Tab 8-25-25 MG

Chlorphen-PSE & Methscopolamine Tab SR 12HR 8-120-

CLARITIN-D OTC

ANTIHISTAMINES

Diphenhydramine 25,50 mg

Chlorpheniramine 4mg

Chlorpheniramine CR 8,12 mg

Chlorpheniramine Syrup 2mg/5mL

Dexchlorpheniramine CR 4,6 mg

Dexchlorpheniramine Syrup 2mg /5mL

Clemastine Fumarate 2.68mg

Diphenhydramine 12.5mg/5mL

Diphenydramine Tannate Chew 25mg

Diphenhydrmaine Tannate Susp 25mg/5ml

Cyproheptadine Tab 4mg

Cyproheptadine Syrup 2mg/5mL

Cetirizine 5,10mg

Cetirizine Chew 5,10 mg

Cetirizine Syrup 10mg/10mL

Loratidine 10mg

Loratidine Syrup 10mg/10mL

Loraditine RDT 10mg

Hydroxyzine HCl 10,25,50 mg

CLARITIN OTC

ANTITUSSIVE COMBINATION PRODUCTS

Guaifenesin/codeine LIQ 10-100mg/5mL

Hydrocodone/guaifenesin

Phenylephrine-Promethazine w/ Codeine Syrup 5-6.25

Phenylephrine-Chlorphen-Dihydrocodeine Liqd 5-2-7.

Pseudoephedrine-Chlorphen w/ Codeine Liq 30-2-10 M

Pseudoephedrine-Triprolidine w/ COD Syrup 30-1.25-

Pseudoeph-Carbinoxamine w/ Hydrocodone Liqd 30-2-5

Phenylephrine-Dexbromphen-Hydrocodone Syrup 5-1-2.

Phenylpropanolamine w/ Caramiphen Cap CR 75-40 MG

Pseudoephed-Bromphen-DM Syrup 45-4-15 MG/5ML

Pseudoephed-Carbinoxamine-DM Soln 25-2-4 MG/ML

Promethazine-DM Syrup 6.25-15 MG/5ML

Hydrocodone/homatropine

phenylephrine/chlorpheniramine/hydrocodone

Promethazine/codeine

pseudoephedrine/hydrocodone bitartrate

Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML

Pseudoephedrine w/ Hydrocodone-GG Elixir 30-2.5-10

Pseudoephedrine w/ COD-GG Soln 30-10-100 MG/5ML

Phenylephrine w/ Hydrocodone-GG Solution 10-2.5-22

Phenylephrine w/ Hydrocodone-GG Liquid 10-5-200 MG

Dextromethorphan-Guaifenesin Tab SR 12HR 60-1000 M

Dextromethorphan-Guaifenesin Tab SR 12HR 60-1200 M

EXPECTORANTS AND DECONGESTANT/EXPECTORANT COMBINATIONS

Guaifenesin Tab 200mg

Guaifenesin Tab CR 600mg

Guaifenesin LIQ 100mg/5mL

Guaifenesin Tab SR 12hr 1200mg

Phenylephrine-Guaifenesin Cap SR 12HR 20-375 MG

Phenylephrine-Guaifenesin Tab SR 12HR 30-600 MG

Pseudoephedrine-Guaifenesin Tab SR 12HR 50-1200 MG

Pseudoephedrine-Guaifenesin Tab SR 12HR 120-600 MG

Dextromethorphan-Guaifenesin Syrup

DECONGESTANTS

Pseudoephedrine 30, 60mg

COUGH SUPPRESSANTS

Benzonatate Cap 100mg

NASAL AGENTS

STEROIDS

Flunisolide 0.025% (limit 3 inh/90days)

NASAREL (limit 3 inh/90days)

Fluticasone (limit 3 inh/90days)

ASTHMA/COPD

ANTI-CHOLINERGICS

ATROVENT HFA

BETA-AGONIST INHALERS

albuterol metered-dose inhaler (limit 1 inh/mo)

Albuterol HFA

INHALED CORTICOSTEROID MEDICATIONS

Qvar (limit 1 inh/mo)

Fluticasone HFA 44,110,200 mcg

INHALATIONS FOR NEBULIZATION

Acetylcysteine 10,20 %

Cromolyn sodium 20mg/2mL

Ipratropium bromide 0.02%

Albuterol Neb 0.083%

Albuterol Neb 0.5%

Metaproterenol Neb 0.4,0.6,5 %

LEUKOTRIENE MODIFIERS

ACCOLATE 10,20 mg

ORAL MEDICATIONS

BETA AGONISTS

Albuterol 2,4 mg

Albuterol Syrup 2mg/5mL

Metaproterenol 10,20 mg

Metaproterenol Syrup 10mg/5mL

Terbutaline 2.5,5 mg

ORAL STEROIDS

Prednisolone sodium 5mg

Prednisolone sodium 5mg/5mL,15mg/5mL, 6.7mg/15mL

Prednisone 5,10,20 mg

Prednisone 5,10 mg dose pak

Fludrocortisone 0.1 mg

Methylprednisolone 4,6 mg

Dexamethasone 0.5,0.75,1.5, mg

Dexamethasone Elixir 0.5mg/5mL

Dexamethasoen Dose Pak 0.75 mg

THEOPHYLLINES

Aminophylline 100,200 mg

Aminophylline Oral Soln 105mg/5mL

Dyphylline 200mg

Theophylline CR 100,200,300,450 mg

Theophylline Elixir 80mg/15mL

Theophylline SR 50,75,100,125,200,300 mg

MISCELLANEOUS

Cromolyn sodium metered-dose inhaler

Diphylline-Guaifenesin Elixir

COMBINATION PRODUCTS

Albuterol-Ipratropium Aer 103-18/Act

SUPPLEMENTS

POTASSIUM SUPPLEMENTS

TABLET

Potassium chloride ext-rel (8 mEq)

Potassium chloride ext-rel (10 mEq)

Potassium chloride (10 mEq)

Potassium chloride (20 mEq)

LIQUID

Potassium chloride 10%,20%

ELIXIR

Potassium gluconate 20mEq/15mL

POWDER

Potassium chloride (25mEq)

VITAMINS

B-Complex w/ C & Folic Acid Tab

Multiple Vitamins w/ Minerals Tab

Prenatal Vitamins

Pediatric Multiple Vitamins w/ Fluoride Soln 0.5

Pediatric Multiple Vitamins w/ Fluoride Chew Tab

Leucovorin Calcium Tab 5 MG

Folic Acid 400 mcg,800 mcg, 1 mg

Ergocalciferol 50000 IU

UROLOGICAL

ANESTHETIC AGENTS

Phenazopyridine 200mg

Acetic Acid Irrig 0.25%

SYMPTOMATIC BENIGN PROSTATIC

HYPERPLASIA

Doxazosin 1,2,4,8 mg

Terazosin 1,2,5,10 mg

URINARY INCONTINENCE

Oxybutynin 5mg

Oxybutynin Syrup 5mg/5mL

MISCELLANEOUS

Bethanechol 5,10,25,50 mg

Hyoscyamine 0.15mg

Phenazopyridine-Butabarbital-Hyoscyamine Tab 150-1

Methenamine-Bella Alk-Meth Blue-Phenyl Sal Tab

WOMEN’S HEALTH

MENOPAUSE/

POSTMENOPAUSAL OSTEOPOROSIS

ESTROGENS

Estradiol 0.5,1,2 mg

Estradiol transdermal weekly

0.025,0.0375,0.05,0.06,0.075,0.1 mg

Estropipate 0.75,1.5,3 mg

Climara

Premarin 0.3,0.45,0.625,0.9,1.25 mg

Estrogens, Conj Vag Crm 0.625mg/GM

CONTRACEPTIVES

Cylessa

Desogen

Levlen

Levlite

Mircette

Trilevlen

PROGESTIN ONLY

Depo-Provera

Medroxyprogesterone acetate

2.5,5,10 mg

OTHER DELIVERY SYSTEMS

Ortho- Evra – Prior Authorization

OSTEOPOROSIS AGENTS

Fosamax 5mg, 10mg, 35mg, 75mg,

solution

Evista 60mg

OSCAL-D

VAGINAL INFECTIONS

Nystatin vaginal

Terconazole 0.4,0.8 %

Terconazole Vag Suppos 80mg

Triple sulfa Vag Crm

Clotrimazole Vag Tab 100,200 mg

Clotrimazole Vag Crm 1,2 %

Clotrimazole Vag Tab 200mg, 1% Crm Kit

Miconazole Vag Crm 2%

Miconazole Vag Suppos 200mg

CENTRAL NERVOUS SYSTEM

ANTIANXIETY MEDICATIONS

Alprazolam 0.25,0.5,1,2 mg

Buspirone 5,7.5,10,15,30 mg

Lorazepam 0.5,1,2 mg

Oxazepam 10,15,30 mg

Flurazepam 15,30 mg

Diazepam 2,5,10 mg

Clorazepate 3.75,7.5,15 mg

Chlordiazepoxide 5,10,25 mg

Temazepam 15,30 mg

Meprobamate 200,400 mg

INSOMNIA

Temazepam 15,30 mg

Rozerem-Prior Authorizatuion Required

ALZHEIMER’S DISEASE

Namenda 5mg, 10mg

Aricept 5mg, 10mg, and ODT forms

Exelon (Prior Authorization) 1.5mg, 3mg, 4.5mg, 6mg, and

2mg/ml solution

Razadyne (Prior Authorization) 4mg, 8mg, 12mg, 16mg,

24mg and 4mg/ml sol

PARKINSON’S DISEASE

Amantadine 100 mg

Amantadine Syrup 50mg/5mL

Benztropine 0.5,1,2 mg

Carbidopa/levodopa 10/100,25/100,25/250

Carbidopa/levodopa CR 25/100,50/200

Selegiline 5mg

Mirapex .125mg, .25mg, .5mg, 1mg,

1.5 mg,

Requip 0.25mg, 0.5mg, 1mg, 2mg, 3mg,

4mg, 5mg

Trihexyphenidyl 2,5 mg

Trihexyphenidy Elixir 0.4mg/mL

CENTRAL NERVOUS SYSTEM STIMULANTS

Methylphenidate 5,10,20 mg- Prior Authorization

Methylphenidate CR 20mg- Prior Authorization

SEDATIVES AND HYPNOTICS

Chloral Hydrate Syrup 500mg/5mL

ANTIALCOHOLIC AGENTS

Disufuram 250 mg

IMMUNOSUPPRESSANTS

Azathioprine Tab 50 MG

HEPATITS C THERAPY

Intron A* (Interferon Alfa-2B)

Roferon A* (Interferon Alfa-2A

Ribavirin Cap 200mg

Ribavirin Soln 40mg/ml

Ribavirin-Interferon Alfa-2B

Peginterferon alfa-2b

MULTIPLE SCLEROSIS

THERAPY

Copaxone* Inj Kit 20 MG/ML

Avonex* 30MCG

Betaseron* 0.3 MG

RHEUMATOID ARTHRITIS

Enbrel* (Prior Authorization) 25mg, 50mg

Humira* (Prior Authorization) 40mg

HEMATOPOIETIC AGENTS

Aranesp* (Prior Authorization)25mcg, 40mcg, 60mcg, 100mcg, 150mcg, 200mcg, 300mcg, 500mcg

Epogen*(Prior Authorization)2000mg, 3000mg, 4000mg, 10000mg, 40000mg

Procrit* (Prior Authorization)2000 U/ml, 3000U/ml, 4000 U/ml, 10000 U/ml, 20000 U/ml, 40000 U/ml

Non-Preferred Product	Preferred PDL Alternatives	Non-Preferred Product	Preferred PDL Alternatives
Aceon	Lisinopril	Nordette	Levlen
Aciphex	Prilosec OTC	Noroxin	Cipro
Advicor	Lovastatin, Niacin	Orthocept	Desogen
Alesse	Levlite	Ortho-Cyclen	Cyclessa, Levlen, Levlite, Mircette, Tri-Levlen
Allegra, Clarinex	Claritin OTC, Loratadine	Ortho-Tricyclen	Cyclessa, Levlen, Levlite, Mircette, Tri-Levlen
Alphagan	Brimonidine – Generic Only	Oxycontin	Avinza
Alphagan P	Brimonidine – Generic Only	Pravachol	Lovastatin
Benicar	Diovan, Micardis	Prevacid	Prilosec OTC
Cozaar	Diovan, Micardis	Rhinocort, Nasacort	Flunisolide, Fluticasone
Duragesic	Avinza	Rhinocort-AQ, Nasonex	Flunisolide, Fluticasone
Hyzaar	Diovan HCT, Micardis HCT	Singulair (Asthma)	Accolate
Lescol-XL	Lovastatin	Singulair (Allergy)	Claritin OTC
Lotensin	Lisinopril	Tri-phasil	Tri-Levlen
Lumigan	Xalatan	Univasc	Lisinopril
Maxalt	Imitrex, Relpax, Zomig (Prior Authorization)	Vivelle	Climara
Zocor	Lovastatin	Zetia	Lovastatin

Provider

Member

CARDIOSELECTIVE

NONCARDIOSELECTIVE

AVINZA 30,60,90,120 mg-Prior Authorization

DIABETIC SUPPLIES

OSCAL-D