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2011- 2012 Drug Formulary

For Commercial, Medicaid, Point-of-Service, PPO,


Signature PPO Closed Formulary, TPA, MIChild
and MedicarePlus (non-Part D)

Updated 10/1/2001

The Drug Formulary for Commercial, Medicaid, Point-of-Service, PPO,


Signature PPO Closed Formulary, TPA, MIChild and MedicarePlus (non-Part D)
2011- 2012 DRUG FORMULARY
TABLE OF CONTENTS
PREFACE TO THE SIXTEENTH EDITION ............................................................................................... ii
TABLE OF FORMULARY SECTIONS ..................................................................................................... iii
HOW TO USE THIS FORMULARY........................................................................................................ viii
DEFINITIONS ...........................................................................................................................................x
MEMBER PRESCRIPTION BENEFIT...................................................................................................... xi
GENERIC SUBSTITUTION GUIDELINES ............................................................................................... xi
PRIOR AUTHORIZATION PROGRAM ................................................................................................... xii
PHARMACY AUDIT PROGRAM............................................................................................................ xiii
DRUG RECALL SURVEILLANCE PROGRAM ...................................................................................... xiii
DOSE OPTIMIZATION PROGRAM ....................................................................................................... xiii
DRUG UTILIZATION REVIEW (DUR) .................................................................................................... xiv
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP) ........................................................ xiv
ASK FOR 90 RX PROGRAM ................................................................................................................. xiv
SPECIALTY PHARMACY PROGRAM .................................................................................................... xv
HEALTHPLUS DENTAL FORMULARY .................................................................................................. xv
PHARMACY & THERAPEUTICS COMMITTEE .................................................................................... xvii
FORMULARY UPDATES AND REVISIONS ......................................................................................... xvii
SMOKING CESSATION PHARMACOTHERAPY ................................................................................ xviii
FORMULARY KEY ................................................................................................................................ xix
FORMULARY DRUG PRODUCT .......................................................................................................... 20
PHARMACOLOGIC STEP PROTOCOL ................................................................................................ 82
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY .................................................... 104
HEALTHPLUS PARTNERS (MEDICAID) OVER-THE-COUNTER (OTC) MEDICATIONS .................. 105
MEDICATION PRIOR AUTHORIZATION FORM ................................................................................. 106
COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA PRIOR AUTHORIZATION CRITERIA ... 107
MEDICAID PRIOR AUTHORIZATION CRITERIA ................................................................................ 125
SPECIALTY INJECTABLE PRIOR AUTHORIZATION CRITERIA ....................................................... 144
PRESCRIPTION BENEFIT LIMITATIONS ........................................................................................... 175
A RESOURCE FOR PROMOTING QUALITY IN HEALTHCARE
Visit the HealthPlus website at www.healthplus.org

PREFACE TO THE SIXTEENTH EDITION


Since the publication of the 2011 edition of the HealthPlus Drug Formulary, many new drugs
and treatment options have become available. Every section of the Formulary has been
reviewed and updated. Recommendations in the Formulary are intended to promote the most
cost-effective therapy while maintaining a high quality drug benefit. The Drug Formulary is not
meant to take the place of the product package insert, and users are encouraged to refer to the
full prescribing information provided with the product.
Input and suggestions for inclusion in the 2013 edition are encouraged. Please direct your
comments and suggestions to:
HealthPlus of Michigan
Pharmacy Department
2050 S Linden Road
P.O. Box 1700
Flint, MI 48501-1700
Or e-mail:
rx@healthplus.org
Formulary information is also available at www.healthplus.org.
You may also download formulary information to a PDA or view the formulary online with a PC
through www.epocrates.com. To learn more about the Epocrates formulary program, please go
to www.epocrates.com. Formulary information may also be available through various eprescribing applications (along with eligibility verification and prescription history).

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TABLE OF FORMULARY SECTIONS


GASTROINTESTINAL DRUGS ..................................................................................................... 20
ANTI-ULCER AGENTS .............................................................................................................. 20
INFLAMMATORY BOWEL DISEASE ......................................................................................... 20
DIGESTIVE ENZYMES .............................................................................................................. 21
HEMORRHOIDS AND OTHER GASTROINTESTINALS ............................................................ 21
ANTIEMETICS ........................................................................................................................... 21
PROMOTILITY AGENTS ........................................................................................................... 22
ANTIDIARRHEALS .................................................................................................................... 22
ANTISPASMODICS ................................................................................................................... 22
LAXATIVES/CATHARTICS ........................................................................................................... 23
CARDIOVASCULAR AGENTS ..................................................................................................... 23
NITRATES ................................................................................................................................. 23
ANTIARRHYTHMICS ................................................................................................................. 24
CARDIAC GLYCOSIDES ........................................................................................................... 25
DIURETICS ................................................................................................................................ 25
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs) ................................................ 25
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs) ............................................................ 26
VASODILATORS ....................................................................................................................... 27
CALCIUM CHANNEL BLOCKERS ............................................................................................. 27
BETA-BLOCKERS ..................................................................................................................... 28
ALPHA BLOCKERS ................................................................................................................... 28
PULMONARY ANTIHYPERTENSIVES ...................................................................................... 29
MISCELLANEOUS ANTIHYPERTENSIVES .............................................................................. 29
ANTIHYPERLIPIDEMICS .............................................................................................................. 29
ANTIMICROBIALS AND INFECTIOUS DISEASE ........................................................................ 30
PENICILLINS ............................................................................................................................. 30
CEPHALOSPORINS .................................................................................................................. 31
TETRACYCLINES ...................................................................................................................... 31
MACROLIDES............................................................................................................................ 31
SULFONAMIDES ....................................................................................................................... 32
QUINOLONES ........................................................................................................................... 32
MISCELLANEOUS ANTIBIOTICS .............................................................................................. 32
URINARY ANTI-INFECTIVES (UTI) ........................................................................................... 33
ORAL ANTIFUNGALS................................................................................................................ 33
ANTITUBERCULOSIS AGENTS ................................................................................................ 34

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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

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COLONY STIMULATING FACTORS ......................................................................................... 49


ERYTHROCYTE STIMULATORS .............................................................................................. 49
HEMOSTATICS ......................................................................................................................... 49
EENT DRUGS ............................................................................................................................... 50
GLAUCOMA AGENTS ............................................................................................................... 50
TOPICAL OPHTHALMIC STEROIDS......................................................................................... 51
TOPICAL OPHTHALMIC ANTIBIOTICS..................................................................................... 51
TOPICAL OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY ......................................... 52
TOPICAL OPHTHALMIC VASOCONSTRICTORS/ANTIHISTAMINES ...................................... 53
TOPICAL OPHTHALMIC NSAIDS.............................................................................................. 53
OTIC AGENTS ........................................................................................................................... 53
BEHAVIORAL HEALTH ................................................................................................................ 54
DEPRESSION ............................................................................................................................ 54
ANXIETY .................................................................................................................................... 55
INSOMNIA ................................................................................................................................. 56
PSYCHOSIS/MANIC DEPRESSIVES ........................................................................................ 56
ATTENTION DEFICIT DISORDER/NARCOLEPSY ................................................................... 57
ANTICONVULSANTS ................................................................................................................... 58
MIGRAINE MEDICATIONS ........................................................................................................... 59
SKELETAL MUSCLE RELAXANTS ............................................................................................. 60
MISCELLANEOUS AUTONOMIC AGENTS ................................................................................. 60
PARKINSON'S DISEASE (PD) ..................................................................................................... 60
ALZHEIMER'S DISEASE .............................................................................................................. 61
HORMONES.................................................................................................................................. 61
ORAL ADRENAL CORTICOSTEROIDS .................................................................................... 61
ORAL CONTRACEPTIVES, GF ................................................................................................. 62
NON-ORAL CONTRACEPTIVES, GF ........................................................................................ 67
ESTROGENS, GF ...................................................................................................................... 67
PROGESTINS ............................................................................................................................ 68
COMBINATION ESTROGEN/PROGESTINS ............................................................................. 68
DDAVP-DESMOPRESSIN ACETATE ........................................................................................ 68
ANDROGENS, GM .................................................................................................................... 69
INFERTILITY .............................................................................................................................. 69
ENDOMETRIOSIS ......................................................................................................................... 70
OSTEOPOROSIS .......................................................................................................................... 70
SELECTIVE ESTROGEN RECEPTOR MODULATOR............................................................... 70

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

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IRRITABLE BOWEL SYNDROME/CHRONIC CONSTIPATION ................................................. 79


FIBROMYALGIA ........................................................................................................................ 79
MULTIPLE SCLEROSIS ............................................................................................................ 79
ELECTROLYTES & MISCELLANEOUS NUTRIENTS................................................................ 79
ANTINEOPLASTIC - ALL ONCOLOGY DRUGS ARE ON FORMULARY .................................. 80
GROWTH HORMONES ............................................................................................................. 80
HIV ALL HIV SELF-ADMINISTERED DRUGS ARE ON FORMULARY ................................... 80
ONCOLOGY ALL ONCOLOGY DRUGS ARE ON FORMULARY ............................................ 80
MEDICAL PRIOR AUTHORIZATION DRUGS AT A ZERO COPAY ........................................... 80
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM COVERED AT A ZERO COPAY
WITH PRESCRIPTION .......................................................................................................................... 80

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HOW TO USE THIS FORMULARY


ORGANIZATION
The HealthPlus Drug Formulary contains information about medication coverage, generic and
preferred brand prescriptions, and information about HealthPlus Pharmacy policies and
procedures that reflect best practices in the pharmacy industry and current treatment standards.
The Formulary is organized into SECTIONS according to classes of drugs and/or disease state.
When searching for a particular drug, you may use the Find or Search function if you are
viewing the PDF document electronically. If you are viewing a paper copy, it is best to refer to
the index (see last section) under the brand or generic name. Similarly, when looking for the
drugs used to treat a particular disease state, you may use the Find or Search function or refer
to the TABLE OF FORMULARY SECTIONS starting on page xix.
CONTENT
Formulary recommendations are developed through the Pharmacy & Therapeutics Committee
and are based on a review of current drug information and medical literature. HealthPlus
recognizes that it is the sole responsibility of the physician to determine the best course of care
for a particular patient. The HealthPlus Drug Formulary is VOLUNTARY or OPEN, with some
restrictions for drugs included in special programs such as the Prior Authorization program
(including Step Therapy). Procedures for requesting consideration of non-Formulary drugs for
addition to the Formulary are discussed under the heading Formulary Revisions on page xvii.
This document also includes copay tier and status of drugs for a closed formulary (currently
administered only for Signature PPO products).
DRUG LISTING
For each Formulary Section, there is an alphabetic listing of medications that includes both the
commonly used brand name and the generic name. The list includes products that are
Formulary and Non-Formulary. There is also a column that indicates generic availability
(Y=yes, a generic is available). The copay level/tier is included for each medication, along with
any type of restrictions such as prior authorization, quantity limits, etc.
For Commercial/Medicaid/POS/TPA/MedicarePlus (non-Part D) products, the following copay
tiers apply:
Generic Drugs=Tier 1, lowest copay
Formulary Brand Drugs=Tier 2, medium copay
Non-Formulary Brand Drugs=Tier 3, highest copay
NOTE: For members with a two tier copay (generic/brand), the standard brand copay applies
for all drugs in copay tiers 2 and 3.
In some cases, an employer group(s) may choose to place specific drugs in a different copay
tier from the standard formulary. Members have access to up-to-date information about
prescription drugs, the formulary and information specific to their benefit at the website at
www.healthplus.org.

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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.

MEMBER PRESCRIPTION BENEFIT


For HMO Commercial/Medicaid/MedicarePlus, prescriptions must be written by a participating
physician, or a non-participating physician with the required referral (this does not apply to PPO
members). If the medication is a covered benefit, members may fill their prescription at a
participating HealthPlus pharmacy by presenting their identification card. A list of participating
pharmacies may be found in the Provider Directory, on-line at www.healthplus.org or by
contacting the Customer Service Department.
Based on the members benefit level, a copayment may be required. Copayments vary. If you
or the member has questions about copayments or deductibles (if applicable), please contact
the HealthPlus Customer Service Department at 1-800-332-9161. For specific information
about PPO members, please contact HealthPlus PPO Customer Service at 1-888-212-1512.
GENERIC SUBSTITUTION GUIDELINES
Specified drugs which have generic equivalents MUST BE DISPENSED GENERICALLY.
These drugs are identified by a Y for YES in the GEQ column in the Formulary. Maximum
Allowable Cost (MAC) limits have been established for the majority of these agents. Drug
products considered to be generically and therapeutically equivalent are pharmaceutical
equivalents that can be expected to have the same therapeutic effects when administered to
patients under the conditions specified in the labeling.
The FDA assigns a rating for all generic products. Products with a rating that begins with an A
are considered equivalent to the brand name product. Some products approved before 1962 do
not have a designated rating. Therefore, even though generic equivalents are available, no A
rating has been assigned. These products will be reviewed on a case-by-case basis for addition
to the MAC list.
In cases of medical necessity, generic substitution may be overridden by the use of the
Dispense as Written notation, with Prior Authorization required in these instances (please refer
to Appendix D, page 107, Prior Authorization Criteria). For Commercial/PPO/MedicarePlus
Supplemental and RDS lines of business, if DAW is not medically necessary on a generically
available brand name prescription or the member chooses the brand product in the absence of
a DAW, he or she may do so by paying the difference in cost and/or any applicable copayment.
Based on the members benefit level, there may be a higher copay for branded products. For
HealthPlus Partners, if the member requests the brand name drug he or she may be
responsible for the entire cost of the prescription.

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

Toll-free phone (877) 710-0993

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.

ASK FOR 90 RX PROGRAM


Based on their benefit, the member may be eligible for the HealthPlus Ask for 90 Rx 90-day
medication program. With the Ask for 90 Rx program, there are two options for obtaining a 90day supply of medications:
1. LOCAL PHARMACIES-Members may receive up to a 90-day supply of medication from
participating local retail pharmacies, with copay savings. For more information, go to
www.healthplus.org for a Frequently Asked Questions flyer and a list of retail pharmacies
that participate in the Ask for 90 Rx program. Or, you may contact the HealthPlus
Customer Service Department.
2. MAIL SERVICE PROGRAM-Members may receive up to a 90-day of medication by mail
order through Express Scripts, save money on copays, and have prescriptions delivered
to their home with no shipping costs. For more information about mail service, go to
www.healthplus.org, or contact the HealthPlus Customer Service Department.
For most benefits, copay savings from both of these programs are the same. Based on their
benefit, the member pays the same copay for a 90-day supply at an Ask for 90 Rx retail
pharmacy as they do at mail order.
xiv

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

HEALTHPLUS DENTAL FORMULARY


Antifungals
nystatin

MYCOSTATIN*
Antivirals

acyclovir
valacyclovir

ZOVIRAX*
VALTREX*
Antibiotics
Cephalosporins

cephalexin HCL
cefadroxil
cefuroxime

KEFLEX* (NOT 750MG)


DURICEF*
CEFTIN*
Erythromycins

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*

Nonsteroidal Anti-Inflammatory Agents


RX MOTRIN*
INDOCIN*
NAPROSYN*
Narcotic Analgesics
acetaminophen/codeine
TYLENOL W/CODEINE*
acetaminophen 500/hydrocodone 5
VICODIN*
acetaminophen 750/hydrocodone 7.5
VICODIN ES*
acetaminophen 325/oxycodone 5
PERCOCET*
aspirin/caffeine/dihydrocodeine
SYNALGOS-DC*
aspirin/codeine
EMPIRIN W/CODEINE*
aspirin 325/oxycodone 5
PERCODAN*
butalbital/aspirin/caffeine/codeine
FIORINAL W/CODEINE*
ibuprofen
indomethacin
naproxen

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

PHARMACY & THERAPEUTICS COMMITTEE


The Pharmacy & Therapeutics Committee is an interdisciplinary body made up of practicing
physicians and pharmacists from the community, in addition to staff. The committee may invite
persons within or outside the organization who can contribute specialized or unique knowledge,
skills, and judgments. The function of the committee is to serve in an evaluative, educational,
and advisory capacity to the physician providers in all matters pertaining to drug use. The
committee also provides strategic guidance for pharmacy programs. The committee is involved
in the development and updating of pharmaceutical management procedures. In addition, the
committee meets at least five times annually to evaluate drugs for inclusion in the formulary.
The recommendations of the Pharmacy & Therapeutics Committee are communicated to the
Medical Affairs Committee and finally sent to the Board of Directors for approval.
FORMULARY UPDATES AND REVISIONS
The Formulary is revised regularly through recommendations from the Pharmacy &
Therapeutics Committee. HealthPlus reviews medications and medication categories on an
ongoing basis to help ensure that the Drug Formulary provides an ample, up-to-date selection of
quality, cost-effective medication choices. The Formulary is revised and republished annually
with notification to providers, and is available with quarterly updates on the website at
www.healthplus.org; providers and members may also receive a printed copy upon request.
Quick-Check references that include formulary recommendations for the most-prescribed
categories are also available and updated regularly. HealthPlus routinely provides updated
information to physicians, pharmacies and members through letters, bulletins, e-mails, articles in
the newsletters, etc. The Formulary is also available for providers at www.epocrates.com for
downloading to a PDA or in an on-line version, and through various e-prescribing software
applications available to physicians.
Members may obtain up-to-date formulary and cost information specific to their benefit and
copays at www.healthplus.org. For more information, please contact the HealthPlus Pharmacy
Department at 1-810-230-2118.
Physician requests for additions to the Formulary must be made on a Request for Addition to
the Formulary form, which includes the reason for the request and any clinical data supporting
that request. Please refer to APPENDIX A (page 92) for a copy of the HEALTHPLUS
REQUEST FOR ADDITION TO THE FORMULARY form. Member requests for additions to the
formulary are forwarded to the Pharmacy Department for appropriate review and consideration.

xvii

SMOKING CESSATION PHARMACOTHERAPY


HealthPlus will cover prescriptions for smoking cessation pharmacotherapy if the following
criteria are met:
1. The member is enrolled in a smoking cessation behavioral modification program or other
counseling satisfactory to their primary care physician.
2. Coverage is provided only when the product is prescribed by the members primary care
physician, including the specialties of internal medicine, family practice, pediatrics, and
behavioral health. (This does not apply to PPO members).
3. Smoking cessation pharmacotherapy may be limited to no more than one course of
therapy per medication every utilization year.
4. Smoking cessation pharmacotherapy will be consistent with the HealthPlus Drug
Formulary.
5. Smoking cessation products covered as a Preventative Medication as required by
Health Care Reform are listed on page 80.
For specific formulary recommendations and limitations, please see SMOKING CESSATION
PRODUCTS on page 76.
HealthPlus offers a Smoking Cessation Pathway to members. The goals of this pathway are to
help smokers begin thinking about quitting without pressure to do so, and if the member is ready
to quit, to help prevent relapses.
To enroll a patient in the HealthQuest Smoking Cessation Pathway, contact the Health and
Lifestyle Management Department at 1-810-230-2118.

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

ORALLY INHALED DRUGS


ACCUNEB

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

SCABICIDES & PEDICULOCIDES


EURAX
OVIDE
ULESFIA

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

TOPICAL OPHTHALMIC STEROIDS


ALREX
DECADRON
FLAREX
FML
FML FORTE
FML S.O.P.
LOTEMAX
MAXIDEX
PRED FORTE
PRED MILD
VEXOL

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

TOPICAL OPHTHALMIC ANTIBIOTICS


ALODOX
AZASITE
BESIVANCE
BLEPH-10

DOXYCYCLINE/
EYELID CLNS NO.2&3
AZITHROMYCIN
BESIFLOXACIN
HYDROCHLORIDE
SULFACETAMIDE
SODIUM

3
3

NF-NC
NF-NC

NF-NC

51

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

TOPICAL OPHTHALMIC NSAIDS

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

PARKINSON'S DISEASE (PD)


APOKYN
AZILECT
COGENTIN
COMTAN

PA

PA

PA
MDCH

NF-NC
2
1
2

60

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

SELECTIVE ESTROGEN RECEPTOR MODULATOR


EVISTA

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

NICOTINE PATCH OTC

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

FORMULARY DRUG PRODUCT


NOTES

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

Consumer Healthcare Products Association


(CHPA) in cooperation with The Food and Drug
Administration (FDA) has revised product labels
of over the counter (OTC) cough and cold
medicines to state "do not use" in children under
4 years of age.

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.

Children >12 years: 1-2 sprays per


nostril daily or twice a day
Adult: 1-2 sprays per nostril BID
Generic Astelin 137
mcg

200

Generic Atrovent
0.03%

345

OTC generic
Loratadine
(Claritin, Alavert)
OTC generic
Loratadine-D
(Claritin-D,
Alavert-D)

Perennial Allergic Rhinitis

Intranasal Steroid
OR
Antihistamine (nasal or oral) or
intranasal ipratropium
Start treatment 10-14 days
before pollen season or at onset of
symptoms

Manage with OTC


+
Antihistamines or OTC
cromolyn sodium

Product

Consistent Symptoms

Peds (age 5-11): 1 spray per nostril


BID
Adult and Children > 6 years: 2
sprays per nostril 2-3 times per day
for up to 4 days

Adult: 10mg daily


Peds (age 2-5): 5mg daily

Adult: 10/240mg daily

6.

Intranasal Steroid
OR
Nasal Antihistamine
Breakthrough Symptoms

Oral Antihistamine (with/without


decongestant)

Allergy triggers should be identified and


patients should be educated on allergen
avoidance.
Intranasal corticosteroids are first-line
therapy for allergic rhinitis, especially
when nasal obstruction is a major
component of the patients rhinitis.
The most effective use of intranasal
corticosteroids is to begin therapy 10-14
days prior to the onset of allergy season.
Therapeutic benefit is typically seen
within 3 or 4 days of initiating therapy.
Reserve addition of antihistamines to the
regimen for breakthrough symptoms of
itching, sneezing, and rhinorrhea, or if a
patient exhibits related ocular symptoms.
Although there is evidence that oral antileukotriene agents (i.e. Singulair,
Accolate) may be of value in treatment of
allergic rhinitis, these agents should not
be considered as first line therapy and
may require prior authorization.
Ocular preparations may be used for
allergic conjunctivitis that is uncontrolled
with oral antihistamine therapy.

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

PHARMACOLOGIC STEP PROTOCOL

FOR TYPE 2 DIABETES MELLITUS


Initial Therapy

Insulin

Metformin plus
Lifestyle Intervention (Meal
Planning and Physical Activity)

Intermediate bid

Consider insulin if:


Very Symptomatic
Severe
Hyperglycemia
Ketoacidosis
Possible Type 1
Pregnancy

Glycemic
goals not
achieved

Intermediate + short-acting before


meals bid
Multiple (3 or more) injections
intermediate or long acting + shortacting before meals
Basal insulin once-twice daily

Addition of
Oral Agent

OR

Glycemic
goals not
achieved

Addition of
Third Agent **

Addition
of
Insulin

Continuous insulin infusion pump


Rapid
Short
Intermediate
Long
Acting
Acting
Acting
Acting
lispro
regular
NPH
insulin
aspart
70/30
glargine
glulisine
insulin detemir
(See the American Diabetes Association Position
Statements, Insulin Administration, and Continuous
Subcutaneous Insulin Infusion, for further discussion on
this subject.)

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

FORMULARY ANTIDIABETIC AGENTS


Sulfonylureas

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

Actoplus MET (pioglitazone/metformin)


#
Avandamet (rosiglitazone/metformin)
#
Misc
Precose* (acarbose)
Avandaryl (rosiglitazone/glimepiride)
GLP-1 Receptor Agonists
Duetact (pioglitazone/glimepiride)
Symlin (pramlintide)
Byetta (exenatide)
Glucovance* (glyburide/metformin)
Welchol (colesevelam)
Victoza (liraglutide)
Metaglip* (glipizide/metformin)
Starlix* (nateglinide)
*available in generic
#
The FDA limits the use of rosiglitazone-containing products through a restricted distribution Risk Evaluation
andMitigation Strategy (REMS) program effective 11/2011.
Alpha-Glucosidase Inhibitors

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

Peptic Ulcer Disease/H. pylori


Pharmacologic Step Protocol
Stop NSAID

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

H. pylori PPI-Based Triple Therapy


NO ALLERGIES TO
PENICILLIN ALLERGIC
PENICILLIN
Amoxil 1,000mg BID with meals for Metronidazole 500mg BID with
10-14 days
meals for 10-14 days
Clarithromycin 500mg BID with
Clarithromycin 500mg BID with
meals for 10-14 days
meals for 10-14 days
And PPI**BID before meals for
And PPI** BID before meals for
10-14 days #
10-14 days #
Add antacids as needed
Continued PPI treatment for 2-3 weeks beyond therapy (for a total of 4
weeks) may be needed to promote ulcer healing
PPI treatment may be needed for 12 weeks if NSAIDs cannot be
discontinued.
** Omeprazole 20 mg BID is the first line PPI of choice
# BID dosing for PPIs requires prior authorization, except for omeprazole.
Formulary PPIs require: documented failure of omeprazole.
- generic Prevacid, generic Protonix and Aciphex
Non-formulary PPIs require: documented failure of omeprazole,
Aciphex, generic Prevacid and generic Protonix before a non-formulary
PPI will be approved.
- Zegerid
- Nexium; specifically, requires documented failure of formulary
PPIs and documented diagnosis of Barretts Esophagus, ZollingerEllison, or Erosive Esophagitis.
- Dexilant, specifically, requires documented diagnosis of Erosive
Esophagitis.
- Prilosec DR suspension
OR combination products:
HELIDAC (bismuth/metronidazole/tetracycline) plus H2 blocker or PPI for 14
days or
PREVPAC (amoxicillin/clarithromycin/Prevacid) for 14 days

References:
American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J
Gastroenterol 2007; 102:1808-1825.

Revised 7/2011

84

HYPERTENSION STEP PROTOCOL


PHARMACOLOGIC THERAPY
LIFESTYLE MODIFICATIONS
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for patients with diabetes and chronic kidney disease)

INITIAL DRUG CHOICES

Without Compelling Indications

Stage 1
Hypertension

With Compelling Indications

Stage 2
Hypertension

(SBP =140-159 or
DBP =90-99 mmHg)
Thiazide-type diuretics for
most.
May consider ACEI, ARB, BB,
CCB, or combination.

Drug(s) for the compelling


indications

(SBP > 160 or DBP > 100mmHg)


Two-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB).

Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB, or
combination.

NOT AT GOAL BLOOD PRESSURE


Optimize dosages or add additional drugs until goal blood pressure is
achieved. Consider consultation with hypertension specialist.

Compelling Indication*
Heart Failure
Postmyocardial infarction
High coronary disease risk
Diabetes
Chronic kidney disease
Recurrent stroke prevention

Compelling indications for individual drug classes


RECOMMENDED DRUGS
Diuretic
BB
ACEI
ARB
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x

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

Direct Renin Inhibitor

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

Revised date 3/2011

85

ACUTE OTITIS MEDIA IN CHILDREN


PHARMACOLOGIC STEP PROTOCOL
Diagnosis of Otitis Media
Otoscopic exam and clinical signs and symptoms

Optional observation (deferring antibiotic medication for 48-72


hours) for children with mild symptoms (see footnote 1 below)
Treatment with analgesics (acetaminophen or ibuprofen)

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

Treatment Failure (no improvement within 2-3 days) OR Recurrence

Augmentin Suspension* (ES 600 mg)


80-90mg/kg/day in two divided doses x 5-10days
(Daily dose can be given in three divided doses for
suspected resistant S.pneumoniae after failed low
dose amoxicillin.)

Azithromycin 20mg/kg/day x 3 days^

ENT Consult/Tympanocentesis or IM ceftriaxone or clindamycin (for PCN allergy)


*available in generic
^per UMHS Otitis Media Guidelines
1. It is estimated that 70-90% of acute otitis media episodes resolve without therapy within 7-10 days. Observation (delaying
treatment for 48-72 hours) of the following mildly symptomatic children is encouraged with parental acceptance:

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

Failure to Respond (after 3-10 days treatment)

Severe Disease in Adults

Levaquin* 750 mg daily x 5 days or


#
Avelox 400 mg daily x 10 days

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 Step Protocol for Heart Failure (HF)

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

Patients who have


marked symptoms at
rest despite maximal
medical therapy

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

Class II & III


Stage C
Structural heart disease with
prior or current symptoms of
HF

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

Patients at stage B or higher whose condition is worsening should be referred to a specialist


^Consider an Angiotensin II Receptor Blocker (e.g., Benicar, Cozaar*, Diovan) for patients who are contraindicated or intolerant to an ACE Inhibitor.
* Generic available
# Digoxin has a narrow therapeutic range and the toxicity is affected by individual hydration/electrolytes status. Frequent renal function and digoxin
monitoring is highly recommended. The use of digoxin at a 0.25 mg dose or higher should be avoided in the elderly and in patients with renal insufficiency.

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

Beta Blockers Recommended for 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

PHARMACOLOGIC STEP PROTOCOL

FOR MAJOR DEPRESSION


1

SSRI

(Prozac*, Paxil*, Zoloft*, Celexa*)


Side effects noted (i.e., GI intolerance)
Reduce dose if needed (SSRIs are all
equally effective with comparable tolerability)

Complaint of persistent insomnia


1. Add low dose (50-100 mg) trazodone QHS
2. Consider Ambien*/Sonata* if patient fails
trazodone

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*

Effexor* or Effexor XR*

1. Preferred in geriatric patients

1. Effective in moderate to severe depression

with poor appetite or insomnia


2. Well-tolerated with no
significant drug interactions or
dosage adjustment needed for
renal dysfunction

2. May be associated with increased blood


pressure (dose-dependent)
3. Effexor XR provides slower rate of absorption
(less SE, improved compliance), but the same
extent of absorption and comparable drug
exposure and plasma fluctuation as the
immediate release product

Wellbutrin* or Wellbutrin SR*


1. May be beneficial for patients with
impulsive behavior
2. Approved for smoking cessation
3. May not work well in severe
depression
4. Minimize alcohol use; use caution in
patients with history of seizure or head
trauma

Allow 8-12 weeks for full therapeutic effect


When diagnosis is a new episode of depression, instruct patient to continue to take the antidepressant for at least 6-12
months. For patients with recurrent major depression, maintenance therapy will likely be required indefinitely.
If depression is not resolved and patient has experienced treatment failure with at least two of the above
alternatives, refer to a psychiatrist
1

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

PHARMACOLOGIC STEP PROTOCOL


FOR MIGRAINE
Make or confirm migraine diagnosis (Consider co-morbid conditions and treat, e.g., HTN)
Key migraine signs/symptoms:
Symptoms not usually associated with migraine:
Chronic, episodic headache
Duration of 4 to 72 hours
Pulsatile/throbbing pain
Unilateral or bilateral location
Aggravated by light and/or sound
Nausea and/or vomiting
Onset age 12-44 years

First headache >50 years


Abnormal headache pattern
Worst ever experience
Abrupt onset
Pain progressively worsens over time
Abnormal medical evaluation
Abnormal neurological exam

Assess frequency, severity, and disability


Assess management needs and set individual goals; define action plan
Self-care techniques (Non-pharmacologic management)
Initiate pharmacologic management for
abortive treatment based on STEP CARE for
4
MIDAS Questionnaire grade I (score 0-5)

NSAIDs (First Line):


(e.g., ibuprofen, naproxen, ketorolac,
diclofenac)

Initiate pharmacologic management for abortive


treatment based on STRATIFIED CARE for MIDAS
4
Questionnaire grades II-IV (score 6-21+)
Mild Intensity, Low Disability
(MIDAS Scale Grade II)

Simple Analgesics:

NSAIDs (First Line):

(e.g., aspirin, Excedrin,)

(e.g., ibuprofen, naproxen, ketorolac,


diclofenac)

Simple Analgesics:
(e.g., aspirin, Excedrin,)

No relief 2 hours later


2
Anti-migraine (triptan therapy)
Stronger analgesics may be used if antimigraine therapy is contraindicated

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 Level at Which to Consider


Drug Therapy
>190 mg/dL
drug optional if 160-189 mg/dL
>160 mg/dL
(> 130mg/dL if 10 year risk 10-20%)
>130 mg/dL
(drug optional if 100-129 mg/dL)

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%

+Prior authorization is required for Zetia monotherapy or


dose >10 mg/d
# Simvastatin 80 mg has been associated with an
Increased risk of muscle damage. Simvastatin
should be used with caution when prescribed with
other medications known to increase simvastatin levels.

2.

3.

4.

Treatment LDL Goal


<160 mg/dL
<130 mg/dL
<100 mg/dL
More stringent recommendation
<70 mg/dL

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]

Other Formulary Antihyperlipidemics


Nicotinic Acid:
Niaspan (niacin ER)
Bile Acid Sequestrants:
Colestid* (colestipol)
Questran* (cholestyramine)
Prevalite* (cholestyramine/aspartame)
Welchol (colesevelam)
Fibric Acid Derivatives:
Lofibra* (fenofibrate)
Fibricor* (fenofibric acid)
*
Generic available
** Branded Statin therapy requires:
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).

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

CHRONIC PAIN MANAGEMENT


PHARMACOLOGIC THERAPY
INITIAL ASSESSMENT OF PAIN

1)
2)
3)
4)
5)
6)
7)
8)
9)

Determine causes of pain: (Malignant vs. Non-malignant)


Differentiate type of pain: Structural (MRI) vs. Functional (EMG)
Screen for alcohol use (AUDIT tool).
Screen for depression (PHQ-2, PHQ-9).
Screen for addiction/abuse risk (DAST, DIRE)
Urine Drug Screen and blood work (e.g., CBC, ESR, LFT, BUN/SCr)
Evaluate history of pain and results of previous treatments. Evaluate fatigue for malignant pain.
Evaluate the effect of co-existing illness related to pain.
Psycho-social evaluations (e.g., impact of life, family or work, potential addiction)
If decision is made to start chronic opioid therapy (for pain greater than 3 months
duration), a written contractual agreement between patient and physician is
recommended.

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

2) Short-acting opioids for


breakthrough pain (as needed)

+ 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

^ADJUNCTS (see Table 5):


1) Consider diet, exercise (especially for weight bearing joints),
heat/cold applications, smoking cessation or physical therapy if needed.
2) Antidepressants (i.e., SNRI) or anticonvulsants (i.e., Neurontin, Lyrica) may be helpful for neurological type of pain.
3) Short-term muscle relaxants may be used for spasm-related pain; long-term use for pain management is NOT
recommended.

A written contractual agreement may include the following discussion:


Goals of therapy (pain relief, physical improvement or social functioning)
The requirement for a single provider or treatment team
A prohibition on use of alcohol, other sedating or illegal medications without discussing with providers
(e.g., urine drug screening and alcohol testing)
The limitation on dose, quantities or refills of prescribed medications (e.g., pill counts, no early refills).
Against changing dosage or quantities without permission
Prohibition of selling, sharing, lending or giving prescribed medications to others
Agree to keep medication safe and secure and understand the potential side effects and dependence
The option of sharing information with family members and other providers if necessary
Compliance with all components of overall treatment plan and need for periodic reevaluation
Consequences of non-adherence
Reference: 1. Assessment and Management of Chronic Pain. Institute for Clinical Systems Improvement. November 2009
2. Opioid Treatment Guidelines. The Journal of Pain. Vol 10, No 2. February 2009
3. WHO Pain Relief Ladder
Revised date: 12/2010

92

TABLE 1. Comparison of Non-opioid Analgesics3,4


Chemical
Class

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

Consider a maximum of 2-3


gm/day for chronic use to avoid
the risk of liver toxicity. Lack of
anti-inflammatory effects
Risk of GI bleed
Less GI toxicity than aspirin

8-12h

1000mg q12h

4000mg

Less GI toxicity than aspirin

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

High risk of GI toxicity. CNS


side effects. Avoid in elderly.

2h

25mg q6-8h

200mg

7h

200mg q6-8h

1200mg

Less risk of GI toxicity

4-7h

10mg q6h

40mg

Sulindac
(Clinoril)

14h

150mg q12h

400mg

High risk of GI toxicity. FDA


recommends not to exceed 5
days therapy
Possibly less renal toxicity than
other NSAIDs. Metabolized via
liver. Good choice for patients
also on beta-blocker.

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:

Less risk of GI toxicity (lowdose).

No more effective than other


NSAIDs.
Prior Authorization required.

Acetaminophen is considered as a first-line for treating osteoarthritis pain in elderly.


The initial dose should be reduced to 30-50% of recommended starting dose in elderly or patients with
renal dysfunction.
All nonsteroidal anti-inflammatory drugs (NSAIDs) including Cox-2 inhibitors include a boxed warning of
increased risk of cardiovascular events and serious, potential life-threatening gastrointestinal bleeding
associated with their use.
When switching to different NSAIDs due to efficacy or side effects, consider selecting one from different
chemical class.

93

Consider PPI (i.e., generic Prilosec RX 20mg) for patients with risk of GI bleed requiring long-term NSAID
therapy.

TABLE 2. Comparison of Oral Opioid Analgesics3,4,5,6,7


Opioid Agonist

Equianalgesic
Dose (mg)

Plasma
Half-Life
(hr)

Short-Acting Opioids (For breakthrough pain)


Codeine
200mg
3h
(alone or in
combination with
APAP or ASA)
Fentanyl
(Actiq)
Oral lozenge
Hydrocodone

NA
(see Table 3)

Usual
Starting Dose

Usual Dosing
Frequency
(hr)

Notes

30mg

4 6h

Limited dosing due to potential acetaminophen


toxicity with which it is often combined. (see
Table 4)

200mcg

Not recommended for long-term use.


Analgesia does not increase with doses
>200 mg (ceiling dose).
Difficult to predict the daily maintenance
dose. Handle and dispose of in a manner
that is child-safe.

30mg

2 4h

5 10mg

15 minutes
and may
repeat
4 6h

8mg

2 3h

2mg

4 6h

300mg

3 4h

50mg

3 4h

Poor oral absorption, short half-life, longlasting active neurotoxic metabolite


NOT recommended for chronic pain.
Active metabolite. May accumulate in
patients with renal impairment.
Active metabolite, oxymorphone.
Efficacy decreased in patients taking
CYP 2D6 inhibitors.*
Slower initiation and titration improves
tolerability. Efficacy decreased in patients
taking CYP 2D6 inhibitors.* Risk of seizure
may be increased in patients taking SSRI,
MAO, TCA.

(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

Consider in patients who cannot tolerate


oral long-acting morphine or methadone.

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

Risk of accumulation. Requires careful


titration.
Risk of accumulation. Requires careful
titration. Good choice for opioid rotation.
QTc interval prolongation, hypotension &
cardiac dysrhythmias can occur.
Recommend consult with pain specialist for
prescribing. Baseline ECG prior to
initiation of methadone, repeated after 30
days and then annually.
GOLD standard therapy
Due to prolonged absorption of the drug,
the dosage should not be adjusted more
frequently than every 48 hours. Adjust
dosage in renal impairment.
Consider in patients who cannot tolerate
oral long-acting morphine or methadone.
Conversion to the active metabolite,
oxymorphone. Efficacy decreased in
patients taking CYP 2D6 inhibitors.*

Long-Acting Opioids
Fentanyl
(Duragesic)
topical patch
Levorphanol
Methadone

* Examples of CYP 2D6 inhibitors: SSRIs, ketoconazole, cimetidine, amiodarone, Haldol, Benadryl.

94

Starting dose should be determined at 50%-75% of calculated dose from equianalgesic


conversion.

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).

Management of Side Effects of Opioids:

- Nausea/ vomiting: Reglan 10 mg q6-8h or Compazine 10 mg q6-8h or Phenergan 25 mg q8h


- Constipation: Diet and/or Colace 200 mg BID or Senokot 2 tablets BID (may increase to 4 tablets BID)
or Dulcolax suppositories, 1 prn daily
- Pruritis: hydroxyzine 25 - 100 mg q6-8h
- Anxiety: hydroxyzine 25 - 100 mg q6-8h or Phenergan 25 50 mg q8h
- Sedation, CNS side effects: Prevention and recognition of the risks (e.g., elderly, post-surgery, impaired
renal function, combination with other sedatives)
- Opiate overdose (i.e., respiratory depression): Reverse opioids with naloxone 0.4-2 mg SC/IV/IM q2-3
minutes; if no response after 10 minutes, diagnosis should be questioned.

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

TABLE 3. Quick Conversion Table

6,8

Fentanyl Transdermal Dosing Conversion


Convert FROM oral Morphine
TO Fentanyl Transdermal Patch
Oral Daily
Fentanyl
Morphine (mg/d) (mcg/h) Q 72 hr
45 134
25
135 224
50
225 314
75
315 404
100
405 494
125
495 584
150

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.

TABLE 5. Equianalgesic Dosing of Opioids for Pain Management


Refer to Table 6 for detailed doses of hydrocodone or oxycodone in acetaminophen containing products
Hydrocodone
Total daily dose
30 mg
60 mg
80 mg
100 mg
120 mg

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

TABLE 6. Dosing Guideline for Acetaminophen Containing Analgesics


Brand Name

Acetaminophen
(Tylenol) mg/tab

Other Ingredient(s)

Max QTY/day (Based on safety


Max QTY/day
recommendation of 4gm/day with (3gm/day with
short-term use: 1-3 mo)
long-term use)
6
4
6
4

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

TABLE 7. Example of Adjuvant Analgesics

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)

100 mg PO BID TID

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

Behaviors that Require Attention:


Requesting specific drugs
Requesting appointment(s) at the end
of day
Aggressive complaining about needing
more of the drug
Obtaining similar drugs from different
prescribers
Missing appointment(s) or not following
other components of the treatment
plan (e.g., physical therapy or
exercise)
Resistance to a change in therapy
(expression of anxiety)
Increasing dosage or using the drug to
treat another symptom without
consulting physicians on more than
one occasion

2,3

Predictors of Opioid Misuse:


History of illegal behavior (e.g., selling, forgery,
or stealing)
Dangerous behavior (e.g., motor vehicle
accidents, alcohol intoxication, or
aggressive/threatening/violent behaviors)
Obtaining opioids from multiple prescribers
(including emergency room) or filling
prescriptions at different pharmacy locations
Multiple episodes of prescription loss
Concurrent abuse of alcohol or illegal drugs
Unexpected results from urine drug screen
Evidence of sudden deterioration in the ability to
function at work or socially, which appears to be
related to drug use
Repeated requests for dose increases, early
refills, or resistance to change in therapy

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

Table 8. Example of Detoxification Schedule for Opioid Dependency: 10


Buprenorphine (Suboxone) dose (mg), sublingual tablet
Day Number
10-day schedule
7-day schedule
1
8
8
2
6
6
3
4
4
4
4
4
5
4
2
6
2
2
7
2
0
8
2
9
2
10
0
*Doses may be adjusted to titrate off opioid in longer period of time.
To locate the physician(s) authorized to prescribe buprenorphine, go to
http://buprenorphine.samhsa.gov/bwns_locator/index.html

3-day schedule
4+8 (stat and 24h)
8 (48h)
8 (72h)

99

Table 9. Pharmaceutical Interventions for Neuropathic Pain13

Drug

Formulary
Status

Dosage

Side effects, Contraindications &


Comments

ANTICONVULSANTS

Gabapentin*
(Neurontin)

Formulary

100 to 300 mg at bedtime;


increase by 100-300 mg every 3
days up to 1,800 to 3,600 mg per
day taken in divided doses three
times daily. Higher doses might
be used.

Initial drug of choice. Side effects: drowsiness,


dizziness, fatigue, nausea, sedation, edema, weight
gain. No significant drug-drug interactions. Reduce
dose/increase interval in renal failure (give 10x
1
creatinine clearance per day).

Pregabalin*
(Lyrica)

Formulary

50 mg 75 mg twice daily-three
times daily to start. Up to 200 mg
three times daily.

Lamotrigine
(Lamictal)

Formulary

25 mg per day; increase by 25


mg-50 mg every 1-2 weeks up to
400 mg per day.

Oxcarbazepine
(Trileptal)

Formulary

Start 150 mg - 300 mg twice


daily. Increase by 600 mg per
day each week to max 1200 mg
twice daily.

Initial drug of choice. Side effects: drowsiness,


dizziness, fatigue, nausea, sedation, edema, weight
gain. No drug-drug interactions. Reduce dose/increase
interval in renal failure (give 5x creatinine clearance per
1
day). Schedule V medication.
Side effects: Stevens-Johnson syndrome, rare lifethreatening rash unlikely with gradual dose titration.
Dizziness, drowsiness, headache, nausea,
1
blurred/double vision.
Initial drug of choice for trigeminal neuralgia. Similar
adverse effects to carbamazepine but less likely. Fewer
1
drug-drug interactions.

Carbamazepine*
(Tegretol)

Formulary

200 mg-400 mg twice daily.


Increase to max 600 mg twice
daily.

Topiramate
(Topamax)

Formulary

25 mg twice daily to start;


increase by 25-50 mg per week
up to 200-400 mg per day.

Duloxetine *
(Cymbalta)

Non-formulary

Initial drug of choice. Side effects: nausea, dry mouth,


2
constipation, dizziness, insomnia.

Venlafaxine
(Effexor)

Formulary

20 to 60 mg per day taken once


or twice daily in divided doses
(for depression); 60 mg twice
daily for fibromyalgia.
37.5 mg per day; increase by
37.5 mg per week up to 300 mg
per day.

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.

Initial drug of choice. Tertiary amines have greater


anticholinergic side effects and may cause arrhythmia,
orthostatic hypotension; therefore, these agents should
2
not be used in elderly patients.

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.

Secondary amines have fewer anticholinergic side


effects, but should still be used cautiously in elderly
2
patients.

Non-formulary
PA Required

Up to 3 patches to intact skin 12


hrs per day (12 hrs on/12 hrs off)

Indicated for postherpetic neuralgia. Commonly used for


other neuropathic conditions. May be used daily or as
needed.

Over-theCounter

0.025% or 0.075% apply to intact


skin 3-4 times per day

Burning irritation of skin, eyes, airway. Requires regular


application for four to six weeks to achieve effect; then
maintenance.

Initial drug of choice for trigeminal neuralgia. Watch


for hyponatremia, leucopenia, allergic rash (StevensJohnson syndrome). Other side effects: dizziness,
drowsiness, blurred/double vision, ataxia. Not favored
for other neuropathic pain. Available in extended
1,3
release.
Most evidence is for migraine prevention, other
neuropathic pains may respond. Side effects:
drowsiness, abnormal thinking, weight loss, urinary tract
1
stones, increased intraocular pressure.

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)

Side effects: headache, nausea, sweating, sedation,


hypertension, seizures. Serotonergic properties in
dosages below 150 mg per day; mixed serotonergic and
noradrenergic properties in dosages above 150 mg per
2
day. Available in extended-release formulation.

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

Side effects, Contraindications, and


Comments

50-100 mg 4 times daily as


needed. Max 400 mg per day

Side effects: abdominal discomfort, dizziness,


constipation, seizures. May interact with other
serotonergic drugs to cause serotonin syndrome. Abuse
potential despite unscheduled status

5 mg-10 mg (oxycodone) every 4


hours as needed.
Maximum daily doses:
- Acetaminophen & Aspirin
4000mg
- Ibuprofen 3200mg

Schedule II medication. Side effects: constipation,


drowsiness, confusion, nausea, itching, dependence,
abstinence syndrome upon abrupt withdrawal at doses >
20 mg per day.

*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

TABLE 10. Narcotic Prescribing Assessment Tools


click on the tool name to access the form

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

Drug Abuse Screening Test


A yes/no self-report for identifying patients with existing drug abuse or
addiction problems.

DIRE

Diagnosis, Intractability, Risk, Efficacy


This is a clinician-rated, 7-item scale to screen for the appropriateness of
long-term opioid therapy in patients with chronic noncancer pain, taking into
account the likelihood of drug abuse, misuse, addiction, or drug diversion.

Pain
Assessment

SISAP

5-Point

AUDIT

Alcohol Use

The Pain Disability Index


Measures the impact that pain has on the ability of a person to participate in
essential life activities. This can be used to evaluate patients initially, to monitor
them over time, and to judge the effectiveness of interventions.

Screening Instrument for Substance Abuse Potential


Five questions to address concerns about alcohol, marijuana, and cigarette
use in order to stratify patients with chronic non-cancer pain according to
potential risks of developing problematic behaviors during opioid therapy.
Prescription Opiate Abuse Checklist
A brief checklist is based on DSM-III-R parameters to gauge a patients level
of adherence to a current opioid analgesia regimen.
Alcohol Use Disorders Identification Test
The AUDIT questionnaire was developed by the World Health Organization
(WHO) as a simple method of screening for excessive drinking as the cause of
the presenting illness.

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

An alcohol screening tool to be used for pregnant women

102

PHQ-2

Depression
Screening

PHQ-9

Patient Health Questionnaire


This 2-question tool is used as the initial screening test for major depressive
episode.

Patient Health Questionnaire


A nine item depression scale for assisting in diagnosing depression as well as
selecting and monitoring treatment.

MDQ

Mood Disorder Questionnaire


This tool assists in the accurate diagnosis of bipolar disorder.

Zung

Zung Self-Rating Depression Scale


A short self-administered survey to quantify the depressed status of a patient.

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

MEDICATION PRIOR AUTHORIZATION FORM


Forward form to the HealthPlus Pharmacy Department via facsimile:
Flint facsimile: 810-720-2757
Saginaw facsimile: 989-797-4181
For questions or to request via telephone:
Flint local phone: 810-720-2758
Toll free phone: 877-710-0993
FOR A TIMELY RESPONSE, PLEASE PROVIDE COMPLETE INFORMATION.
HealthPlus ID#:
Date of Birth:

Patient Name:
Height:

This is a request for (check one):

Weight:

DAW

BMI:

Medication Requiring P/A

P/A for Dosage Regimen

Medical Claim Requiring P/A


MedicarePlus Part D:

Exception Request

Signature PPO Closed Formulary:

Medically Urgent

Exception Request

Prescribed Drug and Dosing Regimen:


Reason for Use (Diagnosis):
Previous Medications:
Please attach pertinent laboratory test(s) or procedure(s): (if applicable)
Reason why an alternative drug (or dosing regimen) cannot be used:

DEA#:
Office Phone: (_____)

HealthPlus Provider ID#:


Office Facsimile: (_____)

Pharmacy Name (optional):

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

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA PRIOR AUTHORIZATION CRITERIA
DRUG/CATEGORY

QTY
LIMIT

CRITERIA

ADD Medications
Vyvanse
(lisdexamfetamine dimesylate)
Strattera (atomoxetine)

1. The patient has tried and responded to generic Adderall in


the past 120 days based on Rx claims or chart
documentation provided.
1. The patient must have documented failure based on chart
documentation or Rx claims with the generic form of both
Ritalin AND Adderall.

Focalin/XR
(dexmethylphenidate)
Metadate CD
(methylphenidate ER)
Ritalin LA
(methylphenidate ER)
Daytrana
(methylphenidate patch)

1. The patient has tried and responded to generic Ritalin,


generic Ritalin SR or generic Metadate ER in the past 120
days based on Rx claims or chart documentation provided.

1. The patient is at least six years of age and has a documented


diagnosis of ADD/ADHD, AND
2. The patient has tried and responded to generic Ritalin,
generic Ritalin SR or generic Metadate ER in the past 120
days based on Rx claims or chart documentation provided
OR the patient is unable to swallow an oral tablet.
1. The patient must have documented failure based on chart
documentation or Rx claims with the generic form of Ritalin
and Adderall, AND
2. The patient has tried and responded to immediate-release
guanfacine.
1. Does not require prior authorization if patient has asthma or is
receiving asthma medications, or has received 2 or more
prescriptions for oral inhaled glucocorticoids in past year, or if
patient is less than 10 years of age.
2. For patients being treated for allergic rhinitis:
a. Must have documented failure or Rx claims for at least
two antihistamines in the past year, AND
b. Must have documented failure or Rx claims for at least
one nasal steroid in the past year.

Intuniv (guanfacine)

Allergy Medications
Accolate (zafirlukast)

Clarinex (desloratadine)
Xyzal
(levocetirizine dihydrochloride)

Clarinex
and Xyzal
are limited
to a qty of
30 units
per month

1. The patient must have documented failure or Rx claims for


generic OTC Claritin in the past year.
NOTE: For Xyzal, prior authorization is not required for patients
with a diagnosis of chronic urticaria.
For Clarinex, prior authorization is only required for patients over
12 years of age.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

QTY
LIMIT

Allergy Medications, continued


Clarinex-D
(desloratadine/pseudoephedrine)

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)

1. The patient must have documented failure or Rx claims for


two generic nasal steroids (i.e., Flonase, flunisolide) in the
past year.

Analgesics
Fentora
(fentanyl citrate buccal tablet)
Onsolis (fentanyl soluble film)

1. The patient has a documented current diagnosis of cancer.


2. The patient is already receiving and is tolerant to opioid
therapy for underlying persistent cancer pain.
NOTE: System will automatically approve if written by an
oncologist (or if there are prescription claims for chemotherapyrelated medications) and the patient is receiving opioid pain
medications.

On Formulary with PA:


Actiq (fentanyl citrate oral
transmucosal)
Opana ER (oxymorphone)

Avinza (morphine sulfate,


sustained release)

Qty is
limited to
60 units
per 30
days

1. The patient has a documented current diagnosis of active


cancer.
System will automatically approve if written by an oncologist or if
there are previous claims for chemotherapy-related medications.

Qty is
limited to
30 units
per 30
days

1. The patient has a documented current diagnosis of active


cancer.
System will automatically approve if written by an oncologist or if
there are previous claims for chemotherapy-related medications.

On Formulary with PA:


Ultram ER (tramadol)
Non Formulary with PA:
Ryzolt (tramadol ext. rel.)
Rybix ODT (tramadol)

1. The patient must have documented failure or Rx claim for


generic Ultram in the past 60 days.

All acetaminophen-containing
narcotic analgesics

DOSE OPTIMIZATION ONLY


NOTE: System edits apply for prescription claims with a
monthly quantity that exceeds the MAX recommended dose of
4gm/day of acetaminophen. Physician must submit signed
request stating he/she is allowing the patient to exceed the MAX
recommended dose of acetaminophen.

1. The patient must have documented failure or Rx claims with


generic Ultram in the past 60 days, or
2. The patient must have documented inability to swallow or
absorb oral medications.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

QTY
LIMIT

Analgesics, continued
Oxycontin (oxycodone)

Exalgo (extended release


hydromorphone)

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

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

1. The patient must have documented failure or Rx claim(s) for


at least one formulary ARB or ARB combination product (i.e.,
generic Cozaar/Hyzaar, Benicar/HCT or Diovan/HCT).

1. The patient must have documented failure or Rx claim for


generic Xanax in the past year.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

QTY
LIMIT

CRITERIA

Antibiotics
Adoxa CK (doxycycline kit)
Adoxa TT (doxycycline kit)
Oracea
(doxycycline monohydrate)

1. The patient must have documented failure or Rx claim for


generic Vibramycin.

Keflex 750mg
(cephalexin monohydrate)

1. The patient must have documented failure or Rx claim for a


generic cephalosporin (e.g., Keflex, Ceclor, Cefzil or Ceftin) in
the past 60 days.

Moxatag ER
(amoxicillin trihydrate)
Minocin PAC (minocycline kit)

1. The patient must have documented failure or Rx claim for a


generic amoxicillin product in the past 14 days.
1. The patient must have documented failure or Rx claims for a
generic tetracycline AND minocycline in the past 60 days.
1. The patient must have documented failure or Rx claim for a
formulary fluoroquinolone (e.g., generic Cipro, Levaquin or
Avelox) in the past 60 days.
NOTE: Individual requests are reviewed to include consideration
of the diagnosis, culture and sensitivity, and other
documentation.
1. The patient must have documented failure or Rx claim for
generic Cipro in the past 60 days.

Factive
(gemifloxacin mesylate)

On Formulary with PA:


Cipro XR (ciprofloxacin)
Non-Formulary with PA:
Proquin XR
(ciprofloxacin, sust. release)
Antidepressants
Lexapro (escitalopram oxalate)
Luvox CR
(fluvoxamine ext. release)
Pexeva (paroxetine mesylate)
Prozac Weekly (fluoxetine)

Limited to
a qty of
30 units
per month

1. The patient has a diagnosis of depression, AND


2. The patient has been treated with fluoxetine 20mg daily for at
least 13 weeks, based on Rx claims, and has responded to
treatment with symptom control.
1. The patient must have documented failure or Rx claim for
generic Prozac.

On Formulary with PA:


Sarafem (fluoxetine)
Effexor XR
(venlafaxine, ext. release)
Pristiq
(desvenlafaxine succinate)
Oleptro ER (trazodone
hydrochloride extended release)
Aplenzin (bupropion hbr)

1. The patient must have documented failure with dose titration


and Rx claims for at least two generic SSRI medications (i.e.,
Prozac, Celexa, Paxil and Zoloft).

Limited to
a qty of
30 units
per month

DOSE OPTIMIZATION ONLY


NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
1. The patient must have documented failure or Rx claims with
generic Desyrel (trazodone).
1. The patient must have documented failure or prescription
claims at an equivalent dosage of bupropion HCl extendedrelease (24hr) in the past year.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

QTY
LIMIT

Antidepressants, continued
Wellbutrin XL
(bupropion, ext. release)

Viibryd (vilazodone hcl)

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

DOSE OPTIMIZATION ONLY


NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
doses greater than the maximum recommended dose.
1. Geodon: Maximum recommended dose is 160mg/day.
2. Risperdal: Maximum recommended dose is 12mg/day.
3. Seroquel: Maximum recommended dose is 800mg/day.
1. The patient must have documented treatment failure or Rx
claims with all formulary MDI, short-acting beta agonists (i.e.,
Ventolin HFA, ProAir HFA).

Asthma/COPD
Proventil HFA (albuterol)
Xopenex/HFA (levalbuterol)

Coreg CR (carvedilol phosphate


controlled release)

DOSE OPTIMIZATION ONLY


1. For Wellbutrin XL 150mg tablets are limited to Once Daily
Dosing. Wellbutrin XL 300mg requires the physician to
prescribe a 300mg tablet (not 2 of the 150mg tablets) once
daily to optimize the dose.
2. The maximum recommended daily dose is 450mg. For this
dosage, prescribe Wellbutrin XL 300mg tablets, 1 tablets
daily. Dosages greater than 450mg per day will require the
physician to submit medical necessity for that dosing
regimen.
1. If there is no contraindication present, the patient must have
documented failure with dose titration and Rx claim(s) for at
least two generic SSRI medications (i.e., Prozac, Celexa,
Paxil and Zoloft).
2. The patient must try and fail an adequate course of therapy
with generic Zofran ODT.
Age Restriction: Recommended for patients younger than 75
years of age with no history of stroke and undergoing PCI (not
coronary artery bypass graft [CABG]).

Geodon (ziprasidone)
Risperdal (risperidone)
Seroquel (quetiapine fumarate)

Beta Blockers
Bystolic (nebivolol)

CRITERIA

Limited to
a qty of
30 units
per month

1. The patient must have documented intolerant side effects to


albuterol (e.g., palpitations, tremors and tachycardia).
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
1. The patient must have documented failure on immediate
release carvedilol of equivalent dose and attempted at least
one dose increase (6.25mg/day IR = 10mg/day ER when
converting).

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

QTY
LIMIT

Calcium Channel Blockers


Dynacirc CR
(isradipine controlled release)

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 and Dilacor XR).

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

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).

1. The patient's triglyceride (TG) levels are >500mg/dL (with


chart documentation provided) OR
2. The patient must have documented failure or Rx claims in the
past six months for at least two or more lipid-lowering agents,
with at least one being a generic product (e.g., statins,
fenofibrate, nicotinic acid).
1. The patient must have documented failure or Rx claim for a
formulary fenofibrate (i.e., generic Lofibra) in the past year
with at least one documented dosage increase.

AUTHORIZATION IS ONLY REQUIRED FOR THE FOLLOWING:

1. If the patient has not had an Rx claim for an HMG statin


medication in the previous six months. Criteria for
authorization for monotherapy include a documented
contraindication for both hydrophilic (Pravachol, Lescol) and
lipophilic (Zocor, Lipitor) statins, elevated liver enzymes, etc.
2. A dose >10mg per day requires documentation to support
safety and efficacy.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Contraceptives
All Brand Contraceptives
Femcon Fe
LoEstrin 24 Fe 1/20
LoSeasonique
Natazia
Ovcon-50
Safyral
NuvaRing
Ortho Evra
Ortho Tri-Cyclen Lo
Dermatologicals
Altabax (retapamulin)

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.

1. The patient must have a documented treatment failure with


generic Bactroban ointment for each instance of impetigo
AND
2. A diagnosis of impetigo.
1. The patient must have a diagnosis of post-herpetic neuralgia
(document previous diagnosis or titer).
1. The patient must be an infant greater than 4 weeks old with a
diagnosis of candidal diaper dermatitis or candidal infection.
1. The patient must have documented failure and Rx claims for
four generic antifungals (e.g., Loprox, Nizoral, Spectazole and
Grifulvin V).

1. Patient must have documented failure or Rx claim(s) for


topical generic clindamycin product in the past 90 days (e.g.,
GEQ Cleocin T).
1. Patient must have documented failure or Rx claim(s) for both
of the individual components in the combination product in
the past 90 days (i.e., GEQ benzoyl peroxide: Benzac,
Brevoxyl, Zaclir, Lavoclen; GEQ Clindamycin: Cleocin-T:
GEQ Erythromycin: Erygel, Ery, Delmycin, Benzamycin).

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Dermatologicals, continued
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
Benziq LS Gel (benzoyl
peroxide/salicylic acid)
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)
Triaz Gel (benzoyl peroxide)
Zacare
(benzoyl peroxide/hyaluront)
All Tretinoin Products
All Brand Tretinoin Products
Atralin (tretinoin)
Retin A Liquid (tretinoin)
Retin A Micro (tretinoin)
Solage (tretinoin/mequinol)
Tretin-X (tretinoin)
Veltin (tretinoin/clindamycin)
Ziana (tretinoin/clindamycin)
All Brand Topical Steroids
Clobex (clobetasol propionate)
Clobex 0.05% Lotion
(clobetasol propionate)
Ultravate PAC Kit (halobetasol
propionate/ammonium lactate)
Vanos 0.1% Cream
(fluocinonide)
Olux-Olux-E
(clobetasol propionate/emollient)

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).

1. The patient must have documented failure or Rx claim(s) for a


generic benzoyl peroxide product.

Age Restriction: Patients > 25 years of age must have a


documented diagnosis of acne.
1. The patient must have documented failure or Rx claim for a
generic tretinoin product (e.g., Retin-A, Avita) in the past 90
days.
NOTE: Age restriction for all topical tretinoin products for age >
25 based on a diagnosis of acne.

1. The patient must have documented failure or Rx claim with a


generic topical steroid in the same potency class (e.g.,
Temovate, Ultravate, Diprolene) in the past 60 days.

1. The patient must have documented failure or Rx claims with


two generic topical steroids in the same potency class (e.g.,
Temovate, Ultravate and Diprolene) in the past 60 days.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

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.

1. The patient must have documented failure or Rx claim with a


generic topical steroid in the same potency class (e.g., BetaVal Cr, Cutivate Cr, Dermatop Cr) in the past 60 days.

1. The patient must have documented failure or Rx claim with a


generic topical steroid in the same potency class (e.g.,
Aclovate, Desowen and Synalar) in the past 60 days.

Desowen Combo
(desonide/emollient)

1. The patient must have documented failure or Rx claims with a


generic topical steroid in the same potency class (e.g.,
Aclovate, Desowen and Synalar) AND OTC Cetaphil in the
past 60 days.

Vanoxide-HC 0.5%-5% Lotion


(hydrocortisone/benzoyl peroxide)

1. The patient must have documented failure and Rx claims with


a combined therapy of generic Hydrocortisone 0.5% AND
generic Benzoyl Peroxide 5% in the past 60 days.

Protopic (tacrolimus)

1. The patient must have documented failure or Rx claims with


at least two generically available topical steroids AND
pimecrolimus in the past 180 days.

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

1. The patient must have documented failure or Rx claims in the


past year for generic Glucophage AND generic Glucophage
XR.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Erectile Dysfunction
On Formulary:
Cialis (tadalafil)
Viagra (sildenafil)
Non-Formulary:
Caverject, Edex, Muse
(alprostadil)

QTY
LIMIT
All ED
meds are
limited to
a qty of 6
units per
month

ED meds are covered when


written by PCP or in-plan
urologist. Males Only. Limit 6
units per 30 days (for all ED drugs
combined).
Non-Formulary with PA:
Levitra (vardenafil)
Staxyn (vardenafil)
ED meds are covered for males
only. Limit 6 units per 30 days (for
all ED drugs combined).

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.

1. The patient must have documented failure based on chart


documentation or Rx claims for a generically available alpha1blocker indicated for BPH (i.e., generic Cardura, Hytrin or
Flomax).
Confirmation of Coverage:
1. The patients benefit includes coverage for infertility, AND
2. There is an appropriate referral, if applicable, AND
3. The service/procedure is a covered benefit.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Migraine Medications
Axert (almotriptan)
Frova (frovatriptan)
Maxalt/MLT
(rizatriptan benzoate)
Treximet (sumatriptan/naproxen)
Zomig/ZMT (zolmitriptan)

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)

On Formulary with PA:


Revatio (sildenafil)
Non-Formulary with PA:
Adcirca (tadalafil)
On Formulary with PA:
Savella (milnacipran)

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
NSAIDs
Arthrotec
(diclofenac/misoprostol)
Naprelan (naproxen sodium)
Naprelan CR Dosepak
(naproxen sodium)

Vimovo
(esomeprazole/naproxen)

Flector (diclofenac epolamine


transdermal patch)

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
NSAIDs, continued
Ketoprofen Powder/Cmpd

Voltaren Gel
(diclofenac sodium)

Zipsor (diclofenac potassium)

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.

1. The patient must have documented failure or Rx claim for


generic OTC Zaditor (covered with written prescription).
2. If the patient fails treatment with generic OTC Zaditor, then
Patanol is the second-line formulary alternative with prior
authorization required.
3. The patient must have documented failure or Rx claims for
the formulary alternatives (OTC Zaditor and Patanol) before a
non-formulary drug will be approved.

1. The patient must have documented failure or Rx claim for


generic Timolol (i.e., Timoptic).

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

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

1. If there is no contraindication present, the patient must have


documented failure or Rx claim(s) for three generically
available sleeping agents (e.g., Ambien, Desyrel, Halcion,
Prosom, Restoril or Sonata).
2. If a contraindication to benzodiazepines is present, the
patient must try and fail an adequate course of therapy with
generic Ambien AND Sonata.
NOTE: Limited to 30 units per month. Prior Authorization for
more than 30 per month is based on a specific review of medical
necessity.
Quantity Limits Only
NOTE: Limited to 30 units per month. Prior Authorization is
only required for quantities that exceed the limit, and is based
on a specific review of medical necessity.
1. The patient must have documented failure or Rx claim for
generic OTC nicotine patches in the past year.
NOTE: Generic OTC nicotine patches are a covered benefit.
Coverage for smoking cessation is limited to 1 course of therapy
per year.
DURATION LIMITS ONLY
Coverage for smoking cessation is limited to one course of
therapy per year (the course of therapy for Chantix is routinely
defined as 24 weeks).

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Substance Abuse Medications
Subutex (buprenorphine)
Suboxone
(buprenorphine/naloxone)
Weight Management
All medications for the treatment
of obesity
Examples:
Adipex (phentermine)
Xenical (orlistat)

QTY
LIMIT

CRITERIA
1. The patient must discontinue use of all other narcotic
analgesics.
2

1. The patient has a body mass indiex (BMI) of >35kg/m , OR


2
2. The patient has a body mass index (BMI) of >30kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
3. The patient has a body mass index (BMI) of >30kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis,
pregnancy, and/or lacation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician-supervised diet and exercise program
consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet and a
regular exercise program.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total
coverage.

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY

QTY
LIMIT

Dispense as Written DAW


Specific request for a brand
name product when a generic is
available

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.

Signature PPO Closed Formulary


DRUG/CATEGORY
Exceptions Criteria
(for all non-formulary drugs)

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
HEALTHPLUS OF MICHIGAN
High Risk Medications in the Elderly (65 years old)
Based on the availability of safer alternatives, the following medications have been added to the Prior Authorization Program for members
65 years of age and older for HealthPlus Commercial/Medicare and HealthPlus Partners (Medicaid) with the following criteria:
1) The recommended alternative treatment(s) 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 the recommended alternative treatment(s).

Name

Concern

Alternative Treatment

Diazepam (Valium)

Fall risk

Anxiety: Buspar, Zoloft


1
Hypnotic: Ambien, Desyrel, Sonata

Cyclobenzaprine (Flexeril)

Anticholinergic effects, sedation, cognitive impairment

Estrogens (Premarin)

Breast/Endometrial cancer;
not cardio protective

Promethazine-Codeine

Anticholinergic effects (i.e., urine retention, confusion, sedation)

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
Antihistamine: Claritin , Clarinex
1
1
Antiemetic: Antivert, Zofran , Kytril

Promethazine (Phenergan)
Nitrofurantoin (Macrodantin)

Nephrotoxicity

Thyroid USP

Cardiac adverse effects

Depends on site of infection, culture, and


sensitivity.
1
Bactrim, Vibramycin, Azithromycin, Fluoroquinolone
Levothyroxine (LT4): Synthroid, Levoxyl

(Armour Thyroid, Desiccated)

Dicyclomine (Bentyl)

Anticholinergic, worsened cognition and behavioral problems in


dementia, urinary retention or incontinence, questionable
efficacy

Methocarbamol (Robaxin)

Anticholinergic effects, sedation, cognitive impairment

Hydroxyzine
(Vistaril, Atarax)

Anticholinergic effects, urinary retention, confusion, sedation

Constipation: Fiber (Psyllium) , Polyethylene glycol,


2
1
softener (docusate) , Amitiza
2
2
Diarrhea: Imodium , Aluminum hydroxide , Fiber
2
(Psyllium)
Physiotherapy: Correct seating or footwear
Spasticity: Baclofen, Zanaflex tablets, treat
underlying problems
2

Antihistamine: Claritin , Clarinex

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.

HEALTHPLUS COMMERCIAL/MEDICAREPLUS (NON-PART D)/PPO/TPA/MICHILD


DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D

Name

Concern

Carisoprodol (Soma)

Alternative Treatment
Physiotherapy; correct seating & footwear

Orphenadrine (Norflex)
Chlorzoxazone (Parafon
Forte DSC)

Anticholinergic effects, sedation, cognitive impairment,


weakness, urinary retention

Diphenoxylate-Atropine
(Lomotil)

Dependence, sedation, cognitive impairment

Evaluate diet. Psyllium , Imodium , Pepto-Bismol

Hyoscyamine (Hyomax-SL,
Hyomax-SR, Hyomax-FT)

Anticholinergic effects, worsened cognition & behavioral


problems in dementia, urinary retention or incontinence,
questionable efficacy

Methylphenidate
(Methylin/ER)

Agitation, insomnia, hypertension, myocardial ischemia,


appetite suppression, seizures

Diet therapy: Psyllium , fluids


2
2
Constipation: Psyllium , polyethylene glycol , stool
2
1
softner , Amitiza
2
2
Diarrhea: Imodium , Pepto-Bismol/Kaopectate ,
Questran, Prevalite
Depression: Pamelor, Norpramin, Desyrel,
1
Wellbutrin/XL (cardiac patients), Remeron (if
insomnia, anorexia), Paxil, Zoloft, Celexa

Chlordiazepoxide (Librium)
Trimethobenzamide (Tigan)

Sedation, confusion, incontinence, depression, risk of falls and


fractures.
Extrapyramidal side effects, poor efficacy

Ketorolac (Toradol)

GI bleeding

Spasticity: Baclofen, Zanaflex tablets. Treat


underlying problems
2

Weight control: Diet and lifestyle modifications


Anxiety: Xanax, Ativan, Serax, Buspar, Zoloft
1

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.

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D

MEDICAID PRIOR AUTHORIZATION CRITERIA


CATEGORY/DRUG

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)

1. The patient must have documented failure or Rx claim for


topical generic clindamycin (e.g., Cleocin T) in the past 90
days.
2. 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).

All Tretinoin Products

Age Restriction: Patients > 25 years of age must have a


documented diagnosis of acne.

1. The patient must have documented failure or Rx claim(s) for


a generic benzoyl peroxide product (e.g., Brevoxyl,
Desquam) in the past 90 days.

1. Patient must have documented failure or Rx claim(s) for both


of the individual components in the combination product in
the past 90 days (i.e., GEQ benzoyl peroxide: Benzac,
Brevoxyl, Zaclir, Lavoclen; GEQ Clindamycin: Cleocin-T:
GEQ Erythromycin: Erygel, Ery, Delmycin, Benzamycin).

125

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

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 ODT (fexofenadine)


Clarinex (desloratadine)
Xyzal
(levocetirizine dihydrochloride)

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

1. Does not require prior authorization if patient has asthma or


is receiving asthma medications, or has received 2 or more
prescriptions for oral inhaled glucocorticoids in past year, or
if patient is less than 10 years of age.
2. For patients being treated for allergic rhinitis:
a. Must have documented failure or Rx claims for at least
two antihistamines in the past year, AND
b. Must have documented failure or Rx claims for at least
one nasal steroid in the past year.
1. The patient must have documented failure or Rx claim for
generic OTC Claritin (covered with written prescription) in
the past year.

1. The patient must have documented failure or Rx claim for


generic OTC Claritin (covered with written prescription) in
the past year.
2. If the patient fails treatment with generic OTC Claritin, then
generic Allegra is the second line alternative with prior
authorization required for Allegra.
3. The patient must have documented failure or Rx claims for
all formulary alternatives before a non-formulary drug will
approved.
NOTE: For Xyzal, prior authorization is not required for patients
with a diagnosis of chronic urticaria.
For Clarinex, prior authorization is only required for patients
over 12 years of age.
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 (all are
covered with written prescription) in the past year.
2. If the patient fails treatment with a generic OTC Claritin
combination, then generic Allegra in combination with OTC
pseudoephedrine is the second line alternative with prior
authorization required for Allegra.
3. The patient must have documented failure or Rx claims for
all formulary alternatives before a non-formulary drug will be
approved.
NOTE: For Clarinex-D, prior authorization is only required for
patients over 12 years of age.

126

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

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

1. The patient must have documented failure or Rx claims for


two generic nasal steroids (i.e., Flonase, flunisolide) in the
past year.

1. The patient has a documented current diagnosis of cancer.


2. The patient is already receiving and is tolerant to opioid
therapy for underlying persistent cancer pain.
NOTE: System will automatically approve if written by an
oncologist (or if there are prescription claims for chemotherapyrelated medications) and the patient is receiving opioid pain
medications.

Kadian
(morphine sulfate, sustained
release)

Qty limit
of 60
units per
30 days

Duragesic Patches (fentanyl)

Qty limit
of 1
patch per
72 hours

OxyContin (oxycodone)

Qty limit
60 in 30
days

Avinza (morphine sulfate)

Qty is
limited to
30 units
per 30
days
Qty is
limited to
60 units
per 30
days

Opana ER (oxymorphone)

CRITERIA

DOSE OPTIMIZATION ONLY


NOTE: System edits apply for prescription claims with a
monthly quantity that exceeds the MAX recommended dose of
4gm/day of acetaminophen. Physician must submit signed
request stating that he/she is allowing the patient to exceed the
MAX recommended dose of acetaminophen.
1. The patient must try and fail on generic MS Contin AND
documentation of failure must be provided.

NOTE: System will automatically approve if written by an


oncologist or if there are prescription claims for chemotherapyrelated medications.
For indications other than cancer:
1. The patient must have documented failure or prescription
claims for at least two formulary alternatives (including
generic MS Contin, and short-acting narcotic analgesic) OR
2. Based on chart documentation, all formulary alternatives are
inappropriate.
1. The patient must have a current documented diagnosis of
active cancer.
NOTE: System will automatically approve if written by an
oncologist (or if there are prescription claims for chemotherapyrelated medications) and the patient is receiving opioid pain
medications.
1. The patient must have a current documented diagnosis of
active 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 a current documented diagnosis of
active cancer.
System will automatically approve if written by an oncologist or
if there are previous claims for chemotherapy-related
medications.
NOTE: Prior authorization applies to new start patients only.

127

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

QTY
LIMIT

CRITERIA

Analgesics, continued
Reprexain
(ibuprofen/hydrocodone)
Ultracet
(tramadol/acetaminophen)

1. The patient must have documented failure or Rx claims with


generic Vicoprofen or Vicodin.

On Formulary with PA:


Ultram ER (tramadol)
Non Formulary with PA:
Ryzolt (tramadol ext. rel.)
Rybix ODT (tramadol)

1. The patient must have documented failure or Rx claim for


generic Ultram in the past 60 days.

1. The patient must have documented failure or Rx claims for


generic Ultram in combination with OTC acetaminophen (all
are covered) in the past 60 days.

1. The patient must have documented failure or Rx claims with


generic Ultram in the past 60 days, or
2. The patient must have documented inability to swallow or
absorb oral medications.

Exalgo (extended release


hydromorphone)

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

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

2. The patient must have documented failure or Rx claim(s)


for at least one formulary ARB or ARB combination product
(i.e., generic Cozaar/Hyzaar, Benicar/HCT or Diovan/HCT).

Antibiotics
Adoxa CK (doxycycline kit)
Adoxa TT (doxycycline kit)
Oracea
(doxycycline monohydrate)

3. The patient must have documented failure or Rx claim for


generic Vibramycin.

Moxatag ER (amoxicillin
trihydrate)
Keflex 750mg
(cephalexin monohydrate)

1. The patient must have documented failure or Rx claim for a


generic amoxicillin product in the past 14 days.
1. The patient must have documented failure or Rx claim for a
generic cephalosporin (e.g., Keflex, Ceclor, Cefzil or Ceftin)
in the past 60 days.
1. The patient must have documented failure or Rx claims for a
generic tetracycline AND minocycline in the past 60 days.

Minocin PAC (minocycline kit)

128

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

QTY
LIMIT

Antibiotics, continue
Avelox (moxifloxacin)
Factive (gemifloxacin)

1. The patient must have documented failure or Rx claim for


generic Cipro OR Noroxin in the past 60 days before any
other quinolone will be covered.
NOTE: Individual requests are reviewed to include
consideration of the diagnosis, culture and sensitivity, and other
documentation.
1. The patient must have documented failure or Rx claim for
generic Cipro in the past 60 days.

On Formulary with PA:


Cipro XR (ciprofloxacin)
Non-Formulary with PA:
Proquin XR (ciprofloxacin)
Flagyl ER (metronidazole)
Antidepressants
Viibryd (vilazodone hcl)

CRITERIA

Limited
to a qty
of 30
units per
month

1. The patient must have documented failure or Rx claim for


generic metronidazole.
1. If there is no contraindication present, the patient must have
documented failure with dose titration and Rx claim(s) for at
least two generic SSRI medications (i.e., Prozac, Celexa,
Paxil and Zoloft).

Antiemetic
Zuplenz (ondansetron)

1. The patient must try and fail an adequate course of therapy


with generic Zofran ODT.

Anti-Nausea
Anzemet
(dolasetron mesylate)

Requires prior authorization for indications other than cancer. If


the patient has cancer (and related medication), the system will
allow the claim to pay at a limited quantity.
1. The patient must try and fail an adequate course of therapy
with two generically available products (e.g., Reglan, Tigan
or Compazine).
Age Restriction: Recommended for patients younger than 75
years of age with no history of stroke and undergoing PCI (not
coronary artery bypass graft [CABG]).

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

1. The patient must have documented treatment failure or Rx


claims with all formulary MDI, short-acting beta agonists
(e.g., Ventolin HFA, ProAir HFA).
1. The patient must have documented intolerant side effects to
albuterol (e.g., palpitations, tremors and tachycardia).
1. The patient must have documented failure or Rx claims
with at least three generically available beta blockers (e.g.,
Inderal, Tenormin, Lopressor, Corgard).
1. The patient must have documented failure on immediate
release carvedilol of equivalent dose and attempted at least
one dose increase (6.25/day IR = 10mg/day ER when
converting).
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.

129

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

QTY
LIMIT

Calcium Channel Blockers


Dynacirc CR
(isradipine controlled release)

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).

Non-Formulary with PA:


Advicor (lovastatin/niacin)
Altoprev (lovastatin SR)
Caduet
(atorvastatin/amlodipine)
Livalo (pitavastatin calcium)
Welchol (colesevelam)

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)

1. The patient must have a diagnosis of diabetes and


documented failure or Rx claim(s) for Metformin OR
2. The patient must have documented failure of both generic
Questran AND generic Colestid.
1. The patient's triglyceride (TG) levels are >500mg/dL (with
chart documentation provided) OR
2. The patient must have documented failure or Rx claims in
the past six months for at least two or more lipid-lowering
agents, with at least one being a generic product (i.e.,
statins, fenofibrate, nicotinic acid).
1. The patient must have documented failure or Rx claim for a
formulary fenofibrate (i.e., generic Lofibra) in the past year
with at least one documented dosage increase.

AUTHORIZATION IS ONLY REQUIRED FOR THE


FOLLOWING:
1. If the patient has not had an Rx claim for an HMG statin
medication in the previous six months. Criteria for
authorization for monotherapy include a documented
contraindication for both hydrophilic (Pravachol, Lescol)
and lipophilic (Zocor, Lipitor) statins, elevated liver
enzymes, etc.
2. A dose >10mg per day requires documentation to support
safety and efficacy.

130

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

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)

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.

1. The patient must be intolerant to oral contraceptives (based


on chart documentation provided).
NOTE: Injectable Depo-Provera is an alternative if compliance
is a potential issue.
1. The patient must have documented failure or Rx claims
with generic Peridex oral rinse.

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

1. The patient must have documented failure or Rx claims for


at least two generically available steroid creams in the past
6 months OR
2. Be under the treatment of a dermatologist.

1. The patient must have documented failure or Rx claims with


at least two generically available topical steroids AND
pimecromlimus in the past 180 days.
Safety
limited to
a qty of <
100g per
7 days
Safety
limited to
a qty of <
200g per
7 days
1. The patient must have documented diagnosis of actinic
keratosis; OR
2. The patient must have documented diagnosis of superficial
basal cell cancer; OR
3. The patient must have documented treatment failure or Rx
claims with generic Condylox.
1. The patient must have documented failure or Rx claim with
an OTC antiparasitic for each instance of pediculosis.
1. The patient must have a diagnosis of post herpetic neuralgia
(document previous diagnosis or titer).
1. The patient must have documented failure or Rx claim for
generic urea (e.g., Carmol, Hydrofoam) in the past 90 days.

131

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Dermatologicals, continued
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)
Vusion
(miconazole nitrate/zinc oxide)
Altabax (retapamulin)

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)

Vanoxide-HC 0.5%-5% Lotion


(hydrocortisone/benzoyl
peroxide)

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).

1. The patient must be greater than 4 weeks old with a


diagnosis of candidal diaper dermatitis or candidal infection.
1. The patient must have a documented treatment failure with
generic Bactroban ointment for each instance of impetigo
AND
2. A diagnosis of impetigo.
1. The patient must have documented failure or Rx claims with
two generic topical steroids in the same potency class (e.g.,
Temovate, Ultravate and Diprolene) in the past 60 days.
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.

1. The patient must have documented failure or Rx claim with a


generic topical steroid in the same potency class (e.g.,
Aclovate, Desowen and Synalar) AND OTC Cetaphil in the
past 60 days.
1. The patient must have documented failure or Rx claims with
a combined therapy of generic Hydrocortisone 0.5% AND
generic Benzoyl Peroxide 5% in the past 60 days.

132

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

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)

1. The patient must have documented failure or Rx claim for a


generic topical steroid (e.g., Aclovate, Cormax, Cutivate,
Desowen, Synalar, Temovate and Topicort) in the past 60
days.

All Brand Topical Emollients


Epiceram (emollient combo)
Gordo-Urea (urea)
Hylatopic (emollient combo)
Kerafoam (urea)
Kerol/ZX
(urea/lactic acid/salicyl acid)
Neosalus (emollient combo)
Uramaxin (urea)

1. The patient must have documented failure or Rx claim for a


generic topical emollient (e.g., Carmol, Lac-Hydrin,
Mectalyte and Vanamide) in the past 60 days.

Diabetes
Apidra Solostar Pen
(insulin glulisine)
Insulin Prefilled Pens
Insulin Penfills
Levemir Flexpen
(insulin detemir)
Fortamet (metformin)
Glumetza (metformin)

These dosage forms require prior authorization.


1. The patient must have a document diagnosis of arthritis, OR
2. Be visually impaired (chart documentation) OR
3. Must be for child's use at school.

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. The patient must have documented failure or Rx claims in


the past year for generic Glucophage and generic
Glucophage XR.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.

1. Confirmation of diagnosis.
Note: Not covered for infertility (infertility services are
excluded).

133

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

QTY
LIMIT

Hormone Replacement
Cenestin
(estrogens, conj synthetic)
Premarin
(conjugated estrogens)
Prempro
(conj estrogens/medroxypro)
Prometrium (progesterone)

1. The patient must have documented failure or Rx claims for


both generically available estrogen products (i.e., Estrace,
Ogen).

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

Qty for all


triptans
combined
is limited
to 9
tablets
per
month or
two
injections

1. The patient must have documented failure or Rx claims for


generic Provera in the past year.
1. The patient must have documented treatment failure with
generic Estrace, Ogen and Premarin (which requires Prior
Authorization).
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.
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 claims for
at least three generically available antispasmotics (i.e.,
Bentyl, Levsinex, Librax) in the past year.
1. The patient must have documented failure or Rx claim for a
generically available alpha 1-adrenergic antagonist (e.g.,
Cardura or Hytrin) in the past year.
1. The patient must have documented left ventricular systolic
dysfunction (with left ventricular ejection fraction [LVEF]<
40%) or clinical evidence of congestive heart failure after an
acute myocardial infarction OR
2. The patient must have documented failure/intolerance to
generic spironolactone (i.e., gynecomastia, edema,
mastodynia).
1. The patient must have a documented diagnosis of chronic
angina; in addition, there must be a pharmacy claim for
amlodipine or beta-blocker or non-acute nitrates.
1. The patient must have documented failure or Rx claim for
generic oral nitroglycerin in the past 90 days.
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.

134

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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG

QTY
LIMIT

Miscellaneous, continued
On Formulary with PA:
Savella (milnacipran)

Clindesse
(clindamycin phosphate)
Gynazole
(butoconazole nitrate)
Thyrolar (liotrix)

Amitiza (lubiprostone)

Moviprep (peg 3350/ sod


sul/nacl/asb/c/kcl)
Osmoprep (naphos
mb0mh/naphos, di-ba)
Uloric (febuxostat)

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

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
NSAIDs
On Formulary with PA:
Celebrex (celecoxib)
Non-Formulary with PA:
Arthrotec
(diclofenac/misoprostol)
Naprelan (naproxen sodium)
Naprelan CR Dosepak
(naproxen sodium)

Flector (diclofenac epolamine


transdermal patch)

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

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
NSAIDs, continued
Ketoprofen Powder/Cmpd

Voltaren Gel
(diclofenac sodium)

Zipsor (diclofenac potassium)

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.

1. The patient must have documented failure or Rx claim for


generic OTC Zaditor (covered with written prescription).
2. If the patient fails treatment with generic OTC Zaditor, then
Patanol is the second-line formulary alternative with prior
authorization required.
3. The patient must have documented failure or Rx claims for
the formulary alternatives (OTC Zaditor and Patanol) before
a non-formulary drug will be approved.

1. The patient must have documented treatment failure with a


generic ophthalmic anti-inflammatory (e.g., Voltaren drops)
or Rx claim must be present.
1. The patient must have a documented diagnosis of
keratoconjunctivitis sicca.
1. The patient must have documented contraindication or
documented treatment failure with the use of generic
brimonidine ophth.

137

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Ophthalmic Products,
continued
Lotemax
(loteprednol etabonate)
Betimol (timolol)
Istalol (timolol maleate)
All Brand Topical Ophthalmic
NSAIDs
Acular PF (ketorolac)
Acuvail
(ketorolac tromethamine)
Bromday (bromfenac sodium)
Nevanac (nepafenac)
Xibrom (bromfenac sodium)
Lumigan 0.01% and 0.03%
(bimatoprost)
Travatan-Z (travoprost)

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.

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 for
generic Fosamax in the past year.
NOTE: Exceptions will be made for patients in active treatment
for cancer. Applies to new start patients only.
1. The patient must have a documented diagnosis of
osteoporosis (active or prevention).
NOTE: Applies to new start patients only.
1. The patient must have documented failure or Rx claims for
at least two generically available products in the past 90
days before any brand otic product will be covered.

1. The patient must have documented failure or Rx claim with


an adequate course of therapy with generic Floxin Otic
Solution.

138

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
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)

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

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 secondline alternatives with prior authorization required.
3. The patient must fail all formulary alternatives (omeprazole,
Aciphex, generic Protonix) 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.
1. The patient must have documented failure or Rx claim for
generic OTC nicotine patches in the past year.

DURATION LIMITS ONLY


Coverage for smoking cessation is limited to one course of
therapy per year (the course of therapy for Chantix is routinely
defined as 24 weeks).
1. The patient must have documented failure or Rx claims for
at least two formulary agents (e.g., generic Azulfidine,
generic Azulfidine-EN, or Asacol) in the past 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

1. The patient must have documented failure or Rx claim for


generic Ditropan tablets in the past year.
1. The patient must have documented failure based on chart
documentation or Rx claims for a generically available
alpha1-blocker indicated for BPH (i.e., generic Cardura,
Hytrin or Flomax).
Limited
to a qty
of 30
units per
month

DOSE OPTIMIZATION ONLY


NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.

139

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Vitamins
All Brand Prenatal Vitamins
Atabex
Natalvit
Neevo DHA
Nexa Select
OB Complete
Obstetrix
Prefera OB
Prenate Elite
Prenate Plus
Vitafol-One
Niferex-150 Forte 150-25-1
Weight Management
All medications for the treatment
of obesity
Examples:
Adipex (phentermine)
Xenical (orlistat)

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.

1. The patient must have documented failure or Rx claims


with generic Niferex-150 Forte.
2
1. The patient has a body mass index (BMI) of >35kg/m , OR
2
2. The patient has a body mass index (BMI) of >30kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
3. The patient has a body mass index (BMI) of >30kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis, pregnancy, and/or lactation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician supervised diet and exercise
program consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet, and a
regular exercise program.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total
coverage.

140

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Dispense as Written DAW
Specific request for a brand
name product when a generic is
available

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

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION APPENDIX D
HEALTHPLUS PARTNERS
High Risk Medications in the Elderly (65 years old)
Based on the availability of safer alternatives, the following medications have been added to the Prior Authorization Program for members
65 years of age and older for HealthPlus Commercial/Medicare and HealthPlus Partners (Medicaid) with the following criteria:
1) The recommended alternative treatment(s) 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 the recommended alternative treatment(s).

Name

Concern

Cyclobenzaprine (Flexeril)

Anticholinergic effects, sedation, cognitive impairment

Estrogens (Premarin)

Breast/Endometrial cancer;
not cardio protective

Promethazine-Codeine

Anticholinergic effects (i.e., urine retention, confusion, sedation)

Promethazine (Phenergan)
Nitrofurantoin (Macrodantin)

Nephrotoxicity

Thyroid USP

Cardiac adverse effects

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

(Armour Thyroid, Desiccated)

Dicyclomine (Bentyl)

Anticholinergic, worsened cognition and behavioral problems in


dementia, urinary retention or incontinence, questionable
efficacy

Methocarbamol (Robaxin)

Anticholinergic effects, sedation, cognitive impairment

Hydroxyzine
(Vistaril, Atarax)

Anticholinergic effects, urinary retention, confusion, sedation

Constipation: Fiber (Psyllium) , Polyethylene glycol,


2
1
softener (docusate) , Amitiza
2
2
Diarrhea: Imodium , Aluminum hydroxide , Fiber
2
(Psyllium)
Physiotherapy: Correct seating or footwear
Spasticity: Baclofen, Zanaflex tablets, treat
underlying problems
2

Antihistamine: Claritin , Allegra , Clarinex

142

HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY


PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION APPENDIX D

Name

Concern

Carisoprodol (Soma)

Alternative Treatment
Physiotherapy; correct seating & footwear

Orphenadrine (Norflex)
Chlorzoxazone (Parafon
Forte DSC)

Anticholinergic effects, sedation, cognitive impairment,


weakness, urinary retention

Diphenoxylate-Atropine
(Lomotil)

Dependence, sedation, cognitive impairment

Evaluate diet. Psyllium , Imodium , Pepto-Bismol

Hyoscyamine (Hyomax-SL,
Hyomax-SR, Hyomax-FT)

Anticholinergic effects, worsened cognition & behavioral


problems in dementia, urinary retention or incontinence,
questionable efficacy

Trimethobenzamide (Tigan)

Extrapyramidal side effects, poor efficacy

Ketorolac (Toradol)

GI bleeding

Diet therapy: Psyllium , fluids


2
2
Constipation: Psyllium , polyethylene glycol , stool
2
1
softner , Amitiza
2
2
Diarrhea: Imodium , Pepto-Bismol/Kaopectate ,
Questran, Prevalite
1
Zofran, Kytril , Compazine or Reglan (avoid longterm use and avoid in Parkinsons disease)
2
2
Tylenol , Motrin , Vicodin

1
2

Spasticity: Baclofen, Zanaflex tablets. Treat


underlying problems
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

SPECIALTY INJECTABLE PRIOR AUTHORIZATION CRITERIA


Brand (generic) Name
Antiarthritics
Euflexxa
Hyalgan
Orthovisc
Supartz
Synvisc
Synvisc-One
(hyaluronic acid derivatives)

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)

1. For diagnosis of hairy cell leukemia,


malignant melanoma, follicular lymphoma,
AIDS related Kaposi's Sarcoma and CML,
patients must be >18 years of age; OR
2. For the diagnosis of condylomata
acuminata, documented failure of, or
intolerance to, traditional treatment
modalities (e.g., podofilox, imiquimod, acidtherapy, or surgical options); OR
3. For the diagnosis of chronic hepatitis B,
patients must have documented liver
disease and hepatitis B viral replication; OR
4. For the diagnosis of chronic hepatitis C,
allow 6-month initial authorization and 6month renewal permitted if the patient has
Genotype 1 HCV; or has initial viral load >2
million copies/mL.

Duration of Approval
Long-term

Initial authorization approved


for 6 months.
Renewal approved for 6
months.
-renewal permitted if the
patient has Genotype 1
HCV; or has initial viral load
>2 million copies/mL.

Notes

Interferons are usually


dosed three times a week
for 6 to 18 months.
Treatment nave patients
usually start with the 9mcg
dose and non-treatment
nave patients usually start
with the 15mcg dose.

Approvals for diagnosis of


condylomata acuminata
should be approved for 4
months.
Approvals for all other
diagnoses should be
approved for 6 months.

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

Renewal approved for 6


months.
-renewal permitted if the
patient has Genotype 1
HCV; or has initial viral load
>2 million copies/mL.

146

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Antivirals, continued
Synagis (palivizumab)

Criteria

Duration of Approval

1. Infants and children younger than 2


years of age with documented chronic lung
disease (CLD), formerly known as
bronchopulmonary dysplasia (BPS), who
have required medical therapy (e.g.,
supplemental oxygen, bronchodilator,
diuretics, or corticosteroid therapy) for their
CLD within 6 months before the anticipated
RSV season may receive a maximum of 5
monthly doses; OR
2. Infants born at 28 weeks gestation (up to and
including 28 weeks, 6 days) or earlier without
CLD and who are 12 months of age or younger
may receive a maximum of 5 monthly doses; OR
3. Infants born between 29 and 32 weeks gestation
(29 weeks, 0 days thru 31 weeks, 6 days or less)
or earlier without CLD and who are 6 months of
age or younger may receive a maximum of 5
monthly doses; OR
4. Infants born between 32 to 35 weeks (32 weeks,
0 days thru 34 weeks, 6 days) gestation without
CLD, are 3 months of age or younger, and have
at least 1 of the following risk factors may
receive a maximum of 3 monthly doses or until 3
months of age (whichever comes first):
a. Infant is attending child care
b. Infant has a sibling younger than 5 years
of age OR
5. Infants and children who are 2 years or younger
with hemodynamically significant cyanotic or
acyanotic congenital heart disease (CHD) or
severe immunodeficiencies may receive a
maximum of 5 doses.
6. Infants born before 35 weeks who have either
congenital abnormalities of the airway or a
neuromuscular condition that compromises
handling of respiratory secretions may receive a
maximum of 5 doses.

Approved for 5 months interval,


during the region's RSV
season, beginning as soon as
October and ending as late as
April.

Notes

147

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D

Brand (generic) Name


Bisphosphonates
Reclast (zoledronic acid)

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)

1. The patient must have diagnosis of Fabry


disease

Evaluate in 3 months for


response/development of
sensitivity

Myozyme
(alglucosidase alfa)

1. The patient must have diagnosis of Pompe


disease (GAA deficiency)

Evaluate in 3 months for


response/development of
sensitivity

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

1. Patient has a diagnosis of primary IGF1 deficiency or GH gene deletion,


- AND2. Increlex is prescribed by or after
consultation with a pediatric
endocrinologist, -AND3. Patient is 2 years to 18 years of age,
- AND4. Epiphyses are open, -AND5. Patients bone age is < 16 years for
males or < 14 years for females

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.

A negative TB test before initiating therapy; OR


Treatment for latent TB infections must be
initiated before treatment with Actemra; AND
Patient has no active infection (including
bacterial sepsis, tuberculosis, invasive fungal
and other opportunistic infections; AND
3
Patient has ANC >2000/mm AND Platelets
3
>100,000/mm AND ALT or AST <1.5x upper
limits of normal; AND
Patient is not also receiving TNF antagonists, or
other biologics (Enbrel, Humira, Remicade,
Simponi, Cimzia, Kineret, Rituxan, Orencia), or
live vaccines and diagnostic specific criteria are
met.

Duration of Approval

Notes
The dose of Actemra is
4mg/kg IV every 4 weeks;
may increase to 8 mg/kg IV
based on clinical response
(Max: 800mg per infusion).
Infuse over 60 minutes with
infusion set.

Rheumatoid Arthritis
6. Diagnosis of moderate to severe rheumatoid
arthritis; 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

HEALTHPLUS
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.

Ankylosing Spondylitis OR Psoriatic Arthritis:


5. Diagnosis of ankylosing spondylitis or psoriatic
arthritis.
6. The dose of Humira is 40mg administered
subcutaneously every other week.
Crohns Disease:
5. Diagnosis of moderate to severe Crohns
disease; AND
6. Documented failure of, intolerance or
contraindication to, conventional therapy
(azathioprine, mesalamine, mercaptopurine,
sulfasalazine, methotrexate, corticosteroids);
AND
7. The dose of Humira is 160mg on day 1, 80mg on
day 15 and then 40mg every other week starting
on day 28.
Juvenile Idiopathic Arthritis (JIA)/Juvenile
Rheumatoid Arthritis (JRA):
5. Patient is 4 years of age and older; AND
6. Patient has moderately to severely active
polyarticular JIA/JRA.
7. The dose of Humira for patients:
- 15 kg (33 lbs) to <30 kg (66 lbs) is 20 mg
administered subcutaneously every other week.
- 30 kg (66 lbs) is 40 mg administered
subcutaneously every other week.

157

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued

(FDA approved indications


vary by product)
Immune Globulin (IM)
GamaSTAN
Immune Globulin (IV)
Carimune NF
Flebogamma
Gammagard
Gammaplex
Gamunex
Privigen
Immune Globulin (SQ)
Gamunex-C
Hizentra

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

1. A serum trough IgG of 400 mg/dl.


(In rare circumstances where serum trough
level is recommended >600 mg/dl,
documentation should support rationale)
Selective IgG subclass deficiencies with
severe infection
including Specific Antibody Deficiency (SAD)
1. Documentation of IgG subclass deficiency
(Appendix 1), -or2. Documentation of severe polysaccharide
non-responsiveness (inability to make IgG
antibody against diphtheria and tetanus
toxoids, pneumococcal polysaccharide
vaccine, or both), -or3. Documentation of antigen testing with less
than 4 fold increase in specific antibody titer
and lack of protective antibody titer
(specific IgG antibody titer <1.3 mcg/ml),
-and4. Documented trial and failure of an antibiotic
within the last year (for initial authorization
only).

159

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued

(FDA approved indications


vary by product)
Immune Globulin (IM)
GamaSTAN
Immune Globulin (IV),
continued
Carimune NF
Flebogamma
Gammagard
Gammaplex
Gamunex
Privigen
Immune Globulin (SQ)
Gamunex-C
Hizentra

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

Kawasaki syndrome/Mucocutaneous Lymph


Node Syndrome (MCLS)
1. Therapy is started within 10 days of fever, and2. Concurrent aspirin administration.

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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued

(FDA approved indications


vary by product)
Immune Globulin (IM)
GamaSTAN
Immune Globulin (IV),
continued
Carimune NF
Flebogamma
Gammagard
Gammaplex
Gamunex
Privigen
Immune Globulin (SQ)
Gamunex-C
Hizentra

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

Chronic Lymphocytic Leukemia (CLL)


1. Immunoglobulin (IgG) level of < 600 mg/dl, and2. Documented trial and failure of an antibiotic
within the last year (for initial authorization
only)

1 year

Dosage guidelines:
100-500 mg/kg every 3-4
weeks

Pediatric HIV infection


1. Documentation of 2 bacterial infections in
a 1 year period, -or2. Patient has HIV-associated
thrombocytopenia, -or3. Patient has bronchiectasis, -or3
4. Documentation of T4 cell count 200 /mm

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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued

(FDA approved indications


vary by product)
Immune Globulin (IM)
GamaSTAN
Immune Globulin (IV),
continued
Carimune NF
Flebogamma
Gammagard
Gammaplex
Gamunex
Privigen
Immune Globulin (SQ)
Gamunex-C
Hizentra

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

Multiple Sclerosis (MS)


1. Patient must have relapse-remitting MS only
(not primary or secondary progressive MS),
-and2. Documented treatment with, intolerance, or
contraindication to any interferon therapy
(Betaseron, Avonex, or Rebif).

1 year

Dosage guidelines:
0.15-0.2 g/kg/day

162

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued

(FDA approved indications


vary by product)
Immune Globulin (IM)
GamaSTAN
Immune Globulin (IV),
continued
Carimune NF
Flebogamma
Gammagard
Gammaplex
Gamunex
Privigen
Immune Globulin (SQ)

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

Dermatomyositis and Polymyositis


1. Documented failure of, intolerance, or
contraindication to at least 2 of the
following: corticosteroids, methotrexate,
azathioprine, cyclophosphamide, or
cyclosporine.

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

Systemic Lupus Erythematosus (SLE)


1. Documentation of severe (solid organ
involvement), active SLE, -and2. Documented failure of, intolerance, or
contraindication to at least 2 of the
following: corticosteroids. methotrexate,
azathioprine, or cyclophosphamide

Not limited

Dosage guidelines:
200-400 mg/kg X 5 days
once a month

Maintenance therapy
considered experimental
and investigational

Gamunex-C
Hizentra

163

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued

(FDA approved indications


vary by product)
Immune Globulin (IM)
GamaSTAN
Immune Globulin (IV),
continued
Carimune NF
Flebogamma
Gammagard
Gammaplex
Gamunex
Privigen

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

Multifocal Motor Neuropathy


1. Diagnosis is required

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

Stiff Person Syndrome


1. Diagnosis is required

Not limited

Dosage guidelines:
2gm/kg divided into 2 daily
doses given every 3
months

Immune Globulin (SQ)


Gamunex-C
Hizentra

164

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

Ankylosing Spondylitis OR Psoriatic Arthritis:


6. Diagnosis of ankylosing spondylitis or
psoriatic 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).
Crohns Disease:
6. Patient is > 6 years old; AND
7. Patient has a diagnosis of moderate to
severe Crohns disease; OR
8. Diagnosis of Crohns disease with draining
enterocutaneous fistulae; AND
9. Documented failure of, or intolerance to,
mesalamine and corticosteroids and 6mercaptopurine or azathioprine; AND
10.
Patient has documented failure of, or
intolerance to, or inability to inject a
formulary subcutaneously administered
anti-TNF agent (e.g., Humira).

167

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

Dose: 120 mg every 4


weeks subcutaneously.
Administer calcium and Vit
D PRN to treat or prevent
hypocalcemia
Not indicated in patients
with multiple myeloma.

171

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

1. Diagnosis of relapsing-remitting multiple


sclerosis.

Long-term

Gilenya (fingolimod)

1. The patient must have documented


diagnosis of a relapsing form of multiple
sclerosis;
2. There is documentation of the following
within the last 6 months:
a. CBC, Liver Function Tests, and
b. Ophthalmologic Evaluation; and
3. There is a documented EKG within 6
months if patient
a. is using an antiarrhythmic (including
beta-blocker or calcium channel
blockers), or
b. has history of sick sinus syndrome,
prolonged QT interval, ischemic heart
disease, congestive heart failure,
bradycardia, or irregular heat beat.
Note: Patient should not receive Gilenya
concomitantly with another immunomodulator
therapy for multiple sclerosis (e.g. Avonex,
Rebif, Betaseron, Extavia, Copaxone, or
Tysabri).
1. Patient must have a documented diagnosis
of cervical dystonia.

Neuromuscular Blocking
Agent
Botox
Dysport
Xeomin
(botulism toxin type A)

Notes

Quantity is limited to 30
units per month.

Approved 3 months

173

HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
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

The warnings for Xolair


include malignancy and
anaphylaxis.

Renewals may be
authorized long-term.

174

PRESCRIPTION BENEFIT LIMITATIONS


APPENDIX E
GENERAL LIMITATIONS (All Lines of Business)
Michigan State Law Limitations:
Schedule II prescriptions are not refillable, and must be filled within 60 days of the date
prescription is actually written.
Schedule III, IV, & V prescriptions are only refillable for 6 months from the date of the
original prescription (if refills are indicated by the prescriber).
Non-Scheduled prescriptions are refillable for 1 year from the date the prescription was
actually written (if refills are indicated by the prescriber).
HealthPlus Contractual Exclusions:
Medications used for cosmetic purposes are not covered.
Medications used in conjunction with the in-vitro fertilization procedure are not covered.
Non-prescription drugs, dietary supplements and medical foods are not a covered
benefit, with the exception of OTC medications specifically added to coverage by
HealthPlus.
HealthPlus Administrative Limitations:
Prescription drugs are limited to the reasonable cost of generically-available products,
unless no generically-equivalent product exists or a member-specific review for medical
necessity determines the need for the brand name medication.
Prescription drugs are limited to FDA-approved indications when reviewed, unless a
member-specific review for medical necessity determines the need for a particular
medication for an off-label use.
Prescriptions written by a Dentist are limited to those medications on the HealthPlus
Dental Formulary.
Prescriptions for testosterone products are limited to male members only, unless a
member-specific review for a female member determines medical necessity or if the
medication is being used for an FDA-approved indication.
Prescriptions for products that contain estrogen are limited to female members only.
Prior Authorization based on specific criteria is required for medications included in the
Pharmacy Prior Authorization Program including the Dose Optimization Program.
Coverage for medications included in the Dose Optimization Program is limited to once
daily dosing, or maximum dose recommendations with quantity limits, unless a member
specific review determines medical necessity for the specified dosing regimen.
Coverage for specific migraine medications is limited to 9 tablets per month, unless a
member specific review determines that the member is also currently taking medication
for the prophylaxis of migraine and still requires more than 9 tablets per month.
Coverage for smoking cessation medications is limited to one course of therapy per year.
Prescription medications for weight loss require Prior Authorization, initiated through the
Pharmacy Department.

175

PRESCRIPTION BENEFIT LIMITATIONS


APPENDIX E
LIMITATIONS BY LINE OF BUSINESS
HealthPlus of Michigan (Commercial, PPO, MedicarePlus (non-Part D)
Limitations:
Prescription drugs for the treatment of impotency are covered for male members only and
are limited to a quantity of 6 units/tablets total (for all ED products combined) every 30
days. These drugs are limited to males 35 years of age and older. If a member-specific
review for a male member under 35 years of age meets medical necessity criteria, the
Primary Care Physician or participating treating urologist may obtain prior authorization
from HPM for coverage of the product. (The same limitations for quantity apply.) For
PPO members, any physician may prescribe ED medications.
Selected antipsychotic medications are limited to maximum daily dosage
recommendations from the manufacturer.
Selected sleeping medications are limited to a quantity of 30 in 30 days.
OTC Generic Nicotine Patches are a covered benefit, limited to the original prescription
plus two additional refills (12 weeks); prescription nicotine patches require prior
authorization.
Covered medications are limited to a 30-day supply (for some benefits up to a 34-day
supply) at participating 30-day supply retail pharmacies, and a 90-day supply through
participating HealthPlus Ask for 90 Rx retail pharmacies and the designated mail service
provider. Refills may be obtained when 80% of the day supply received has passed.
Specifically for the Ask for 90 Rx programs (mail service and retail pharmacies),
injectable medications are not covered with the exception of injectable diabetes
medications, Epipen, glucagon, and Imitrex.
HealthPlus Partners (Medicaid)
State Limitations and Exclusions:
Coverage is limited to the generic product when a generic product is available.
Combination cough and cold products are not a covered benefit.
Certain Over-the-Counter (OTC) products (as mandated by the State) are covered when
written as a prescription and dispensed by the pharmacy, with coverage limited to the
generic product when the product is generically available.
Male condoms (latex only) and the female condom are a covered benefit, limited to
members 10 years of age or older, and limited to a maximum of 12 condoms per
prescription and 36 condoms per month.
Prescription medications for weight loss require Prior Authorization, initiated through the
Pharmacy Department
OTC generic nicotine patches and Nicorette gum are covered; prescription brand only
nicotine patches require Prior Authorization.
Medications used to treat infertility are not a covered benefit.
Medications for erectile dysfunction are not a covered benefit.
Behavioral health medications, HIV medications and specific medications in other
categories are carved out to MDCH.
Administrative Limitations:
Covered medications are limited to a 31-day supply at participating retail pharmacies.
Refills may be obtained when 80% of the day supply received has passed.
A generic/brand copay of $1.00/$3.00 applies for prescriptions for members age 21 and
older, with the exception of insulin, insulin syringes, covered OTC products, prenatal
vitamins, oral contraceptives and other family planning products. Copays for brand
medications apply for the first five brand medications in each calendar month, after which
the brand copay reverts to zero until the next calendar month.
Nicotrol Inhalers are not a covered benefit.
176

HealthPlus Signature PPO


Limitations:
Prescription drug coverage is limited to those products that are listed on the PPO Closed
Formulary.
Exclusions:
Prescription drugs when there is a non-prescription drug available in the drug category.
Non-sedating antihistamines (NSAs) and NSA antihistamine decongestants
Ophthalmic antihistamines
Erectile dysfunction medications
Weight loss medications
Drugs for the treatment of infertility.

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

ALBUTEROL/ IPRATROPIUM ............................................ 40


ALCAFTADINE ................................................................... 53
ALCLOMETASONE ............................................................ 42
ALDACTAZIDE 25/25 ........................................................ 25
ALDACTAZIDE 50/50 ........................................................ 25
ALDACTONE ..................................................................... 25
ALDARA ............................................................................ 48
ALDOMET ......................................................................... 29
ALDOMET 125 .................................................................. 29
ALDORIL-D ....................................................................... 29
ALENDRONATE................................................................. 70
ALENDRONATE/ VITAMIN D3 .......................................... 70
ALFUZOSIN ....................................................................... 78
ALINIA .............................................................................. 35
ALISKIREN ........................................................................ 29
ALISKIREN/ ........................................................... 27, 28, 29
ALISKIREN/ HCTZ .............................................................. 29
ALITRETINOIN .................................................................. 48
ALLEGRA OTC ................................................................... 38
ALLEGRA-D ....................................................................... 39
ALLEGRA-D 12 HOUR ....................................................... 39
ALLOPURINOL .................................................................. 73
ALMOTRIPTAN ................................................................. 59
ALOCRIL ........................................................................... 53
ALODOX ........................................................................... 51
ALOMIDE .......................................................................... 53
ALORA .............................................................................. 67
ALOSETRON ............................................................... 21, 79
ALPHAGAN P .................................................................... 50
ALPRAZOLAM ............................................................. 55, 56
ALPROSTADIL ............................................................. 76, 77
ALREX ............................................................................... 51
ALTABAX .......................................................................... 44
ALTACE CAPS.................................................................... 25
ALTOPREV ........................................................................ 29
ALUPENT INHALER ..................................................... 40, 41
ALVESCO .......................................................................... 40
AMANTADINE .................................................................. 34
AMARYL ........................................................................... 71
AMBIEN ............................................................................ 56
AMERGE ........................................................................... 59
AMICAR ............................................................................ 49
AMICAR 1,000MG ............................................................ 49
AMINOCAPROIC ACID ...................................................... 49
AMINOPHYLLINE .............................................................. 41
AMIODARONE .................................................................. 24
AMITIZA ..................................................................... 21, 79
AMLACTIN 12% ................................................................ 43
AMLODIPINE .................................................................... 27
AMLODIPINE/ .................................................................. 26
AMLODIPINE/ ATORVASTATIN ........................................ 29
AMLODIPINE/ BENAZEPRIL ........................................ 25, 27
AMLODIPINE/ OLMESARTAN ........................................... 26
AMLODIPINE/ VALSARTAN .............................................. 26
AMMONIUM LACTATE ............................................... 43, 44

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

BACTROBAN NASAL OINT .................................................45


BALSALAZIDE DISODIUM ..................................................20
BANZEL .............................................................................58
BECLOMETHASONE DIPROPIONATE ................................41
BECLOMETHASONE, AQUEOUS ........................................39
BECONASE AQ ..................................................................39
BELLADONNA ALKALOIDS/ PHENOBARBITAL ...................22
BENADRYL .................................................................. 38, 56
BENAZEPRIL ......................................................................25
BENAZEPRIL/ HCTZ ...........................................................25
BENICAR ...........................................................................26
BENICAR HCT ....................................................................26
BENTYL .............................................................................22
BENZACLIN 1%-5% Gel (pump).........................................46
BENZACLIN CARE KIT 1%-5% PUMP (ampoules) ..............46
BENZAMYCIN GEL .............................................................46
BENZAMYCINPAK .............................................................46
BENZEFOAM .....................................................................46
BENZIQ, LS ........................................................................46
BENZONATATE .................................................................40
BENZOYL PEROXIDE .................................................... 46, 47
BENZOYL PEROXIDE MICROSPHERES ...............................47
BENZOYL PEROXIDE WITH ALOE/GREEN TEA ...................47
BENZOYL PEROXIDE/ ALOE VERA .....................................46
BENZOYL PEROXIDE/ HC/SKIN CLNSR NO. 14 ..................47
BENZOYL PEROXIDE/ HYALURONT ...................................47
BENZOYL PEROXIDE/ SULFUR ...........................................47
BENZTROPINE ...................................................................60
BENZYL ALCOHOL .............................................................48
BEPOTASTINE BESILATE ....................................................53
BEPREVE ...........................................................................53
BESIFLOXACIN HYDROCHLORIDE......................................51
BESIVANCE .......................................................................51
BETAGAN ..........................................................................50
BETAMET DIPROP/ ...........................................................44
BETAMETHASONE ...................................................... 43, 61
BETAMETHASONE DIPROPIONATE ...................................42
BETAPACE, AF ...................................................................24
BETASERON ......................................................................79
BETAXOLOL................................................................. 28, 50
BETHANECHOL .................................................................78
BETIMOL ...........................................................................50
BETOPTIC S .......................................................................50
BEXAROTENE ....................................................................48
BEYAZ ...............................................................................62
BIAXIN, XL .........................................................................31
BIDIL .................................................................................23
BILTRICIDE ........................................................................35
BIMATOPROST..................................................................50
BISOPROLOL .....................................................................28
BISOPROLOL/ HCTZ ..........................................................28
BLEPH-10 ..........................................................................51
BLEPHAMIDE ....................................................................52
BLEPHAMIDE S.O.P. ..........................................................52
BLOCADREN......................................................................28

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

CARDIZEM CD 360 ............................................................27


CARDIZEM LA ...................................................................27
CARDURA.................................................................... 28, 78
CARDURA XL .....................................................................28
CARISOPRODOL ................................................................60
CARMOL ...........................................................................43
CARNITOR .........................................................................76
CARTIA XT .........................................................................27
CARVEDILOL .....................................................................28
CATAFLAM ........................................................................35
CATAPRES-TTS ..................................................................29
CAVERJECT........................................................................76
CECLOR .............................................................................31
CEDAX ...............................................................................31
CEFACLOR .........................................................................31
CEFDITOREN .....................................................................31
CEFIXIME ..........................................................................31
CEFTIBUTEN ......................................................................31
CEFTIN ..............................................................................31
CEFUROXIME ....................................................................31
CELEBREX..........................................................................35
CELECOXIB ........................................................................35
CELESTONE .......................................................................61
CELEXA..............................................................................54
CELLCEPT ..........................................................................77
CELONTIN .........................................................................58
CENESTIN ..........................................................................67
CEPHALEXIN .....................................................................31
CERTOLIZUMAB PEGOL ....................................................77
CETIRIZINE ........................................................................38
CETRAXAL .........................................................................53
CETRORELIX ACETATE .......................................................69
CETROTIDE .......................................................................69
CHANTIX ...........................................................................76
CHLORAL HYDRATE ..........................................................56
CHLOROQUINE ........................................................... 34, 35
CHLOROXYLENOL/ ............................................................54
CHLORTHALIDONE............................................................25
CHLORZOXAZONE .............................................................60
CHOLESTYRAMINE POWDER ............................................30
CHOLESTYRAMINE/ ..........................................................30
CIALIS ................................................................................76
CICLESONIDE .............................................................. 39, 40
CICLOPIROX ......................................................................45
CICLOPIROX OLAMINE ......................................................45
CILOSTAZOLE ....................................................................49
CILOXAN GEL ....................................................................52
CILOXAN SOLN ..................................................................52
CIMETIDINE ......................................................................20
CIMZIA ..............................................................................77
CIPRO.......................................................................... 32, 33
CIPRO HC ..........................................................................53
CIPRO XR ..........................................................................32
CIPRODEX .........................................................................54
CIPROFLOXACIN ............................................. 32, 33, 52, 53

CIPROFLOXACIN HCL/ HC ................................................. 53


CIPROFLOXACIN/ DEXAMETH .......................................... 54
CITALPRAM ...................................................................... 54
CITRACAL PRENATAL + DHA ............................................. 73
CITRANATAL HARMONY .................................................. 73
CLARINEX, REDITABS........................................................ 38
CLARINEX-D...................................................................... 39
CLARITHROMYCIN............................................................ 31
CLARITIN OTC ................................................................... 38
CLARITIN-D OTC ............................................................... 39
CLEMASTINE .................................................................... 38
CLEOCIN 150, 300MG ...................................................... 32
CLEOCIN VAGINAL CREAM ............................................... 48
CLEOCIN VAGINAL OVULE................................................ 48
CLEOCIN-T ........................................................................ 46
CLIDINIUM BROMIDE/ CHLORDIAZEPOXIDE ................... 23
CLIMARA .......................................................................... 67
CLIMARA PRO .................................................................. 68
CLINAC BPO ..................................................................... 46
CLINDACIN PAC ................................................................ 46
CLINDAGEL ....................................................................... 46
CLINDAMYCIN ...................................................... 32, 46, 48
CLINDAMYCIN/ .......................................................... 46, 47
CLINDAMYCIN/BENZOYL PEROXIDE ................................ 46
CLINDESSE ........................................................................ 48
CLINORIL .......................................................................... 35
CLOBETASOL EMOLL ........................................................ 43
CLOBETASOL PROPIONATE ........................................ 42, 43
CLOBEX ............................................................................ 42
CLOCORTOLONE PIVALATE .............................................. 42
CLODERM ......................................................................... 42
CLOMID ............................................................................ 69
CLOMIPHENE ................................................................... 69
CLOMIPRAMINE ............................................................... 54
CLONAZEPAM .................................................................. 58
CLONIDINE ................................................................. 29, 57
CLOPIDOGREL .................................................................. 49
CLORAZEPATE .................................................................. 55
CLOTRIMAZOLE 1% .......................................................... 45
CLOTRIMAZOLE TROCHES ................................................ 33
CLOTRIMAZOLE/ BETAMETHASONE ................................ 45
CLOZAPINE ....................................................................... 56
CLOZARIL.......................................................................... 56
COARTEM ........................................................................ 34
CODEINE .......................................................................... 36
COGENTIN ........................................................................ 60
COLAZAL .......................................................................... 20
COLCHICINE 0.6MG.......................................................... 73
COLCRYS........................................................................... 73
COLESEVELAM ................................................................. 30
COLESTID ......................................................................... 29
COLESTID 7.5 ................................................................... 29
COLESTIPOL ..................................................................... 29
COLY-MYCIN S .................................................................. 54
COLYTE ............................................................................. 23

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

DALTEPARIN SODIUM,PORCINE ...................................... 49


DANTRIUM ....................................................................... 60
DANTROLENE ................................................................... 60
DAPSONE ......................................................................... 46
DARAPRIM ....................................................................... 34
DARBEPOETIN ALFA IN POLYSORBATE ............................ 49
DARIFENACIN HYDROBROMIDE....................................... 78
DAYPRO ........................................................................... 35
DAYTRANA ....................................................................... 57
DDAVP NASAL SPRAY ....................................................... 69
DDAVP RHINAL TUBE ....................................................... 69
DECADRON ...................................................................... 51
DECONAMINE SYRUP ....................................................... 39
DECONAMINE TABS ......................................................... 39
DEFERASIROX ................................................................... 75
DEFEROXAMINE MESYLATE ............................................. 75
DELOS .............................................................................. 46
DEMADEX ........................................................................ 25
DEMEROL ......................................................................... 36
DEPAKENE ........................................................................ 58
DEPAKOTE ........................................................................ 58
DERMA-SMOOTHE-FS 0.01% OIL ..................................... 42
DESFERAL ......................................................................... 75
DESIPRAMINE .................................................................. 54
DESLORATIDINE ............................................................... 38
DESMOPRESSIN ACETATE ................................................ 69
DESOGEN ......................................................................... 62
DESONATE GEL ................................................................ 42
DESONIDE .................................................................. 42, 43
DESONIDE/EMOLLIENT COMBO ...................................... 42
DESOWEN ........................................................................ 42
DESOWEN COMBO .......................................................... 42
DESOXIMETASONE........................................................... 43
DESOXYN .......................................................................... 57
DESQUAM X ..................................................................... 46
DESVENLAFAXINE SUCCINATE ......................................... 55
DETROL ............................................................................ 78
DETROL LA ....................................................................... 78
DEXAMETHASONE ........................................................... 51
DEXAMETHASONE/ NEOMYCIN/ POLYMYXIN ................. 52
DEXAMETHASONE/ TOBRAMYCIN ................................... 53
DEXEDRINE ...................................................................... 57
DEXILANT ......................................................................... 20
DEXLANSOPRAZOLE ......................................................... 20
DEXMETHYLPHENIDATE................................................... 57
DEXTROAMPHETAMINE................................................... 57
DIABETA ........................................................................... 71
DIAMOX SEQUELS ............................................................ 50
DIASTAT ........................................................................... 58
DIAZEPAM .................................................................. 55, 58
DIBENZYLINE .................................................................... 29
DICLOFENAC .............................................................. 35, 36
DICLOFENAC EPOLAMINE ................................................ 35
DICLOFENAC SODIUM ...................................................... 48
DICLOFENAC, EXTENDED RELEASE................................... 36

182

DICLOFENAC/ MISOPROSTOL ...........................................35


DICLOFENAX POTASSIUM .................................................36
DICYCLOMINE ...................................................................22
DIDRONEL .........................................................................70
DIFENOXIN/ ATROPINE.....................................................22
DIFFERIN 0.1% CREAM, GEL .............................................46
DIFFERIN 0.1% LOTION .....................................................46
DIFFERIN 0.3% GEL ...........................................................46
DIFLORASONE DIACETATE ................................................42
DIFLUCAN ................................................................... 33, 48
DIFLUNISAL .......................................................................35
DIGOXIN ..................................................................... 24, 25
DIHYDROERGOTAMINE ....................................................59
DILACOR XR ......................................................................27
DILANTIN 100MG CAPS ....................................................58
DILANTIN 30 KEPSEAL ......................................................58
DILANTIN 50 INFATAB ......................................................58
DILATRATE-SR ...................................................................23
DILAUDID ..........................................................................36
DILAUDID 5 LIQUID...........................................................36
DILTIAZEM ........................................................................27
DIOVAN ............................................................................26
DIOVAN HCT .....................................................................26
DIPENTUM ........................................................................20
DIPHENHYDRAMINE ................................................... 38, 56
DIPHENOXYLATE/ ATROPINE ............................................22
DIPIVEFRIN .......................................................................51
DIPROSONE ......................................................................42
DIPYRIDAMOLE .................................................................49
DISOPYRAMIDE ................................................................24
DISULFIRAM .....................................................................76
DITROPAN XL ....................................................................78
DIVALPROEX SODIUM ......................................................58
DIVIGEL .............................................................................67
DL-E AC/ GRAPE/ HYALURONIC ACID ...............................43
DOCYCYCLINE ...................................................................31
DOFETILIDE .......................................................................25
DOLASETRON MESYLATE ..................................................22
DOLOBID...........................................................................35
DOLOPHINE ......................................................................36
DOMEBORO......................................................................54
DONEPEZIL .......................................................................61
DONNATAL .......................................................................22
DORNASE ALFA .................................................................41
DORYX ..............................................................................31
DORZOLAMIDE .................................................................51
DOVONEX CRM ................................................................44
DOVONEX SOLN ...............................................................44
DOXAZOSIN ................................................................ 28, 78
DOXEPIN ...........................................................................55
DOXYCYCLINE ............................................................. 31, 33
DOXYCYCLINE KIT .............................................................31
DOXYCYCLINE/ EYELID CLNS NO.2&3 ...............................51
DOXYCYCLINE/SALICY/OCT/ZINC OX ................................31
DRONEDARONE HYDROCHLORIDE ...................................24

DROSPIR/ETH ESTRA/LEVOMEF OL CA ............................ 62


DROSPIR/ETHESTRA/LEVOMEFOL CA .............................. 66
DROXIA ............................................................................ 80
DUET DHA COMPLETE ..................................................... 73
DUETACT .......................................................................... 72
DULERA ............................................................................ 40
DULOXETINE .............................................................. 54, 79
DUONEB ........................................................................... 40
DURAGESIC PATCH .......................................................... 36
DUTASTERIDE................................................................... 78
DUTASTERIDE/ ........................................................... 28, 78
DYAZIDE ........................................................................... 25
DYNACIRC CR ................................................................... 27
DYRENIUM ....................................................................... 25
E
E.E.S. ................................................................................ 31
ECHOTHIOPHATE ............................................................. 51
EDEX................................................................................. 77
EDLUAR ............................................................................ 56
EFFEXOR XR ..................................................................... 54
EFFIENT ............................................................................ 49
ELESTAT ........................................................................... 53
ELETRIPTAN ..................................................................... 60
ELIDEL .............................................................................. 44
ELIXOPHYLLIN ELIXIR ........................................................ 41
ELMIRON .......................................................................... 78
ELOCON ........................................................................... 42
EMADINE ......................................................................... 53
EMBEDA ........................................................................... 36
EMEDASTINE DIFUMARATE ............................................. 53
EMEND ............................................................................. 22
EMOLLIENT COMBO .................................................. 43, 44
EMSAM PATCH ................................................................ 54
E-MYCIN ........................................................................... 32
ENABLEX .......................................................................... 78
ENALAPRIL ....................................................................... 26
ENALAPRIL/ HCTZ............................................................. 26
ENBREL............................................................................. 77
ENJUVIA ........................................................................... 67
ENOXAPARIN ................................................................... 49
ENPRESSE ......................................................................... 62
ENTACAPONE ................................................................... 60
ENTEX ER.......................................................................... 39
ENTEX LIQUID .................................................................. 39
ENTOCORT EC .................................................................. 21
EPICERAM ........................................................................ 43
EPIDUO ............................................................................ 46
EPINASTINE ...................................................................... 53
EPLERENONE.............................................................. 25, 29
EPOETIN ALFA .................................................................. 49
EPOGEN ........................................................................... 49
EPROSARTAN ................................................................... 26
EPROSARTAN/ HCTZ ........................................................ 26
ERGOTAMINE/ CAFFEINE ................................................. 59

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

FLUORABON BASIC ...........................................................75


FLUORABON CHEW TABLET .............................................75
FLUORABON DROPS .........................................................75
FLUOROMETHOLONE .......................................................51
FLUOXETINE .....................................................................55
FLUOXYMESTERONE.........................................................69
FLURANDRENOLIDE ..........................................................42
FLURBIPROFEN .................................................................35
FLUTICASONE ............................................................. 39, 40
FLUTICASONE FUROATE ...................................................39
FLUTICASONE PROPIONATE .............................................42
FLUTICASONE/ SALMETEROL ...........................................40
FLUVASTATIN ...................................................................29
FLUVOXAMINE MALEATE .................................................54
FML ...................................................................................51
FML FORTE .......................................................................51
FML S.O.P. ........................................................................51
FOCALIN XR ......................................................................57
FOLIC ACID.................................................................. 73, 80
FOLLISTIM AQ ...................................................................69
FOLLITROPIN ALPHA,RECOMB .........................................69
FOLLITROPIN BETA,RECOMB ............................................69
FORADIL............................................................................40
FORMOTEROL FUMARATE ...............................................40
FORTAMET .......................................................................72
FORTEO ............................................................................70
FORTICAL ..........................................................................70
FOSAMAX .........................................................................70
FOSAMAX PLUS D .............................................................70
FOSFOMYCIN TROMETHAMINE .......................................33
FOSINOPRIL ......................................................................25
FOSINOPRIL/ HCTZ ...........................................................25
FOSRENOL ........................................................................79
FRAGMIN ..........................................................................49
FROVA ..............................................................................59
FROVATRIPTAN ................................................................59
FULVICIN U/F ....................................................................33
FURAZOLIDONE ................................................................32
FUROSEMIDE ....................................................................25
FUROXONE .......................................................................32
G
GABAPENTIN .............................................................. 58, 59
GABITRIL ...........................................................................58
GALANTAMINE .................................................................61
GARAMYCIN ............................................................... 45, 52
GASTROCROM ..................................................................21
GELNIQUE .........................................................................78
GEMFIBROZIL ...................................................................30
GEMIFLOXACIN MESYLATE ...............................................32
GENERESS FE ....................................................................62
GENGRAF ..........................................................................77
GENOTROPIN ....................................................................80
GENTAMICIN .............................................................. 45, 52
GEODON ...........................................................................56

GESTICARE, DHA .............................................................. 73


GILENYA ........................................................................... 79
GLATIRAMER ACETATE .................................................... 79
GLIMEPIRIDE .................................................................... 71
GLIPIZIDE ......................................................................... 71
GLUCAGON ...................................................................... 73
GLUCOPHAGE XR ............................................................. 72
GLUCOSE TEST STRIPS...................................................... 72
GLUCOTROL XL ................................................................ 71
GLUCOVANCE .................................................................. 72
GLUMETZA ....................................................................... 72
GLYBURIDE ....................................................................... 71
GLYBURIDE/ METFORMIN ............................................... 72
GLYNASE PRESTAB ........................................................... 71
GLYSET ............................................................................. 72
GOLIMUMAB ................................................................... 77
GOLYTELY ......................................................................... 23
GONADOTROPIN, CHORIONIC,HUMAN ........................... 69
GONAL-F .......................................................................... 69
GORDO-UREA .................................................................. 43
GRANISETRON ................................................................. 22
GRANULEX ....................................................................... 48
GRIFULVIN-V .................................................................... 33
GRISEOFULVIN ................................................................. 33
GRISEOFULVIN, ULTRAMICROSIZE ................................... 33
GRIS-PEG .......................................................................... 33
GUAIFENESIN/ PHENYLEPHRINE ................................ 39, 40
GUANFACINE ............................................................. 29, 57
GYNAZOLE 1 ..................................................................... 48
H
HALCINONIDE .................................................................. 42
HALDOL ............................................................................ 56
HALOBETASOL PROP/ AMMONIUM LAC ......................... 43
HALOG ............................................................................. 42
HALOPERIDOL .................................................................. 56
HCG ALPHA,RECOMBINANT ............................................ 69
HIPREX ............................................................................. 32
HOMATROPINE ................................................................ 50
HUMALOG ....................................................................... 71
HUMALOG MIX ................................................................ 71
HUMATROPE.................................................................... 80
HUMIRA ........................................................................... 77
HUMULIN INSULINS ......................................................... 71
HYDRALAZINE .................................................................. 27
HYDRO 40 ........................................................................ 43
HYDROCODONE BIT/ ACETAMINOPHEN ......................... 38
HYDROCODONE/ CHLORPHEN POLIS .............................. 39
HYDROCODONE/ IBUUPROFEN ....................................... 37
HYDROCORTISONE........................................................... 61
HYDROCORTISONE ACETATE ........................................... 20
HYDROCORTISONE BUTYRATE 0.1% ................................ 42
HYDROCORTISONE BUTYRATE/ EMOLL ........................... 42
HYDROCORTISONE PROBUTATE ...................................... 43
HYDROCORTISONE SUPP ................................................. 21

185

HYDROCORTISONE VALERATE ..........................................43


HYDROCORTISONE/ EMOLLIENT ......................................43
HYDROCORTISONE/ NEOMYCIN/ POLYMYXIN .................54
HYDROCORTISONE/ NEOMYCIN/ POLYMYXIN/
BACITRACIN .................................................................52
HYDROCORTISONE/ NEOMYCIN/POLYMYXIN/ BACITRACIN
.....................................................................................45
HYDROCORTISONE/ PRAMOXINE.....................................21
HYDROCORTISONE/ALOE VERA........................................43
HYDROCORTISONE/BENZOYL PEROXIDE ..........................43
HYDROCORTISONE/UREA .................................................43
HYDROMORPHONE ..........................................................36
HYDROXYCHOLORO- ........................................................35
HYDROXYUREA .................................................................80
HYDROXYZINE PAMOATE .................................................55
HYLATOPIC .......................................................................44
HYLATOPIC PLUS ..............................................................44
HYOSCYAMINE ........................................................... 22, 23
HYZAAR.............................................................................26
I
IBANDRONATE..................................................................70
IBUDONE 10/200 ..............................................................37
IBUPROFEN .......................................................................36
IBUPROFEN/ HYDROCODONE .................................... 37, 38
ILOPERIDONE....................................................................56
ILOTYCIN ...........................................................................52
IMDUR ..............................................................................24
IMIPRAMINE PAMOATE ...................................................55
IMIQUIMOD .....................................................................48
IMITREX KIT ......................................................................59
IMITREX SPRAY .................................................................59
IMITREX TABLET ...............................................................59
IMODIUM .........................................................................22
IMURAN ............................................................................77
INDAPAMIDE ....................................................................25
INDERAL ...........................................................................59
INDERAL LA .......................................................................59
INDERAL, LA......................................................................28
INDOCIN ...........................................................................35
INDOCIN SUSP ..................................................................73
INDOMETHACIN ......................................................... 35, 73
INH ...................................................................................34
INOVA ...............................................................................47
INSPRA ........................................................................ 25, 29
INSULIN ............................................................................71
INSULIN ASPART ...............................................................71
INSULIN DETEMIR .............................................................71
INSULIN DETIMIR ..............................................................71
INSULIN GLARGINE ...........................................................71
INSULIN GLULISINE ...........................................................71
INSULIN LISPRO ................................................................71
INSULIN SYRINGES ............................................................71
INTERFERON BETA-1A ......................................................79
INTERFERON BETA-1A/ALBUMIN .....................................79

INTERFERON BETA-1B ...................................................... 79


INTUNIV ........................................................................... 57
INVEGA ............................................................................ 56
IODOQUINOL ................................................................... 35
IOPIDINE .......................................................................... 50
IPRATROPIUM BROMIDE ........................................... 38, 40
IPRATROPIUM/ ALBUTEROL SULFATE ............................. 40
IQUIX ................................................................................ 52
IRBESARTAN ..................................................................... 26
IRBESARTAN/ HCTZ .......................................................... 26
IRON PS CMPLX/VIT B12/FA ............................................ 73
IRON SUPPLEMENTS ........................................................ 80
ISOETHARINE ................................................................... 40
ISONIAZID ........................................................................ 34
ISOPTIN ............................................................................ 27
ISOPTO CARBACHOL ........................................................ 50
ISOPTO HOMATROPINE ................................................... 50
ISORDIL 5, 10 ................................................................... 24
ISOSORBIDE DINITRATE ............................................. 23, 24
ISOSORBIDE DINITRATE/ HYDRALAZINE .......................... 23
ISOSORBIDE MONONITRATE ........................................... 24
ISRADIPINE ....................................................................... 27
ISTALOL ............................................................................ 50
ITRACONAZOLE ................................................................ 34
IVERMECTIN ..................................................................... 35
J
JALYN ......................................................................... 28, 78
JANUMET ......................................................................... 72
JANUVIA ........................................................................... 72
JOLIVETTE ........................................................................ 62
K
KADIAN ............................................................................ 37
KAPVAY ............................................................................ 57
KARIVA ............................................................................. 62
KAYEXALATE..................................................................... 78
KEFLEX ............................................................................. 31
KEFLEX 750MG ................................................................. 31
KENALOG ......................................................................... 42
KENALOGAEROSOL SPRAY ............................................... 42
KEPPRA ............................................................................ 58
KEPPRA XR ....................................................................... 58
KERAFOAM ...................................................................... 44
KERALAC .......................................................................... 44
KERLONE .......................................................................... 28
KEROL 50% SUSPENSION ................................................. 44
KEROL AD ......................................................................... 44
KETEK ............................................................................... 32
KETOCONAZOLE ......................................................... 45, 46
KETOPROFEN ................................................................... 35
KETOPROFEN POWDER.................................................... 35
KETOROLAC...................................................................... 36
KETOROLAC TROMETHAMINE ......................................... 53
KETOTIFEN ....................................................................... 53

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

LUPRON DEPOT 3.75 KIT ............................................ 69, 70


LURASIDONE ....................................................................56
LUVOX CR .........................................................................54
LUXIQ................................................................................43
LYBREL ..............................................................................63
LYRICA ........................................................................ 59, 79
M
MACROBID ................................................................. 32, 33
MACRODANTIN 25MG ............................................... 32, 33
MACRODANTIN 50, 100MG .............................................33
MAFENIDE ACETATE .........................................................45
MALARONE .......................................................................34
MALATHION .....................................................................48
MAVIK...............................................................................25
MAXAIR ............................................................................40
MAXALT, MLT ...................................................................59
MAXIDEX ..........................................................................51
MAXITROL ........................................................................52
MAXZIDE...........................................................................25
MECLIZINE ........................................................................21
MEDROL ...........................................................................61
MEDROXY-PROGESTERONE/ MPA ...................................68
MEFENAMIC ACID ............................................................36
MELOXICAM .....................................................................36
MEMANTINE.....................................................................61
MENEST ............................................................................67
MENOTROPINS .................................................................69
MENTAX ...........................................................................45
MEPENZOLATE BROMIDE .................................................22
MEPERIDINE .....................................................................36
MEPHYTON .......................................................................75
MEPROBAMATE ...............................................................55
MEPRON ...........................................................................34
MESALAMINE ............................................................. 20, 21
MESTINON ........................................................................60
MESTINON 180 .................................................................60
MESTRANOL 50MCG .................................................. 64, 65
METADATE CD ..................................................................57
METADATE ER ..................................................................57
METAPROTERENOL .................................................... 40, 41
METAPROTERENOL SYRUP ...............................................41
METAPROTERENOL, 10MG/5ML ......................................41
METAXALONE ...................................................................60
METFORMIN .....................................................................72
METHADONE ........................................................ 36, 37, 76
METHAMPHETAMINE.......................................................57
METHAZOLAMIDE ............................................................50
METHENAMINE ................................................................32
METHENAMINE/METH BLUE/SALICYLATE .......................33
METHERGINE ....................................................................78
METHIMAZOLE .................................................................70
METHITEST .......................................................................69
METHOCARBAMOL ..........................................................60
METHOTREXATE ...............................................................44

METHOTREXATE TABS ..................................................... 44


METHSCOPOLAMINE BROMIDE ...................................... 23
METHSCOPOLAMINE COMBO ......................................... 23
METHSUXIMIDE ............................................................... 58
METHYLDOPA .................................................................. 29
METHYLDOPA/ HCTZ ....................................................... 29
METHYLERGONOVINE ..................................................... 78
METHYLIN CHEW TAB ...................................................... 57
METHYLIN SOLN 5MG/5ML ............................................. 57
METHYLPHENIDATE ................................................... 57, 58
METHYLPHENIDATE PATCH ............................................. 57
METHYLPHENIDATE, SUST. RELEASE ............................... 57
METHYLPREDNISOLONE .................................................. 61
METHYLTESTOSTERONE .................................................. 69
METIPRANOLOL ............................................................... 50
METOCLOPRAMIDE ......................................................... 22
METOLAZONE .................................................................. 25
METOPROLOL .................................................................. 28
METOPROLOL SUCCINATE ............................................... 28
METOPROLOL/ HCTZ ....................................................... 28
METROGEL 0.75% ............................................................ 45
METROGEL-VAGINAL ................................................. 45, 48
METRONIDAZOLE........................................... 32, 35, 45, 48
MEVACOR ........................................................................ 30
MIACALCIN NASAL ........................................................... 70
MICARDIS ......................................................................... 26
MICARDIS HCT ................................................................. 26
MICONAZOLE ................................................................... 33
MICONAZOLE NITRATE/ZINC OXIDE ................................ 45
MICROGESTIN FE 1.5/30 .................................................. 63
MICROGESTIN FE 1/20 ..................................................... 64
MICRO-K 10MEQ ............................................................. 75
MICRONASE ..................................................................... 71
MIDRIN ............................................................................ 59
MIGLITOL ......................................................................... 72
MIGRANAL NASAL SPRAY ................................................ 59
MILTOWN ........................................................................ 55
MINICYCLINE KIT .............................................................. 31
MINIPRESS ....................................................................... 28
MINOCIN .......................................................................... 31
MINOCIN PAC .................................................................. 31
MINOCYCLINE .................................................................. 31
MIRAPEX .......................................................................... 61
MIRAPEX ER ..................................................................... 61
MIRCETTE......................................................................... 64
MIRTAZAPINE .................................................................. 55
MISOPROSTOL ................................................................. 20
MOBAN ............................................................................ 56
MOBIC .............................................................................. 36
MODAFINIL ...................................................................... 58
MODICON ........................................................................ 64
MOEXIPRIL ....................................................................... 26
MOEXIPRIL/ HCTZ ............................................................ 26
MOLINDONE .................................................................... 56
MOMETASONE ................................................................ 39

188

MOMETASONE FUROATE ........................................... 40, 42


MOMETASONE FUROATE/AMMONIUM LAC ...................43
MOMETASONE/ ...............................................................40
MOMEXIN.........................................................................43
MONODOX .......................................................................31
MONOKET ........................................................................24
MONONESSA ....................................................................64
MONOPRIL .......................................................................25
MONOPRIL HCT ................................................................25
MONTELUKAST ........................................................... 38, 41
MONUROL ........................................................................33
MORPHINE .......................................................................37
MORPHINE SULFATE .................................................. 36, 37
MORPHINE SULFATE/ .......................................................36
MORPHINE TABLETS .........................................................37
MORPHINE, SUSTAINED RELEASE ....................................37
MOTOFEN .........................................................................22
MOTRIN ............................................................................36
MOVIPREP ........................................................................23
MOXATAG 775 MG ER ......................................................30
MOXIFLOXACIN .......................................................... 32, 52
MS CONTIN .......................................................................37
MULTAQ ...........................................................................24
MUPIROCIN 2% ................................................................45
MUPIROCIN 2% CRM ........................................................45
MUPIROCIN 2% OINT .......................................................45
MUSE ................................................................................77
MYAMBUTOL ....................................................................34
MYCELEX TROCHES...........................................................33
MYCOBUTIN .....................................................................34
MYCOPHENOLATE ............................................................77
MYCOPHENOLATE MOFETIL .............................................77
MYCOSTATIN .............................................................. 45, 48
MYDRIACYL .......................................................................50
MYFORTIC.........................................................................77
MYSOLINE .........................................................................59
N
NABUMETONE..................................................................36
NADOLOL ..........................................................................28
NADOLOL/ BENDROFLUMETHIAZIDE ...............................28
NAFARELIN ACETATE ........................................................70
NAFTIFINE .........................................................................45
NAFTIN .............................................................................45
NALTREXONE ....................................................................76
NAMENDA ........................................................................61
NAPHOS MB-MH/NAPHOS, DI-BA ....................................23
NAPRELAN ........................................................................36
NAPRELAN CR DOSEPAK ...................................................36
NAPROSYN........................................................................36
NAPROXEN .......................................................................36
NAPROXEN CONTROLLED RELEASE ..................................36
NAPROXEN SODIUM................................................... 35, 36
NARATRIPTAN ..................................................................59
NARDIL .............................................................................54

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

RYBIX ODT ........................................................................ 37


RYTHMOL SR .................................................................... 24
RYZOLT ............................................................................. 37
S
SABRIL .............................................................................. 59
SAFYRAL ........................................................................... 66
SALMETEROL.................................................................... 41
SANCTURA ....................................................................... 78
SANCTURA, XR ................................................................. 78
SANCUSO ......................................................................... 22
SANDIMMUNE ................................................................. 77
SAPHRIS ........................................................................... 57
SARAFEM ......................................................................... 55
SARGRAMOSTIM.............................................................. 49
SAXAGLIPTIN HYDROCHLORIDE ....................................... 72
SAXAGLIPTIN/ .................................................................. 72
SCOPOLAMINE ................................................................. 22
SEASONALE ...................................................................... 66
SEASONIQUE .................................................................... 66
SECTRAL ..................................................................... 25, 28
SELECT-OB........................................................................ 74
SELECT-OB + DHA............................................................. 74
SELEGILINE ................................................................. 54, 61
SELENIUM SULFIDE .......................................................... 45
SEMPREX-D ...................................................................... 39
SEREVENT DISKUS ............................................................ 41
SEROMYCIN PULVULES .................................................... 34
SEROQUEL, XR ................................................................. 57
SERTACONAZOLE NITRATE .............................................. 45
SERTRALINE ..................................................................... 55
SEVELAMER...................................................................... 79
SEVELAMER CARBONATE ................................................. 80
SILDENAFIL ....................................................................... 77
SILDENAFIL CITRATE ........................................................ 29
SILENOR ........................................................................... 55
SILODOSIN ....................................................................... 78
SILVADENE ....................................................................... 45
SILVER SULFADIAZINE ...................................................... 45
SIMCOR ............................................................................ 30
SIMPONI .......................................................................... 77
SIMVASTATIN ................................................................... 30
SINEMET, CR .................................................................... 61
SINGULAIR ................................................................. 38, 41
SIROLIMUS ....................................................................... 77
SITAGLIPTIN PHOS/ METFORMIN .................................... 72
SITAGLIPTIN PHOSPHATE ................................................. 72
SKELAXIN.......................................................................... 60
SODIUM /POTASSIUM/MAG SULFATES ........................... 23
SODIUM FLUORIDE .......................................................... 75
SODIUM OXYBATE ........................................................... 56
SODIUM POLYSTYRENE SULFONATE................................ 78
SOLARAZE ........................................................................ 48
SOLIFENACIN SUCCINATE ................................................ 78
SOLODYN ......................................................................... 31

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

TIZANIDINE COMBO .........................................................60


TOBRADEX ........................................................................53
TOBRADEX ST ...................................................................53
TOBRAMYCIN ...................................................................52
TOBRAMYCIN/ ..................................................................53
TOBRAMYCIN/LOTEPRED ETAB ........................................52
TOBREX OINT ....................................................................52
TOBREX SOLN ...................................................................52
TOFRANIL PM ...................................................................55
TOLCAPONE ......................................................................61
TOLTERODINE TARTRATE .................................................78
TOPAMAX .........................................................................59
TOPICORT .........................................................................43
TOPIRAMATE ....................................................................59
TOPROL XL ........................................................................28
TORADOL ..........................................................................36
TORSEMIDE ......................................................................25
TOVIAZ..............................................................................78
TRACLEER .........................................................................29
TRAMADOL ................................................................. 37, 38
TRAMADOL ER ..................................................................37
TRAMADOL SUST. RELEASE ..............................................38
TRAMADOL/ ACETAMINOPHEN .......................................38
TRANDATE ........................................................................28
TRANDOLAPRIL .................................................................25
TRANDOLAPRIL/ VERAPAMIL ...........................................26
TRANSDERM-NITRO .........................................................24
TRANSDERM-SCOP ...........................................................22
TRANXENE T .....................................................................55
TRANYLCYPROMINE .........................................................55
TRAVATAN Z .....................................................................51
TRAVOPROST ....................................................................51
TRAZODONE HYDROCHLORIDE EXTENDED RELEASE .......54
TRENTAL ...........................................................................49
TREPROSTINIL/NEBULIZER KIT .........................................29
TRETIN X ...........................................................................47
TRETINOIN .................................................................. 46, 47
TRETINOIN MICROSPHERES .............................................47
TREXIMET .........................................................................60
TRIAMCINOLONE ........................................................ 42, 61
TRIAMCINOLONE, AQUEOUS ...........................................39
TRIAMCINOLONE/ ............................................................43
TRIAMTERENE ..................................................................25
TRIAMTERENE/ HCTZ .......................................................25
TRIAZ CLEANER/PADS.......................................................47
TRIAZ GEL .........................................................................47
TRIBENZOR .......................................................................27
TRICOR..............................................................................30
TRIFLURIDINE ...................................................................52
TRIGLIDE ...........................................................................30
TRILEPTAL .........................................................................59
TRILIPIX .............................................................................30
TRIMETHOBENZAMIDE ....................................................22
TRIMETHOPRIM ...............................................................33
TRIMIPRAMINE MALEATE ................................................55

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

VANOXIDE-HC 0.5%-5% LOTION ......................................43


VARDENAFIL .....................................................................77
VARENICLINE TARTRATE ..................................................76
VASERETIC ........................................................................26
VASOTEC...........................................................................26
VECTICAL ..........................................................................48
VELTIN ..............................................................................47
VENLAFAXINE ...................................................................54
VENTOLIN .........................................................................41
VENTOLIN HFA .................................................................41
VERAMYST ........................................................................39
VERAPAMIL .......................................................... 24, 27, 28
VERDESO ..........................................................................43
VERELAN ...........................................................................28
VESICARE ..........................................................................78
VEXOL ...............................................................................51
VFEND...............................................................................34
VIAGRA .............................................................................77
VIBRAMYCIN ............................................................... 31, 33
VIBRAMYCIN SYRUP .........................................................31
VICODIN............................................................................38
VICODIN ES .......................................................................38
VICODIN HP ......................................................................38
VICOPROFEN ....................................................................38
VICTOZA ...........................................................................73
VIGABATRIN .....................................................................59
VIGAMOX .........................................................................52
VIMOVO ...........................................................................36
VIMPAT .............................................................................59
VIOKASE 8 .........................................................................21
VIRAZOLE ..........................................................................79
VIROPTIC ..........................................................................52
VISTARIL ...........................................................................55
VITAFOL-OB ......................................................................74
VITAMIN, PRENATAL ........................................................73
VITAMINS, PRENATAL ................................................ 73, 74
VITMAINS, PRENATAL ......................................................73
VIVACTIL ...........................................................................55
VIVELLE-DOT.....................................................................68
VOLTAREN GEL .................................................................36
VOLTAREN XR ...................................................................36
VORICONAZOLE ................................................................34
VOSOL...............................................................................54
VOSOL HC .........................................................................54
VOSPIRE ER .......................................................................41
VUSION .............................................................................45
VYTORIN ...........................................................................30
VYVANSE ..........................................................................58
W
WARFARIN ........................................................................49
WELCHOL..........................................................................30
WELLBUTRIN ....................................................................55
WELLBUTRIN XL ................................................................55
WESTCORT .......................................................................43

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

ZOVIRAX OINT .................................................................. 34


ZUPLENZ .......................................................................... 22
ZYBAN .............................................................................. 76
ZYFLO, CR ......................................................................... 41
ZYLET ................................................................................ 52
ZYLOPRIM ........................................................................ 73
ZYPREXA ZYDIS ................................................................. 57
ZYRTEC OTC ..................................................................... 38
ZYVOX .............................................................................. 33

197

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