Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Updated 10/1/2001
ii
iii
ANTIVIRALS .............................................................................................................................. 34
ANTIMALARIALS/ANTIPROTOZOALS ...................................................................................... 34
ANTIHELMINTICS ..................................................................................................................... 35
AMEBICIDES ............................................................................................................................. 35
ANALGESICS ............................................................................................................................... 35
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) ................................................... 35
NARCOTIC ANALGESICS ......................................................................................................... 36
RESPIRATORY DRUGS ............................................................................................................... 38
ALLERGIES ............................................................................................................................... 38
NASAL SPRAYS ........................................................................................................................ 38
ANTIHISTAMINE/ANTITUSSIVES ............................................................................................. 39
DECONGESTANT/ANTIHISTAMINES ....................................................................................... 39
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT ............................................................ 39
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES ...................................................... 40
ORALLY INHALED DRUGS ....................................................................................................... 40
OTHER BRONCHODILATORS, ORAL ...................................................................................... 41
THEOPHYLLINES...................................................................................................................... 41
LEUKOTRIENE RECEPTOR ANTAGONISTS ........................................................................... 41
MUCOLYTICS ............................................................................................................................ 41
DERMATOLOGICS ....................................................................................................................... 42
TOPICAL STEROIDS ................................................................................................................. 42
TOPICAL EMOLLIENTS ............................................................................................................ 43
TOPICAL IMMUNOMODULATORS ........................................................................................... 44
PSORIASIS ................................................................................................................................ 44
ANTI-INFECTIVES (TOPICAL) .................................................................................................. 44
BURN PREPARATIONS ............................................................................................................ 45
ANTIFUNGALS (TOPICAL) ........................................................................................................ 45
ACNE ......................................................................................................................................... 46
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS ................................................................... 47
SCABICIDES & PEDICULOCIDES ............................................................................................ 48
TOPICAL ENZYMES .................................................................................................................. 48
OTHER AGENTS ....................................................................................................................... 48
BLOOD MODIFIERS ..................................................................................................................... 49
ANTICOAGULANTS................................................................................................................... 49
ANTI-PLATELET DRUGS .......................................................................................................... 49
HEMORRHEOLOGIC AGENTS ................................................................................................. 49
iv
BISPHOSPHONATES ................................................................................................................ 70
THYROID DISORDERS................................................................................................................. 70
DIABETES..................................................................................................................................... 71
INSULINS................................................................................................................................... 71
NEEDLES/SYRINGES ............................................................................................................... 71
SULFONYLUREAS .................................................................................................................... 71
ORAL ANTIHYPERGLYCEMICS ............................................................................................... 71
THIAZOLIDINEDIONES ............................................................................................................. 72
MISCELLANEOUS ..................................................................................................................... 72
GLUCAGON............................................................................................................................... 73
ANTI-GOUT DRUGS ..................................................................................................................... 73
SUPPLEMENTS ............................................................................................................................ 73
ANTI-ANEMIA DRUGS .............................................................................................................. 73
PRENATAL VITAMINS............................................................................................................... 73
POTASSIUM .............................................................................................................................. 74
VITAMIN D ................................................................................................................................. 75
VITAMINS WITH FLUORIDE ..................................................................................................... 75
TOPICAL FLUORIDE ................................................................................................................. 75
VITAMIN K ................................................................................................................................. 75
MISCELLANEOUS AGENTS ........................................................................................................ 75
HEAVY METAL ANTAGONISTS ................................................................................................ 75
QUININE SULFATE ................................................................................................................... 75
ALKALINIZING AGENTS ........................................................................................................... 75
AMINO ACID DERIVATIVES...................................................................................................... 76
GALLSTONE SOLUBILIZERS ................................................................................................... 76
SMOKING CESSATION PRODUCTS ........................................................................................ 76
SUBSTANCE ABUSE DETERRENTS ....................................................................................... 76
APHRODISIACS ........................................................................................................................ 76
ERECTILE DYSFUNCTION (ED) ............................................................................................... 76
IMMUNE SUPPRESSANTS ....................................................................................................... 77
RHEUMATOLOGIC MEDCATIONS ........................................................................................... 77
LOCAL ANESTHETICS.............................................................................................................. 77
POTASSIUM REMOVING RESINS ............................................................................................ 77
UROLOGY ................................................................................................................................. 78
OXYTOCICS .............................................................................................................................. 78
HEPATITIS C PRODUCTS ........................................................................................................ 79
vi
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viii
HealthPlus encourages the consideration of OTC products. In general, OTC products are not
covered for the Commercial/PPO/MedicarePlus (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 105.
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 175).
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 175) 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 106.
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 106 and 107). Please note that the criteria documents include criteria
for Commercial/PPO/MedicarePlus (non-Part D) lines of business, HealthPlus Partners
(Medicaid) criteria, and criteria for 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.
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
Prior Authorization Form. For medications included in the specialty injectable program,
xii
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 beta blockers, selected urinary
incontinence drugs and selected non-sedating or low-sedating antihistamines. 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 maintenance medications are covered through the 90-day programs. Compounded
medications and injectable medications, with the exception of injectable diabetes medications,
glucagon, Epi-Pen 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 and
Endometriosis (for HealthPlus Partners).
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
VALIUM*
acetaminophen 325/hydrocodone 10
ibuprofen 200/hydrocodone 7.5
Systemic Corticosteroids
methylprednisolone
Miscellaneous Rinses
chlorhexidine gluconate
Miscellaneous
lidocaine viscous solution/ointment
NORCO*
VICOPROFEN*
MEDROL DOSE PAK*
PERIDEX*
LIDOCAINE*
NOTE: Behavior health medications (ex. diazepam) are carved out for HealthPlus Partners Medicaid and HealthPlus MIChild.
*generic available
xvi
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xviii
FORMULARY KEY
Abbreviation
AG
DL
DO
GEQ
GF
GM
HMO
M
M-INJ
M-SUPP
MAND 90
MAND SPEC
MDCH
NA
NC
NF-NC
PA
PARTNERS
POS
PPO
QL
SP
SPEC
TPA
Description
Age Restriction
Duration Limit
Dose Optimization
Generically Available
Female Gender Restriction
Male Gender Restriction
Health Maintenance Organization
Medical injectable (not self-administered)
Medical injectable/infused drugs that require Prior Authorization
MedicarePlus Supplemental 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 (Behavioral Health Drug Carve Out)
Not Applicable
Not Covered, Excluded
Non-Formulary, Not Covered (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
Third Party Administrator
xix
BRAND NAME
ACIPHEX
AXID
CARAFATE
CARAFATE SUSP
CYTOTEC
DEXILANT
NEXIUM
PEPCID RPD
GEQ
Y
Y
Y
GENERIC NAME
TIER
RABEPRAZOLE
NIZATIDINE
SUCRALFATE
SUCRALFATE
MISOPROSTOL
DEXLANSOPRAZOLE
ESOMEPRAZOLE
FAMOTIDINE
2
1
1
2
1
3
3
3
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
MICHILD
PPO
MEDICAID
GASTROINTESTINAL DRUGS
ANTI-ULCER AGENTS
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
FAMOTIDINE
PREVACID
PRILOSEC 20MG
PRILOSEC 40MG
Y
Y
Y
LANSOPRAZOLE
OMEPRAZOLE
OMEPRAZOLE
1
1
1
PA, DO
PRILOSEC DR
SUSP
PROTONIX TABS
TAGAMET
ZANTAC
ZANTAC
EFFERDOSE
3
1
1
1
PA
Y
Y
Y
OMEPRAZOLE
MAGNESIUM
PANTOPRAZOLE
CIMETIDINE
RANITIDINE
RANITIDINE
ZEGERID CAPS
OMEPRAZOLE/SODIUM
BICARBONATE
MESALAMINE
MESALAMINE
2
3
2
NF-NC
Y
Y
SULFASALAZINE
MESALAMINE
BALSALAZIDE
DISODIUM
HYDROCORTISONE
ACETATE
OLSALAZINE
1
3
1
NF-NC
3
2
NF-NC
NF-NC
AZULFIDINE,
ENTAB
CANASA
COLAZAL
CORTIFOAM
DIPENTUM
PARTNERS
MAND
SPEC
NF-NC
1
1
2
1
NF-NC
NF-NC
NF-NC
PEPCID TABS,
SUSP
ASACOL
ASACOL HD
MAND
SPEC
1
NF-NC
1
NF-NC
PA
PA
NF-NC
NF-NC
1
1
NF-NC
PA, DO
PA, DO
PA, DO
INFLAMMATORY BOWEL DISEASE
PA
NF-NC
20
BRAND NAME
ENTOCORT EC
LIALDA
PENTASA
ROWASA ENEMA
GEQ
GENERIC NAME
BUDESONIDE
MESALAMINE
MESALAMINE
MESALAMINE
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
3
3
2
1
PA
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
NF-NC
MAND 90
2
1
MAND
SPEC
PARTNERS
MAND
SPEC
DIGESTIVE ENZYMES
CREON
AMYLASE/ LIPASE/
PROTEASE
PANCREAZE
AMYLASE/ LIPASE/
PROTEASE
NF-NC
ULTRASE
AMYLASE/ LIPASE/
PROTEASE
NF-NC
ULTRASE MT
AMYLASE/ LIPASE/
PROTEASE
NF-NC
VIOKASE
AMYLASE/ LIPASE/
PROTEASE
NF-NC
AMYLASE/ LIPASE/
PROTEASE
ZENPEP 5,000
ZENPEP 10,000,
15,000 AND 20,000
AMYLASE/ LIPASE/
PROTEASE
AMITIZA
LUBIPROSTONE
HYDROCORTISONE
SUPP
CROMOLYN SODIUM
ALOSETRON
PRAMOXINE
1
3
2
1
HYDROCORTISONE/
PRAMOXINE
ANUSOL HC
GASTROCROM
LOTRONEX
PROCTOFOAM
PROCTOFOAM HC
NF-NC
3
HEMORRHOIDS AND OTHER GASTROINTESTINALS
PA
2
1
NF-NC
NF-NC
1
2
ANTIEMETICS
ANTIVERT 12.5,
25MG
ANTIVERT 50MG
MECLIZINE
MECLIZINE
1
2
1
2
21
BRAND NAME
GEQ
ANZEMET
COMPAZINE
SYRUP
COMPAZINE TABS,
SUPP
EMEND
PHENERGAN
SANCUSO
TIGAN
TRANSDERMSCOP
ZOFRAN, ODT
ZUPLENZ
REGLAN
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
NF-NC
DOLASETRON
MESYLATE
PROCHLORPERAZINE
PROCHLORPERAZINE
APREPITANT
PROMETHAZINE
GRANISETRON
TRIMETHOBENZAMIDE
1
3
1
3
1
1
NF-NC
1 AG
NF-NC
1 AG
SCOPOLAMINE
ONDANSETRON
ONDANSETRON
2
1
3
METOCLOPRAMIDE
AG
AG
AG
AG
AG
AG
PA
PA
PA
PROMOTILITY AGENTS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
1
NF-NC
1
ANTIDIARRHEALS
IMODIUM
LOMOTIL
MOTOFEN
LOPERAMIDE
DIPHENOXYLATE/
ATROPINE
DIFENOXIN/ ATROPINE
1
3
1
AG
AG
AG
1 AG
NF-NC
AG
AG
AG
AG
1 AG
1 AG
AG
PA
AG
NF-NC
NF-NC
ANTISPASMODICS
ANASPAZ
BENTYL
Y
Y
AG
AG
HYOSCYAMINE
DICYCLOMINE
1
1
CANTIL
CYSTOSPAZ M
MEPENZOLATE
BROMIDE
HYOSCYAMINE
3
3
DONNATAL TAB,
ELIXIR
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
NF-NC
DONNATAL ER
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
AG
22
BRAND NAME
AG
Y
Y
CLIDINIUM BROMIDE/
CHLORDIAZEPOXIDE
HYOSCYAMINE
1
1
PAMINE
METHSCOPOLAMINE
BROMIDE
PAMINE FORTE
METHSCOPOLAMINE
BROMIDE
METHSCOPOLAMINE
COMBO
NF-NC
PROPANTHELINE
HYOSCYAMINE
2
1
COLYTE
GOLYTELY
LACTULOSE SOLN
Y
Y
MOVIPREP
OSMOPREP
SUPREP
1
1 AG
LIBRAX
NULEV
HYOSCYAMINE
SIGNATURE
PPO CLOSED
FORMULARY
1 AG
LEVSIN
PRO-BANTHINE
7.5MG
SYMAX, DUOTAB
TIER
PARTNERS
MEDICAID
AG
GEQ
Y
PAMINE FQ
GENERIC NAME
HMO
POS
TPA
M-SUPP
RDS
MICHILD
AG
PEG3350/NA
SULF/BICARB/CL/KCL
PEG3350/NA
SULF/BICARB/CL/KCL
LACTULOSE
PEG3350/SOD
SUL/NACL/ASB/CL/KCL
NAPHOS MBMH/NAPHOS, DI-BA
SODIUM
/POTASSIUM/MAG
SULFATES
AG
PPO
AG
AG
AG
AG
AG
LAXATIVES/CATHARTICS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
1 AG
1
1
1
1
PA
NF-NC
PA
NF-NC
NF-NC
3
CARDIOVASCULAR AGENTS
NITRATES
BIDIL
DILATRATE-SR
ISOSORBIDE
DINITRATE/
HYDRALAZINE
ISOSORBIDE
DINITRATE
NF-NC
23
BRAND NAME
GEQ
IMDUR
ISORDIL 10MG
NITROSTAT
PAPAVERINE
TRANSDERMNITRO
ISOSORBIDE
MONONITRATE
ISOSORBIDE
DINITRATE
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
GENERIC NAME
ISOSORBIDE
MONONITRATE
NITROGLYCERIN
NITROGLYCERIN
TRANSDERMAL
NITROGLYCERIN
TRANSDERMAL
Y
Y
NITROGLYCERIN
NITROGLYCERIN
SUBLINGUAL
PAPAVERINE
NITROGLYCERIN
TRANSDERMAL
HMO
POS
TPA
M-SUPP
RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
1
2
Y
Y
TIER
PPO
PARTNERS
MEDICAID
1
2
PA
PA
NF-NC
Y
Y
PA
MAND
SPEC
PARTNERS
MAND
SPEC
ANTIARRHYTHMICS
BETAPACE, AF
CALAN
CORDARONE
LANOXIN
Y
Y
Y
Y
MULTAQ
NORPACE
NORPACE CR
PACERONE
PRONESTYL
RANEXA
RYTHMOL, SR
SOTALOL
VERAPAMIL
AMIODARONE
DIGOXIN
DRONEDARONE
HYDROCHLORIDE
DISOPYRAMIDE
1
1
1
1
1
1
1
1
Y
Y
Y
Y
2
1
2
1
DISOPYRAMIDE
AMIODARONE
PROCAINAMIDE
RANOLAZINE
PROPAFENONE
3
1
3
2
1
NF-NC
1
NF-NC
PA
2
1
Y
Y
24
BRAND NAME
SECTRAL
TAMBOCOR
TIKOSYN
GEQ
Y
Y
GENERIC NAME
ACEBUTOLOL
FLECAINIDE
DOFETILIDE
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
1
3
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
1
NF-NC
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
CARDIAC GLYCOSIDES
LANOXIN
DIGOXIN
1
DIURETICS
ALDACTAZIDE
25/25
ALDACTAZIDE
50/50
ALDACTONE
CHLORTHALIDONE
DEMADEX
DYAZIDE
DYRENIUM
INSPRA
LASIX
LOZOL
MAXZIDE
ZAROXOLYN
Y
Y
Y
Y
Y
Y
Y
Y
Y
ACCUPRIL
ACCURETIC
ACEON
ALTACE
CAPOTEN
LOTENSIN
LOTENSIN HCT
Y
Y
Y
Y
Y
Y
Y
LOTREL
MAVIK
MONOPRIL
MONOPRIL HCT
Y
Y
Y
Y
SPIRONOLACTONE/
HCTZ
1
1
SPIRONOLACTONE/
NF-NC
HCTZ
3
SPIRONOLACTONE
1
1
CHLORTHALIDONE
1
1
TORSEMIDE
1
1
TRIAMTERENE/ HCTZ
1
1
NF-NC
TRIAMTERENE
3
PA
EPLERENONE
1
1
FUROSEMIDE
1
1
INDAPAMIDE
1
1
TRIAMTERENE/ HCTZ
1
1
METOLAZONE
1
1
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)
QUINAPRIL
QUINAPRIL/ HCTZ
PERINDOPRIL
RAMIPRIL
CAPTOPRIL
BENAZEPRIL
BENAZEPRIL/ HCTZ
AMLODIPINE/
BENAZEPRIL
TRANDOLAPRIL
FOSINOPRIL
FOSINOPRIL/ HCTZ
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Y
Y
Y
Y
Y
Y
Y
1
1
1
1
1
1
1
1
Y
Y
Y
Y
25
BRAND NAME
PRINIVIL
PRINZIDE
GEQ
Y
Y
GENERIC NAME
TARKA
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
Y
Y
Y
Y
Y
Y
LISINOPRIL
LISINOPRIL/ HCTZ
TRANDOLAPRIL/
VERAPAMIL
MOEXIPRIL/ HCTZ
MOEXIPRIL
ENALAPRIL/ HCTZ
ENALAPRIL
LISINOPRIL/ HCTZ
ZESTRIL
LISINOPRIL
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
AZOR
BENICAR
BENICAR HCT
COZAAR
DIOVAN
DIOVAN HCT
EDARBI
EXFORGE
EXFORGE HCT
HYZAAR
MICARDIS
MICARDIS HCT
TEVETEN
TEVETEN HCT
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
1
1
1
MAND 90
Y
Y
1
1
1
1
1
1
1
1
1
1
1
1
Y
Y
Y
Y
Y
Y
NF-NC
NF-NC
NF-NC
NF-NC
Y
Y
Y
Y
2
2 DO
2
1
2 DO
2
Y
Y
Y
Y
Y
Y
NF-NC
Y
Y
Y
Y
Y
Y
Y
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs)
PA, DO
PA
PA
PA, DO
PA, DO
PA
PA
PA, DO
PA, DO
PA
PA
PA, DO
DO
DO
DO
DO
DO
DO
PA, DO
PA, DO
PA, DO
CANDESARTAN
CANDESARTAN
IRBESARTAN/ HCTZ
IRBESARTAN
AMLODIPINE/
OLMESARTAN
OLMESARTAN
OLMESARTAN/ HCTZ
LOSARTAN
VALSARTAN
VALSARTAN/ HCTZ
AZILSARTAN
MEDOXOMIL
AMLODIPINE/
VALSARTAN
AMLODIPINE/
VALSARTAN/HCTZ
LOSARTAN/ HCTZ
TELMISARTAN
TELMISARTAN/ HCTZ
EPROSARTAN
3
3
3
3
2
1
3
3
3
PA, DO
PA
PA, DO
PA, DO
PA
PA, DO
PA, DO
PA
PA, DO
2
1
NF-NC
NF-NC
NF-NC
EPROSARTAN/ HCTZ
PA
PA
PA
NF-NC
2
2
2
1
2
2
3
MAND
SPEC
PARTNERS
MAND
SPEC
26
BRAND NAME
GEQ
TRIBENZOR
TWYNSTA
VALTURNA
GENERIC NAME
OLMESARTAN MED/
AMLODIPINE/HCTZ
TELMISARTAN/
AMLODIPINE
ALISKIREN/
VALSARTAN
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
2
3
PA
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
MAND
SPEC
PARTNERS
MAND
SPEC
VASODILATORS
APRESOLINE
HYDRALAZINE
1
CALCIUM CHANNEL BLOCKERS
ADALAT CC
AMTURNIDE
CALAN, SR
CARDENE
CARDENE SR
CARDIZEM
CARDIZEM CD 120,
180, 240, 300
CARDIZEM CD 360
CARDIZEM LA
120MG
CARDIZEM LA 180,
240, 300, 360 AND
420MG
CARTIA XT
COVERA HS
DILACOR XR
DYNACIRC CR
ISOPTIN SR
LOTREL
NIMOTOP
NORVASC
PROCARDIA, XL
SULAR 8.5, 17,
25.5, 34
NIFEDIPINE
ALISKIREN/
AMLODIPINE/HCTZ
VERAPAMIL
NICARDIPINE
NICARDIPINE
DILTIAZEM
2
1
1
3
1
2
1
1
NF-NC
1
Y
Y
Y
Y
Y
DILTIAZEM
DILTIAZEM
1
2
1
2
Y
Y
DILTIAZEM
1
1
3
1
3
1
Y
Y
Y
Y
DILTIAZEM
DILTIAZEM
VERAPAMIL
DILTIAZEM
ISRADIPINE
VERAPAMIL
AMLODIPINE/
BENAZEPRIL
NIMODIPINE
AMLODIPINE
NIFEDIPINE
1
1
1
1
1
1
1
1
NISOLDIPINE
Y
Y
Y
Y
Y
Y
Y
Y
PA
PA
NF-NC
PA
PA
1
1
NF-NC
1
NF-NC
Y
Y
Y
Y
Y
Y
PA
PA
PA
27
BRAND NAME
GEQ
TEKAMLO
VERELAN, PM
GENERIC NAME
ALISKIREN/
AMLODIPINE
VERAPAMIL
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
2
1
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
2
1
Y
Y
1
2 DO
1
NF-NC
1
Y
Y
Y
Y
Y
1
1
1
NF-NC
1
1
1
1
Y
Y
Y
Y
Y
Y
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
BETA-BLOCKERS
BLOCADREN
BYSTOLIC
COREG
COREG CR
CORGARD
CORZIDE
INDERAL LA
KERLONE
LEVATOL
LOPRESSOR
LOPRESSOR HCT
NORMODYNE
SECTRAL
Y
Y
Y
Y
Y
Y
Y
TIMOLOL
NEBIVOLOL
CARVEDILOL
CARVEDILOL
NADOLOL
NADOLOL/
BENDROFLUMETHIAZIDE
PROPRANOLOL
BETAXOLOL
PENBUTOLOL
METOPROLOL
METOPROLOL/ HCTZ
LABETALOL
ACEBUTOLOL
TENORETIC
TENORMIN
Y
Y
ATENOLOL/
CHLORTHALIDONE
ATENOLOL
1
1
1
1
Y
Y
TOPROL XL
TRANDATE
ZEBETA
ZIAC
Y
Y
Y
Y
METOPROLOL
SUCCINATE
LABETALOL
BISOPROLOL
BISOPROLOL/ HCTZ
1
1
1
1
1
1
1
1
Y
Y
Y
Y
1
NF-NC
1
Y
Y
Y
2
1
Y
Y
1
2
1
3
1
DO
DO
DO
PA
PA
PA
1
1
1
3
1
1
1
1
PA
ALPHA BLOCKERS
CARDURA
CARDURA XL
FLOMAX
JALYN
MINIPRESS
Y
Y
DOXAZOSIN
DOXAZOSIN
TAMSULOSIN
DUTASTERIDE/
TAMSULOSIN
PRAZOSIN
1
3
1
2
1
PA
PA
28
BRAND NAME
GEQ
GENERIC NAME
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
TIER
MICHILD
PPO
MEDICAID
PULMONARY ANTIHYPERTENSIVES
ADCIRCA
REVATIO
TRACLEER
TADALAFIL
SILDENAFIL CITRATE
BOSENTAN
3
2
2
TYVASO
TREPROSTINIL/NEBULI
ZER KIT
ALDOMET
ALDOMET 125
ALDORIL-D
CATAPRES, TTS
DIBENZYLINE
INSPRA
NEXICLON XR
TEKTURNA
TEKTURNA HCT
TENEX
Y
Y
VALTURNA
METHYLDOPA
METHYLDOPA
METHYLDOPA/ HCTZ
CLONIDINE
PHENOXYBENZAMINE
EPLERENONE
CLONIDINE
ALISKIREN
ALISKIREN/ HCTZ
GUANFACINE
ALISKIREN/
VALSARTAN
PA
PA
SP
PA
PA
SP
PA
PA
SP
SP
SP
SP
MISCELLANEOUS ANTIHYPERTENSIVES
1
2
3
1
3
1
3
2
2
1
PA
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
2 PA
4 SP
NF-NC
1
2
NF-NC
Y
Y
1
NF-NC
1
NF-NC
2
2
1
Y
Y
Y
ANTIHYPERLIPIDEMICS
ADVICOR
ALTOPREV
ANTARA
NIACIN/LOVASTATIN
LOVASTATIN
FENOFIBRATE
3
3
3
PA, DO
PA, DO
PA
PA, DO
PA, DO
PA
PA, DO
PA, DO
PA
NF-NC
NF-NC
NF-NC
Y
Y
Y
CADUET
COLESTID
COLESTID 7.5
CRESTOR
FENOGLIDE
FIBRICOR
LESCOL, XL
LIPITOR
LIPOFEN
AMLODIPINE/
ATORVASTATIN
COLESTIPOL
COLESTIPOL
ROSUVASTATIN
FENOFIBRATE
FENOFIBRIC ACID
FLUVASTATIN
ATORVASTATIN
FENOFIBRATE
3
1
3
2
3
1
2
2
3
PA, DO
PA, DO
PA, DO
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
Y
PA, DO
PA
PA, DO
PA
PA, DO
PA
PA, DO
PA, DO
PA
PA, DO
PA, DO
PA
PA, DO
PA, DO
PA
1
NF-NC
2 PA, DO
NF-NC
1
2 PA, DO
NF-NC
NF-NC
29
BRAND NAME
LIVALO
LOFIBRA
LOPID
LOVAZA
MEVACOR
NIASPAN
PRAVACHOL
GEQ
GENERIC NAME
PITAVASTATIN
CALCIUM
Y
Y
Y
Y
PREVALITE
QUESTRAN BULK
SIMCOR
TRICOR
TRIGLIDE 160MG
TRIGLIDE 50MG
FENOFIBRATE
GEMFIBROZIL
OMEGA-3-ACID ETHYL
ESTERS
LOVASTATIN
NIACIN
PRAVASTATIN
CHOLESTYRAMINE/
ASPARTAME
CHOLESTYRAMINE
POWDER
NIACIN/ SIMVASTATIN
FENOFIBRATE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
3
1
1
PA, DO
3
1
2
1
PA
DO
PA
DO
PA
DO
DO
DO
DO
TIER
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA, DO
PA, DO
NF-NC
MAND 90
1
1
Y
Y
Y
NF-NC
1 DO
2
1 DO
Y
Y
Y
Y
1
2
3
PA
PA
PA
PA
PA
PA
1
2 PA
NF-NC
Y
Y
Y
FENOFIBRATE
FENOFIBRATE
1
3
PA
PA
PA
PA
PA
PA
1, PA
NF-NC
Y
Y
PA
PA
PA
NF-NC
FENOFIBRIC ACID
EZETIMIBE/
SIMVASTATIN
COLESEVELAM
EZETIMIBE
SIMVASTATIN
2 PA, DO
2
2 PA
1 DO
Y
Y
Y
Y
AMOXIL
AUGMENTIN
CHEW TABS, 12531.25 SUSP
AMOXICILLIN
AUGMENTIN XR
AUGMENTIN, ES,
250-62.5 SUSP
MOXATAG 775 MG
ER
TRILIPIX
VYTORIN
WELCHOL
ZETIA
ZOCOR
PA, DO
PA, DO
PA, DO
2
PA
2
PA
PA
PA
2
DO
DO
DO
1
ANTIMICROBIALS AND INFECTIOUS DISEASE
MAND
SPEC
PARTNERS
MAND
SPEC
PENICILLINS
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN
TRIHYDRATE
NF-NC
PA
PA
PA
NF-NC
30
BRAND NAME
GEQ
CECLOR
CEDAX
CEFTIN TABS
KEFLEX
KEFLEX 750MG
SPECTRACEF
SUPRAX
Y
Y
Y
Y
GENERIC NAME
CEFACLOR
CEFTIBUTEN
CEFUROXIME
CEPHALEXIN
CEPHALEXIN
CEFDITOREN
CEFIXIME
TIER
1
3
1
1
3
1
3
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
MICHILD
PPO
MEDICAID
CEPHALOSPORINS
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
1
1
NF-NC
1
NF-NC
TETRACYCLINES
ADOXA CK
ADOXA TT
ADOXA, PAK , 150
PA
PA
NF-NC
NF-NC
1
3
3
1
3
NF-NC
1
3
1
3
1
3
1
1
NF-NC
1
NF-NC
1
NF-NC
DOXYCYCLINE
DOXYCYCLINE
MINOCYCLINE
MINOCYCLINE KIT
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
MINOCYCLINE
1
3
Y
Y
Y
MINOCYCLINE
TETRACYCLINE
TETRACYCLINE
DOCYCYCLINE
DOCYCYCLINE
AVIDOXY DK
DORYX 100MG
DORYX 150MG
MINOCIN
MINOCIN PAC
MONODOX
ORACEA
PERIOSTAT
SOLODYN 45, 90,
135
SOLODYN 55,65,
80, 105, 115
SUMYCIN SUSP
TETRACYCLINE
VIBRAMYCIN
VIBRAMYCIN
SYRUP
PA
PA
DOXYCYCLINE KIT
DOXYCYCLINE KIT
DOXYCYCLINE
DOXYCYCLINE/SALICY
/OCT/ZINC OX
Y
Y
Y
PA
PA
PA
PA
PA
1
1
1
1
1
1
1
1
NF-NC
MACROLIDES
BIAXIN, XL
CLARITHROMYCIN
E.E.S.
ERYTHROMYCIN
ETHYLSUCCINATE
31
BRAND NAME
E-MYCIN
ERYPED CHEW
TABS
ERY-TAB
ERYTHROCIN
KETEK
PCE
ZITHROMAX
GEQ
Y
Y
Y
ZMAX
GENERIC NAME
ERYTHROMYCIN BASE
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN BASE
ERYTHROMYCIN
STEARATE
TELITHROMYCIN
ERYTHROMYCIN BASE
AZITHROMYCIN
AZITHROMYCIN
TIER
3
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
1
1
1
1
3
3
1
1
NF-NC
NF-NC
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
SULFONAMIDES
BACTRIM DS,
SEPTRA DS
BACTRIM, SEPTRA
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
SULFAMETHOXAZOLE/
TRIMETHOPRIM
1
QUINOLONES
AVELOX
CIPRO
CIPRO XR
Y
Y
FACTIVE
LEVAQUIN
NOROXIN
PROQUIN XR
CLEOCIN 75, 150,
300MG
FLAGYL
FLAGYL ER
FUROXONE
HIPREX
MACROBID
MACRODANTIN
25MG
Y
Y
Y
Y
MOXIFLOXACIN
CIPROFLOXACIN
CIPROFLOXACIN
2
1
1
GEMIFLOXACIN
MESYLATE
LEVOFLOXACIN
NORFLOXACIN
CIPROFLOXACIN
3
2
3
3
CLINDAMYCIN
METRONIDAZOLE
METRONIDAZOLE
FURAZOLIDONE
METHENAMINE
NITROFURANTOIN
1
1
3
3
1
1
NITROFURANTOIN
PA
PA
PA
PA
PA
PA
PA
PA
MISCELLANEOUS ANTIBIOTICS
PA
AG
AG
AG
2
1
1
NF-NC
2
NF-NC
NF-NC
1
1
NF-NC
NF-NC
1
1
2 AG
32
BRAND NAME
MACRODANTIN 50,
100MG
GEQ
Y
MONUROL
VANCOCIN
XIFAXAN
ZYVOX
GENERIC NAME
NITROFURANTOIN
FOSFOMYCIN
TROMETHAMINE
VANCOMYCIN, ORAL
RIFAXIMIN
LINEZOLID
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
AG
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
AG
AG
1 AG
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
2
3
2
2
NF-NC
2
URINARY ANTI-INFECTIVES (UTI)
BACTRIM DS,
SEPTRA DS
BACTRIM, SEPTRA
CIPRO
MACROBID
Y
Y
Y
MACRODANTIN
25MG
MACRODANTIN 50,
100MG
TRIMETHOPRIM
URELLE
VIBRAMYCIN
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
SULFAMETHOXAZOLE/
TRIMETHOPRIM
CIPROFLOXACIN
NITROFURANTOIN
1
1
1
1
1
1
NITROFURANTOIN
AG
AG
AG
2 AG
Y
Y
NITROFURANTOIN
TRIMETHOPRIM
1
1
AG
AG
AG
1 AG
1
METHENAMINE/METH
BLUE/SALICYLATE
DOXYCYCLINE
2
1
2
1
ORAL ANTIFUNGALS
ANCOBON
DIFLUCAN
FULVICIN U/F
GRIFULVIN-V
GRIS-PEG
LAMISIL
MYCELEX
TROCHES
NOXAFIL
ORAVIG
Y
Y
FLUCYTOSINE
FLUCONAZOLE
GRISEOFULVIN,
ULTRAMICROSIZE
GRISEOFULVIN
GRISEOFULVIN,
ULTRAMICROSIZE
TERBINAFINE
CLOTRIMAZOLE
TROCHES
POSACONAZOLE
MICONAZOLE
3
1
NF-NC
2
3
2
NF-NC
2
1
2
1
1
3
3
1
NF-NC
NF-NC
33
BRAND NAME
SPORANOX CAPS
SPORANOX SOLN
VFEND TABS
GEQ
Y
Y
GENERIC NAME
TIER
ITRACONAZOLE
ITRACONAZOLE
VORICONAZOLE
1
3
1
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
1
ANTITUBERCULOSIS AGENTS
INH
MYAMBUTOL
MYCOBUTIN
PRIFTIN
PYRAZINAMIDE
RIFADIN
RIFAMATE
RIFATER
SEROMYCIN
PULVULES
TRECATOR
Y
Y
Y
Y
Y
ISONIAZID
ETHAMBUTOL
RIFABUTIN
RIFAPENTINE
PYRAZINAMIDE
RIFAMPIN
RIFAMPIN/ ISONIAZID
1
1
3
3
1
1
1
1
1
NF-NC
NF-NC
1
1
1
RIFAMPIN/ INH/
PYRAZINAMIDE
NF-NC
CYCLOSERINE
ETHIONAMIDE
1
3
1
NF-NC
ANTIVIRALS
AMANTADINE
FAMVIR
FLUMADINE TABS
RELENZA
TAMIFLU
VALTREX
ZOVIRAX
ZOVIRAX OINT
Y
Y
Y
Y
Y
AMANTADINE
FAMCICLOVIR
RIMANTADINE
ZANAMIVIR
OSELTAMIVIR
VALACYCLOVIR
ACYCLOVIR
ACYCLOVIR
1
1
1
2
2
1
1
2
1
1
1
2
2
1
1
2
ANTIMALARIALS/ANTIPROTOZOALS
ARALEN
COARTEM
DARAPRIM
MALARONE
MEPRON
CHLOROQUINE
ARTEMETHER/
LUMEFANTRINE
PYRIMETHAMINE
ATOVAQUONE/
PROGUANIL
ATOVAQUONE
3
2
NF-NC
2
3
3
NF-NC
NF-NC
34
BRAND NAME
GEQ
NEBUPENT
PLAQUENIL
PRIMAQUINE
TINDAMAX
GENERIC NAME
TIER
PENTAMIDINE
ISETHIONATE
HYDROXYCHOLOROQUINE
PRIMAQUINE
TINIDAZOLE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
2
3
1
2
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANTIHELMINTICS
ALBENZA
ALINIA
BILTRICIDE
STROMECTOL
ALBENDAZOLE
NITAZOXANIDE
PRAZIQUANTEL
IVERMECTIN
NF-NC
NF-NC
2
NF-NC
3
3
2
3
AMEBICIDES
ARALEN
ERY-TAB
FLAGYL
FLAGYL ER
YODOXIN
Y
Y
Y
CHLOROQUINE
ERYTHROMYCIN BASE
METRONIDAZOLE
METRONIDAZOLE
IODOQUINOL
1
1
1
3
3
PA
1
1
1
NF-NC
NF-NC
ANALGESICS
DOLOBID
DIFLUNISAL
ANAPROX, DS
ANSAID
Y
Y
NAPROXEN SODIUM
FLURBIPROFEN
DICLOFENAC/
MISOPROSTOL
DICLOFENAC
CELECOXIB
SULINDAC
OXAPROZIN
PIROXICAM
DICLOFENAC
EPOLAMINE
INDOMETHACIN
1
1
KETOPROFEN
ARTHROTEC
CATAFLAM
CELEBREX
CLINORIL
DAYPRO
FELDENE
FLECTOR
INDOCIN SUSP
KETOPROFEN
POWDER CMPD
Y
Y
Y
Y
1
1
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
1
1
PA
PA
PA
DO
DO
PA, DO
3
3
PA
PA
PA
NF-NC
NF-NC
PA
PA
PA
NF-NC
3
1
2
1
1
1
NF-NC
1
2 DO
1
1
1
35
BRAND NAME
MOBIC
MOTRIN
NAPRELAN
NAPRELAN CR
DOSEPAK
NAPROSYN
PONSTEL
RELAFEN
TORADOL
GEQ
Y
Y
Y
Y
Y
Y
VIMOVO
VOLTAREN GEL
VOLTAREN XR
EMBEDA
EXALGO
FENTORA
TIER
PPO
DO
PARTNERS
MEDICAID
DO
SIGNATURE
PPO CLOSED
FORMULARY
1 DO
1
MELOXICAM
IBUPROFEN
1
1
NAPROXEN
CONTROLLED RELEASE
PA
PA
PA
NF-NC
NAPROXEN SODIUM
NAPROXEN
MEFENAMIC ACID
NABUMETONE
KETOROLAC
3
1
1
1
1
PA
PA
PA
NF-NC
AG
AG
AG
1
1
1
1 AG
3
3
PA
PA
PA
PA
PA
NF-NC
NF-NC
ESOMEPRAZOLE/
NAPROXEN
DICLOFENAC
DICLOFENAC,
EXTENDED RELEASE
DICLOFENAC
POTASSIUM
1
PA
PA
PA
NARCOTIC ANALGESICS
NF-NC
1
3
2
3
1
1
2
1
PA
PA
1 PA
NF-NC
FENTANYL CITRATE
MORPHINE SULFATE
CODEINE
TRAMADOL
MEPERIDINE
HYDROMORPHONE
HYDROMORPHONE
METHADONE
FENTANYL
MORPHINE SULFATE/
NALTREXONE
HYDROMORPHONE
FENTANYL CITRATE
3
3
3
Y
Y
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ZIPSOR
ACTIQ
AVINZA
CODEINE
CONZIP
DEMEROL
DILAUDID
DILAUDID 5 LIQUID
DOLOPHINE
DURAGESIC
PATCH
GENERIC NAME
HMO
POS
TPA
M-SUPP
RDS
MICHILD
DO
PA
PA
PA
PA
2
NF-NC
1
1
2
1
PA, QL
PA
PA, QL
PA
PA, QL
PA, QL
PA
NF-NC
NF-NC
NF-NC
36
BRAND NAME
GEQ
FIORICET
FIORINAL
W/CODEINE #3
IBUDONE
KADIAN
LORCET, PLUS
METHADONE
MORPHINE
TABLETS
MS CONTIN
Y
Y
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
GENERIC NAME
BUTALBITAL/
ACETAMINOPHEN/
CAFFEINE
BUTALBITAL/ ASPIRIN/
CAFFEINE/ CODEINE
HYDROCODONE/
IBUUPROFEN
MORPHINE SULFATE
ACETAMINOPHEN/
HYDROCODONE
METHADONE
TIER
MORPHINE
MORPHINE SULFATE
TAPENTADOL
HYDROCHLORIDE
TAPENTADOL
HYDROCHLORIDE
OXYMORPHONE
FENTANYL CITRATE
OXYMORPHONE
OXYMORPHONE
MORPHINE,
SUSTAINED RELEASE
OXYCODONE
ACETAMINOPHEN/
OXYCODONE
ASPIRIN/ OXYCODONE
IBUPROFEN/
HYDROCODONE
1
1
1
1
NF-NC
3
3
3
1
3
PA
PA
PA
PA, QL
PA, QL
PA, QL
NF-NC
NF-NC
NF-NC
1
NF-NC
2
2
QL
QL
PA, QL
2
NF-NC
QL
QL
QL
1 QL
1
PA
RYBIX ODT
TRAMADOL
PA
PA
NF-NC
RYZOLT
TRAMADOL ER
PA
PA
NF-NC
QL
QL
QL
1 QL
QL
QL
QL
1 QL
Y
Y
NUCYNTA
NUCYNTA ER
NUMORPHAN
ONSOLIS
OPANA
OPANA ER
ORAMORPH SR
OXYCONTIN
PERCOCET
PERCODAN
Y
Y
REPREXAIN
TYLENOL
W/CODEINE
TYLOX
ACETAMINOPHEN/
CODEINE
ACETAMINOPHEN/
OXYCODONE
PPO
1
2
1
1
1
1
PA, QL
QL
QL
QL
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
2
1 QL
1
37
BRAND NAME
GEQ
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
1
QL
QL
PA, QL
1 QL
1
PA
PA
QL
QL
QL
1 QL
QL
QL
QL
1 QL
QL
QL
QL
1 QL
TIER
QL
QL
QL
RESPIRATORY DRUGS
PA
PA
PA
NC
NC
PA, DO
SIGNATURE
PPO CLOSED
FORMULARY
ULTRACET
ULTRAM
Y
Y
ULTRAM ER
VICODIN
VICODIN ES
VICODIN HP
VICOPROFEN
XODOL
GENERIC NAME
TRAMADOL/
ACETAMINOPHEN
TRAMADOL
TRAMADOL SUST.
RELEASE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
IBUPROFEN/
HYDROCODONE
HYDROCODONE BIT/
ACETAMINOPHEN
ACCOLATE
ALAVERT OTC
ALLEGRA OTC
BENADRYL
Y
Y
Y
Y
ZAFIRLUKAST
LORATADINE
FEXOFENADINE
DIPHENHYDRAMINE
1
1
1
1
DESLORATIDINE
LORATADINE
PROMETHAZINE
MONTELUKAST
CLEMASTINE
LEVOCETIRIZINE
CETIRIZINE
3
1
1
2
1
1
1
AZELASTINE
AZELASTINE
IPRATROPIUM
BROMIDE
1
2
1
2
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1 QL
ALLERGIES
CLARINEX,
REDITABS
CLARITIN OTC
PHENERGAN
SINGULAIR
TAVIST
XYZAL TABS
ZYRTEC OTC
ASTELIN
ASTEPRO
ATROVENT NASAL
SPRAY
Y
Y
Y
Y
Y
Y
1 PA
NC
NC
1
PA, DO
PA, DO
PA, DO
AG
AG
AG
PA, DO
PA, DO
PA, DO
NC
NC
NASAL SPRAYS
NC
NC
1 AG
2
1
PA, DO
NC
38
BRAND NAME
VERAMYST
GENERIC NAME
BECLOMETHASONE,
AQUEOUS
FLUTICASONE
TRIAMCINOLONE,
AQUEOUS
MOMETASONE
CICLESONIDE
OLOPATADINE
BUDESONIDE
FLUTICASONE
FUROATE
TUSSIONEX
PENNKINETIC
HYDROCODONE/
CHLORPHEN POLIS
BECONASE AQ
FLONASE
NASACORT AQ
NASONEX
OMNARIS
PATANASE
RHINOCORT AQUA
ALLEGRA-D 12
HOUR OTC
ALLEGRA-D 24
HOUR OTC
GEQ
Y
Y
TIER
3
1
1
3
3
3
3
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PA
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NF-NC
PA
PA
PA
PA
PA
PA
PA
PA
PA
1
NF-NC
NF-NC
NF-NC
NF-NC
PA
PA
PA
ANTIHISTAMINE/ANTITUSSIVES
NF-NC
NC
DECONGESTANT/ANTIHISTAMINES
NF-NC
SEMPREX-D
ENTEX LA
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
ENTEX LQ
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
ZOTEX GP
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
CLARINEX-D
CLARITIN-D OTC
DECONAMINE
SYRUP
DECONAMINE
TABS
Y
Y
Y
PARTNERS
MAND
SPEC
FEXOFENADINE/
PSEUDOEPHEDRINE
FEXOFENADINE/
PSEUDOEPHEDRINE
PSEUDOEPHEDRINE/
DESLORATADINE
LORATIDINE/
PSEUDOEPHEDRINE
PHENYLEPHRINE/
CHLORPHENIRAMINE
PSEUDOEPHEDRINE/
CHLORPHENIRAMINE
PSEUDOEPHEDRINE/
ACRIVAS
MAND 90
MAND
SPEC
NC
NC
PA
NC
NC
NC
PA
NC
PA
PA
PA
NC
NC
1
1
NC
NC
NC
NF-NC
3
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT
39
BRAND NAME
ZOTEX
BROMFED-DM
TESSALON
PERLES
GEQ
GENERIC NAME
TIER
GUAIFENESIN/
PHENYLEPHRINE
BROMPHENIRAMINE/
PSEUDOEPHEDRINE/
DEXTROMETHORPHA
N
BENZONATATE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NC
1
1
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES
NC
1
1
ADVAIR
AEROBID
ALUPENT INHALER
ALVESCO
ASMANEX
ATROVENT HFA
BROVANA
COMBIVENT
CROMOLYN SOLN
DULERA
DUONEB
FLOVENT HFA
FORADIL
ISOETHARINE
MAXAIR
PROAIR HFA
PROVENTIL HFA
PULMICORT
ALBUTEROL SULFATE
FLUTICASONE/
SALMETEROL
FLUNISOLIDE
METAPROTERENOL
CICLESONIDE
MOMETASONE
FUROATE
IPRATROPIUM
BROMIDE
ARFORMOTEROL
ALBUTEROL/
IPRATROPIUM
2
3
2
3
2
NF-NC
2
2
2
2
CROMOLYN SODIUM
MOMETASONE/
FORMOTEROL HFA
IPRATROPIUM/
ALBUTEROL SULFATE
FLUTICASONE
FORMOTEROL
FUMARATE
ISOETHARINE
PIRBUTEROL
ALBUTEROL
ALBUTEROL
BUDESONIDE
1
2
1
2
2
1
3
2
3
1
2
1
NF-NC
2
NF-NC
PA
PA
PA
2
NF-NC
1
40
BRAND NAME
0.25MG/2ML AND
0.5MG/2ML
RESPULE
PULMICORT
1MG/2ML
RESPULE,
FLEXHALER AND
PULMOZYME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
BUDESONIDE
DORNASE ALFA
BECLOMETHASONE
DIPROPIONATE
2
2
2
2
2
2
2
2
SYMBICORT
VENTOLIN HFA
XOPENEX, HFA
SALMETEROL
TIOTROPIUM BROMIDE
BUDESONIDE/
FORMOTEROL
ALBUTEROL
LEVALBUTEROL
2
2
3
2
2
NF-NC
ALUPENT INHALER
METAPROTERENOL SYRUP
VENTOLIN
VOSPIRE ER
Y
Y
Y
METAPROTERENOL
METAPROTERENOL,
10MG/5ML
ALBUTEROL
ALBUTEROL
1
1
1
1
1
1
AMINOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
1
2
1
LEUKOTRIENE RECEPTOR ANTAGONISTS
1
2
1
Y
Y
Y
ZAFIRLUKAST
MONTELUKAST
ZILEUTON
3
2
3
NF-NC
Y
Y
QVAR
SEREVENT
DISKUS
SPIRIVA
PA
PA
PA
OTHER BRONCHODILATORS, ORAL
MAND
SPEC
PARTNERS
MAND
SPEC
THEOPHYLLINES
AMINOPHYLLINE
ELIXOPHYLLIN
ELIXIR
THEO-24 SR
THEOPHYLLINE
ACCOLATE
SINGULAIR
ZYFLO, CR
PA
PA
PA
2
NF-NC
MUCOLYTICS
PULMOZYME
DORNASE ALFA
41
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
MICHILD
PPO
MEDICAID
DERMATOLOGICS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
TOPICAL STEROIDS
ACLOVATE
APEXICON OINT
APEXICON E
CLOBEX
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,
LIPOCREAM LOTN
LOCOID LOTION
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%
HYDROCORTISONE
BUTYRATE/ EMOLL
PA
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
2
3
PA
PA
PA
2
NF-NC
PA
PA
PA
NF-NC
2
3
1
PA
PA
PA
2
NF-NC
1
PA
PA
PA
NF-NC
1
2
1
1
2
1
PA
PA
PA
1
3
NF-NC
1
PA
PA
PA
NF-NC
42
BRAND NAME
GEQ
LUXIQ
MOMEXIN
NUCORT
OLUX
OLUX-E
PANDEL
PEDIADERM HC
2% KIT
PEDIADERM TA
TEMOVATE
TOPICORT
U-CORT 1%-10%
CREAM
Y
Y
Y
ULTRAVATE PAC
VANOXIDE-HC
0.5%-5% LOTION
VANOS
VERDESO
WESTCORT
GENERIC NAME
BETAMETHASONE
MOMETASONE
FUROATE/AMMONIUM
LAC
HYDROCORTISONE/
ALOE VERA
CLOBETASOL
PROPIONATE
CLOBETASOL EMOLL
HYDROCORTISONE
PROBUTATE
HYDROCORTISONE/
EMOLLIENT
TRIAMCINOLONE/
EMOLLIENT
CLOBETASOL
PROPIONATE
DESOXIMETASONE
HYDROCORTISONE/
UREA
HALOBETASOL PROP/
AMMONIUM LAC
HYDROCORTISONE/
BENZOYL PEROXIDE
FLUOCINONIDE
DESONIDE
HYDROCORTISONE
VALERATE
TIER
3
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PA
PPO
PA
PARTNERS
MEDICAID
PA
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
PA
NF-NC
3
1
PARTNERS
MAND
SPEC
1
3
PA
PA
PA
1
NF-NC
PA
PA
PA
NF-NC
PA
NF-NC
PA
NF-NC
3
3
MAND 90
MAND
SPEC
PA
PA
1
1
1
1
PA
PA
PA
NF-NC
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
NF-NC
1
TOPICAL EMOLLIENTS
AMLACTIN 12%
ATOPICLAIR
CARMOL
EPICERAM
GORDO-UREA
HYDRO 35, 40
Y
Y
AMMONIUM LACTATE
DL-E AC/ GRAPE/
HYALURONIC ACID
UREA
EMOLLIENT COMBO
UREA
UREA
1
1
3
3
1
1
1
NF-NC
NF-NC
1
PA
PA
43
BRAND NAME
HYLATOPIC
HYLATOPIC PLUS
KERAFOAM
KERALAC
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
NF-NC
NF-NC
1
EMOLLIENT COMBO
EMOLLIENT COMBO
UREA
UREA
UREA/LACTIC AC/ZN
UNDECYLENATE
UREA/ LACTIC ACID/
SALICYL ACID
AMMONIUM LACTATE
3
3
3
1
NEOSALUS
PROMISEB
EMOLLIENT COMBO
EMOLLIENT COMBO
3
3
PA
PA
NF-NC
NF-NC
TROPAZONE
UMECTA
SUSPENSION
UMECTA
EMULSION
URAMAXIN
URAMAXIN GT
UREA
X-VIATE
ZENIEVA
EMOLLIENT COMBO
PA
NF-NC
UREA
Y
Y
Y
Y
UREA
UREA
UREA
UREA
UREA
EMOLLIENT COMBO
3
3
1
1
1
1
PIMECROLIMUS
KEROL AD
KEROL 50%
SUSPENSION
LAC-HYDRIN
Y
Y
Y
Y
1
1
1
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
PA
PA
NF-NC
NF-NC
1
1
1
1
TOPICAL IMMUNOMODULATORS
ELIDEL
PA
QL
QL
1
NF-NC
1 QL
PSORIASIS
ANTHRALIN
DOVONEX CRM
DOVONEX SOLN
METHOTREXATE
SORIATANE
TACLONEX OINT,
SCALP SUSP
TAZORAC
Y
Y
Y
ANTHRALIN
CALCIPOTRIENE
CALCIPOTRIENE
METHOTREXATE TABS
ACITRETIN
BETAMET DIPROP/
CALCIPOTRIENE
TAZAROTENE
1
3
1
1
3
3
3
QL
QL
QL
QL
1
NF-NC
QL
QL
QL
NF-NC
NF-NC
ANTI-INFECTIVES (TOPICAL)
ALTABAX
RETAPAMULIN
PA
PA
PA
NF-NC
44
BRAND NAME
BACTROBAN OINT
BACTROBAN CRM
BACTROBAN
NASAL OINT
GEQ
Y
CORTISPORIN
GARAMYCIN
SULFAMYLON
SILVADENE
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MUPIROCIN
MUPIROCIN
1
2
1
2
MUPIROCIN
HYDROCORTISONE/
NEOMYCIN/POLYMYXIN/ BACITRACIN
GENTAMICIN
MAFENIDE ACETATE
2
1
3
2
1
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
BURN PREPARATIONS
SILVER SULFADIAZINE
1
ANTIFUNGALS (TOPICAL)
ERTACZO
EXELDERM
EXTINA
LAMISIL SOLN
LOPROX
LOTRIMIN
LOTRISONE
MENTAX
METROGEL 0.75%
METROGEL 1%
MYCOSTATIN
NAFTIN
NIZORAL
OXISTAT
PEDIADERM AF
PENLAC
TERBINEX
TERSI
VUSION
Y
Y
Y
Y
Y
Y
Y
SERTACONAZOLE
NITRATE
SULCONAZOLE
NITRATE
KETOCONAZOLE
TERBINAFINE
CICLOPIROX OLAMINE
CLOTRIMAZOLE 1%
CLOTRIMAZOLE/
BETAMETHASONE
BUTENAFINE
METRONIDAZOLE
METRONIDAZOLE
NYSTATIN
NAFTIFINE
KETOCONAZOLE
OXICONAZOLE NITRATE
NYSTATIN/EMOLLIENT
CICLOPIROX
TERBINAFINE/
HYDROXYCHITOSAN
SELENIUM SULFIDE
MICONAZOLE
PA
PA
PA
NF-NC
3
1
3
1
1
PA
PA
PA
PA
PA
PA
NF-NC
1
NF-NC
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
1
3
1
3
1
3
1
3
3
1
3
3
3
1
NF-NC
1
NF-NC
1
NF-NC
1
NF-NC
NF-NC
NC
NC
NF-NC
NF-NC
45
BRAND NAME
GEQ
GENERIC NAME
NITRATE/ZINC OXIDE
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
XOLEGEL
KETOCONAZOLE
PA
PA
ACNE
PA
NF-NC
ACANYA
CLINDAMYCIN/
BENZOYL PEROXIDE
PA
PA
PA
NF-NC
DAPSONE
TRETINOIN
AZELAIC ACID
CLINDAMYCIN/
BENZOYL PEROXIDE
CLINDAMYCIN/
BENZOYL PEROXIDE/
HYALURONIC ACID)
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
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
BENZOYL PEROXIDE
BENZOYL PEROXIDE/
ALOE VERA
BENZOYL PEROXIDE
CLINDAMYCIN
BENZOYL PEROXIDE
CLINDAMYCIN
CLINDAMYCIN
BENZOYL PEROXIDE
BENZOYL PEROXIDE
ADAPALENE
ADAPALENE
PA
ADAPALENE
ADAPALENE/BENZOYL
PEROXIDE
3
3
ACZONE 5% GEL
ATRALIN
AZELEX
BENZACLIN 1%-5%
GEL (PUMP)
BENZACLIN CARE
KIT 1%-5% PUMP
(AMPOULES)
BENZAMYCIN GEL
BENZAMYCINPAK
BENZEFOAM
ULTRA
BENZIQ, LS
BREVOXYL
CLEOCIN-T
CLINAC BPO
CLINDACIN PAC
CLINDAGEL
DELOS
DESQUAM X
DIFFERIN 0.1%
CREAM, GEL
DIFFERIN 0.1%
LOTION
DIFFERIN 0.3%
GEL
EPIDUO
Y
Y
3
1
1
3
3
3
3
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
PA
PA
PA
NF-NC
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
1
1
NF-NC
NF-NC
NF-NC
NF-NC
1
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
46
BRAND NAME
GEQ
FINACEA
INOVA
NEOBENZ MICRO
PLUS
NEOBENZ MICRO
PLUS PACK 5.5 %
CREAM WITH
APPLICATION
NUOX GEL
PACNEX
PACNEX HP
PACNEX MX
PACNEX MIX
4.25% CLEANSER
RETIN A
Y
Y
RETIN A MICRO
ROSANIL
TRETIN X
TRIAZ
CLEANER/PADS/
FOAMING CLOTHS
TRIAZ GEL
UMECTA
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
AZELAIC ACID
BENZOYL PEROXIDE
3
3
PA
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
NF-NC
BENZOYL PEROXIDE
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
3
1
3
1
PA
PA
PA
NF-NC
PA
1
NF-NC
3
1
PA
AG
PA
AG
PA
AG
NF-NC
1 AG
PA, AG
PA, AG
PA, AG
NF-NC
3
3
PA, AG
PA, AG
PA, AG
NF-NC
NF-NC
1
3
3
PA
PA
PA
PA
1
NF-NC
NF-NC
PA
PA
PA
NF-NC
PA, AG
PA, AG
PA, AG
NF-NC
PA
PA
PA
NF-NC
GENERIC NAME
BENZOYL PEROXIDE
MICROSPHERES
BENZOYL PEROXIDE/
SULFUR
BENZOYL PEROXIDE
BENZOYL PEROXIDE
BENZOYL PEROXIDE
BENZOYL PEROXIDE
WITH ALOE/GREEN
TEA
TRETINOIN
TRETINOIN
MICROSPHERES
SULFACETAMD/
SULFR/ SKNCLNSR10
TRETINOIN
ZIANA
BENZOYL PEROXIDE
BENZOYL PEROXIDE
UREA
BENZOYL PEROXIDE/
HC/SKIN CLNSR NO. 14
CLINDAMYCIN/
TRETINOIN
BENZOYL PEROXIDE/
HYALURONT
CLINDAMYCIN/
TRETINOIN
AVC CREAM
SULFANILAMIDE
VANOXIDE HC
VELTIN
ZACARE KIT
PA
PA
PARTNERS
MAND
SPEC
PA, AG
PA, AG
PA, AG
3
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS
2
MAND 90
MAND
SPEC
NF-NC
2
47
BRAND NAME
CLEOCIN VAGINAL
CREAM
CLEOCIN VAGINAL
OVULE
CLINDESSE
DIFLUCAN
FLAGYL
FLAGYL ER
GYNAZOLE 1
METROGELVAGINAL 0.75%
MYCOSTATIN
NYSTATIN
VAGINAL TABS
TERAZOL
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
CLINDAMYCIN
Y
Y
CLINDAMYCIN
CLINDAMYCIN
FLUCONAZOLE
METRONIDAZOLE
METRONIDAZOLE
BUTOCONAZOLE
NITRATE
3
3
1
1
3
PA
NF-NC
NF-NC
1
1
NF-NC
PA
NF-NC
Y
Y
METRONIDAZOLE
NYSTATIN
1
1
1
1
Y
Y
NYSTATIN
TERCONAZOLE
1
1
1
1
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
CROTAMITON
MALATHION
BENZYL ALCOHOL
3
1
3
PA
NF-NC
1
NF-NC
TOPICAL ENZYMES
GRANULEX
OPTASE
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
2
OTHER AGENTS
ALDARA
CONDYLOX GEL
CONDYLOX
SOLUTION
PANRETIN
PROTOPIC
SOLARAZE
TARGRETIN
VECTICAL
IMIQUIMOD
PODOFILOX
1
3
PODOFILOX
ALITRETINOIN
TACROLIMUS
DICLOFENAC SODIUM
BEXAROTENE
CALCITRIOL
1
2
3
2
2
3
PA
PA
PA
PA
QL
QL
QL
1
NF-NC
1
2
NF-NC
2
2
NF-NC
48
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
MICHILD
PPO
MEDICAID
BLOOD MODIFIERS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANTICOAGULANTS
BRILINTA
COUMADIN
FRAGMIN
LOVENOX PREFILL
LOVENOX VIAL
PRADAXA
XARELTO
TICAGRELOR
WARFARIN
DALTEPARIN
SODIUM,PORCINE
ENOXAPARIN
ENOXAPARIN
DABIGATRAN
ETEXILATE MESYLATE
RIVAROXABAN
3
1
NF-NC
1
3
1
2
NF-NC
1
4 SPEC
2
3
2
NF-NC
ANTI-PLATELET DRUGS
AGGRENOX
AGRYLIN
EFFIENT
PERSANTINE
PLAVIX
PLETAL
ASPIRIN/
DIPYRIDAMOLE
ANEGRELIDE
PRASUGREL
HYDROCHLORIDE
DIPYRIDAMOLE
CLOPIDOGREL
CILOSTAZOLE
PENTOXIFYLLINE
3
1
2
1
2
1
AG
AG
AG
NF-NC
1
Y
Y
2 AG
1
2
1
Y
Y
Y
HEMORRHEOLOGIC AGENTS
TRENTAL
1
COLONY STIMULATING FACTORS
LEUKINE
NEUPOGEN
SARGRAMOSTIM
FILGRASTIM
ARANESP
EPOGEN
PROCRIT
DARBEPOETIN ALFA IN
POLYSORBATE
EPOETIN ALFA
EPOETIN ALFA
3
2
2
AMINOCAPROIC ACID
AMINOCAPROIC ACID
1
3
4 SPEC
4 SPEC
2
2
ERYTHROCYTE STIMULATORS
AMICAR
AMICAR 1,000MG
PA
PA
PA
PA
PA
PA
HEMOSTATICS
PA
PA
PA
NF-NC
4 SPEC PA
4 SPEC PA
1
NF-NC
49
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
MICHILD
PPO
MEDICAID
EENT DRUGS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
1
2
1
1
NF-NC
NF-NC
1
MAND
SPEC
PARTNERS
MAND
SPEC
GLAUCOMA AGENTS
ALPHAGAN P
0.15%
ALPHAGAN P 0.1%
ATROPINE
AZOPT
BETAGAN
BETAXOLOL
BETIMOL
BETOPTIC S
COSOPT
CYCLOGYL 0.5%,
2%
CYCLOGYL 1%
DIAMOXSEQUELS
IOPIDINE 0.5%
IOPIDINE 1%
ISOPTO
CARBACHOL1%,
2%, 4%
ISOPTO
CARBACHOL 8%
ISOPTO
HOMATROPINE 5%
ISOPTO
HOMATROPINE 2%
ISTALOL
LUMIGAN 0.01%
LUMIGAN 0.03%
METIPRANOLOL
MYDRIACYL
NEPTAZANE
Y
Y
Y
BRIMONIDINE
TARTRATE
BRIMONIDINE
TARTRATE
ATROPINE SULFATE
BRINZOLAMIDE
LEVOBUNOLOL
BETAXOLOL
TIMOLOL
BETAXOLOL
TIMOLOL/ DORZOLAM
1
3
1
2
1
1
3
3
1
PA
PA
PA
PA
Y
Y
Y
Y
Y
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
Y
Y
Y
HOMATROPINE
TIMOLOL
BIMATOPROST
BIMATOPROST
METIPRANOLOL
TROPICAMIDE
METHAZOLAMIDE
3
3
2
3
1
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
2 PA
NF-NC
1
1
1
Y
Y
Y
50
BRAND NAME
PHOSPHOLINE
IODIDE SOLN
PILOCAR
PILOPINE HS
PROPINE
TIMOPTIC
TIMOPTIC
OCUDOSE
TIMOPTIC XE
TRAVATAN Z
TRUSOPT
XALATAN
GEQ
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
ECHOTHIOPHATE
PILOCARPINE
PILOCARPINE
DIPIVEFRIN
TIMOLOL
2
1
2
3
1
2
1
2
NF-NC
Y
Y
Y
TIMOLOL
TIMOLOL
TRAVOPROST
DORZOLAMIDE
LATANOPROST
1
3
1
1
PA
PA
PA
1
NF-NC
1
1
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
PREDNISOLONE
PREDNISOLONE
RIMEXOLONE
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
2
3
3
3
3
3
2
3
2
1
2
3
PA
NF-NC
2
1
2
NF-NC
DOXYCYCLINE/
EYELID CLNS NO.2&3
AZITHROMYCIN
BESIFLOXACIN
HYDROCHLORIDE
SULFACETAMIDE
SODIUM
3
3
NF-NC
NF-NC
NF-NC
51
BRAND NAME
CILOXAN GEL
CILOXAN SOLN
ERYTHROMYCIN
GARAMYCIN
ILOTYCIN
IQUIX
NATACYN
GEQ
Y
Y
Y
Y
NEOSPORIN
OCUFLOX
Y
Y
POLYSPORIN
POLYTRIM
QUIXIN
TOBREX OINT
TOBREX SOLN
VIGAMOX
VIROPTIC
Y
Y
Y
Y
GENERIC NAME
TIER
CIPROFLOXACIN
CIPROFLOXACIN
ERYTHROMYCIN
GENTAMICIN
ERYTHROMYCIN
LEVOFLOXACIN
NATAMYCIN
POLYMYXIN/
BACITRACIN/
NEOMYCIN
OFLOXACIN
POLYMYXIN/
BACITRACIN
POLYMYXIN/
TRIMETHOPRIM
LEVOFLOXACIN
TOBRAMYCIN
TOBRAMYCIN
MOXIFLOXACIN
TRIFLURIDINE
3
1
1
1
1
3
3
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
1
1
1
NF-NC
NF-NC
1
1
1
1
1
1
2
1
2
1
1
1
2
1
2
1
TOBRAMYCIN/
LOTEPRED ETAB
ZYLET
BLEPHAMIDE
BLEPHAMIDE
S.O.P.
CORTISPORIN
MAXITROL
RESTASIS
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
TOPICAL OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY
SULFACETAMIDE/
PREDNISOLONE
SULFACETAMIDE/
PREDNISOLONE
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN/
BACITRACIN
DEXAMETHASONE/
NEOMYCIN/
POLYMYXIN
CYCLOSPORINE
1
2
1
2
PA
52
BRAND NAME
TOBRADEX
GEQ
Y
TOBRADEX ST
ALAMAST
ALOCRIL
ALOMIDE
BEPREVE
ELESTAT
EMADINE
LASTACAFT
OPTIVAR
PATADAY
PATANOL
ZADITOR OTC
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
GENERIC NAME
TIER
PPO
DEXAMETHASONE/
TOBRAMYCIN
1
1
TOBRAMYCIN/
NF-NC
DEXAMETHASONE
3
TOPICAL OPHTHALMIC VASOCONSTRICTORS/ANTIHISTAMINES
PEMIROLAST
PA
PA
PA
NC
POTASSIUM
3
NC
PA
PA
PA
NEDOCROMIL SODIUM
3
LODOXAMIDE
NC
PA
PA
PA
TROMETHAMINE
3
BEPOTASTINE
NC
PA
PA
PA
BESILATE
3
1
EPINASTINE
1
EMEDASTINE
DIFUMARATE
ALCAFTADINE
AZELASTINE
OLOPATADINE
OLOPATADINE
KETOTIFEN
3
3
1
3
2
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NC
NC
NC
NC
NC
NC
ACUVAIL
BROMDAY
NEVANAC
KETOROLAC
TROMETHAMINE
KETOROLAC
TROMETHAMINE
KETOROLAC
TROMETHAMINE
BROMFENAC SODIUM
NEPAFENAC
AURALGAN
BENZOCAINEANTIPYRINE
ACULAR, LS
ACULAR PF
PA
NF-NC
3
3
2
PA
PA
PA
NF-NC
NF-NC
2
OTIC AGENTS
CETRAXAL
CIPRO HC
CIPROFLOXACIN
CIPROFLOXACIN HCL/
HC
NF-NC
NF-NC
PA
NF-NC
53
BRAND NAME
GEQ
CIPRODEX
COLY-MYCIN S
CORTISPORIN
CORTISPORIN-TC
DOMEBORO
FLOXIN OTIC
SINGLES
TREAGAN OTIC
TRIOXIN
VOSOL
Y
Y
VOSOL HC
GENERIC NAME
CIPROFLOXACIN/
DEXAMETH
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
ACETIC ACID
TIER
OFLOXACIN
ANTIPYRINEBENZOCAINEPOLYCOSANOL
CHLOROXYLENOL/
BENZOC/HYDROCORT
ACETIC ACID
ACETIC ACID/
HYDROCORTISONE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
PA
3
1
PA
PA
PA
NF-NC
1
PA
NF-NC
1
1
1
1
1
BEHAVIORAL HEALTH
DEPRESSION
NOTE: FOR HEALTHPLUS MICHILD, 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).
ANAFRANIL
APLENZIN
CELEXA
CYMBALTA
EFFEXOR XR
EMSAM PATCH
LEXAPRO
LUVOX CR
NARDIL
NORPRAMIN
OLEPTRO ER
Y
Y
Y
Y
Y
CLOMIPRAMINE
BUPROPION
CITALPRAM
DULOXETINE
VENLAFAXINE
SELEGILINE
ESCITALOPRAM
FLUVOXAMINE
MALEATE
PHENELZINE
DESIPRAMINE
TRAZODONE
1
3
1
3
1
3
3
3
1
1
3
PA
PA
DO
PA, DO
PA, DO
PA, DO
PA, DO
PA
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
NF-NC
1
NF-NC
1
NF-NC
NF-NC
MDCH
MDCH
MDCH
MDCH
NF-NC
1
1
NF-NC
54
BRAND NAME
PAMELOR
PARNATE
PAXIL, CR
PEXEVA
PRISTIQ
PROZAC
PROZAC WEEKLY
REMERON
SARAFEM
DOXEPIN
SURMONTIL
TOFRANIL, PM
VIIBRYD
VIVACTIL
WELLBUTRIN, SR
WELLBUTRIN XL
ZOLOFT
GEQ
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
GENERIC NAME
HYDROCHLORIDE
EXTENDED RELEASE
NORTRIPTYLINE
TRANYLCYPROMINE
PAROXETINE
PAROXETINE
DESVENLAFAXINE
SUCCINATE
FLUOXETINE
FLUOXETINE
MIRTAZAPINE
FLUOXETINE
DOXEPIN
TRIMIPRAMINE
MALEATE
IMIPRAMINE PAMOATE
VILAZODONE
PROTRIPTYLINE
BUPROPION
BUPROPION
SERTRALINE
TIER
1
1
1
3
2
1
1
1
3
1
2
1
3
1
1
1
1
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PA, DO
DO
DO
PA
PA
PA, DO
DO
PA
PA, DO
DO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MDCH
MDCH
MDCH
MDCH
1
1
1
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2 DO
MDCH
MDCH
PA, DO
MDCH
MDCH
MDCH
MDCH
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
1
NF-NC
1
2
1
NF-NC
1
1
1 DO
1
ANXIETY
NOTE: FOR HEALTHPLUS MICHILD, 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
BUSPAR
MILTOWN
NIRAVAM
SILENOR
TRANXENE T
VALIUM
Y
Y
Y
Y
VISTARIL
XANAX
Y
Y
Y
Y
LORAZEPAM
BUSPIRONE
MEPROBAMATE
ALPRAZOLAM
DOXEPIN
CLORAZEPATE
DIAZEPAM
HYDROXYZINE
PAMOATE
ALPRAZOLAM
1
1
1
1
3
1
1
1
1
PA
PA, DO
PA, DO
AG
AG
AG
AG
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
1
1
1
NF-NC
AG
MDCH
1 AG
1
1
1 AG
55
BRAND NAME
XANAX XR
GEQ
Y
GENERIC NAME
TIER
ATIVAN
BENADRYL
EDLUAR
LUNESTA
RESTORIL
ROZEREM
SOMNOTE
SONATA
XYREM
ZOLPIMIST
Y
Y
Y
ZOLPIDEM
LORAZEPAM
DIPHENHYDRAMINE
ZOLPIDEM TARTRATE
ESZOPICLONE
TEMAZEPAM
RAMELTEON
CHLORAL HYDRATE
ZALEPLON
SODIUM OXYBATE
ZOLPIDEM TARTRATE
1
1
1
3
3
1
3
1
1
2
3
PPO
PARTNERS
MEDICAID
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
INSOMNIA
NOTE: FOR HEALTHPLUS MICHILD, 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).
AMBIEN, CR
ALPRAZOLAM
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PA
DO
PA, DO
PA, DO
DO
PA, DO
DO
PA, DO
PA, DO
MDCH
MDCH
MDCH
MDCH
1 DO
1
1
NF-NC
NF-NC
MDCH
1
MDCH
NF-NC
MDCH
Y
1
MDCH
Y
DO
1
MDCH
2
MDCH
NF-NC
PSYCHOSIS/MANIC DEPRESSIVES
NOTE: FOR HEALTHPLUS MICHILD, 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
DO
ABILIFY
ARIPIPRAZOLE
2
2
MDCH
Y
CLOZAPINE
CLOZAPINE
1
1
MDCH
Y
CLOZARIL
CLOZAPINE
1
1
MDCH
Y
ESKALITH, CR
LITHIUM
1
1
MDCH
NF-NC
FANAPT
ILOPERIDONE
3
MDCH
FAZACLO
CLOZAPINE
2
2
ZIPRASIDONE
MDCH
QL
GEODON
MESYLATE
2
2
MDCH
Y
HALDOL
HALOPERIDOL
1
1
MDCH
INVEGA
PALIPERIDONE
2
2
MDCH
NF-NC
LATUDA
LURASIDONE
3
MDCH
Y
LITHOBID
LITHIUM
1
1
MDCH
Y
LOXITANE
LOXAPINE
1
1
MDCH
NF-NC
MOBAN
MOLINDONE
3
MDCH
Y
NAVANE
THIOTHIXENE
1
1
Y
PA, DO
56
BRAND NAME
NAVANE 20
ORAP
RISPERDAL
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
THIOTHIXENE
PIMOZIDE
RISPERIDONE
2
2
1
QL
RISPERDAL
CONSTA
RISPERIDONE
MICROSPHERES
SP
SAPHRIS
ASENAPINE
QUETIAPINE
FUMARATE
OLANZAPINE/
FLUOXETINE
OLANZAPINE
SEROQUEL, XR
2
2
QL
PPO
SP
PARTNERS
MEDICAID
MDCH
MDCH
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
2
1
MDCH
MDCH
MDCH
MDCH
2
2
MDCH
DO
2
2
ATTENTION DEFICIT DISORDER/NARCOLEPSY
NOTE: FOR HEALTHPLUS MICHILD, 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).
AMPHETAMINE/
DEXTROAMPHETMDCH
ADDERALL, XR
Y
1
AMINE
1
METHYLPHENIDATE,
MDCH
Y
CONCERTA
SUST. RELEASE
1
1
METHYLPHENIDATE
MDCH
PA
PA
NF-NC
DAYTRANA
PATCH
3
MDCH
Y
DESOXYN
METHAMPHETAMINE
1
1
DEXTROAMPHETMDCH
Y
PA
PA
1 PA
DEXEDRINE
AMINE
1
DEXMETHYLPHENIMDCH
Y
PA
PA
NF-NC
FOCALIN
DATE
1
DEXMETHYLPHENIMDCH
PA
PA
NF-NC
FOCALIN XR
DATE
3
MDCH
PA
PA
NF-NC
INTUNIV
GUANFACINE
3
MDCH
NF-NC
KAPVAY
CLONIDINE
3
MDCH
PA, AG
PA
NF-NC
METADATE CD
METHYLPHENIDATE
3
MDCH
Y
AG
AG
1 AG
METADATE ER
METHYLPHENIDATE
1
METHYLIN CHEW
MDCH
AG
AG
NF-NC
TAB
METHYLPHENIDATE
3
METHYLIN SOLN
MDCH
Y
AG
AG
1
5MG/5ML
METHYLPHENIDATE
1
MDCH
PA, DO
PA, DO
2 PA
NUVIGIL
ARMODAFINIL
2
SYMBYAX
ZYPREXA, ZYDIS
57
BRAND NAME
PROVIGIL
RITALIN
RITALIN LA
RITALIN SR
STRATTERA
GEQ
Y
Y
VYVANSE
BANZEL
CARBATROL
CELONTIN
DEPAKENE
DEPAKOTE
DIASTAT
DIASTAT ACUDIAL
DILANTIN 100MG
CAPS
DILANTIN 30
KEPSEAL
DILANTIN 50
INFATAB
FANATREX
FELBATOL
GABITRIL
GRALISE,
STARTER PACK
KEPPRA
KEPPRA XR
KLONOPIN
LAMICTAL 5, 25MG
DISPER TABLET
LAMICTAL TAB,
STARTER KIT
LAMICTAL ODT
Y
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PA
AG
PA
AG
PA
PPO
PA
PARTNERS
MEDICAID
MDCH
MDCH
MDCH
MDCH
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
NF-NC
1
2 PA
MODAFINIL
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE
ATOMOXETINE
LISDEXAMFETAMINE
DIMESYLATE
3
1
3
1
3
3
MDCH
PA
PA
ANTICONVULSANTS
NF-NC
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
NF-NC
MDCH
NF-NC
1
2
2
2
PHENYTOIN
PA
PA
PHENYTOIN
GABAPENTIN
FELBAMATE
TIAGABINE
3
2
2
2
MDCH
MDCH
MDCH
MDCH
Y
Y
Y
GABAPENTIN
LEVETIRACETAM
LEVETIRACETAM
CLONAZEPAM
3
1
1
1
MDCH
MDCH
MDCH
1
1
1
LAMOTRIGINE
MDCH
LAMOTRIGINE
LAMOTRIGINE
1
2
MDCH
MDCH
1
2
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
58
BRAND NAME
LAMICTAL XR,
STARTER KIT
LYRICA
MYSOLINE
NEURONTIN
PEGANONE
PHENOBARBITAL
SABRIL
TEGRETOL, XR
TOPAMAX
TRILEPTAL TAB
VIMPAT
ZARONTIN
ZONEGRAN
AMERGE
AXERT
GEQ
Y
Y
Y
Y
Y
Y
Y
Y
Y
CAFERGOT
FIORINAL
FROVA
IMITREX KIT
IMITREX SPRAY
IMITREX TABLET
PROPRANOLOL
INDERAL LA
MAXALT, MLT
Y
Y
Y
Y
MIDRIN
MIGRANAL NASAL
SPRAY
GENERIC NAME
TIER
LAMOTRIGINE
PREGABALIN
PRIMIDONE
GABAPENTIN
ETHOTOIN
PHENOBARBITAL
VIGABATRIN
CARBAMAZEPINE
TOPIRAMATE
OXCARBAZEPINE
LACOSAMIDE
ETHOSUXIMIDE
ZONISAMIDE
2
2
1
1
2
1
2
1
1
1
2
1
1
NARATRIPTAN
ALMOTRIPTAN
ERGOTAMINE/
CAFFEINE
BUTALBITAL/ ASA/
CAFFEINE
FROVATRIPTAN
SUMATRIPTAN
INJECTION
SUMATRIPTAN NASAL
SPRAY
SUMATRIPTAN TABLET
PROPRANOLOL
PROPRANOLOL SR
RIZATRIPTAN
ACETAMINOPHEN/
DICHORALPHENAZON
E/ ISOMETHEPTENE
DIHYDROERGOTAMINE
1
3
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MIGRAINE MEDICATIONS
QL
QL
PA, QL
QL
PA, QL
QL
PA, QL
PA, QL
PA, QL
PA, QL
1
1
1
1
1
3
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
2
1
1
2
1
2
1
1
1
2
1
1
1 QL
NF-NC
NF-NC
3
1
3
SIGNATURE
PPO CLOSED
FORMULARY
1
NF-NC
1
QL
PA, QL
QL
PA, QL
QL
1
1 QL
PA, QL
1
1
NF-NC
NF-NC
59
BRAND NAME
PRODRIN
RELPAX
GEQ
TREXIMET
ZOMIG NASAL
SPRAY
ZOMIG, ZMT
GENERIC NAME
ACETAMINOPHENISOMETHEPTENECAFFEINE
ELETRIPTAN
SUMATRIPTAN/
NAPROXEN
ZOLMITRIPTAN NASAL
SPRAY
ZOLMITRIPTAN
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
2
QL
QL
QL
1
2 QL
PA, QL
PA, QL
PA, QL
NF-NC
3
3
PA, QL
PA, QL
PA, QL
SKELETAL MUSCLE RELAXANTS
PARTNERS
MAND
SPEC
NF-NC
NF-NC
AMRIX
BACLOFEN
COMFORT PACTIZANIDINE
DANTRIUM
FLEXERIL
FEXMID
NORFLEX
PARAFON FORTE
DSC
ROBAXIN
SKELAXIN
SOMA
ZANAFLEX
CAPSULES
ZANAFLEX
TABLETS
Y
Y
CYCLOBENZAPRINE
BACLOFEN
1
1
1
1
Y
Y
Y
Y
TIZANIDINE COMBO
DANTROLENE
CYCLOBENZAPRINE
CYCLOBENZAPRINE
ORPHENADRINE
3
1
1
1
1
AG
AG
AG
AG
AG
AG
NF-NC
1
1 AG
1
1 AG
Y
Y
Y
Y
CHLORZOXAZONE
METHOCARBAMOL
METAXALONE
CARISOPRODOL
1
1
1
1
AG
AG
PA
AG
AG
AG
AG
AG
PA
NC
1
NF-NC
TIZANIDINE
PA
PA
NF-NC
TIZANIDINE
1
MISCELLANEOUS AUTONOMIC AGENTS
MESTINON
MESTINON 180
PYRIDOSTIGMINE
PYRIDOSTIGMINE
1
3
APOMORPHINE
RASAGILINE
BENZTROPINE
ENTACAPONE
3
2
1
2
AG
MAND 90
MAND
SPEC
1 AG
1 AG
1
1
NF-NC
PA
PA
PA
MDCH
NF-NC
2
1
2
60
BRAND NAME
LODOSYN
MIRAPEX
MIRAPEX ER
GEQ
Y
PARCOPA
PARLODEL
REQUIP
REQUIP XL
Y
Y
Y
SINEMET, CR
STALEVO
TASMAR
ZELAPAR
GENERIC NAME
CARBIDOPA
PRAMIPEXOLE
PRAMIPEXOLE DI-HCL
CARBIDOPA/
LEVODOPA
BROMOCRIPTINE
ROPINIROLE
ROPINIROLE
LEVODAPA/
CARBIDOPA
CARBIDOPA/
LEVODOPA/
ENTACAPONE
TOLCAPONE
SELEGILINE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
3
1
3
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
NF-NC
1
1
1
3
1
1
1
NF-NC
2
3
3
2
NF-NC
NF-NC
TIER
PPO
PARTNERS
MEDICAID
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ALZHEIMER'S DISEASE
ARICEPT 5MG,
10MG, 5MG ODT
AND 10MG ODT
ARICEPT 23MG
EXELON
CAPSULES
EXELON SOLN
AND PATCH
NAMENDA
RAZADYNE ER
DONEPEZIL
DONEPEZIL
1
2
1
2
RIVASTIGMINE
RIVASTIGMINE
MEMANTINE
GALANTAMINE
2
2
1
2
2
1
HORMONES
ORAL ADRENAL CORTICOSTEROIDS
ARISTOCORT
CELESTONE
CORTEF TABS
CORTISONE
MEDROL,
DOSEPAK
PEDIAPRED
LIQUID
2
2
1
1
2
2
1
1
TRIAMCINOLONE
BETAMETHASONE
HYDROCORTISONE
CORTISONE ACETATE
METHYLPREDNISOLONE
PREDNISOLONE
Y
Y
61
BRAND NAME
PREDNISOLONE
GEQ
Y
GENERIC NAME
TIER
PREDNISOLONE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ORAL CONTRACEPTIVES, GF
APRI
ARANELLE
AVIANE
BEYAZ
CAMILA
CRYSELLE
DESOGEN
ENPRESSE
ERRIN
ESTROSTEP FE
FEMCON FE
GENERESS FE
JOLIVETTE
KARIVA
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
NORETHINDRONE
0.35MG
NORETH A-ET
ESTRA/FE FUMARATE
NORETH-ETHINYL
ESTRADIOL/IRON
NORETH-ETHINYL
ESTRADIOL/IRON
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
DESOGESTREL
NF-NC
PA
PA
PA
62
BRAND NAME
GEQ
LESSINA
LEVORA
LO/OVRAL
LOESTRIN FE 1/20
LOESTRIN 21
1.5/30
LOESTRIN 21 1/20
LOESTRIN 24 FE
LOSEASONIQUE
LOW-OGESTREL
LYBREL
MICROGESTIN FE
1.5/30
GENERIC NAME
ETHINYL ESTRADION
20MCG
LEVONORGESTREL
0.1MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
L-NORGEST-ETH
ESTR/ETHIN ESTRA
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
LEVONORGESTREL
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
HMO
POS
TPA
M-SUPP
RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
TIER
PPO
PARTNERS
MEDICAID
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
MAND
SPEC
PARTNERS
MAND
SPEC
63
BRAND NAME
GEQ
MICROGESTIN FE
1/20
MIRCETTE
MODICON
MONONESSA
NATAZIA
NECON 0.5/35
NECON 1/35
NECON 1/50
NECON 10/11
NECON 7/7/7
NORA-BE
NORDETTE
GENERIC NAME
ETHINYL ESTRADIOL
20MCG/ FE/
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
DESOGESTREL
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ESTRADIOL
VALERATE/DIENOGEST
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
NORETHINDRONE
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
HMO
POS
TPA
M-SUPP
RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
TIER
PA
PPO
PA
PARTNERS
MEDICAID
PA
MAND
SPEC
PARTNERS
MAND
SPEC
64
BRAND NAME
GEQ
NORINYL 1/35
NORINYL 1+50
NORTREL 0.5/35
NORTREL 1/35
NORTREL 7/7/7
OGESTREL
ORTHO
MICRONOR
ORTHO TRICYCLEN
ORTHO TRICYCLEN LO
Y
Y
ORTHO-CYCLEN
ORTHO-NOVUM
1/35
ORTHO-NOVUM
1/50
ORTHO-NOVUM
7/7/7
Y
Y
GENERIC NAME
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
50MCG
NORGESTREL 0.5MG
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
NORETHINDRONE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
TIER
PA
PPO
PA
PARTNERS
MEDICAID
PA
MAND
SPEC
PARTNERS
MAND
SPEC
65
BRAND NAME
GEQ
ORTHO-CEPT
OVCON 35
OVCON 50
PORTIA
SAFYRAL
SEASONALE
SEASONIQUE
SPRINTEC
TRINESSA
TRI-NORINYL
TRI-SPRINTEC
TRIVORA
YASMIN
GENERIC NAME
ETHINYL ESTRADIOL
30MCG
DESOGESTREL
0.15MG
ETHINYL ESTRADIOL
35MCG
NORETHINDRONE
0.4MG
ETHINYL ESTRADIOL
50MCG
NORETHINDRONE
1MG
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
HMO
POS
TPA
M-SUPP
RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
NF-NC
TIER
PA
PPO
PA
PARTNERS
MEDICAID
PA
1
3
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
66
BRAND NAME
GEQ
YAZ
ZOVIA 1/35
ZOVIA 1/50
GENERIC NAME
ETHINYL ESTRADIOL
20MCG
DROSPIRENONE 3MG
ETHINYL ESTRADIOL
35MG
ETHYNODIOL
DIACETATE 1MG
ETHINYL ESTRADIOL
50MCG
ETHYNODIOL
DIACETATE 1MG
HMO
POS
TPA
M-SUPP
RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
TIER
PPO
PARTNERS
MEDICAID
MAND
SPEC
PARTNERS
MAND
SPEC
NON-ORAL CONTRACEPTIVES, GF
ETONOGESTREL
ETHINYL ESTRADIOL
ETHINYL ESTRADIOL
NORELGESTROMIN
NUVARING
ORTHO EVRA
PATCH
ALORA
CENESTIN
CLIMARA
DIVIGEL
ENJUVIA
ESTRACE TABS
ESTRADERM
ESTRASORB
ESTRING
ESTROGEL GEL
FEMRING
FEMTRACE
MENEST
OGEN
ESTRADIOL,
TRANSDERMAL
CONJUGATED
ESTROGENS
ESTRADIOL,
TRANSDERMAL
ESTRADIOL
CONJUGATED
ESTROGENS
ESTRADIOL
ESTRADIOL,
TRANSDERMAL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTROGENS
ESTROPIPATE
PA
PA
PA
NF-NC
PA
PA
ESTROGENS, GF
PA
NF-NC
2
3
PA
1
3
3
1
2
3
3
3
3
3
3
1
PA
NF-NC
1
NF-NC
NF-NC
1
Y
Y
2
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
Y
Y
Y
Y
Y
Y
Y
67
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
AG
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
AG
PA, AG
2 AG
2
NF-NC
Y
Y
1
NF-NC
Y
Y
NF-NC
NF-NC
NF-NC
PREMARIN ORAL
CONJUGATED
ESTROGENS
PREMARIN VAG
CREAM
VAGIFEM
CONJUGATED
ESTROGENS
ESTRADIOL
2
3
VIVELLE-DOT
ESTRADIOL,
TRANSDERMAL
MAND
SPEC
PARTNERS
MAND
SPEC
PROGESTINS
AYGESTIN
PROMETRIUM
PROVERA
NORETHINDRONE
ACETATE
PROGESTERONE
1
3
MEDROXYPROGESTERONE/ MPA
PA
COMBINATION ESTROGEN/PROGESTINS
ACTIVELLA
CLIMARA PRO
COMBIPATCH
FEMHRT 1MG5MCG
FEMHRT 0.5MG2.5MCG
PREFEST
PREMPHASE
PREMPRO
ESTRADIOL/
NORETHINDRONE
ACETATE
ESTRADIOL/
LEVONORGESTREL
ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
ESTRADIOL/
NORGESTIMATE
CONJUGATED
ESTROGEN/ MPA
CONJUGATED
ESTROGEN/ MPA
PA
DDAVP-DESMOPRESSIN ACETATE
68
BRAND NAME
DDAVP NASAL
SPRAY
DDAVP RHINAL
TUBE
GEQ
Y
Y
GENERIC NAME
DESMOPRESSIN
ACETATE
DESMOPRESSIN
ACETATE
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ANDROGENS, GM
ANDRODERM
ANDROGEL
ANDROID
ANDROXY
METHITEST
OXANDRIN
TESTRED
TESTOSTERONE
TESTOSTERONE,
TRANSDERMAL
METHYLTESTOSTERONE
FLUOXYMESTERONE
METHYLTESTOSTERONE
OXANDROLONE
METHYLTESTOSTERONE
NF-NC
2
1
2
1
Y
Y
3
1
NF-NC
1
Y
Y
NF-NC
3
INFERTILITY
BRAVELLE
CETROTIDE
CLOMID
FOLLISTIM AQ
GONAL-F
LUPRON DEPOT
3.75 KIT
NOVAREL
OVIDREL
PREGNYL
PROFASI 5,000
REPRONEX
UROFOLLITROPIN
(FSH)
CETRORELIX
ACETATE
CLOMIPHENE
FOLLITROPIN
BETA,RECOMB
FOLLITROPIN
ALPHA,RECOMB
LEUPROLIDE ACETATE
GONADOTROPIN,
CHORIONIC,HUMAN
HCG
ALPHA,RECOMBINANT
GONADOTROPIN,
CHORIONIC,HUMAN
GONADOTROPIN,
CHORIONIC,HUMAN
MENOTROPINS
PA
PA
NC
NC
3
1
PA
PA
PA
PA
NC
NC
NC
NC
PA
PA
NC
NC
PA
PA
NC
NC
PA
PA
NC
NC
PA
PA
NC
NC
PA
PA
NC
NC
PA
PA
NC
NC
3
3
PA
PA
PA
PA
NC
NC
NC
NC
Y
Y
69
BRAND NAME
GEQ
LUPRON DEPOT
3.75 KIT
SYNAREL NASAL
SPRAY
GENERIC NAME
TIER
LEUPROLIDE ACETATE
NAFARELIN ACETATE
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
MICHILD
PPO
MEDICAID
ENDOMETRIOSIS
SIGNATURE
PPO CLOSED
FORMULARY
PA
MAND 90
4 SPEC
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
OSTEOPOROSIS
RALOXIFENE
PA
PA
NF-NC
2
1
NF-NC
NF-NC
Y
Y
Y
BISPHOSPHONATES
ACTONEL
ATELVIA
BONIVA
DIDRONEL
FORTEO
FORTICAL
FOSAMAX
FOSAMAX PLUS D
MIACALCIN NASAL
RISEDRONATE
RISEDRONATE
SODIUM
IBANDRONATE
ETIDRONATE
TERIPARATIDE
CALCITONIN
ALENDRONATE
ALENDRONATE/
VITAMIN D3
CALCITONIN
2
3
2
1
3
3
1
PA
PA
Y
Y
NF-NC
1
Y
Y
1 AG
1
1
1
1
Y
Y
3
1
THYROID DISORDERS
THYROID,
DESSICATED
LIOTHYRONINE
SODIUM
ARMOUR THYROID
CYTOMEL
LEVOTHROID
LEVOXYL
METHIMAZOLE
PROPYLTHIOURACIL
Y
Y
LEVOTHYROXINE
SODIUM
LEVOTHYROXINE
SODIUM
METHIMAZOLE
PROPYLTHIOURACIL
Y
Y
LEVOTHYROXINE
SODIUM
METHIMAZOLE
1
1
1
1
Y
Y
SYNTHROID
TAPAZOLE
AG
AG
AG
70
BRAND NAME
GEQ
THYROLAR
GENERIC NAME
LIOTRIX
LEVOTHYROXINE
SODIUM
PARICALCITOL
TIROSINT
ZEMPLAR
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA
SIGNATURE
PPO CLOSED
FORMULARY
2
MAND 90
Y
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
2
2
DIABETES
INSULINS
APIDRA
APIDRA
SOLOSTAR
HUMALOG
HUMALOG MIX
HUMULIN
INSULINS
LANTUS
LEVEMIR
LEVEMIR FLEXPEN
NOVOLIN
INSULINS
PREFILLED PENS,
PENFILLS,
CARTRIDGES
NOVOLOG
INSULINS
NOVOLOG MIX
INSULIN GLULISINE
INSULIN GLULISINE
INSULIN LISPRO
INSULIN
2
2
2
INSULIN
INSULIN GLARGINE
INSULIN DETEMIR
INSULIN DETEMIR
2
2
2
2
INSULIN
INSULIN
INSULIN ASPART
INSULIN
2
2
2
PA
PA
PA
2
2
2
2
2
2
2
Y
Y
Y
Y
2
2
NEEDLES/SYRINGES
INSULIN
SYRINGES
SYRINGES
1
SULFONYLUREAS
AMARYL
DIABETA
GLUCOTROL, XL
GLYNASE
PRESTAB
MICRONASE
Y
Y
GLIMEPIRIDE
GLYBURIDE
GLIPIZIDE
1
3
1
1
NF-NC
1
Y
Y
Y
Y
Y
GLYBURIDE
GLYBURIDE
1
1
1
1
Y
Y
ORAL ANTIHYPERGLYCEMICS
71
BRAND NAME
FORTAMET
GLUCOPHAGE, XR
GLUCOVANCE
GLUMETZA
GEQ
Y
Y
KOMBIGLYZE XR
ONGLYZA
PRANDIMET
PRANDIN
STARLIX
GENERIC NAME
METFORMIN
METFORMIN
GLYBURIDE/
METFORMIN
METFORMIN
SAXAGLIPTIN/
METFORMIN
SAXAGLIPTIN
HYDROCHLORIDE
REPAGLINIDE/METFOR
MIN
REPAGLINIDE
NATEGLINIDE
TIER
3
1
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PA
PPO
PARTNERS
MEDICAID
PA
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
MAND 90
Y
Y
Y
PA
1
NF-NC
DO
DO
NF-NC
DO
DO
NF-NC
NF-NC
NF-NC
1
Y
Y
Y
3
2
NF-NC
2
Y
Y
NF-NC
3
3
NF-NC
NF-NC
Y
Y
NF-NC
NF-NC
1
3
PA
DO
DO
3
3
1
MAND
SPEC
PARTNERS
MAND
SPEC
THIAZOLIDINEDIONES
ACTOPLUS MET
ACTOPLUS MET
XR
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
DUETACT
JANUMET
JANUVIA
PIOGLITAZONE/
METFORMIN
PIOGLITAZONE/
METFORMIN
PIOGLITAZONE
ROSIGLITAZONE/
METFORMIN
ROSIGLITAZONE/
GLIMEPIRIDE
ROSIGLITAZONE
PIOGLITAZONE/
GLIMEPIRIDE
SITAGLIPTIN PHOS/
METFORMIN
SITAGLIPTIN
PHOSPHATE
3
MISCELLANEOUS
BYETTA
GLUCOSE TEST
STRIPS
GLYSET
LANCETS
EXENATIDE
STRIPS
MIGLITOL
LANCETS
2
3
2
2
NF-NC
2
Y
Y
Y
72
BRAND NAME
PRECOSE
GEQ
Y
SYMLIN
SYMLINPEN
VICTOZA
GENERIC NAME
ACARBOSE
PRAMLINTIDE
ACETATE
PRAMLINTIDE
ACETATE
LIRAGLUTIDE
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
2
2
2
2
MAND 90
Y
MAND
SPEC
PARTNERS
MAND
SPEC
GLUCAGON
GLUCAGON
GLUCAGON
2
ANTI-GOUT DRUGS
COLCRYS
INDOCIN SUSP
PROBENECID
ULORIC
ZYLOPRIM
Y
Y
COLCHICINE 0.6MG
INDOMETHACIN
PROBENECID
FEBUXOSTAT
ALLOPURINOL
2
2
1
3
1
DO, PA
DO, PA
DO, PA
2
2
1
NF-NC
1
Y
Y
SUPPLEMENTS
ANTI-ANEMIA DRUGS
FOLIC ACID
NIFEREX-150
FORTE
Y
Y
FOLIC ACID
IRON PS CMPLX/VIT
B12/FA
PA
PA
NF-NC
PRENATAL VITAMINS
ATABEX EC
CITRANATAL
ASSURE
CITRANATAL
HARMONY
COMPLETE-RF
PRENATAL
CONCEPT OB,
DHA
DUET DHA
BALANCED
DUET DHA
COMPLETE
GESTICARE DHA
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITMAINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
Y
Y
VITAMIN, PRENATAL
VITAMINS, PRENATAL
1
1
1
1
73
BRAND NAME
HEMOCYTE-F
TABLET
NATALVIT
NATELLE ONE
NESTABS
NESTABS DHA
NEEVO DHA
NEXA SELECT
NIFEREX-PN
OB COMPLETE,
PREMIER, ONE,
400, DHA
OBSTETRIX EC
PREFERA OB
PREFERA-OB ONE
PREFERA-OB
PLUS DHA
PREMESIS RX
PRENATAL
COMPLETE
GEQ
Y
Y
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
PA
1
NF-NC
1
NF-NC
NF-NC
NF-NC
NF-NC
GENERIC NAME
VITAMINS, PRENATAL
PREP
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
TIER
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
3
3
3
PA
PA
PA
PA
NF-NC
NF-NC
NF-NC
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
1
PA
NF-NC
PA
PPO
1
3
1
3
3
3
3
1
VITAMINS, PRENATAL
PRENATAL PLUS
PRENATE
ESSENTIAL
PRENATE PLUS
PRENATE ELITE
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
1
3
3
PRENEXA
SELECT-OB
SELECT-OB + DHA
Y
Y
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
1
1
3
VITAFOL-OB
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAFOL-ONE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
1
PA
PA
1
NF-NC
NF-NC
PA
1
1
NF-NC
1
PA
NF-NC
POTASSIUM
KLOR-CON
K-PHOS ORIGINAL
POTASSIUM
CHLORIDE
POTASSIUM
PHOSPHATE
74
BRAND NAME
MICRO-K
GEQ
Y
GENERIC NAME
POTASSIUM
CHLORIDE
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
VITAMIN B
NEURIN-SL
CYANOCOBALAMIN/ME
COBALAMIN
1
VITAMIN D
ROCALTROL
CALCITRIOL
1
VITAMINS WITH FLUORIDE
FLUORABON
BASIC
1
TOPICAL FLUORIDE
FLUORABON
DROPS
FLUORABON
CHEW TABLET
PREVIDENT 5000
BOOSTER GEL
PREVIDENT 5000
PLUS CREAM
PREVIDENT
DENTAL RINSE
PREVIDENT GEL
PREVIDENT 5000
SENSITIVE 1.1%5%
SODIUM FLUORIDE
SODIUM FLUORIDE
SODIUM FLUORIDE
SODIUM FLUORIDE
Y
Y
SODIUM FLUORIDE
SODIUM FLUORIDE
1
1
1
1
SODIUM FLUORIDE
PA
PA
NF-NC
NF-NC
VITAMIN K
MEPHYTON
PHYTONADIONE
2
MISCELLANEOUS AGENTS
HEAVY METAL ANTAGONISTS
CUPRIMINE
DESFERAL
EXJADE
QUININE SULFATE
PENICILLAMINE
DEFEROXAMINE
MESYLATE
DEFERASIROX
NF-NC
1
2
1
2
QUININE SULFATE
QUININE SULFATE
1
ALKALINIZING AGENTS
75
BRAND NAME
GEQ
GENERIC NAME
TIER
UROCIT-K 5,
10MEQ
UROCIT-K 15MEQ
POTASSIUM CITRATE
POTASSIUM CITRATE
1
3
CARNITOR
LEVOCARNITINE
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
AMINO ACID DERIVATIVES
1
GALLSTONE SOLUBILIZERS
ACTIGALL
URSODIOL
1
SMOKING CESSATION PRODUCTS
CHANTIX
NICORETTE GUM
OTC
NICOTINE PATCH,
RX
NICOTINE PATCH
OTC
NICOTROL
INHALER
NICOTROL NS
ZYBAN
VARENICLINE
TARTRATE
NICOTINE
POLACRILEX
DL
DL
NC
NC
NICOTINE PATCH
PA, DL
PA, DL
PA, DL
NF-NC
DL
DL
DL
1 DL
NC
NF-NC
3
1
NC
NF-NC
NICOTINE INHALER
NICOTINE NASAL
SPRAY
BUPROPION
DL
2 DL
NF-NC
1
SUBSTANCE ABUSE DETERRENTS
ANTABUSE
METHADONE
REVIA
Y
Y
Y
SUBOXONE
DISULFIRAM
METHADONE
NALTREXONE
1
1
1
BUPRENORPHINE/
NALOXONE
PA
PA
SUBUTEX
BUPRENORPHINE
YOCON
YOHIMBINE
MDCH
MDCH
MDCH
1
1
1
MDCH
PA
MDCH
APHRODISIACS
PA
NF-NC
ERECTILE DYSFUNCTION (ED)
CAVERJECT
ALPROSTADIL
GM, QL
CIALIS
TADALAFIL
AG, GM,
PA, QL
GM, QL
AG,
GM,
PA, QL
NC
NC
NC
NC
76
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
GM, QL
PARTNERS
MEDICAID
NC
PPO
GM, QL
AG,
AG, GM,
GM,
PA, QL
PA, QL
NC
GM, QL
GM, QL
NC
GM, QL
GM, QL
NC
AG,
AG, GM,
GM,
PA, QL
PA, QL
NC
IMMUNE SUPPRESSANTS
SIGNATURE
PPO CLOSED
FORMULARY
NC
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
4 SPEC PA
4 SPEC PA
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
2
NF-NC
MAND 90
EDEX
ALPROSTADIL
LEVITRA
MUSE
STAXYN
VARDENAFIL
ALPROSTADIL
VARDENAFIL
3
3
3
VIAGRA
SILDENAFIL
AZASAN
AZATHIOPRINE
CELLCEPT
GENGRAF
IMURAN
MYFORTIC
NEORAL
PROGRAF
RAPAMUNE
SANDIMMUNE
MYCOPHENOLATE
MOFETIL
CYCLOSPORINE
AZATHIOPRINE
MYCOPHENOLATE
CYCLOSPORINE
TACROLIMUS
SIROLIMUS
CYCLOSPORINE
1
1
1
2
1
1
2
1
1
1
1
2
1
1
2
1
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NC
NC
NC
NC
RHEUMATOLOGIC MEDCATIONS
ARAVA
LEFLUNOMIDE
CIMZIA
ENBREL
HUMIRA
KINERET
RIDAURA
SIMPONI
CERTOLIZUMAB
PEGOL
ETANERCEPT
ADALIMUMAB
ANAKINRA
AURANOFIN
GOLIMUMAB
3
2
2
2
2
3
LIDODERM 5%
PATCH
LIDOCAINE
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
LOCAL ANESTHETICS
PA
PA
PA
POTASSIUM REMOVING RESINS
NF-NC
77
BRAND NAME
GEQ
KAYEXALATE
GENERIC NAME
SODIUM
POLYSTYRENE
SULFONATE
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
UROLOGY
AVODART
CARDURA
CARDURA XL
DETROL
DETROL LA
DITROPAN XL
ELMIRON
ENABLEX
FLOMAX
GELNIQUE
JALYN
OXYTROL PATCH
PROSCAR
PYRIDIUM
RAPAFLO
SANCTURA
SANCTURA XR
Y
Y
Y
TOVIAZ
URECHOLINE
UROXATRAL
VESICARE
METHERGINE
DUTASTERIDE
DOXAZOSIN
DOXAZOSIN
TOLTERODINE
TARTRATE
TOLTERODINE
TARTRATE
OXYBUTYNIN
PENTOSAN
POLYSULFATE
SOLIFENACIN
SUCCINATE
TAMSULOSIN
OXYBUTYNIN
CHLORIDE
DUTASTERIDE/
TAMSULOSIN
OXYBUTYNIN
FINASTERIDE
PHENAZOPYRIDINE
SILODOSIN
TROSPIUM CHLORIDE
TROSPIUM CHLORIDE
FESOTERODINE
FUMARATE
BETHANECHOL
2
1
3
2
1
NF-NC
2 DO
1 DO
Y
Y
2
1
DO
DO
DO
DO
DO
DO
2
3
2
2
DO
DO
2
1
ALFUZOSIN
DARIFENACIN
HYDROBROMIDE
METHYLERGONOVINE
NF-NC
2
3
2
3
1
1
3
1
3
DO
PA
PA
PA
NF-NC
PA
1
NF-NC
PA
1
1
NF-NC
1
NF-NC
DO
DO
DO
DO
OXYTOCICS
DO
DO
Y
Y
Y
Y
Y
Y
Y
2 DO
1
2 DO
78
BRAND NAME
COPEGUS
GEQ
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
PARTNERS
MICHILD
PPO
MEDICAID
HEPATITIS C PRODUCTS
SIGNATURE
PPO CLOSED
FORMULARY
MAND
SPEC
PARTNERS
MAND
SPEC
MAND 90
RIBAVIRIN
PEGASYS
PEGINTERFERON
ALFA-2A
PA
PA
PA
4 SPEC PA
PEG-INTRON
PEGINTERFERON
ALFA-2B
PA
PA
PA
NF-NC
NF-NC
3
1
1
1
1
1
1
NF-NC
3
IRRITABLE BOWEL SYNDROME/CHRONIC CONSTIPATION
Y
Y
Y
Y
Y
Y
Y
Y
REBETOL ORAL
SOLUTION
REBETOL
RIBASPHERE
RIBATAB
VIRAZOLE
Y
Y
Y
AMITIZA
LOTRONEX
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
LUBIPROSTONE
ALOSETRON
PA
2
2
2
NF-NC
FIBROMYALGIA
NF-NC
2
CYMBALTA
LYRICA
DULOXETINE
PREGABALIN
3
2
AMPYRA
AVONEX
BETASERON
3
2
2
SP
PA
PA
SP
PA
PA
SP
PA
PA
NF-NC
4 SPEC PA
4 SPEC PA
Y
Y
Y
Y
Y
Y
COPAXONE
DALFAMPRIDINE
INTERFERON BETA-1A
INTERFERON BETA-1B
GLATIRAMER
ACETATE
PA
PA
PA
4 SPEC PA
EXTAVIA
INTERFERON BETA-1B
PA
PA
PA
4 SPEC PA
GILENYA
PA, DO
PA, DO
PA, DO
4 SPEC PA, DO
REBIF
FINGOLIMOD
INTERFERON BETA1A/ALBUMIN
FOSRENOL
PHOSLO
RENAGEL
LANTHANUM
CARBONATE
CALCIUM ACETATE
SEVELAMER
QL
QL
MULTIPLE SCLEROSIS
PA
PA
PA
4 SPEC PA
2
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
2
1
2
2
1
2
79
BRAND NAME
GEQ
RENVELA
GENERIC NAME
SEVELAMER
CARBONATE
TIER
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
2
2
ANTINEOPLASTIC - ALL ONCOLOGY DRUGS ARE ON FORMULARY
HYDROXYUREA
2
2
CRIZOTINIB
2
2
VEMURAFENIB
2
2
GROWTH HORMONES
DROXIA
XALKORI
ZELBORAF
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
ONCOLOGY ALL ONCOLOGY DRUGS ARE ON FORMULARY
MEDICAL PRIOR AUTHORIZATION DRUGS AT A ZERO COPAY
GENOTROPIN
HUMATROPE
NORDITROPIN
NUTROPIN
OMNITROPE
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
BOTOX, DYSPORT,
XEOMIN
IMMUNE
GLOBULIN
ORENCIA
REMICADE
RITUXAN
SYNAGIS
BOTULISM TOXIN
TYPE A
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
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PA
PA
PA
M PA
PA
PA
M PA
PA
IVIG
M
M PA
PA
PA
PA
ABATACEPT
M
M PA
PA
PA
PA
INFLIXIMAB
M
M PA
PA
PA
PA
RITUXIMAB
M
M PA
PA
PA
PA
PALIVIZUMAB
M
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM COVERED AT A ZERO COPAY WITH PRESCRIPTION
Y
NA
NA
NA
NA
80
BRAND NAME
YEARS)
OTC NICOTINE
PATCHES
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP
RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NA
81
ALLERGIC RHINITIS
PHARMACOLOGIC STEP PROTOCOL
Symptoms of Allergic Rhinitis
(Sneezing, Itching, Nasal Discharge, Congestion)
Allergen Avoidance Counseling
Seasonal Allergic Rhinitis
Intermittent Symptoms
No Response
Comparison
Generic Flonase
50MCG
Sprays
per
Canister
120
Generic Nasarel
29MCG
200
Generic Nasalide
0.025%
Astepro 0.15%
200
Daily Dosage
Anti-Leukotriene
1.
2.
Adult: 2 sprays per nostril daily
Peds (age 4-12):
1 spray per nostril daily
Adult: 2 sprays per nostril BID
TID
Peds (age 6-14):
2 sprays per nostril BID
or
1 spray per nostril TID
Adult: 1-2 sprays per nostril BID.
(Seasonal 1-2 sprays per nostril
BID or 2 sprays per nostril once
daily. Perennial 2 sprays per
nostril BID)
3.
4.
5.
200
Generic Atrovent
0.03%
345
OTC generic
Loratadine
(Claritin, Alavert)
OTC generic
Loratadine-D
(Claritin-D,
Alavert-D)
Intranasal Steroid
OR
Antihistamine (nasal or oral) or
intranasal ipratropium
Start treatment 10-14 days
before pollen season or at onset of
symptoms
Product
Consistent Symptoms
6.
Intranasal Steroid
OR
Nasal Antihistamine
Breakthrough Symptoms
References:
The Diagnosis and Management of Rhinitis: An
Updated Practice Parameter. J Allergy Clin
Immunology, August 2008; 122; S1-84.
Drugs for Allergic Disorders. Treatment Guidelines
from the Medical Letter, Vol. 5, Issue 60, August
2007.
Diagnosis and Treatment of Respiratory Illness in
Children and Adults. Institute for Clinical Systems
Improvement. January 2011.
Revised 7/2011
82
Insulin
Metformin plus
Lifestyle Intervention (Meal
Planning and Physical Activity)
Intermediate bid
Glycemic
goals not
achieved
Addition of
Oral Agent
OR
Glycemic
goals not
achieved
Addition of
Third Agent **
Addition
of
Insulin
Glycemic
goals not
achieved
Intensify
Insulin
Therapy
Glycemic goals: A1C < 7% or individualize to a goal < 8% based on complex patient factors. Check A1C every 3
months until glycemic goal is met, then at least once every 6 months
** 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* (metformin)
Humulin insulins
Humalog (lispro)
Novolin insulins
Novolog (aspart)
Novolin Penfill
Lantus (insulin glargine)
Apidra (insulin glulisine)
Levemir (insulin detemir)
Thiazolidinediones
Avandia (rosiglitazone)
Actos (pioglitazone)
Combination Products
Reference:
DiabetesCare, vol 34, supplement 1, January 2011
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults. Institute for Clinical Systems Improvement, July 2010
Revised date: 7/2011
83
On
NSAID?
Yes
No
Symptoms
Resolved?
Yes
Alarm
features
present?
No
No further
treatment
No
Select &
perform
H. pylori test
PUD unlikely:
consider another
diagnosis
Test
positive?
No
Yes
Prescribe
H. pylori
eradication
therapy
Refer to specialist
for further evaluation
Yes
Still
symptomatic?
No
Successful
treatment
Yes
Refer to
gastroenterologist
References:
American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J
Gastroenterol 2007; 102:1808-1825.
Revised 7/2011
84
Stage 1
Hypertension
Stage 2
Hypertension
(SBP =140-159 or
DBP =90-99 mmHg)
Thiazide-type diuretics for
most.
May consider ACEI, ARB, BB,
CCB, or combination.
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB, or
combination.
Compelling Indication*
Heart Failure
Postmyocardial infarction
High coronary disease risk
Diabetes
Chronic kidney disease
Recurrent stroke prevention
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.
Diuretics
Beta-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*,
Formulary Drugs
ACE Inhibitors
ARBs
Accupril*,
Aceon*, Altace*
Capoten*,
Lotensin*,
Mavik*
Monopril*,
Univasc*
Vasotec*,
Zestril*
Benicar (HCT)
Cozaar*/Hyaar*
Diovan (HCT)
Dihydropyridine
Calcium Antagonists
Adalat CC*,
Cardene*,
DynaCirc*
Nimotop*,
Norvasc*,
Plendil*,
Procardia XL*,
Sular* (not 10mg)
Tekturna (HCT)
Combination Agents
Azor
(amlodipine/olmesartan)
Exforge
(Diovan/Norvasc)
Lotrel*
(Lotensin/Norvasc)
Valturna
(aliskiren/valsartan)
* 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
85
AMOXICILLIN*
80-90mg/kg/day in three divided doses x 5-10days
Penicillin Allergy:
Azithromycin* 10mg/kg on first day, then 5mg/kg/day on days 2-5 OR
30mg/kg x 1 dose^
Clarithromycin* 15mg/kg/day in two divided doses x 10 days
TMP/SMX* 6-10mg/kg/day of TMP in two divided doses x 10 days
Erythromycin* 20-50mg/kg/day in 2-4 divided doses x 10 days
Children 2 years of age and older without severe symptoms (moderate to severe otalgia and fever >39 C) or with an uncertain
diagnosis
2. When highly-resistant S.pneumoniae is suspected, there is an 80% chance that patients are likely to fail on Bactrim or
Zithromax after failing Augmentin.
3. The prevalence rate of highly drug-resistant S.pneumoniae around Genesee County area is <10%; therefore, high-dose
amoxicillin should be effective in treating more than 90% of S.pneumoniae cases.
4. Ear drops for use in the external ear canal are not recommended for routine treatment of acute otitis media in addition to
oral antibiotics.
References:
Diagnosis and Management of Acute Otitis Media, AAP, published in Pediatrics, May 2004.
University of Michigan Health System (UMHS) Otitis Media Guideline, July 2007.
Revised 7/2011
86
SINUSITIS
PHARMACOLOGIC STEP PROTOCOL
Diagnosis of Sinusitis
Prolonged (at least 7 days) non-specific upper respiratory signs
and symptoms or more severe upper respiratory tract signs
(purulent nasal discharge) and symptoms of facial pain/swelling.
Adult
Amoxicillin* 1gm Q8H x 10 days
Peds
NO
Abx in past
YES
Amoxicillin* 90mg/kg/day divided Q8-12H
x 10 days
NO
Abx in past
4-6 weeks?
Adult:
Penicillin Allergy
TMP/SMX DS (Bactrim DS, Septra DS)*
1BID x 3-10 days
Penicillin or TMP/SMX allergy:
Zithromax* 500 mg daily x 3 days or
Biaxin* 500 mg BID x 10 days
Peds:
If not type I hypersensitivity
Omnicef 14 mg/kg/day or divided BID x 10 days or
Ceftin 30 mg/kg/day divided Q12H x 10 days or
Vantin 10 mg/kg/day divided Q12-24H (max
400mg) x 10 days
If type I hypersensitivity
Biaxin 15 mg/kg/day divided Q12H x 10 days or
Zithromax 10mg/kg x 1, then 5mg/kg/day x 3 days
Mild/Moderate Disease
Adult
Augmentin XR* 2000/125 mg BID x 10 days or
Omnicef* 300mg Q12H x 10 days or 600mg Q24H x
10 days or
Vantin* 200 mg BID x 10 days or
Cefzil* 200-500 mg BID x 10 days
Peds
Augmentin XR* 90mg/kg/day divided Q12H x 10days or
Omnicef *14 mg/kg/day or divided BID x 10 days or
Ceftin* 30 mg/kg/day divided Q12H x 10 days or
Vantin* 10 mg/kg/day divided Q12-24H (max 400mg) x 10
days
*available in generic
#
the use of these medications can be associated with QT prolongation
Adults
Augmentin XR* 2000/125 mg BID x
10 days or
#
Levaquin* 750 mg daily x 5 days or
#
Avelox 400 mg daily x 10 days
Peds
Augmentin XR* 90mg/kg/day divided
Q12H x 10days
YES
Partial Improvement:
Extend duration of treatment to total of 3 weeks
Principles of Treatment:
1. Antibiotics should not be given for viral
sinusitis.
2. Antibiotics are usually not effective in adult
chronic sinusitis. If there is an acute
exacerbation, the recommended drug
treatment is the same as for acute sinusitis.
3. Encourage the patient to complete an entire
course of therapy; 10-14 days of treatment
may be necessary to prevent recurrence.
References:
Acute Sinusitis in Adults, Institute for Clinical Systems Improvement, December 2010
Clinical Practice Guidelines: Adult Sinusitis, Otolaryngol Head Neck Surg, Sep 2007
The Sanford Guide to Antimicrobial Therapy 2010
Revised date: 7/2011
87
Pharmacologic Therapy
Based on symptoms or ACC/AHA and NYHA classification
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^
Drugs
- Diuretics for fluid retention
- Use ACEI or ARB^
- Use Beta-Blockers
Drugs in select patients
- Aldosterone antagonist
- ARB
- Digitalis #
- Hydralazine/Nitrates
Devices in Selected Patients
-Biventricular Pacing
-Implantable Defibrillators
Goals
Appropriate measures under
Stages A, B, and C
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
Coreg* (carvedilol)
Toprol XL* (metoprolol)
Zebeta* (bisoprolol)
References: This guideline is based on the 2009 Focused Update American College of Cardiology/American Heart Association
Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation, April 14, 2009.
Individual patient considerations and advances in medicine may supersede or modify the recommendations.
Revised date:
7/2011
88
SSRI
1. Allow 8-12 weeks for full therapeutic effect Schedule at least 3 follow-up visits during the first 3
months (insomnia or somatic complaint of pain can be part of symptoms for depression)
2. If patient responds, continue antidepressant for at least 6 months for a new episode of depression
3. If NOT responding after 8 weeks at MAXIMUM dose Consider the following alternatives:
Remeron*
Dosing Guideline: Initiate at low dose and gradually increase dose until symptoms of depression are resolved.
Usual Dose Range
Initial Dose
Fluoxetine (Prozac)*
20 mg daily
20 60 mg daily
Citalopram (Celexa)*
20 mg daily
20 60 mg daily
Paroxetine (Paxil or Paxil CR)*
20 mg daily
20 60 mg daily
Sertraline (Zoloft)*
50 mg daily
50 200 mg daily
Mirtazapine (Remeron)*
15 mg QHS
15 45 mg QHS
Venlafaxine (Effexor)*
37.5 mg BID TID
75 225 mg daily (in 2-3 div doses)
Venlafaxine (Effexor XR)*
37.5 mg daily
75 225 mg daily
Bupropion (Wellbutrin)*
100 mg BID
300-450 mg daily (in 2-3 div doses)
Buproprion (Wellbutrin XL)*
150 mg QAM
300-450 mg daily
Buproprion (Wellbutrin SR)*
150 mg QAM
300-400 mg daily
Duloxetine (Cymbalta)
40 mg daily
40-60 mg daily
Desvenlafaxine (Pristiq)
50 mg daily
50 mg daily
Serzone (nefazodone)*
100mg BID
300-600mg daily
*available in generic
References:
1. Practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry 2000;157 (4 Suppl):1-45.
2. Major Depression in Adults in Primary Care. Institute for Clinical Systems Improvement May 2011.
NOTE: Behavioral health medications are carved out to the State for HealthPlus Partners Medicaid and to CMH for MIChild.
Revised 7/2011
89
Simple Analgesics:
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)
Beta-Blocker (e.g., propranolol 40-240 mg/day or Timolol 5-30 mg/day)
Calcium Channel Blocker (e.g., verapamil 120 mg/day) - modest effect
Antidepressant (e.g., TCA, amitriptyline 10-150 mg/day, Doxepin 25-100mg QHS and Nortriptyline 10-150mg QHS)
Anti-epileptic agent (Depakote 500-1250 mg/day or Depacon 500-1250 mg/day, Gabapentin 900-2400mg/day [titrate from 300mg],
Topamax 50-200mg/day [titrate slowly from 15-25mg])
Principles of Treatment
1. Self-care techniques include avoidance of any aggravating factors associated with migraine (e.g., stress, environmental, dietary).
2. HPM formulary anti-migraine agents include: Amerge, Imitrex, and Relpax. Quantities greater than 9 tablets of anti-migraine agents per month require prior
authorization. Non-formulary triptans (Axert, Frova, Maxalt/MLT, Zomig/ZMT, Treximet) require Prior Authorization.
3. Prophylactic treatment is used to reduce the frequency and severity of attacks. Consider using prophylactic treatment when patient has two or more severe migraines
per month with the attacks producing disability for three or more days per month, use of abortive medication more than twice a week, failure of or contraindication to
acute treatments, or presence of uncommon migraine conditions (eg. Prolonged aura, migrainous infarction, hemiplegic migraine).
4. The MIDAS Questionnaire assesses the impact a patients migraine has on their work and social life to aid in their treatment plan. It is available at:
http://www.achenet.org/tools/migraine/index.asp
References:
AAFP/ACP-ASIM release guidelines on the management and prevention of migraines. Am Fam Physician, Mar 2003
Stratified Care vs. Step Care Strategies for Migraine, JAMA Nov 2000
Saper JR, Magee KR. Freedom From Headaches. First Fireside Edition. New York: Simon & Schuster, Inc; 1981
Comparison of Available Triptans, Pharmaceutical Letter/Prescribers Letter, 2009; 25(5); 250509
Diagnosis and Treatment of Headache. Institute for Clinical System Improvement. January 2011.
NOTE: Behavioral health medications are carved out to the State for HealthPlus Partners Medicaid and to CMH for MIChild.
Revised date: 7/2011
90
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**#
DOSE
Generic Mevacor*
(lovastatin)
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
20 mg
40 mg
80 mg
10 mg
20 mg
40 mg
80 mg
10 mg
10/10
10/20
10/40
10/80#
500/20
750/20
1000/20
Generic
Pravachol*(pravastatin)
Generic Zocor*
(simvastatin)
Crestor
(rosuvastatin)
Lescol
(fluvastatin)
Lescol XL(fluvastatin)
Lipitor
(atorvastatin)
Zetia+ (ezetimibe)
Vytorin
(ezetimibe/simvastatin)
Simcor
(ER niacin + simvastatin)
LDL
1.
21%
24%
30%
22%
32%
34%
37%
26%
30%
38%
28- 41%
36- 47%
28- 45%
45- 52%
31- 55%
43- 63%
22%
24- 25%
33- 35%
27- 39%
30-43%
50%
41- 60%
20%
46%
52%
56%
60%
--11.9%
2.
3.
4.
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]
References:
1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults, September 2001.
2. US Drug Product Labeling.
3. Implications of recent clinical trials for the National Cholesterol Education Program ATP III Guidelines. J Am Coll
Cardiol, Aug 2004
Revised date: 7/2011
91
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
92
Drug Name
HalfLife
(hr)
2-4h
Recommended
Starting Dose
650mg q4-6h
Maximum
Recommended
Dose (mg/day)
4000mg
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
Note:
93
Consider PPI (i.e., generic Prilosec RX 20mg) for patients with risk of GI bleed requiring long-term NSAID
therapy.
Equianalgesic
Dose (mg)
Plasma
Half-Life
(hr)
NA
(see Table 3)
Usual
Starting Dose
Usual Dosing
Frequency
(hr)
Notes
30mg
4 6h
200mcg
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.
94
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), propoxyphene (little analgesic effect, 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.
95
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 5/500 6 tabs /
day
Lorcet 10/650
6 tabs / day
Lortab 10/500
8 tabs / day
Zydone 10/400
10 tabs / day
Norco 10/325
12 tabs / day
Oxycodone
Total daily dose
Morphine
Equivalent dose per DAY
20 mg
30 mg
40 mg
60 mg
53.3 mg
80 mg
66.7 mg
100 mg
80 mg
120 mg
96
Acetaminophen
(Tylenol) mg/tab
Other Ingredient(s)
Anexsia
Anexsia
660 mg
650 mg
hydrocodone 10 mg
hydrocodone 7.5 mg
Anexsia
500 mg
hydrocodone 5 mg
Anexsia
325 mg
hydrocodone 5 mg
12
Anexsia
325 mg
hydrocodone 7.5 mg
12
Bancap HC
500 mg
hydrocodone 5 mg
Co-gesic
500 mg
hydrocodone 5 mg
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
Endocet 7.5-500
500 mg
oxycodone 7.5 mg
Endocet 10-650
650 mg
oxycodone 10 mg
Fioricet w/ codeine
325 mg
12
Lorcet 10-650
650 mg
butalbital/caffeine/ codeine
30 mg
hydrocodone 10 mg
Lorcet HD
500 mg
hydrocodone 5 mg
Lorcet Plus
650 mg
hydrocodone 7.5 mg
Lortab 2.5-500
500 mg
hydrocodone 2.5 mg
Lortab 7.5-500
500 mg
hydrocodone 7.5 mg
Lortab 10-500
500 mg
hydrocodone 10 mg
Lortab
500 mg
hydrocodone 5 mg
Maxidone
750 mg
hydrocodone 10 mg
Margesic H
500mg
hydrocodone 5 mg
Norco
325 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 10-650
650 mg
oxycodone 10 mg
Percocet 2.5-325
325 mg
oxycodone 2.5 mg
12
Percocet 7.5-500
500 mg
oxycodone 7.5 mg
Roxicet
325 mg
oxycodone 5 mg
12
Roxicet
Talacen
500 mg
650 mg
oxycodone 5 mg
pentazocine 25 mg
8
6
6
4
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
Tylox
500 mg
oxycodone 5 mg
Ultracet
325 mg
tramadol 37.5 mg
12
Vicodin
500 mg
hydrocodone 5 mg
Vicodin ES
750 mg
hydrocodone 7.5 mg
Vicodin HP
660 mg
hydrocodone 10 mg
Xodol
300 mg
hydrocodone 10 mg
12
Zydone
400 mg
hydrocodone 5 mg
10
Zydone
400 mg
hydrocodone 7.5 mg
10
Zydone
400 mg
hydrocodone 10 mg
10
97
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 (Suboxone). (Table 6)
98
3-day schedule
4+8 (stat and 24h)
8 (48h)
8 (72h)
99
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)
Non-formulary
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)
100
Drug
AS-NEEDED MEDS
Tramadol (Ultram);
(Ultram ER)
Ultracet)
Oxycodone
w/ Acetaminophen
(Percocet/Tylox)
w/Ibuprofen
(Combunox)
with Aspirin
(Percodan)
Formulary
Status
Formulary
Formulary
PA Required
Formulary
PA Required
for Partners
Medicaid
Formulary
Dosage
*Approved by the U.S. Food and Drug Administration for treatment of neuropathic pain
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. 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. 4th Ed. Institute for Clinical Systems Improvement. pp. 64-5, 67. November
2009
6.
7.
8.
9.
10.
11.
12.
101
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
102
PHQ-2
Depression
Screening
PHQ-9
MDQ
Zung
103
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
104
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
Nicorette Gum
Nicotine Patches
Nix (permethrin cream rinse)
Pepto-Bismol caplet, chewable, suspension
Peri-Colace (docusate sodium w/ casanthranol) 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.
105
STATUS
APPENDIX C
Patient Name:
Height:
Weight:
DAW
BMI:
Exception Request
Medically Urgent
Exception Request
DEA#:
Office Phone: (_____)
Pharmacy Phone:
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:
For HealthPlus Use Only
Request Date & Time:
LOB:
MR
Non-Urgent Request:
Urgent Request:
CPT Review Time
RPh Review Time
Med Dir Review Time
Comments:
Approved
Partial Approval
Denied
Approved by:
Reason for Denial:
Effective Date:
End Date:
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.
106
QTY
LIMIT
CRITERIA
ADD Medications
Vyvanse
(lisdexamfetamine dimesylate)
Strattera (atomoxetine)
Focalin/XR
(dexmethylphenidate)
Metadate CD
(methylphenidate ER)
Ritalin LA
(methylphenidate ER)
Daytrana
(methylphenidate patch)
Intuniv (guanfacine)
Allergy Medications
Accolate (zafirlukast)
Clarinex (desloratadine)
Xyzal
(levocetirizine dihydrochloride)
Clarinex
and Xyzal
are limited
to a qty of
30 units
per month
107
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
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.
Beconase AQ
(beclomethasone dipropionate)
Nasonex
(mometasone furoate)
Omnaris (ciclesonide)
Rhinocort Aqua (budesonide)
Veramyst (fluticasone furoate)
Analgesics
Fentora
(fentanyl citrate buccal tablet)
Onsolis (fentanyl soluble film)
Qty is
limited to
60 units
per 30
days
Qty is
limited to
30 units
per 30
days
All acetaminophen-containing
narcotic analgesics
108
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Analgesics, continued
Oxycontin (oxycodone)
Qty is
limited to
30 units
per 30
days
All ARBs
except
Cozaar
(not
combos)
are
limited to
a qty of
30 units
per month
Anti-Anxiety
On Formulary with PA:
Niravam (alprazolam)
Xanax XR (alprazolam)
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. 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.
New Starts Only
109
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
Antibiotics
Adoxa CK (doxycycline kit)
Adoxa TT (doxycycline kit)
Oracea
(doxycycline monohydrate)
Keflex 750mg
(cephalexin monohydrate)
Moxatag ER
(amoxicillin trihydrate)
Minocin PAC (minocycline kit)
Factive
(gemifloxacin mesylate)
Limited to
a qty of
30 units
per month
Limited to
a qty of
30 units
per month
110
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.For
MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Antidepressants, continued
Wellbutrin XL
(bupropion, ext. release)
Limited to
a qty of
30 units
per month
Antiemetic
Zuplenz (ondansetron)
Antiplatelet
Effient (prasugrel)
Antipsychotics, Atypical
Abilify (aripiprazole)
Zyprexa/Zydis (olanzapine)
Limited to
a qty of
30 units
per month
Asthma/COPD
Proventil HFA (albuterol)
Xopenex/HFA (levalbuterol)
Geodon (ziprasidone)
Risperdal (risperidone)
Seroquel (quetiapine fumarate)
Beta Blockers
Bystolic (nebivolol)
CRITERIA
Limited to
a qty of
30 units
per month
111
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.For
MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Cardizem LA
(diltiazem, long-acting)
Cholesterol Medications
On Formulary with PA:
Crestor (rosuvastatin)
Lescol/XL (fluvastatin)
Lipitor (atorvastatin)
Simcor
(niacin ext. release/simvastatin)
Vytorin (ezetimibe/simvastatin)
Non-Formulary with PA:
Advicor (lovastatin/niacin)
Altoprev (lovastatinSR)
Caduet
(atorvastatin/amlodipine)
Livalo (pitavastatin calcium)
Lovaza
(omega-3-acid ethyl esters)
Antara
(fenofibrate, micronized)
Fenoglide (fenofibrate)
Lipofen (fenofibrate)
Tricor (fenofibrate, micronized)
Triglide (fenofibrate)
Trilipix (fenofibric acid)
On Formulary with PA:
Zetia (ezetimibe)
CRITERIA
All HMGs
are
limited to
a qty of
30 units
per month
112
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.For
MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Lidoderm (lidocaine)
Vusion
(miconazole nitrate/zinc oxide)
All Branded Topical Antifungal
Agents
Ertaczo
(sertaconazole nitrate)
Exelderm (sulconazole nitrate)
Lamisil Soln
(terbinafine soln)
Mentax (butenafine)
Naftin (naftifine)
Oxistat (oxiconazole nitrate)
Pediaderm AF
(nystatin/emollient)
Terbinex
(terbinafine/hydroxychitosan)
Tersi (selenium sulfide)
Xolegel (ketoconazole)
All Branded Topical
Clindamycin Products
Clindagel 1% Gel (clindamycin)
All Brand Benzoyl Peroxide
Combination Products
Acanya 1.2%-2.5%
(clindamycin/benzoyl peroxide)
Benzaclin 1%-5% Gel (pump)
(clindamycin/benzoyl peroxide)
Benzamycin Pak 3%-5% Gel
(erythromycin base/benzoyl
peroxide)
Benzaclin Care Kit 1%-5%
pump (clindamyxin/benzoyl
peroxide/hyaluronic acid)
QTY
LIMIT
CRITERIA
1. The patient must have a documented trial or Rx claims for at
least two generically available oral contraceptives in the past
year before any brand product will be covered.
113
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
1. The patient must have documented failure or Rx claim(s) for a
generic benzoyl peroxide product (e.g., Benzac, Bevoxyl,
Benziq) AND a generic tretinoin (e.g., Avita, Retin-A).
114
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Dermatologicals, continued
Cutivate 0.05% Lotion
(fluticasone propionate)
Kenalog 0.147mg/g Aerosol
Spray (triamcinolone acetonide)
Luxiq 0.12% Foam
(betamethasone valerate)
Pandel 0.1% Cream
(hydrocortisone probutate)
Pediaderm TA (triamcinolone)
Cloderm 0.1% Cream
(clocortolone pivalate)
Cordran 0.05% Lotion
(flurandrenolide)
Cordran SP 0.05% Cream
(flurandrenolide)
Locoid 0.1% Lotion
(hydrocortisone butyrate)
Desonate 0.05% Gel (desonide)
Verdeso 0.05% Foam
(desonide)
CRITERIA
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g.,
Elocon, Westcort and Synalar) in the past 60 days.
Desowen Combo
(desonide/emollient)
Protopic (tacrolimus)
Dovonex (calcipotriene)
Taclonex
(betamethasone/calcipotriene)
Vectical (calcitriol)
Diabetes
Fortamet (metformin)
Glumetza (metformin)
Kombiglyze XR
(saxagliptin/metformin er)
Onglyza (saxagliptin)
Safety
limited to
a qty of <
100g per
7 days
Safety
limited to
a qty of <
200g per
7 days
Limited to
a qty of
30 units
per month
115
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
All ED
meds are
limited to
a qty of 6
units per
month
Genitourinary Medications
Detrol LA
(tolterodine, long-acting)
Ditropan XL
(oxybutynin, sust. release)
Enablex
(darifenacin hydrobromide)
Toviaz (fesoterodine)
Vesicare (solifenacin)
Rapaflo (silodosin)
Infertility
All medications for infertility
(subject to the members benefit).
All ED
meds are
limited to
a qty of 6
units per
month
Limited to
a qty of
30 units
per month
CRITERIA
PRIOR AUTHORIZATION IS ONLY REQUIRED IN THE
FOLLOWING INSTANCES:
1. If the patient <35, the patient must have a documented
diagnosis of ED OR a history of ED with contributing OR
concomitant disease state.
2. If the patient has a history of nitrate use, and the physician
is prescribing Cialis, Levitra, or Viagra:
Criteria:
a. The physician must submit a written request
stating that the patient is no longer using
nitrates.
**Request must be on physician letterhead with physician's
signature**
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.
116
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
All
triptans
combined
is limited
to a qty of
9 tablets
per month
Miscellaneous
Cardura XL
(doxazosin mesylate ext. release)
Lyrica (pregabalin)
Nuvigil (armodafinil)
Provigil (modafinil)
Uloric (febuxostat)
Muscle Relaxants
Skelaxin (metaxalone)
Zanaflex capsules (tizanidine)
Limited to
a qty of
30 units
per month
CRITERIA
1. The patient must have documented failure or Rx claims for all
formulary alternatives (i.e., Amerge, Imitrex, and Relpax), or
formulary alternatives must be inappropriate with chart
documentation provided.
NOTE: Formulary triptans are limited to nine tablets (cumulative
with all oral products) or two injections per month.
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.
1. The patient must have documented failure or Rx claim in the
past year for a generically available alpha 1-adrenergic
antagonist (i.e., Cardura or Hytrin).
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).
2. For Provigil, the patient must have documented failure or
prescription claims for Nuvigil (armodafinil) in the past year.
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. Patient must have documented failure or prescription claims
with allopurinol, OR
2. The patient cannot tolerate therapeutic doses or is not an
appropriate candidate for allopurinol based on documentation
provided.
1. The patient must have documented failure or Rx claims in the
past 90 days for all generic prescription muscle relaxants (i.e.,
Flexeril, Norflex, Parfon Forte, Robaxin, Lioresal, Zanaflex
tablets, etc).
117
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Vimovo
(esomeprazole/naproxen)
QTY
LIMIT
All Cox-2
drugs and
Mobic are
limited to
a qty of
30 units
per month
CRITERIA
1. Documented indication for acute or chronic treatment of the
signs and symptoms of osteoarthritis or rheumatoid arthritis,
AND
2. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
3. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following
risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
4. Active ulcer or recent documented history of ulcer (within 6
months) on history of GI bleed/perforation.
1. The patient must have a documented diagnosis of arthritis,
AND
2. The patient must be high risk for developing GI complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous
ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy
3. The patient must fail all formulary proton pump inhibitor
alternatives (i.e., Omeprazole, Aciphex, generic Prevacid,
generic Protonix) in combination with generic naproxen.
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
2. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
3. Active ulcer or recent documented history of ulcer (within 6
months) or history of GI bleed/perforation.
118
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Voltaren Gel
(diclofenac sodium)
Ophthalmic Products
On Formulary with PA:
Patanol (olopatadine)
Non-Formulary with PA:
Ketotifen Rx
All Brand Topical Ophthalmic
Antihistamines
Alamast
(pemirolast potassium)
Alocril (nedocromil sodium)
Alomide
(lodoxamide tromethamide)
Bepreve
(bepotastine besilate)
Elestat
(epinastine hydrochloride)
Emadine
(emedastine difumarate)
Lastacaft (alcaftadine)
Pataday (olopatadine)
Betimol (timolol)
Istalol (timolol maleate)
QTY
LIMIT
CRITERIA
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic oral
NSAID medications.
2. If the patient fails therapy with at least two generic oral
NSAID alternatives, then the patient must have documented
failure or Rx claims for an adequate course of therapy with
commerically available Voltaren gel, with Prior Authorization
required.
NOTE: Similar to the criteria for all branded NSAIDs, special
consideration is given to high risk or elderly patients who may
not be able to tolerate oral NSAIDs.
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.).
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.), and one must be
generic Voltaren. Adequate course of therapy is defined as a
full therapeutic dose on a scheduled basis for at least 1-2
weeks.
1. The patient must have documented failure or Rx claim for
generic OTC Zaditor (covered with a written prescription) in
the past 90 days.
119
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
Ophthalmic Products,
continued
Lumigan 0.01% and 0.03%
(bimatoprost)
Travatan-Z (travoprost)
Otic Products
Floxin Otic Singles (ofloxacin)
Proton Pump Inhibitors
On Formulary with PA:
Aciphex (rabeprazole)
Generic Prevacid (lansoprazole)
Non-Formulary with PA:
Dexilant (dexlansoprazole)
Nexium (esomeprazole)
Prilosec DR Susp (omeprazole
magnesium)
Zegerid (omeprazole)
All PPIs
are limited
to a qty of
30
tabs/caps
per month
CRITERIA
1. The patient must have documented failure or prescription
claims for a generic prostaglandin analog (i.e., generic
Xalatan).
2. If the patient fails treatment with all generic prostaglandin
analogs, then Lumigan 0.01% is the second-line formulary
alternative with prior authorization required.
3. The patient must have documented dailure or prescription
claims for all formulary alternatives (generic Xalatan AND
branded Lumigan 0.01%) before a non-formulary brand drug
will be approved.
1. The patient must have documented failure or Rx claim with
an adequate course of therapy with generic Floxin Otic
Solution.
1. The patient must have documented failure or Rx claims for
omeprazole and generic Protonix.
2. If the patient fails treatment with omeprazole and generic
Protonix, then Aciphex and generic Prevacid are second-line
alternatives with prior authorization required.
3. The patient must fail all formulary alternatives based on
documentation or Rx claims before a non-formulary PPI will
be approved, AND
4. Specifically for Nexium, the patient must have a current
documented diagnosis of Barrett's Esophagus, ZollingerEllison or Erosive Esophagitis. Approved automatically for
children under 2 years of age.
5. Specifically for Dexilant, the patient must have a current
documented diagnosis of Erosive Esophagitis.
NOTE: OTC Prilosec is no longer covered; generic Rx omeprazole is preferred.
Sleeping Aids
Edluar SL (zolpidem)
Lunesta (eszopiclone)
Rozerem (ramelteon)
Silenor (doxepin)
Ambien/CR (zolpidem)
Restoril (temazepam)
Sonata (zaleplon)
Smoking Cessation
All prescription nicotine patches
Chantix (varenicline)
Quantity is
limited to
30 per
month
120
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
1. The patient must discontinue use of all other narcotic
analgesics.
2
121
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, 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 the
difference in cost between the brand and generic product
plus their usual co-payment.
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.
122
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Name
Concern
Alternative Treatment
Diazepam (Valium)
Fall risk
Cyclobenzaprine (Flexeril)
Estrogens (Premarin)
Breast/Endometrial cancer;
not cardio protective
Promethazine-Codeine
Promethazine (Phenergan)
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Thyroid USP
Dicyclomine (Bentyl)
Methocarbamol (Robaxin)
Hydroxyzine
(Vistaril, Atarax)
123
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
Name
Concern
Carisoprodol (Soma)
Alternative Treatment
Physiotherapy; correct seating & footwear
Orphenadrine (Norflex)
Chlorzoxazone (Parafon
Forte DSC)
Diphenoxylate-Atropine
(Lomotil)
Hyoscyamine (Hyomax-SL,
Hyomax-SR, Hyomax-FT)
Methylphenidate
(Methylin/ER)
Chlordiazepoxide (Librium)
Trimethobenzamide (Tigan)
Ketorolac (Toradol)
GI bleeding
Zofran, Kytril , Compazine or Reglan (avoid longterm use and avoid in Parkinsons disease)
2
2
Tylenol , Motrin , Vicodin
Drug may require prior authorization or may have limited coverage depending on members benefit plan
2
Available OTC
124
These criteria apply to all HealthPlus Commercial lines of business except as noted, and may also apply to PPO benefits.
For MIChild, all behavioral health medications and services, except for ADHD, are carved out to CMH.
QTY
LIMIT
CRITERIA
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 Brand Benzoyl Peroxide
Products
Benzig LS Gel (benzoyl
peroxide/aloe)
Breze (benzoyl peroxide/cnclr)
Clinac BPO (benzoyl peroxide)
Delos (benzoyl peroxide)
Inova (benzoyl peroxide)
Neobenz Micro Plus Pack
Cream (benzoyl peroxide
microspheres)
Pacnex HP (benzoyl peroxide)
Pacnex Mix Cleanser (benzoyl
peroxide with aloe/green tea)
Soluclenz Rx
(benzoyl peroxide)
Triaz (benzoyl peroxide)
Zacare
(benzoyl peroxide/hyaluront)
All Branded Benzoyl Peroxide
Combination Products
Acanya 1.2%-2.5%
(clindamycin/benzoyl peroxide)
Benzaclin 1%-5% Gel (pump)
(clindamycin/benzoyl peroxide)
Benzamycin Pak 3%-5% Gel
(erythromycin base/benzoyl
peroxide)
Benzaclin Care Kit 1%-5% pump
(clindamyxin/benzoyl
peroxide/hyaluronic acid)
125
QTY
LIMIT
Acne, continued
All Brand Tretinoin Products
Atralin (tretinoin)
Retin A Liquid (tretinoin)
Retin A Micro (tretinoin)
Tretin-X (tretinoin)
Veltin (tretinoin/clindamycin)
Ziana (tretinoin/clindamycin)
Allergy Medications
Accolate (zafirlukast)
Allegra (fexofenadine)
Allegra 180mg (fexofenadine)
Allegra-D
(fexofenadine/pseudoephedrine)
Clarinex-D
(desloratadine/pseudoephedrine)
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.
Qty is
limited to
30 units
per
month for
Allegra
180
Clarinex
and
Xyzal are
limited to
a qty of
30 units
per
month for
126
QTY
LIMIT
Allergy Medications,
continued
All Brand Nasal Steroids
Beconase AQ
(beclomethasone dipropionate)
Nasonex
(mometasone furoate)
Omnaris (ciclesonide)
Rhinocort Aqua (budesonide)
Veramyst (fluticasone furoate)
Analgesics
On Formulary with PA:
Actiq (fentanyl citrate oral
transmucosal)
Non-Formulary with PA:
Fentora
(fentanyl citrate buccal tablet)
Onsolis (fentanyl soluble film)
All acetaminophen-containing
narcotic analgesics
Kadian
(morphine sulfate, sustained
release)
Qty limit
of 60
units per
30 days
Qty limit
of 1
patch per
72 hours
OxyContin (oxycodone)
Qty limit
60 in 30
days
Qty is
limited to
30 units
per 30
days
Qty is
limited to
60 units
per 30
days
Opana ER (oxymorphone)
CRITERIA
127
QTY
LIMIT
CRITERIA
Analgesics, continued
Reprexain
(ibuprofen/hydrocodone)
Ultracet
(tramadol/acetaminophen)
Qty is
limited to
30 units
per 30
days
All Non-Formulary
Angiotensin II Receptor
Blockers
Atacand (candesartan cilexetil)
Atacand HCT
(candesartan/HCTZ)
Avalide (irbesartan HCT)
Avapro (irbesartan)
Micardis (telmisartan)
Micardis HCT (telmisartan)
Teveten (eprosartan mesylate)
Teveten HCT
(eprosartan mesylate)
Twynsta
(telmisartan/amlodipine)
Edarbi (azilsartan medoxomil)
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
Antibiotics
Adoxa CK (doxycycline kit)
Adoxa TT (doxycycline kit)
Oracea
(doxycycline monohydrate)
Moxatag ER (amoxicillin
trihydrate)
Keflex 750mg
(cephalexin monohydrate)
128
QTY
LIMIT
Antibiotics, continue
Avelox (moxifloxacin)
Factive (gemifloxacin)
CRITERIA
Limited
to a qty
of 30
units per
month
Antiemetic
Zuplenz (ondansetron)
Anti-Nausea
Anzemet
(dolasetron mesylate)
Antiplatelet
Effient (prasugrel)
Asthma/COPD
Proventil HFA (albuterol)
Xopenex/HFA (levalbuterol)
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
129
QTY
LIMIT
Cardizem LA
(diltiazem, long-acting)
Cholesterol Medications
On Formulary with PA:
Crestor (rosuvastatin)
Lescol/XL (fluvastatin)
Lipitor (atorvastatin)
Simcor
(niacin ext. release/simvastatin)
Vytorin (ezetimibe/simvastatin)
All HMGs
are
limited to
a qty of
30 units
per
month
CRITERIA
1. The patient must have documented failure on immediate
release isradipine of equivalent dose and attempted at least
one dose increase AND
2. The patient must have documented failure/contraindication
to three generically available dihydropyridine CCB agents
(e.g., nisoldipine, nifedipine, amlodipine, nicardipine,
felodipine) in the past year.
1. The patient must have documented failure or Rx claims for
at least two generically available formulary alternatives (e.g.,
Cardizem CD, Cardizem SR, Dilacor XR).
1. The patient must have documented failure or Rx claim(s) for
generic Zocor, OR
2. The patient is currently receiving a medication that
potentiates simvastatin levels (i.e., itraconazole,
ketoconazole, HIV protease inhibitors, erythromycin,
gemfibrozil, cyclosporine, amiodarone, verapamil, diltiazem,
amlodipine, ranolazine).
Lovaza
(omega-3-acid ethyl esters)
Antara
(fenofibrate, micronized)
Fenoglide (fenofibrate)
Lipofen (fenofibrate)
Tricor (fenofibrate, micronized)
Triglide (fenofibrate)
Trilipix (fenofibric acid)
On Formulary:
Zetia (ezetimibe)
130
QTY
LIMIT
Contraceptives
All Brand Oral Contraceptives
Femcon Fe
LoEstrin 24 Fe 1/20
LoSeasonique
Natazia
Ortho Tri-Cyclen Lo
Ovcon-50
Safyral
Contraceptives, continued
NuvaRing
Ortho Evra
Dental Medications
Prevident 1.1%
(sodium fluoride)
Prevident 5000
(sodium fluoride)
Sensitive 1.1%-5%
(sodium fluoride)
Dermatologicals
On Formulary with PA:
Elidel (pimecrolimus)
Dovonex
is safety
limited to
a qty of <
100g per
7 days
Protopic (tacrolimus)
Taclonex
(betamethasone/calcipotriene)
Vectical (calcitriol)
Aldara (imiquimod)
Ovide (malathion)
Lidoderm Patch (lidocaine)
Umecta (urea)
Umecta PD (urea)
CRITERIA
131
Topical Steroids
Olux-Olux-E
(clobetasol propionate/emollient)
Cutivate
(fluticasone propionate)
Kenalog Aerosol Spray
(triamcinolone acetonide)
Luxiq
(betamethasone valerate)
Pandel
(hydrocortisone probutate)
Desowen Combo
(desonide/emollient)
QTY
LIMIT
CRITERIA
1. The patient must have documented failure and Rx claims for
four generic antifungals (e.g., Loprox, Nizoral, Spectazole
and Grifulvin V).
132
QTY
LIMIT
CRITERIA
Dermatologicals, continued
All Other Brand Topical
Steroids
Analpram
(hc acetate/pramoxine)
Apexicon
(diflorasone diacetate)
Clobex (clobetasol propionate)
Cloderm (clocortolone pivalate)
Cordran/SP (flurandrenolide)
Desonate (desonide)
Locoid
(hydrocortisone butyrate)
Momexin (mometasone
furoat/ammonium lac)
Pediaderm HC 2% Kit
(hydrocortisone/emollient)
Pediaderm TA
(triamcinolone/emollient)
Ultravate PAC
(halobetasol prop/
ammonium lac)
Vanos (fluocinonide)
Verdeso (desonide)
Diabetes
Apidra Solostar Pen
(insulin glulisine)
Insulin Prefilled Pens
Insulin Penfills
Levemir Flexpen
(insulin detemir)
Fortamet (metformin)
Glumetza (metformin)
Kombiglyze XR
(saxagliptin/metformin er)
Onglyza (saxagliptin)
Endometriosis
Lupron Depot 3.75 Kit
(leuprolide acetate)
Limited to
a qty of
30 units
per
month
1. Confirmation of diagnosis.
Note: Not covered for infertility (infertility services are
excluded).
133
QTY
LIMIT
Hormone Replacement
Cenestin
(estrogens, conj synthetic)
Premarin
(conjugated estrogens)
Prempro
(conj estrogens/medroxypro)
Prometrium (progesterone)
Enjuvia
(conjugated estrogen, synthetic)
Migraine Medications
Axert (almotriptan)
Frova (frovatriptan)
Maxalt/MLT
(rizatriptan benzoate)
Treximet
(sumatriptan/naproxen)
Zomig/ZMT (zolmitriptan)
Miscellaneous
Cantil (mepenzolate bromide)
Cardura XL (doxazosin
mesylate ext. release)
Inspra (eplerenone)
Ranexa (ranolazine)
Nitroglycerin Patches
On Formulary with PA:
Revatio (sildenafil)
Non-Formulary with PA:
Adcirca (tadalafil)
CRITERIA
134
QTY
LIMIT
Miscellaneous, continued
On Formulary with PA:
Savella (milnacipran)
Clindesse
(clindamycin phosphate)
Gynazole
(butoconazole nitrate)
Thyrolar (liotrix)
Amitiza (lubiprostone)
Muscle Relaxants
Skelaxin (metaxalone)
Zanaflex capsules (tizanidine)
Excluded:
Soma (carisoprodol)
Limited to
a qty of
30 units
per
month
CRITERIA
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. The patient must have documented treatment failure or Rx
claims with generic vaginal clindamycin for each episode.
1. The patient must have documented treatment failure or Rx
claims with generic vaginal: clotrimazole, miconazole,
terconazole AND generic oral Diflucan.
1. The patient must have documented failure or Rx claims for
at least two generically available thyroid preparations in the
past year.
1. The patient must have documented treatment failure with at
least 2 generic/OTC cathartics (e.g., bisacodyl, ducusate
sodium, lactulose, mineral oil, etc) OR
2. A documented D(x) of constipation predominant IBS.
1. The patient must have documented contraindication or
treatment failure or Rx claims with two generic polyethylene
glycol.electrolyte powders (e.g., Coylte, Golytely, Nulytely
and Trilyte).
1. Patient must have documented failure or prescription claims
with allopurinol, OR
2. The patient cannot tolerate therapeutic doses or is not an
appropriate candidate for allopurinol based on
documentation provided.
1. The patient must have documented failure or Rx claims in
the past 90 days for all generic prescription muscle relaxants
(i.e., Flexeril, Norflex, Parfon Forte, Robaxin, Lioresal,
Zanaflex tablets, etc).
NOTE: Soma is not covered, based on the Michigan Medicaid
Formulary.
135
Vimovo
(esomeprazole/naproxen)
QTY
LIMIT
Cox-2
drugs and
Mobic are
limited to
a qty of
30 units
per
month
CRITERIA
1. Documented indication for acute or chronic treatment of the
signs and symptoms of osteoarthritis or rheumatoid arthritis,
AND
2. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
3. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following
risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
4. Active ulcer or recent documented history of ulcer (within 6
months) or history of GI bleed/perforation.
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
2. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following
risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
3. Active ulcer or recent documented history of ulcer (within 6
months) on history of GI bleed/perforation.
1. The patient must have a documented diagnosis of arthritis,
AND
2. The patient must be high risk for developing GI
complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous
ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy
3. The patient must fail all formulary proton pump inhibitor
alternatives (i.e., Omeprazole, Aciphex, generic Prevacid,
generic Protonix) in combination with generic naproxen.
136
Voltaren Gel
(diclofenac sodium)
Ophthalmic Products
On Formulary with PA:
Patanol (olopatadine)
Non-Formulary with PA:
Ketotifen Rx
All Brand Topical Ophthalmic
Antihistamines
Alamast
(pemirolast potassium)
Alocril (nedocromil sodium)
Alomide
(lodoxamide tromethamide)
Bepreve
(bepotastine besilate)
Elestat
(epinastine hydrochloride)
Emadine
(emedastine difumarate)
Lastacaft (alcaftadine)
Pataday (olopatadine)
Acular 0.5%
(ketorolac tromethamine)
Restasis (cyclosporine)
Alphagan P 0.1% (brimonidine
tartrate)
QTY
LIMIT
CRITERIA
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic oral
NSAID medications.
2. If the patient fails therapy with at least two generic oral
NSAID alternatives, then the patient must have
documented failure or Rx claims for an adequate course of
therapy with commerically available Voltaren gel, with Prior
Authorization required.
NOTE: Similar to the criteria for all branded NSAIDs, special
consideration is given to high risk or elderly patients who may
not be able to tolerate oral NSAIDs.
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.).
1. The patient must have documented failure or Rx claims for
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.), and one must be
generic Voltaren. Adequate course of therapy is defined as
a full therapeutic dose on a scheduled basis for at least 1-2
weeks.
1. The patient must have documented failure or Rx claim for
generic OTC Zaditor (covered with a written prescription) in
the past 90 days.
137
Osteoporosis
Actonel (risedronate sodium)
Boniva (ibandronate 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)
Floxin Otic Singles (ofloxacin)
QTY
LIMIT
CRITERIA
1. The patient must have documented failure or Rx claim for at
least one generic formulary topical ophthalmic steroid (e.g.,
Pred Forte, Inflamase Forte, FML suspension).
1. The patient must have documented failure or Rx claim for at
least one generic Timolol (e.g., Timoptic) ophthalmic
product.
1. The patient must have documented failure or Rx claims for
at least two formulary topical ophthalmic NSAIDs (e.g.,
generic Voltaren, generic Ocufen, Acular, Acular LS) before
any other topical ophthalmic NSAIDs will be covered.
138
Smoking Cessation
All prescription nicotine patches
QTY
LIMIT
All PPIs
are
limited to
a qty of
30
tabs/caps
per
month
Limited
to 1
course of
therapy
per year
Chantix (varenicline)
Ulcerative Colitis
Dipentum (olsalazine sodium)
Pentasa (mesalamine)
Urology
Gelnique (oxybutynin chloride)
Oxytrol Patch (oxybutynin)
Rapaflo (silodosin)
Detrol LA
(tolterodine, long-acting)
Ditropan XL
(oxybutynin, sust. release)
Enablex
(darifenacin hydrobromide)
Toviaz (fesoterodine)
Vesicare (solifenacin)
CRITERIA
139
QTY
LIMIT
CRITERIA
1. The patient must have documented failure or Rx claim for
at least one generic prenatal vitamin in the past 90 days.
140
QTY
LIMIT
CRITERIA
1. The benefit covers generic/specific OTC 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 the
entire cost of the prescription.
141
Name
Concern
Cyclobenzaprine (Flexeril)
Estrogens (Premarin)
Breast/Endometrial cancer;
not cardio protective
Promethazine-Codeine
Promethazine (Phenergan)
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Thyroid USP
Alternative Treatment
Physiotherapy: Correct seating or footwear
Spasticity: Baclofen, Zanaflex, treat underlying
problems
Hot flashes: non-pharmacological therapy, Zoloft,
Paxil, Effexor
Bone density: Calcium with vitamin D, Fosamax,
1
1
Boniva , Evista
1,2
1
1
Antihistamine: Claritin , Allegra , Clarinex
1
1
Antiemetic: Antivert, Zofran , Kytril
Depends on site of infection, culture, and
sensitivity.
1
Bactrim, Vibramycin, Azithromycin, Fluoroquinolone
Levothyroxine (LT4): Synthroid, Levoxyl
Dicyclomine (Bentyl)
Methocarbamol (Robaxin)
Hydroxyzine
(Vistaril, Atarax)
142
Name
Concern
Carisoprodol (Soma)
Alternative Treatment
Physiotherapy; correct seating & footwear
Orphenadrine (Norflex)
Chlorzoxazone (Parafon
Forte DSC)
Diphenoxylate-Atropine
(Lomotil)
Hyoscyamine (Hyomax-SL,
Hyomax-SR, Hyomax-FT)
Trimethobenzamide (Tigan)
Ketorolac (Toradol)
GI bleeding
1
2
Drug may require prior authorization or may have limited coverage depending on members benefit plan
Available OTC
143
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Criteria
Diagnosis of OA of the knee(s):
1. Documented failure of, or contraindication
to acetaminophen and at least one NSAID
or other analgesics; AND
2. Documented failure of, or contraindication
to intra-articular steroid treatment.
Duration of Approval
Notes
1. Synvisc/Euflexxa: 3
weeks (1 injection
weekly for 3 weeks)
2. Hyalgan/Supartz: 5
weeks (1 injection
weekly for 5 weeks)
3. Orthovisc: 3-4 weeks
(1 injection weekly for
3-4 weeks)
4. Synvisc-One: 1
injection for total 1 dose
If additional therapy is
needed after 1 course, wait
> 6 months after last
injection.
Allergies to avian proteins
(eggs, feathers, etc.)
Avoid all agents EXCEPT
Euflexxa.
Latex hypersensitivity
Avoid Euflexxa
144
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals
Fuzeon (enfuvirtide)
Infergen
(interferon alfacon-1)
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.
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.)
Intron A
(interferon alpha-2b)
Roferon A
(interferon alpha-2a)
Duration of Approval
Long-term
Notes
145
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals, continued
On Formulary with PA:
Pegasys
(pegylated interferon alfa-2a)
Non-Formulary with PA:
Peg-Intron
(pegylated interferon alfa-2b)
Criteria
1. Diagnosis of hepatitis C; AND
2. Peg-Intron requires prior authorization for
documented failure of or intolerance to
Pegasys.
Duration of Approval
Initial authorization approved
for 6 months.
Notes
146
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals, continued
Synagis (palivizumab)
Criteria
Duration of Approval
Notes
147
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
1.
2.
3.
4.
5.
Criteria
Creatinine clearance is > 35 ml/min; AND
Documented failure of, or intolerance to, an
oral bisphosphonate agent; AND
Patient has a diagnosis of osteoporosis or is
postmenopausal with osteopenia as
indicated by a t-score <-1; OR
Diagnosis of Pagets disease; OR
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.
For osteoporosis treatment
(postmenopausal, in men,
and glucocorticoid
induced), concomitant
treatment with an average
of at least 1200 mg calcium
and 800-1000 IU vitamin D
daily is recommended
(dietary + supplemental).
148
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
149
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)
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, AND
2. Hgb level is < 11g/dL.
Duration of Approval
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.
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.
150
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Growth Factor,
Recombinant Insulin-like
Increlix (mecasermin [rDNA
origin] injection)
Criteria
Duration of Approval
1 year
Notes
Starting dose: 0.04 to 0.08
mg/kg (40 to 80 mcg/kg)
subcutaneously twice daily.
If well-tolerated for at least
one week, the dose may be
increased by 0.04 mg/kg
per dose, to the maximum
dose of 0.12 mg/kg given
twice daily.
Funduscopic exam is
recommended at the
initiation
Limitations of use:
INCRELEX is not a
substitute to GH for
approved GH
indications.
151
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Growth Hormones
On Formulary with PA:
Norditropin Products
(somatropin)
Non-Formulary with PA:
All other somatropin products
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
th
than 5 percentile for age); AND
b. Growth velocity is subnormal (age
specific growth rate at less than the
th
25 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 Prader-Willi Syndrome; OR
4. Diagnosis of Idiopathic Short Stature (ISS); AND
a. Height is >2 standard deviations below the
th
mean for age and sex (less than 5
percentile for age); AND
b. Documentation that epiphyses are not
closed.
Duration of Approval
Approved for 1 year
Documentation required for
renewal:
1. Growth rate has exceeded
2.5cm/year
2. Epiphyses remain open
Notes
Contraindicated for:
-Diabetic retinopathy
-Epiphyseal closure
-Respiratory insufficiency
-Sleep Apnea
-Product specific
hypersensitivities (Cresol,
Benzyl Alcohol,Glycerin)
-Active neoplastic disease
-Intracranial hypertension
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)
152
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators
Actemra (tocilizumab)
Criteria
1.
2.
3.
4.
5.
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; OR
7. Patient has documented failure of, or
intolerance to, a formulary subcutaneously
administered biologic agent (e.g., Humira,
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)
6. Patient is > 2 years old; AND
7. Patient has a diagnosis of active systemic
JIA/JRA.
153
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Amevive (alefacept)
1.
2.
3.
4.
Criteria
Documentation of a negative TB test before
initiating therapy; AND
Patient does not have a diagnosis of human
immunodeficiency virus (HIV) infection or
acquired immunodeficiency syndrome
(AIDS); AND
Patient has no active infection (including
influenza, systemic fungal or bacterial
infections, or acute hepatitis B or C viral
infections); AND
Documentation of CD4+ T-cell count
>500cells/uL; AND diagnosis specific
criteria are met.
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:
5. Diagnosis of chronic moderate to severe
plaque psoriasis or scalp 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;
AND
8. Dose of Amevive is 15 mg IM or 7.5 mg IV
once weekly for 12 weeks.
Psoriatic arthritis:
5. Documented failure of, intolerance or
contraindication to, methotrexate (MTX)
therapy; AND
6. Documented failure of, or intolerance to,
one other disease modifying antirheumatic
drugs (DMARDS) (e.g., sulfasalazine,
azathioprine, hydroxychloroquine).
7. Dose of Amevive is 15 mg IM or 7.5 mg IV
once weekly for 12 weeks.
154
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Cimzia
(certolizumab pegol)
1.
2.
3.
4.
Criteria
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Cimzia; 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, Enbrel, Remicade or other antiTNF therapy; AND diagnosis specific
criteria are met.
Rheumatoid Arthritis:
5. Diagnosis of moderately to severely active
rheumatoid arthritis.
6. Patient has documented failure of, or
intolerance to, Humira or Enbrel.
Duration of Approval
Approved for 1 year
Notes
1. Cimzia is given as two
subcutaneous injections
of 200 mg initially, and
again at weeks 2 and 4.
2. In patients who obtain a
clinical response, the
recommended
maintenance regimen is
400 mg every four
weeks.
Cimzia has not been
studied for use in pediatric
populations; geriatric
populations have not been
large enough to establish
safety or efficacy data.
Crohns Disease:
5. Diagnosis of moderate to severe active
Crohns disease with documented failure of,
intolerance or contraindication to,
conventional therapy (azathioprine,
mesalamine, mercaptopurine, sulfasalazine,
methotrexate, corticosteroids).
6. Patient has documented failure of, or
intolerance to, Humira.
155
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PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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.
156
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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.
157
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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
The dose of Humira is 40mg every other week.
158
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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
Dosage guidelines:
400 mg/kg /month IV or
100 mg/kg SQ weekly
1 year
Dosage guidelines:
400 mg/kg /month IV or
100 mg/kg SQ weekly
159
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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
Duration of Approval
Acute ITP
1 week
1 week
Chronic ITP
1 year
ITP in pregnancy
1year
Notes
Acute ITP
Dosage guidelines:
1 gm/kg give on 1 or 2
consecutive days; or
400 mg/kg given on each
of 2-5 consecutive days
Chronic ITP
Dosage guidelines:
1 or 2 g/kg (total
cumulative dose) given in
equal amounts over 2-5
days, then 0.8-1 g/kg given
as maintenance dose every
2-6 wks based on platelet
count
ITP in pregnancy
Dosage guidelines:
400mg/kg/d for 3-5 d
Dosage guidelines:
400mg/kg for 4 days
or
Single dose of 1-2g/kg
may repeat X1
160
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
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.
Duration of Approval
4 months
Notes
Dosage guideline:
500 mg/kg given on day 7
and day 2 pre-transplant (2
doses before transplant),
then weekly through day 90
post-transplant
1 year
Dosage guidelines:
100-500 mg/kg every 3-4
weeks
1 year
Dosage guidelines:
200-400 mg/kg every 28
days
Endogenous serum
immunoglobulins may vary
widely regardless of the
age of the child or the
stage of disease, with IgG
and IgM generally much
higher than normal.
161
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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
Notes
Acute CIDP & GBS:
400 mg/kg per day for 5 days
initially or 1 gm/kg daily for 2
days, then
250-400 mg/kg every 3 weeks
maintenance
Chronic CIDP:
1 gm/kg maintenance every 3
weeks (can be given as one
dose or over two consecutive
days)
For GBS
1. Patient must initiate within first four weeks of
illness.
Post transfusion purpura
1. Platelet count less than 10,000/ul, -and2. Infusion must be within 14 days of bleeding
post transfusion, -and3. Documented failure of, intolerance, or
contraindication to corticosteroids,
-or4. Documented plasma exchange.
1 month
(to account for relapse)
Dosage guidelines:
400-500mg/kg/day for 5
days
1 year
Dosage guidelines:
0.15-0.2 g/kg/day
162
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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
Notes
Dosage guidelines:
400 mg/kg IV once daily for
5 successive days
6 months
Dosage guidelines:
Polymyositis:
1 gm/kg/day x 2 days every
month x 4 doses
Dermatomyositis:
2 gm/kg monthly x 3-4
doses
Not limited
Dosage guidelines:
200-400 mg/kg X 5 days
once a month
Maintenance therapy
considered experimental
and investigational
Gamunex-C
Hizentra
163
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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
Notes
Dosing guidelines:
2 gm/kg per month divided
into 1-5 doses
Not limited
Dosage guidelines:
2gm/kg given over 2-5
days, then maintenance
dose of 1gm/kg at 2-4 wk
intervals or 2gm/kg at 4-8
wk intervals
Not limited
Dosage guidelines:
2gm/kg divided into 2 daily
doses given every 3
months
164
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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, intolerance or
contraindication to, another disease
modifying antirheumatic drug (DMARD)
(e.g., azathioprine, leflunomide,
cyclosporine, penicillamine, sulfasalazine);
AND
9. The dose of Kineret is 100 mg
administered subcutaneously once daily.
10. Patient has documented failure of, or
intolerance to, Humira or Enbrel.
165
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Orencia (abatacept)
1.
2.
3.
4.
Criteria
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Orencia;
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 Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF
therapy; AND diagnosis specific criteria are
met.
Duration of Approval
Approved for 1 year
Notes
Arthritis:
5. Diagnosis of moderate to severe
rheumatoid arthritis; OR
6. Diagnosis of moderate to severe
polyarticular juvenile rheumatoid arthritis
(JRA)/juvenile idiopathic arthritis (JIA);
(JRA/JIA approved for > 6 years of age).
7. Patient has documented failure of, or
intolerance to, a formulary subcutaneously
administered biologic agent (e.g., Humira,
Enbrel); OR
8. 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); AND
9. Documented failure of, intolerance or
contraindication to, two other disease
modifying antirheumatic drugs (DMARDS)
(e.g., methotrexate, sulfasalazine,
azathioprine, or hydroxychloroquine).
166
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade (infliximab)
1.
2.
3.
4.
5.
Criteria
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Remicade;
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, Enbrel, or Humira or other antiTNF therapy; AND
The dose of Remicade is not to exceed
10mg/kg; AND diagnosis specific criteria
are met.
Duration of Approval
Approved for 1 year
Notes
167
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade (infliximab),
continued
Criteria
Duration of Approval
Notes
Psoriasis:
6. Diagnosis of chronic, severe (i.e.,
extensive and/or disabling) plaque
psoriasis; AND
7. Documented failure of, or intolerance to, at
least 2 traditional therapies (e.g., PUVA,
UVB, methotrexate, or cyclosporine); AND
8. Patient has documented failure of, or
intolerance to, or inability to inject a
formulary subcutaneously administered
anti-TNF agent (e.g., Humira, Enbrel) AND
9. Prescription is written by a dermatologist.
Rheumatoid Arthritis
6. Diagnosis of rheumatoid arthritis; AND
7. Patient has documented failure of, or
intolerance to, or inability to inject a
formulary subcutaneously administered
anti-TNF agent (e.g., Humira, Enbrel);OR
8. Documented failure of, or intolerance to,
two other disease modifying antirheumatic
drugs (DMARDS) (e.g., methotrexate,
sulfasalazine, azathioprine, or
hydroxychloroquine).
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).
168
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Rituxan (rituximab)
1.
2.
3.
4.
5.
6.
7.
Criteria
Prescription is written by an oncologist or
hematologist; OR
The patient has a diagnosis of moderate to
severe rheumatoid arthritis; 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 Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF
therapy; AND
Patient has documented failure of, or
intolerance to, a formulary subcutaneously
administered biologic agent (e.g., Humira,
Enbrel); OR
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
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.
169
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Simponi (golimumab)
1.
2.
3.
4.
Criteria
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Simponi;
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, 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.
Rheumatoid Arthritis:
5. Diagnosis of moderately to severely active
rheumatoid arthritis; AND
6. Patient is receiving methotrexate
concomitantly; AND
7. The dose of Simponi is 50 mg administered
subcutaneously once a month.
8. Patient has documented failure of, or
intolerance to Humira or Enbrel.
Ankylosing Spondylitis OR Psoriatic Arthritis:
5. Diagnosis of ankylosing spondylitis or
psoriatic arthritis; AND
6. The dose of Simponi is 50 mg once a
month.
7. Patient has documented failure of, or
intolerance to, Humira or Enbrel.
170
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Stelara (ustekinumab)
Immunomodulators
Xgeva (denosumab)
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
4. Documented failure of, intolerance or
contraindication to, at least two traditional
therapies (e.g., PUVA, UVB, methotrexate,
or cyclosporine); AND
5. Patient has documented failure of, or
intolerance to, or inability to inject a
formulary subcutaneously administered
anti-TNF agent (e.g., Humira, Enbrel), and
diagnostic specific criteria are met.
Psoriasis:
6. Diagnosis of moderate to severe plaque
psoriasis; AND
7. Prescription is written by a dermatologist.
1. Patient has a diagnosis of bone metastases
secondary to solid tumor.
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.
1 year
171
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Cryopyrin-Associated
Periodic Syndromes
Criteria
1. Diagnosis of Cryopyrin-Associated
Periodic Syndromes (CAPS), including
Familial Cold Autoinflammatory Syndrome
(FCAS) and Muckle-Wells Syndrome
(MWS) in adults and children 12 years and
older.
Duration of Approval
Evaluate in 3 months for to
determine patient response
1. Diagnosis of Cryopyrin-Associated
Periodic Syndromes (CAPS), including
Familial Cold Autoinflammatory Syndrome
(FCAS) and Muckle-Wells Syndrome
(MWS) in adults and children > 4 years
old.
Long Term
Arcalyst (rilonacept)
Cryopyrin-Associated
Periodic Syndromes
Ilaris (canakinumab)
Notes
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.
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.
172
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APPENDIX D
Brand (generic) Name
Neurological
Avonex, Betaseron,
Extavia, Rebif
(interferon beta)
Copaxone
(glatiramer acetate)
Criteria
1. Patient has a diagnosis of multiple
sclerosis.
Duration of Approval
Long-term
Long-term
Gilenya (fingolimod)
Neuromuscular Blocking
Agent
Botox
Dysport
Xeomin
(botulism toxin type A)
Notes
Quantity is limited to 30
units per month.
Approved 3 months
173
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APPENDIX D
Brand (generic) Name
Parkinsons
Apokyn (apomorphine)
1.
2.
Pulmonary
Xolair (omalizumab)
1.
2.
3.
4.
5.
Criteria
Diagnosis of Parkinson's Disease in
advanced stages; AND
Documented two hours or more of "off"
episodes ("end-of-dose wearing off" and
unpredictable "on/off" episodes) despite
aggressive oral therapy.
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.
Duration of Approval
Long-term
Approved 3 months to
determine patient response.
Notes
Renewals may be
authorized long-term.
174
175
177
A
ABILIFY ..............................................................................56
ACANYA ............................................................................46
ACARBOSE ........................................................................73
ACCOLATE................................................................... 38, 41
ACCUNEB ..........................................................................40
ACCUPRIL ..........................................................................25
ACCURETIC .......................................................................25
ACEBUTOLOL .............................................................. 25, 28
ACEON ..............................................................................25
ACETAMINOPHEN/ CODEINE ...........................................37
ACETAMINOPHEN/ DICHORALPHENAZONE/
ISOMETHEPTENE .........................................................59
ACETAMINOPHEN/ HYDROCODONE .......................... 37, 38
ACETAMINOPHEN/ OXYCODONE .....................................37
ACETAZOLAMIDE ..............................................................50
ACETIC ACID .....................................................................54
ACETIC ACID/ HYDROCORTISONE.....................................54
ACETONIDE .......................................................................42
ACIPHEX............................................................................20
ACITRETIN .........................................................................44
ACLOVATE ........................................................................42
ACTIGALL ..........................................................................76
ACTIQ................................................................................36
ACTIVELLA 1.0-0.5 ............................................................68
ACTONEL ..........................................................................70
ACTOPLUS MET ................................................................72
ACTOPLUS MET XR ...........................................................72
ACTOS ...............................................................................72
ACULAR LS ........................................................................53
ACULAR, PF .......................................................................53
ACUVAIL ...........................................................................53
ACYCLOVIR .......................................................................34
ACZONE 5% GEL ...............................................................46
ADALAT CC .......................................................................27
ADALIMUMAB ..................................................................77
ADAPALENE ......................................................................46
ADAPALENE/BENZOYL PEROXIDE .....................................46
ADCIRCA ...........................................................................29
ADDERALL XR....................................................................57
ADOXA CK .........................................................................31
ADOXA TT .........................................................................31
ADOXA, PAK......................................................................31
ADVAIR .............................................................................40
ADVICOR ...........................................................................29
AEROBID ...........................................................................40
AGGRENOX .......................................................................49
AGRYLIN ...........................................................................49
ALAMAST ..........................................................................53
ALAVERT OTC ...................................................................38
ALBENDAZOLE ..................................................................35
ALBENZA ...........................................................................35
ALBUTEROL................................................................. 40, 41
ALBUTEROL SULFATE ........................................................40
178
AMOXICILLIN ....................................................................30
AMOXICILLIN TRIHYDRATE ...............................................30
AMOXICILLIN/ CLAVULANATE ..........................................30
AMOXIL ............................................................................30
AMPHETAMINE/ DEXTROAMPHETAMINE .......................57
AMPYRA ...........................................................................79
AMRIX ...............................................................................60
AMTURNIDE .....................................................................27
AMYLASE/ LIPASE/ PROTEASE ..........................................21
ANAFRANIL .......................................................................54
ANAKINRA ........................................................................77
ANAPROX, DS ...................................................................35
ANASPAZ ..........................................................................22
ANCOBON .........................................................................33
ANDRODERM....................................................................69
ANDROGEL .......................................................................69
ANDROID ..........................................................................69
ANDROXY .........................................................................69
ANEGRELIDE .....................................................................49
ANSAID .............................................................................35
ANTABUSE ........................................................................76
ANTARA ............................................................................29
ANTHRALIN .......................................................................44
ANTIVERT 12.5, 25MG ......................................................21
ANTIVERT 50MG ...............................................................21
ANUSOL HC.......................................................................21
ANZEMET..........................................................................22
APEXICON .........................................................................42
APIDRA .............................................................................71
APIDRA SOLOSTAR ...........................................................71
APLENZIN..........................................................................54
APOKYN ............................................................................60
APOMORPHINE ................................................................60
APRACLONIDINE ...............................................................50
APREPITANT .....................................................................22
APRESOLINE .....................................................................27
APRI ..................................................................................62
ARALEN ....................................................................... 34, 35
ARANELLE .........................................................................62
ARANESP ..........................................................................49
ARAVA ..............................................................................77
ARFORMOTEROL ..............................................................40
ARICEPT ............................................................................61
ARIPIPRAZOLE ..................................................................56
ARISTOCORT .....................................................................61
ARMODAFINIL ..................................................................57
ARMOUR THYROID ...........................................................70
ARTEMETHER/ ..................................................................34
ARTHROTEC ......................................................................35
ASACOL .............................................................................20
ASACOL HD .......................................................................20
ASENAPINE .......................................................................57
ASMANEX .........................................................................40
ASPIRIN/ DIPYRIDAMOLE .................................................49
ASPIRIN/ OXYCODONE .....................................................37
ASTELIN ............................................................................ 38
ASTEPRO .......................................................................... 38
ATABEX ............................................................................ 73
ATACAND ......................................................................... 26
ATACAND HCT.................................................................. 26
ATELVIA............................................................................ 70
ATENOLOL ........................................................................ 28
ATENOLOL/ CHLORTHALIDONE ....................................... 28
ATIVAN ....................................................................... 55, 56
ATOMOXETINE ................................................................. 58
ATOPICLAIR ...................................................................... 43
ATORVASTATIN ................................................................ 29
ATOVAQUONE ................................................................. 34
ATOVAQUONE/ PROGUANIL ........................................... 34
ATRALIN ........................................................................... 46
ATROPINE ........................................................................ 50
ATROPINE SULFATE ......................................................... 50
ATROVENT HFA ................................................................ 40
ATROVENT NASAL SPRAY................................................. 38
AUGMENTIN CHEW TABS, 125-31.25 SUSP ..................... 30
AUGMENTIN XR ............................................................... 30
AUGMENTIN, ES............................................................... 30
AURANOFIN ..................................................................... 77
AVALIDE ........................................................................... 26
AVANDAMET.................................................................... 72
AVANDARYL ..................................................................... 72
AVANDIA .......................................................................... 72
AVAPRO ........................................................................... 26
AVC CREAM ..................................................................... 47
AVELOX ............................................................................ 32
AVIANE ............................................................................. 62
AVIDOXY DK ..................................................................... 31
AVINZA ............................................................................. 36
AVODART ......................................................................... 78
AVONEX ........................................................................... 79
AXERT............................................................................... 59
AXID ................................................................................. 20
AYGESTIN ......................................................................... 68
AZASAN ............................................................................ 77
AZASITE ............................................................................ 51
AZATHIOPRINE ................................................................. 77
AZELAIC ACID ............................................................. 46, 47
AZELASTINE ................................................................ 38, 53
AZELEX ............................................................................. 46
AZILECT ............................................................................ 60
AZITHROMYCIN .......................................................... 32, 51
AZOPT .............................................................................. 50
AZOR ................................................................................ 26
AZULFIDINE, ENTAB ......................................................... 20
B
BACLOFEN ........................................................................ 60
BACTRIM DS, SEPTRA DS ........................................... 32, 33
BACTRIM, SEPTRA ...................................................... 32, 33
BACTROBAN ..................................................................... 45
179
BONIVA ............................................................................ 70
BOSENTAN ....................................................................... 29
BRAVELLE ......................................................................... 69
BREVOXYL ........................................................................ 46
BRIMONIDINE TARTRATE ................................................. 50
BRINZOLAMIDE ................................................................ 50
BROMDAY ........................................................................ 53
BROMFED-DM ................................................................. 40
BROMFENAC SODIUM ..................................................... 53
BROMOCRIPTINE ............................................................. 61
BROMPHENIRAMINE/ PSEUDOEPHEDRINE/
DEXTROMETHORPHAN ............................................... 40
BROVANA ......................................................................... 40
BUDESONIDE ....................................................... 21, 39, 40
BUDESONIDE/ FORMOTEROL .......................................... 41
BUPRENORPHINE ............................................................. 76
BUPRENORPHINE/ NALOXONE ........................................ 76
BUPROPION ......................................................... 54, 55, 76
BUSPAR ............................................................................ 55
BUSPIRONE ...................................................................... 55
BUTALBITAL/ ACETAMINOPHEN/ CAFFEINE .................... 37
BUTALBITAL/ ASA/ CAFFEINE........................................... 59
BUTALBITAL/ ASPIRIN/ CAFFEINE/ CODEINE ................... 37
BUTENAFINE .................................................................... 45
BUTOCONAZOLE NITRATE ............................................... 48
BYETTA ............................................................................. 72
BYSTOLIC .......................................................................... 28
C
CADUET ............................................................................ 29
CAFERGOT........................................................................ 59
CALAN .............................................................................. 24
CALAN SR ......................................................................... 27
CALCIPOTRIENE................................................................ 44
CALCITONIN ..................................................................... 70
CALCITRIOL ................................................................ 48, 75
CALCIUM ACETATE .......................................................... 79
CAMILA ............................................................................ 62
CANASA............................................................................ 20
CANDESARTAN................................................................. 26
CANTIL ............................................................................. 22
CAPOTEN ......................................................................... 25
CAPTOPRIL ....................................................................... 25
CARAFATE ........................................................................ 20
CARAFATE SUSP ............................................................... 20
CARBACHOL ..................................................................... 50
CARBAMAZEPINE ....................................................... 58, 59
CARBATROL...................................................................... 58
CARBIDOPA ...................................................................... 61
CARBIDOPA/ LEVODOPA ................................................. 61
CARBIDOPA/ LEVODOPA/ ENTACAPONE ......................... 61
CARDENE.......................................................................... 27
CARDENE SR ..................................................................... 27
CARDIZEM ........................................................................ 27
CARDIZEM CD 120, 180, 240, 300 .................................... 27
180
181
COMBIPATCH ...................................................................68
COMBIVENT......................................................................40
COMFORT PAC-TIZANIDINE ..............................................60
COMPAZINE SYRUP ..........................................................22
COMPAZINE TABS , SUPP .................................................22
COMPLETE-RF PRENATAL .................................................73
COMTAN ...........................................................................60
CONCEPT OB, DHA ...........................................................73
CONCERTA ........................................................................57
CONDYLOX GEL ................................................................48
CONDYLOX SOLUTION ......................................................48
CONJUGATED ESTROGEN/ MPA .......................................68
CONJUGATED ESTROGENS ......................................... 67, 68
COPAXONE .......................................................................79
COPEGUS ..........................................................................79
CORDARONE .....................................................................24
CORDRAN 4MCG/SQ CM TAPE .........................................42
CORDRAN, SP ...................................................................42
COREG ..............................................................................28
COREG CR .........................................................................28
CORGARD .........................................................................28
CORTEF TABS ....................................................................61
CORTIFOAM......................................................................20
CORTISONE .......................................................................61
CORTISONE ACETATE .......................................................61
CORTISPORIN ....................................................... 45, 52, 54
CORTISPORIN-TC ..............................................................54
CORZIDE ...........................................................................28
COSOPT ............................................................................50
COUMADIN.......................................................................49
COVERA HS .......................................................................27
COZAAR ............................................................................26
CREON ..............................................................................21
CRESTOR ...........................................................................29
CROMOLYN SODIUM ........................................................21
CROTAMITON ...................................................................48
CRYSELLE ..........................................................................62
CUPRIMINE .......................................................................75
CUTIVATE..........................................................................42
CUTIVATE 0.05% LOTION .................................................42
CYANOCOBALAMIN/MECOBALAMIN ...............................75
CYCLOBENZAPRINE...........................................................60
CYCLOGYL 0.5%, 2% .........................................................50
CYCLOGYL 1% ...................................................................50
CYCLOPENTOLATE ............................................................50
CYCLOSERINE ....................................................................34
CYCLOSPORINE ........................................................... 52, 77
CYMBALTA .................................................................. 54, 79
CYSTOSPAZ, M ..................................................................22
CYTOMEL ..........................................................................70
CYTOTEC ...........................................................................20
D
DABIGATRAN ETEXILATE MESYLATE ................................49
DALFAMPRIDINE ..............................................................79
182
183
ERRIN ................................................................................62
ERTACZO ...........................................................................45
ERYPRED ...........................................................................32
ERY-TAB ...................................................................... 32, 35
ERYTHROCIN .....................................................................32
ERYTHROMYCIN ...............................................................52
ERYTHROMYCIN BASE ................................................ 32, 35
ERYTHROMYCIN BASE/ BENZOYL PEROXIDE ....................46
ERYTHROMYCIN ETHYLSUCCINATE ............................ 31, 32
ERYTHROMYCIN STEARATE ..............................................32
ERYTHROMYCIN/ BENZOYL PEROXIDE .............................46
ESCITALOPRAM ................................................................54
ESKALITH, CR ....................................................................56
ESOMEPRAZOLE ...............................................................20
ESOMEPRAZOLE/ ..............................................................36
ESTRACE ...........................................................................67
ESTRADERM .....................................................................67
ESTRADIOL .................................................................. 67, 68
ESTRADIOL VALERATE/DIENOGEST ..................................64
ESTRADIOL, TRANSDERMAL ....................................... 67, 68
ESTRADIOL/ LEVONORGESTREL .......................................68
ESTRADIOL/ NORETHINDRONE ACETATE .........................68
ESTRADIOL/ NORGESTIMATE ...........................................68
ESTRASORB .......................................................................67
ESTRING ............................................................................67
ESTROGEL GEL ..................................................................67
ESTROGENS ......................................................................67
ESTROPIPATE ....................................................................67
ESTROSTEP FE ...................................................................62
ESZOPICLONE ...................................................................56
ETANERCEPT .....................................................................77
ETHAMBUTOL ...................................................................34
ETHINYL ESTRADIOL ........................... 62, 63, 64, 65, 66, 67
ETHINYL ESTRADIOL 20MCG ................................ 62, 63, 67
ETHINYL ESTRADIOL 20MCG/ FE/.....................................64
ETHINYL ESTRADIOL 30MCG .................... 62, 63, 64, 65, 66
ETHINYL ESTRADIOL 35MCG ............................................66
ETHINYL ESTRADIOL 35MG .................................. 64, 65, 67
ETHINYL ESTRADIOL 50MCG ................................ 65, 66, 67
ETHINYL ESTRADIOL/ NORETHINDRONE ACETATE ..........68
ETHINYL ESTRADION 20MCG ...........................................63
ETHIONAMIDE ..................................................................34
ETHOSUXIMIDE ................................................................59
ETHOTOIN ........................................................................59
ETIDRONATE .....................................................................70
ETONOGESTREL ................................................................67
EURAX...............................................................................48
EVISTA ..............................................................................70
EXALGO ............................................................................36
EXELDERM ........................................................................45
EXELON .............................................................................61
EXENATIDE .......................................................................72
EXFORGE ..........................................................................26
EXFORGE HCT ...................................................................26
EXJADE ..............................................................................75
EXTAVIA ........................................................................... 79
EZETIMIBE ........................................................................ 30
EZETIMIBE/ SIMVASTATIN ............................................... 30
F
FACTIVE ............................................................................ 32
FAMCICLOVIR................................................................... 34
FAMOTIDINE .................................................................... 20
FAMVIR ............................................................................ 34
FANAPT ............................................................................ 56
FANATREX ........................................................................ 58
FAZACLO .......................................................................... 56
FEBUXOSTAT .................................................................... 73
FELBAMATE...................................................................... 58
FELBATOL ......................................................................... 58
FELDENE ........................................................................... 35
FEMCON FE ...................................................................... 62
FEMHRT ........................................................................... 68
FEMRING.......................................................................... 67
FEMTRACE ....................................................................... 67
FENOFIBRATE ............................................................. 29, 30
FENOFIBRIC ACID ....................................................... 29, 30
FENOGLIDE ...................................................................... 29
FENTANYL ........................................................................ 36
FENTANYL CITRATE .................................................... 36, 37
FENTORA .......................................................................... 36
FESOTERODINE FUMARATE ............................................. 78
FEXMID ............................................................................ 60
FEXOFENADINE ................................................................ 38
FEXOFENADINE/ .............................................................. 39
FEXOFENADINE/ PSEUDOEPHEDRINE.............................. 39
FIBRICOR .......................................................................... 29
FILGRASTIM ..................................................................... 49
FINACEA ........................................................................... 47
FINASTERIDE .................................................................... 78
FINGOLIMOD ................................................................... 79
FIORICET .......................................................................... 37
FIORINAL .......................................................................... 59
FIORINAL W/CODEINE #3 ................................................ 37
FLAGYL ................................................................. 32, 35, 48
FLAGYL ER ............................................................ 32, 35, 48
FLAREX ............................................................................. 51
FLECAINIDE ...................................................................... 25
FLECTOR ........................................................................... 35
FLEXERIL ........................................................................... 60
FLOMAX ..................................................................... 28, 78
FLONASE .......................................................................... 39
FLOVENT HFA ................................................................... 40
FLOXIN OTIC SINGLES ...................................................... 54
FLUCONAZOLE ........................................................... 33, 48
FLUCYTOSINE ................................................................... 33
FLUMADINE TABS ............................................................ 34
FLUNISOLIDE .................................................................... 40
FLUOCINOLONE ACETONIDE ........................................... 42
FLUOCINONIDE ................................................................ 43
184
185
186
KINERET ............................................................................77
KLONOPIN ........................................................................58
KLOR-CON ........................................................................74
KOMBIGLYZE XR ...............................................................72
K-PHOS ORIGINAL.............................................................74
L
LABETALOL .......................................................................28
LAC-HYDRIN ......................................................................44
LACOSAMIDE ....................................................................59
LACTULOSE .......................................................................23
LACTULOSE SOLN .............................................................23
LAMICTAL 5, 25MG DISPER TABLET .................................58
LAMICTAL ODT .................................................................58
LAMICTAL TAB, STARTER KIT ............................................58
LAMICTAL XR, STARTER KIT ..............................................59
LAMISIL .............................................................................33
LAMISIL SOLN ...................................................................45
LAMOTRIGINE ............................................................ 58, 59
LANCETS ...........................................................................72
LANOXIN 125MCG ...................................................... 24, 25
LANSOPRAZOLE ................................................................20
LANTHANUM CARBONATE ...............................................79
LANTUS .............................................................................71
LASIX .................................................................................25
LASTACAFT .......................................................................53
LATANOPROST..................................................................51
LATUDA ............................................................................56
LEFLUNOMIDE ..................................................................77
LESCOL, XL ........................................................................29
LESSINA ............................................................................63
LEUKINE ............................................................................49
LEUPROLIDE ACETATE ................................................ 69, 70
LEVALBUTEROL .................................................................41
LEVAQUIN .........................................................................32
LEVATOL ...........................................................................28
LEVEMIR ...........................................................................71
LEVEMIR FLEXPEN ............................................................71
LEVETIRACETAM ...............................................................58
LEVITRA ............................................................................77
LEVOBUNOLOL .................................................................50
LEVOCARNITINE ...............................................................76
LEVOCETIRIZINE................................................................38
LEVODAPA/ CARBIDOPA ..................................................61
LEVOFLOXACIN ........................................................... 32, 52
LEVORA.............................................................................63
LEVOTHROID ....................................................................70
LEVOTHYROXINE SODIUM .......................................... 70, 71
LEVOXYL ...........................................................................70
LEVSIN ..............................................................................23
LEXAPRO ...........................................................................54
LIALDA ..............................................................................21
LIBRAX ..............................................................................23
LIDOCAINE ........................................................................77
LIDODERM 5% PATCH ......................................................77
LINEZOLID ........................................................................ 33
LIOTHYRONINE SODIUM .................................................. 70
LIOTRIX............................................................................. 71
LIPITOR............................................................................. 29
LIPOFEN ........................................................................... 29
LIRAGLUTIDE .................................................................... 73
LISDEXAMFETAMINE DIMESYLATE .................................. 58
LISINOPRIL ....................................................................... 26
LISINOPRIL/ HCTZ ............................................................. 26
LITHIUM ........................................................................... 56
LITHOBID .......................................................................... 56
LIVALO ............................................................................. 30
L-NORGEST-ETH ESTR/ETHIN ESTRA .......................... 63, 66
LO/OVRAL ........................................................................ 63
LOCOID ............................................................................ 42
LOCOID LOTN, LIPOCREAM .............................................. 42
LODOSYN ......................................................................... 61
LODOXAMIDE TROMETHAMINE ...................................... 53
LOESTRIN 21 1.5/30 ......................................................... 63
LOESTRIN 21 1/20 ............................................................ 63
LOESTRIN 24 FE ................................................................ 63
LOESTRIN FE 1/20 ............................................................ 63
LOFIBRA ........................................................................... 30
LOMOTIL .......................................................................... 22
LOPERAMIDE ................................................................... 22
LOPID ............................................................................... 30
LOPRESSOR ...................................................................... 28
LOPRESSOR HCT ............................................................... 28
LOPROX ............................................................................ 45
LORATADINE .................................................................... 38
LORATIDINE/ PSEUDOEPHEDRINE ................................... 39
LORAZEPAM ............................................................... 55, 56
LORCET, PLUS................................................................... 37
LOSARTAN ........................................................................ 26
LOSARTAN/ HCTZ ............................................................. 26
LOSEASONIQUE ............................................................... 63
LOTEMAX ......................................................................... 51
LOTENSIN ......................................................................... 25
LOTENSIN HCT ................................................................. 25
LOTEPREDNOL ETABONATE ............................................. 51
LOTEPREDNOLETABONATE .............................................. 51
LOTREL 2.5-10, 5-10, 5-20, 10-20 .............................. 25, 27
LOTRIMIN ......................................................................... 45
LOTRISONE ....................................................................... 45
LOTRONEX ................................................................. 21, 79
LOVASTATIN ............................................................... 29, 30
LOVAZA ............................................................................ 30
LOVENOX ......................................................................... 49
LOW-OGESTREL ............................................................... 63
LOXAPINE ......................................................................... 56
LOXITANE ......................................................................... 56
LOZOL............................................................................... 25
LUBIPROSTONE .......................................................... 21, 79
LUMIGAN ......................................................................... 50
LUNESTA .......................................................................... 56
187
188
NASACORT AQ ................................................................. 39
NASONEX ......................................................................... 39
NATACYN ......................................................................... 52
NATALVIT ......................................................................... 74
NATAMYCIN ..................................................................... 52
NATAZIA ........................................................................... 64
NATEGLINIDE ................................................................... 72
NATELLE ONE ................................................................... 74
NAVANE ........................................................................... 56
NAVANE 20 ...................................................................... 57
NEBIVOLOL ...................................................................... 28
NEBUPENT ....................................................................... 35
NECON 0.5/35 .................................................................. 64
NECON 1/35 ..................................................................... 64
NECON 1/50 ..................................................................... 64
NECON 10/11 ................................................................... 64
NECON 7/7/7 ................................................................... 64
NEDOCROMIL SODIUM .................................................... 53
NEEVO DHA...................................................................... 74
NEOBENZ MICRO PLUS .................................................... 47
NEOBENZ MICRO PLUS PACK 5.5 % CREAM WITH
APPLICATION ............................................................... 47
NEOMY SULF/ COLIST SUL/ HC/ THONZ .......................... 54
NEORAL ............................................................................ 77
NEOSALUS ........................................................................ 44
NEOSPORIN ...................................................................... 52
NEPAFENAC ..................................................................... 53
NEPTAZANE...................................................................... 50
NESTABS .......................................................................... 74
NESTABS DHA .................................................................. 74
NEUPOGEN ...................................................................... 49
NEURIN-SL ....................................................................... 75
NEURONTIN ..................................................................... 59
NEVANAC ......................................................................... 53
NEXA SELECT .................................................................... 74
NEXICLON XR ................................................................... 29
NEXIUM ........................................................................... 20
NIACIN ............................................................................. 30
NIACIN/ SIMVASTATIN ..................................................... 30
NIACIN/LOVASTATIN ....................................................... 29
NIASPAN .......................................................................... 30
NICARDIPINE .................................................................... 27
NICORETTE GUM OTC ...................................................... 76
NICOTINE INHALER .......................................................... 76
NICOTINE NASAL SPRAY................................................... 76
NICOTINE PATCH ............................................................. 76
NICOTINE PATCH OTC ...................................................... 76
NICOTINE PATCH, RX ....................................................... 76
NICOTINE POLACRILEX ..................................................... 76
NICOTROL INHALER ......................................................... 76
NICOTROL NS ................................................................... 76
NIDOLDIPINE .................................................................... 27
NIFEDIPINE ....................................................................... 27
NIFEREX-150 FORTE ......................................................... 73
NIFEREX-PN ...................................................................... 74
189
NIMODIPINE .....................................................................27
NIMOTOP .........................................................................27
NIRAVAM..........................................................................55
NITAZOXANIDE .................................................................35
NITRO-BID OINT ...............................................................24
NITRO-DUR PATCHES 0.1, 0.2, 0.4, 0.6MG/HR .................24
NITRO-DUR PATCHES 0.3, 0.8MG/HR ..............................24
NITROFURANTOIN ...................................................... 32, 33
NITROGLYCERIN ...............................................................24
NITROGLYCERIN SUBLINGUAL ..........................................24
NITROGLYCERIN TRANSDERMAL ......................................24
NITROLINGUAL SPRAY ......................................................24
NITROSTAT .......................................................................24
NIZATIDINE .......................................................................20
NIZORAL ...........................................................................45
NORA-BE ...........................................................................64
NORDETTE ........................................................................64
NORDITROPIN ..................................................................80
NORETH A-ET ESTRA/FE FUMARATE ................................62
NORETH-ETHINYL ESTRADIOL/IRON ................................62
NORETHINDRONE 0.35MG ................................... 62, 64, 65
NORETHINDRONE ACETATE .............................................68
NORFLEX ...........................................................................60
NORFLOXACIN ..................................................................32
NORINYL 1/35...................................................................65
NORINYL 1+50 ..................................................................65
NORMODYNE ...................................................................28
NOROXIN ..........................................................................32
NORPACE ..........................................................................24
NORPACE CR 100MG ........................................................24
NORPRAMIN .....................................................................54
NORTREL 0.5/35 ...............................................................65
NORTREL 1/35 ..................................................................65
NORTREL 7/7/7 ................................................................65
NORTRIPTYLINE ................................................................55
NORVASC ..........................................................................27
NOVAREL ..........................................................................69
NOVOLIN INSULINS ..........................................................71
NOVOLOG INSULINS .........................................................71
NOVOLOG MIX .................................................................71
NOXAFIL ...........................................................................33
NUCORT............................................................................43
NUCYNTA..........................................................................37
NULEV...............................................................................23
NUMORPHAN ...................................................................37
NUOX GEL .........................................................................47
NUTROPIN ........................................................................80
NUVARING ........................................................................67
NUVIGIL ............................................................................57
NYSTATIN ................................................................... 45, 48
NYSTATIN VAGINAL TABS .................................................48
NYSTATIN/EMOLLIENT .....................................................45
O
OBSTETRIX EC ...................................................................74
OCUFLOX ......................................................................... 52
OFLOXACIN ................................................................ 52, 54
OGEN ............................................................................... 67
OGESTREL ........................................................................ 65
OLANZAPINE .................................................................... 57
OLANZAPINE/ FLUOXETINE.............................................. 57
OLEPTRO ER ..................................................................... 54
OLMESARTAN .................................................................. 26
OLMESARTAN MED/ AMLODIPINE/HCTZ ........................ 27
OLMESARTAN/ HCTZ ....................................................... 26
OLOPATADINE............................................................ 39, 53
OLSALAZINE ..................................................................... 20
OLUX ................................................................................ 43
OLUX-E ............................................................................. 43
OMEGA-3-ACID ETHYL ESTERS......................................... 30
OMEPRAZOLE .................................................................. 20
OMEPRAZOLE MAGNESIUM ............................................ 20
OMNARIS ......................................................................... 39
OMNITROPE ..................................................................... 80
ONDANSETRON ............................................................... 22
ONGLYZA.......................................................................... 72
ONSOLIS ........................................................................... 37
OPANA ............................................................................. 37
OPANA, ER ....................................................................... 37
OPTASE ............................................................................ 48
OPTIVAR ........................................................................... 53
ORACEA............................................................................ 31
ORAL FLUORIDE ............................................................... 80
ORAMORPH SR ................................................................ 37
ORAP ................................................................................ 57
ORAVIG ............................................................................ 33
ORPHENADRINE ............................................................... 60
ORTHO EVRA PATCH ........................................................ 67
ORTHO MICRONOR .......................................................... 65
ORTHO TRI-CYCLEN .......................................................... 65
ORTHO TRI-CYCLEN LO .................................................... 65
ORTHO-CEPT .................................................................... 66
ORTHO-CYCLEN ................................................................ 65
ORTHO-NOVUM 1/35 ...................................................... 65
ORTHO-NOVUM 1/50 ...................................................... 65
ORTHO-NOVUM 7/7/7..................................................... 65
OSELTAMIVIR ................................................................... 34
OSMOPREP ...................................................................... 23
OTC ASPIRIN .................................................................... 80
OTC NICOTINE PATCHES .................................................. 81
OVCON 35 ........................................................................ 66
OVCON 50 ........................................................................ 66
OVIDE ............................................................................... 48
OVIDREL ........................................................................... 69
OXANDRIN ....................................................................... 69
OXANDROLONE ............................................................... 69
OXAPROZIN ...................................................................... 35
OXCARBAZEPINE .............................................................. 59
OXICONAZOLE NITRATE ................................................... 45
OXISTAT ........................................................................... 45
190
OXYBUTYNIN ....................................................................78
OXYBUTYNIN CHLORIDE ...................................................78
OXYCODONE .....................................................................37
OXYCONTIN ......................................................................37
OXYMORPHONE ...............................................................37
OXYTROL PATCH ...............................................................78
P
PACERONE ........................................................................24
PACNEX.............................................................................47
PACNEX HP .......................................................................47
PACNEX MIX 4.25% CLEANSER .........................................47
PACNEX MX ......................................................................47
PALIPERIDONE ..................................................................56
PAMELOR .........................................................................55
PAMINE ............................................................................23
PAMINE FORTE .................................................................23
PAMINE FQ .......................................................................23
PANCREAZE ......................................................................21
PANDEL.............................................................................43
PANRETIN .........................................................................48
PANTOPRAZOLE ...............................................................20
PAPAVERINE .....................................................................24
PARAFON FORTE DSC .......................................................60
PARCOPA ..........................................................................61
PARICALCITOL ...................................................................71
PARLODEL .........................................................................61
PARNATE ..........................................................................55
PAROXETINE .....................................................................55
PATADAY ..........................................................................53
PATANASE ........................................................................39
PATANOL ..........................................................................53
PAXIL, CR ..........................................................................55
PCE ...................................................................................32
PEDIADERM AF .................................................................45
PEDIADERM HC 2% KIT .....................................................43
PEDIADERM TA .................................................................43
PEDIAPRED LIQUID ...........................................................61
PEG3350/NA SULF/BICARB/CL/KCL ..................................23
PEG3350/SOD SUL/NACL/ASB/CL/KCL .............................23
PEGANONE .......................................................................59
PEGASYS ...........................................................................79
PEGINTERFERON ALFA-2A ................................................79
PEGINTERFERON ALFA-2B ................................................79
PEG-INTRON .....................................................................79
PEMIROLAST POTASSIUM ................................................53
PENBUTOLOL ....................................................................28
PENICILLAMINE ................................................................75
PENLAC .............................................................................45
PENTAMIDINE ISETHIONATE ............................................35
PENTASA ...........................................................................21
PENTOSAN POLYSULFATE.................................................78
PENTOXIFYLLINE ...............................................................49
PEPCID RPD ......................................................................20
PEPCID TABS .....................................................................20
PERCOCET ........................................................................ 37
PERCODAN ....................................................................... 37
PERINDOPRIL ................................................................... 25
PERIOSTAT ....................................................................... 31
PERSANTINE ..................................................................... 49
PEXEVA ............................................................................ 55
PHENAZOPYRIDINE .......................................................... 78
PHENELZINE ..................................................................... 54
PHENERGAN .............................................................. 22, 38
PHENOBARBITAL .............................................................. 59
PHENOXYBENZAMINE ...................................................... 29
PHENYLEPHRINE/ CHLORPHENIRAMINE ......................... 39
PHENYTOIN ...................................................................... 58
PHOSLO ............................................................................ 79
PHOSPHOLINE IODIDE SOLN ............................................ 51
PHYTONADIONE............................................................... 75
PILOCAR ........................................................................... 51
PILOCARPINE ................................................................... 51
PILOPINE HS ..................................................................... 51
PIMECROLIMUS ............................................................... 44
PIMOZIDE ......................................................................... 57
PIOGLITAZONE ................................................................. 72
PIOGLITAZONE/ ............................................................... 72
PIOGLITAZONE/ GLIMEPIRIDE ......................................... 72
PIOGLITAZONE/ METFORMIN .......................................... 72
PIRBUTEROL ..................................................................... 40
PIROXICAM ...................................................................... 35
PITAVASTATIN CALCIUM.................................................. 30
PLAQUENIL....................................................................... 35
PLAVIX .............................................................................. 49
PLETAL ............................................................................. 49
PODOFILOX ...................................................................... 48
POLYMYXIN/ BACITRACIN ................................................ 52
POLYMYXIN/ BACITRACIN/ NEOMYCIN ........................... 52
POLYMYXIN/ TRIMETHOPRIM ......................................... 52
POLYSPORIN .................................................................... 52
POLYTRIM ........................................................................ 52
PONSTEL .......................................................................... 36
PORTIA ............................................................................. 66
POSACONAZOLE .............................................................. 33
POTASSIUM CHLORIDE .............................................. 74, 75
POTASSIUM CITRATE ....................................................... 76
POTASSIUM PHOSPHATE ................................................. 74
PRADAXA ......................................................................... 49
PRAMIPEXOLE .................................................................. 61
PRAMIPEXOLE DI-HCL ...................................................... 61
PRAMLINTIDE ACETATE ................................................... 73
PRAMOXINE ..................................................................... 21
PRANDIMET ..................................................................... 72
PRANDIN .......................................................................... 72
PRASUGREL HYDROCHLORIDE ......................................... 49
PRAVACHOL ..................................................................... 30
PRAVASTATIN .................................................................. 30
PRAZIQUANTEL ................................................................ 35
PRAZOSIN ......................................................................... 28
191
PRECOSE ...........................................................................73
PRED FORTE......................................................................51
PRED MILD........................................................................51
PREDNISOLONE .................................................... 51, 61, 62
PREFERA-OB ONE .............................................................74
PREFERA-OB PLUS DHA ....................................................74
PREFEST ............................................................................68
PREFFERA OB ....................................................................74
PREFILLED PENS, PENFILLS, CARTRIDGES .........................71
PREGABALIN ............................................................... 59, 79
PREGNYL ...........................................................................69
PREMARIN ORAL ..............................................................68
PREMARIN VAG CREAM ...................................................68
PREMESIS RX ....................................................................74
PREMPHASE .....................................................................68
PREMPRO .........................................................................68
PRENATAL COMPLETE ......................................................74
PRENATAL PLUS ................................................................74
PRENATE ELITE .................................................................74
PRENATE ESSENTIAL .........................................................74
PRENATE PLUS ..................................................................74
PRENEXA...........................................................................74
PREVACID .........................................................................20
PREVALITE ........................................................................30
PREVIDENT 5000 BOOSTER GEL .......................................75
PREVIDENT 5000 PLUS CREAM.........................................75
PREVIDENT 5000 SENSITIVE 1.1%-5% ..............................75
PREVIDENT DENTAL RINSE ...............................................75
PREVIDENT GEL ................................................................75
PRIFTIN .............................................................................34
PRILOSEC ..........................................................................20
PRILOSEC 40MG ...............................................................20
PRILOSEC DR SUSP............................................................20
PRIMAQUINE ....................................................................35
PRIMIDONE ......................................................................59
PRINIVIL ............................................................................26
PRINZIDE...........................................................................26
PRISTIQ .............................................................................55
PROAIR HFA ......................................................................40
PRO-BANTHINE 7.5MG .....................................................23
PROBENECID.....................................................................73
PROCAINAMIDE ................................................................24
PROCARDIA, XL .................................................................27
PROCHLORPERAZINE ........................................................22
PROCRIT ...........................................................................49
PROCTOFOAM ..................................................................21
PROCTOFOAM HC ............................................................21
PROFASI 5,000 ..................................................................69
PROGESTERONE ...............................................................68
PROGRAF ..........................................................................77
PROMETHAZINE ......................................................... 22, 38
PROMETRIUM ..................................................................68
PROMISEB ........................................................................44
PRONESTYL 375, 500 ........................................................24
PROPAFENONE .................................................................24
PROPANTHELINE .............................................................. 23
PROPINE........................................................................... 51
PROPRANOLOL .......................................................... 28, 59
PROPRANOLOL SR............................................................ 59
PROPYLTHIOURACIL ......................................................... 70
PROQUIN XR .................................................................... 32
PROSCAR .......................................................................... 78
PROTONIX ........................................................................ 20
PROTOPIC ........................................................................ 48
PROTRIPTYLINE ................................................................ 55
PROVENTIL HFA ............................................................... 40
PROVERA ......................................................................... 68
PROVIGIL .......................................................................... 58
PROZAC ............................................................................ 55
PROZAC WEEKLY .............................................................. 55
PSEUDOEPHEDRINE/ ACRIVAS ......................................... 39
PSEUDOEPHEDRINE/ CHLORPHENIRAMINE .................... 39
PSEUDOEPHEDRINE/ DESLORATADINE ........................... 39
PULMICORT ..................................................................... 40
PULMICORT 0.25MG/2ML AND 0.5MG/2ML RESPULE ... 40
PULMICORT 1MG/2ML RESPULE, FLEXHALER AND
TURBUHALER .............................................................. 41
PULMOZYME.................................................................... 41
PYRAZINAMIDE ................................................................ 34
PYRIDIUM ........................................................................ 78
PYRIDOSTIGMINE ............................................................. 60
PYRIMETHAMINE ............................................................. 34
Q
QUESTRAN BULK .............................................................. 30
QUETIAPINE FUMARATE .................................................. 57
QUINAPRIL ....................................................................... 25
QUINAPRIL/ HCTZ ............................................................ 25
QUININE SULFATE ............................................................ 75
QUIXIN ............................................................................. 52
QVAR................................................................................ 41
R
RABEPRAZOLE .................................................................. 20
RALOXIFENE ..................................................................... 70
RAMELTEON .................................................................... 56
RAMIPRIL ......................................................................... 25
RANEXA ............................................................................ 24
RANITIDINE ...................................................................... 20
RANOLAZINE .................................................................... 24
RAPAFLO .......................................................................... 78
RAPAMUNE ...................................................................... 77
RASAGILINE ...................................................................... 60
RAZADYNE ....................................................................... 61
REBETOL........................................................................... 79
REBETOL ORAL SOLUTION ............................................... 79
REBIF ................................................................................ 79
REGLAN ............................................................................ 22
RELAFEN........................................................................... 36
RELENZA........................................................................... 34
192
RELPAX .............................................................................60
REMERON .........................................................................55
RENAGEL ..........................................................................79
RENVELA ...........................................................................80
REPAGLINIDE ....................................................................72
REPAGLINIDE/METFORMIN ..............................................72
REPREXAIN .......................................................................37
REPRONEX ........................................................................69
REQUIP .............................................................................61
REQUIP XL.........................................................................61
RESTASIS ...........................................................................52
RESTORIL ..........................................................................56
RETAPAMULIN ..................................................................44
RETIN A .............................................................................47
RETIN A MICRO.................................................................47
REVATIO ...........................................................................29
REVIA ................................................................................76
RHINOCORT AQUA ...........................................................39
RIBASPHERE......................................................................79
RIBATAB............................................................................79
RIBAVIRIN .........................................................................79
RIDAURA ...........................................................................77
RIFABUTIN ........................................................................34
RIFADIN ............................................................................34
RIFAMATE .........................................................................34
RIFAMPIN .........................................................................34
RIFAMPIN/ INH/ PYRAZINAMIDE .....................................34
RIFAMPIN/ ISONIAZID ......................................................34
RIFAPENTINE ....................................................................34
RIFATER ............................................................................34
RIFAXIMIN ........................................................................33
RIMANTADINE ..................................................................34
RIMEXOLONE....................................................................51
RISEDRONATE ...................................................................70
RISEDRONATE SODIUM ....................................................70
RISPERDAL ........................................................................57
RISPERDAL CONSTA ..........................................................57
RISPERIDONE ....................................................................57
RISPERIDONE MICROSPHERES .........................................57
RITALIN .............................................................................58
RITALIN LA ........................................................................58
RITALIN SR ........................................................................58
RIVASTIGMINE ..................................................................61
RIZATRIPTAN ....................................................................59
ROBAXIN ...........................................................................60
ROCALTROL ......................................................................75
ROPINIROLE ......................................................................61
ROSANIL ...........................................................................47
ROSIGLITAZONE................................................................72
ROSIGLITAZONE/ GLIMEPIRIDE ........................................72
ROSIGLITAZONE/ METFORMIN ........................................72
ROSUVASTATIN ................................................................29
ROWASA ENEMA ..............................................................21
ROZEREM .........................................................................56
RUFINAMIDE ....................................................................58
193
SOMA ...............................................................................60
SOMATROPIN ...................................................................80
SOMNOTE .........................................................................56
SONATA ............................................................................56
SORIATANE .......................................................................44
SOTALOL ...........................................................................24
SPECTRACEF .....................................................................31
SPIRIVA .............................................................................41
SPIRONOLACTONE............................................................25
SPIRONOLACTONE/ HCTZ .................................................25
SPORANOX CAPS ..............................................................34
SPORANOX SOLN ..............................................................34
SPRINTEC ..........................................................................66
STALEVO ...........................................................................61
STARLIX.............................................................................72
STRATTERA .......................................................................58
STRIPS ...............................................................................72
STROMECTOL ...................................................................35
SUBOXONE .......................................................................76
SUBUTEX...........................................................................76
SUCRALFATE .....................................................................20
SULAR 20, 30, 10 ..............................................................27
SULCONAZOLE NITRATE ...................................................45
SULFACETAMD/ SULFR/ SKNCLNSR10 ..............................47
SULFACETAMIDE SODIUM................................................51
SULFACETAMIDE/ PREDNISOLONE ..................................52
SULFAMETHOXAZOLE/ TRIMETHOPRIM .................... 32, 33
SULFAMETHOXAZOLE/ TRIMETHOPRIM DS ............... 32, 33
SULFAMYLON ...................................................................45
SULFANILAMIDE ...............................................................47
SULFASALAZINE ................................................................20
SULINDAC .........................................................................35
SUMATRIPTAN INJECTION ................................................59
SUMATRIPTAN NASAL SPRAY ...........................................59
SUMATRIPTAN TABLET .....................................................59
SUMATRIPTAN/ NAPROXEN .............................................60
SUMYCIN ..........................................................................31
SUPRAX.............................................................................31
SUPREP .............................................................................23
SURMONTIL ......................................................................55
SYMAX, DUOTAB ..............................................................23
SYMBICORT ......................................................................41
SYMBYAX ..........................................................................57
SYMLIN .............................................................................73
SYMLINPEN .......................................................................73
SYNAREL NASAL SPRAY ....................................................70
SYNTHROID.......................................................................70
SYRINGES ..........................................................................71
T
TACLONEX OINT ...............................................................44
TACROLIMUS .............................................................. 48, 77
TADALAFIL .................................................................. 29, 76
TAGAMET .........................................................................20
TAMBOCOR ......................................................................25
TAMIFLU .......................................................................... 34
TAMSULOSIN ............................................................. 28, 78
TAPAZOLE ........................................................................ 70
TAPENTADOL HYDROCHLORIDE ...................................... 37
TARGRETIN ...................................................................... 48
TARKA .............................................................................. 26
TASMAR ........................................................................... 61
TAVIST .............................................................................. 38
TAZAROTENE ................................................................... 44
TAZORAC .......................................................................... 44
TEGRETOL XR ................................................................... 59
TEKAMLO ......................................................................... 28
TEKTURNA........................................................................ 29
TEKTURNA HCT ................................................................ 29
TELITHROMYCIN .............................................................. 32
TELMISARTAN .................................................................. 26
TELMISARTAN/ ................................................................ 27
TELMISARTAN/ HCTZ ....................................................... 26
TEMAZEPAM .................................................................... 56
TEMOVATE ....................................................................... 43
TENEX............................................................................... 29
TENORETIC ....................................................................... 28
TENORMIN ....................................................................... 28
TERAZOL .......................................................................... 48
TERBINAFINE .............................................................. 33, 45
TERBINAFINE/ .................................................................. 45
TERBINEX ......................................................................... 45
TERCONAZOLE ................................................................. 48
TERIPARATIDE .................................................................. 70
TERSI ................................................................................ 45
TESSALON PERLES ............................................................ 40
TESTOSTERONE ................................................................ 69
TESTOSTERONE, TRANSDERMAL ..................................... 69
TESTRED ........................................................................... 69
TETRACYCLINE ................................................................. 31
TEVETEN .......................................................................... 26
TEVETEN HCT ................................................................... 26
THEO-24 SR ...................................................................... 41
THEOPHYLLINE ................................................................. 41
THIOTHIXENE ............................................................. 56, 57
THYROID, DESSICATED ..................................................... 70
THYROLAR ........................................................................ 71
TIAGABINE ....................................................................... 58
TIGAN ............................................................................... 22
TIKOSYN ........................................................................... 25
TIMOLOL .............................................................. 28, 50, 51
TIMOLOL/ DORZOLAM..................................................... 50
TIMOPTIC ......................................................................... 51
TIMOPTIC OCUDOSE ........................................................ 51
TIMOPTIC XE .................................................................... 51
TINDAMAX ....................................................................... 35
TINIDAZOLE ...................................................................... 35
TIOTROPIUM BROMIDE ................................................... 41
TIROSINT .......................................................................... 71
TIZANIDINE ...................................................................... 60
194
TRINESSA ......................................................................... 66
TRI-NORINYL .................................................................... 66
TRIOXIN ............................................................................ 54
TRI-SPRINTEC ................................................................... 66
TRIVORA........................................................................... 66
TROPAZONE ..................................................................... 44
TROPICAMIDE .................................................................. 50
TROSPIUM CHLORIDE ...................................................... 78
TRUSOPT .......................................................................... 51
TRYPSIN/ BALSAM PERU/ CASTOR OIL ............................ 48
TUSSIONEX PENNKINETIC ................................................ 39
TWYNSTA ......................................................................... 27
TYLENOL W/CODEINE ...................................................... 37
TYLOX ............................................................................... 37
TYVASO ............................................................................ 29
U
U-CORT 1%-10% CREAM .................................................. 43
ULESFIA ............................................................................ 48
ULORIC ............................................................................. 73
ULTRACET ........................................................................ 38
ULTRAM ........................................................................... 38
ULTRAM ER ...................................................................... 38
ULTRASE ........................................................................... 21
ULTRASE MT 12, 18.......................................................... 21
ULTRAVATE PAC............................................................... 43
UMECTA ..................................................................... 44, 47
UNIRETIC .......................................................................... 26
UNIVASC .......................................................................... 26
URAMAXIN ....................................................................... 44
URAMAXIN GT ................................................................. 44
UREA .................................................................... 43, 44, 47
UREA/ LACTIC ACID/ SALICYL ACID .................................. 44
UREA/LACTIC AC/ZN UNDECYLENATE ............................. 44
URECHOLINE .................................................................... 78
URELLE ............................................................................. 33
UROCIT-K ......................................................................... 76
UROCIT-K 15MEQ ............................................................ 76
UROFOLLITROPIN (FSH) ................................................... 69
UROXATRAL ..................................................................... 78
URSODIOL ........................................................................ 76
V
VAGIFEM .......................................................................... 68
VALACYCLOVIR................................................................. 34
VALIUM ............................................................................ 55
VALPROIC ACID ................................................................ 58
VALSARTAN ...................................................................... 26
VALSARTAN/ HCTZ ........................................................... 26
VALTREX ........................................................................... 34
VALTURNA ................................................................. 27, 29
VANCOCIN ....................................................................... 33
VANCOMYCIN, ORAL ....................................................... 33
VANOS ............................................................................. 43
VANOXIDE HC .................................................................. 47
195
X
XALATAN .......................................................................... 51
XANAX .............................................................................. 55
XANAX XR......................................................................... 56
XIFAXAN ........................................................................... 33
XODOL.............................................................................. 38
XOLEGEL........................................................................... 46
XOPENEX, HFA ................................................................. 41
X-VIATE ............................................................................ 44
XYREM ............................................................................. 56
XYZAL ............................................................................... 38
Y
YASMIN ............................................................................ 66
YAZ ................................................................................... 67
YOCON ............................................................................. 76
YODOXIN .......................................................................... 35
YOHIMBINE ...................................................................... 76
Z
ZACARE KIT ...................................................................... 47
ZADITOR OTC ................................................................... 53
ZAFIRLUKAST ............................................................. 38, 41
ZALEPLON ........................................................................ 56
ZANAFLEX CAPSULES ....................................................... 60
ZANAFLEX TABLETS .......................................................... 60
ZANAMIVIR ...................................................................... 34
ZANTAC ............................................................................ 20
ZANTAC EFFERDOSE ........................................................ 20
ZARONTIN ........................................................................ 59
ZAROXOLYN ..................................................................... 25
ZEBETA ............................................................................. 28
ZEGERID ........................................................................... 20
ZELAPAR ........................................................................... 61
ZEMPLAR.......................................................................... 71
ZENIEVA ........................................................................... 44
ZENPEP............................................................................. 21
ZESTORETIC ...................................................................... 26
ZESTRIL............................................................................. 26
ZETIA ................................................................................ 30
ZIAC .................................................................................. 28
ZIANA ............................................................................... 47
ZILEUTON ......................................................................... 41
ZIPRASIDONE MESYLATE ................................................. 56
ZIPSOR ............................................................................. 36
ZITHROMAX ..................................................................... 32
ZMAX ............................................................................... 32
ZOCOR.............................................................................. 30
ZOFRAN ODT .................................................................... 22
ZOLMITRIPTAN ................................................................ 60
ZOLMITRIPTAN NASAL SPRAY .......................................... 60
ZOLOFT ............................................................................ 55
ZOLPIDEM ........................................................................ 56
ZOLPIDEM TARTRATE ...................................................... 56
196
ZOLPIMIST ........................................................................56
ZOMIG NASAL SPRAY .......................................................60
ZOMIG, ZMT .....................................................................60
ZONEGRAN .......................................................................59
ZONISAMIDE .....................................................................59
ZOTEX GP ..........................................................................39
ZOVIA 1/35 .......................................................................67
ZOVIA 1/50 .......................................................................67
ZOVIRAX ...........................................................................34
197