florida blue healthy kids 2015 medication guide for ... · florida blue healthy kids medication...

3022-G FL © Prime Therapeutics LLC 01/15

Click to search for a drug name in this document

January 2015

Florida Blue Healthy Kids Medication Guide

Contents

Introduction .................................................................... I

Prescriptions for non-preferred

medications .............................................................. II

Using the medication guide .......................................... II

Key .............................................................................. III

Responsible Rx programs ........................................... III

Medications requiring Prior Authorization ................... III

Responsible Quantity .................................................. IV

Responsible Steps ...................................................... IV

Covered over-the-counter (OTC) products ................. IV

Preventive Medications ............................................... IV

Immunizations ............................................................. IV

Women’s Preventive Services ..................................... V

Notice .......................................................................... VI

Preferred Medication List

Anti-Infective Drugs ...................................................... 1

Immunizing Agents ....................................................... 3

Cancer Drugs ............................................................... 3

Hormones, Diabetes and Related Drugs ..................... 4

Heart and Circulatory Drugs ......................................... 6

Respiratory Drugs ........................................................ 9

Gastrointestinal Drugs ................................................ 10

Genitourinary Drugs ................................................... 11

Central Nervous System Drugs .................................. 11

Pain Relief Drugs ....................................................... 13

Neuromuscular Drugs ................................................ 14

Supplements .............................................................. 15

Blood Modifying Drugs ............................................... 15

Topical Products......................................................... 16

Miscellaneous Categories .......................................... 19

Index ............................................................................. 20

Please consider talking to your doctor about prescribing formulary medications, which may help reduce your

out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.

The drug formulary is regularly updated. Please visit www.floridablue.com for the most up-to-date information.

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in

the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

Florida Blue January 2015 Healthy Kids Medication Drug Guide I

Introduction

This Medication Guide includes an abbreviated listing of Generic, and a complete listing of Brand Prescription Drugs

on the Healthy Kids Preferred Medication List (PML). Changes in the PML can occur over time. The most up-to-date

listing can always be found by viewing the Healthy Kids Medication Guide online at www.floridablue.com or by

calling the customer service number listed on your identification card. For the hearing impaired, call Florida TTY

Relay Service 711.

We reserve the right to add or remove any Drug or Supply on the Healthy Kids Preferred Medication List at any time.

NOTE: Any decision concerning whether a Prescription Drug or Supply should be prescribed must be made by you

and your doctor. Any and all decisions that require or pertain to independent professional medical judgments or

training, or the need for, and dosage of, a Prescription Drug, must be made solely by you and your treating doctor in

accordance with the patient/doctor relationship

Florida Blue January 2015 Healthy Kids Medication Drug Guide II

Prescriptions for non-preferred medications

A formulary exception process is provided to allow for cases where the Healthy Kids PML may not

accommodate the unique medical needs of a member (e.g. documented allergy, ineffectiveness, or intolerable

adverse effects from drugs on the formulary).

The formulary exception form is available at www.floridablue.com/.

Click on the Providers tab

Click Pharmacy, then click Medication Guides

Click Formulary Exception Physician Fax form

Ask your doctor to complete the Healthy Kids Formulary Exception Form at www.floridablue.com, to request

an exception.

Using the medication guide

The Medication List is organized into broad categories (e.g., Antibacterials).

The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface

(e.g., metformin). Brand name medications are capitalized (e.g., CRESTOR).

Separate medication entries are required for some dosage forms or routes of administration including

extended-release, delayed-release, rectal, injectable, otic, ophthalmic, vaginal, nasal, orally disintegrating,

patches, and topical products.

NOTE: Self-administered injectable medications are designated in the Medication List with inj following the

medication name (e.g., enoxaparin inj ).

The second column indicates the Tier level:

1 (Lowest Cost): Covered Generic Prescription Medications.

2 (Higher Cost): Covered Preferred Brand Prescription Medications.

The third column indicates if the medication is a Self-Administered Specialty* medication.

The remaining columns indicate the Responsible Rx Pharmacy program(s) that apply to the prescription

medication (e.g., Prior Authorization, Quantity Limits and Responsible Steps). If an indicator is present in the

column(s), then the Responsible Rx Program applies.

An asterisk (*) next to a drug name signifies that this drug may not be covered. Please refer to your individual

coverage policy.

http://www.floridablue.com/

http://www.bcbsfl.com/DocumentLibrary/Providers/Content/Rx_ClosedFormularyException.pdf

III Florida Blue January 2015 Healthy Kids Medication Drug Guide

Key

caps ................................................................... capsules

chew tabs ............................................ chewable tablets

conc.............................................................. concentrate

crm ........................................................................ cream

ext-release .......................................... extended-release

inhal .................................................................. inhalation

inj ...................................................................... injection

lotn .......................................................................... lotion

NP ............................................................. non-preferred

ODT ...................................... orally disintegrating tablets

OSM ........................................................ osmotic-release

OTC ............................................... over-the-counter drug

oint ........................................................................... ointment

PA .............................. Prior Coverage Authorization required

QL .......Responsible Quantity Program–quantity limit applies

RS .......................................... Responsible Steps Program—

prerequisite drug required

SI .............................................. Self-Administered Injectable

SL .......................................................................... sublingual

SP ............................. Self-Administered Specialty Pharmacy

soln ........................................................................... solution

supp ................................................................. suppositories

susp .................................................................... suspension

tabs ............................................................................. tablets

Generic Drugs

Florida Blue encourages the use of Generic Drugs as a way to provide high-quality Drugs at a reduced cost. Generic

Drugs are as safe and effective as their Brand Name counterparts, and are usually less expensive.

A Food and Drug Administration (FDA) approved Generic Drug may be substituted for its Brand name counterpart

because it:

Contains the same active ingredient(s) as the Brand Name Drug

Is identical in strength, dosage form, and route of administration

Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile

Check with your doctor or health care provider to determine if switching to a Generic Drug is appropriate

for you.

Responsible Rx programs

Some covered medications may have additional requirements or limits on coverage. These requirements and limits

may include:

Medications requiring Prior Authorization

Drugs selected for Prior Authorization (PA) may require that specific clinical criteria are met before the drugs

will be covered under a member’s prescription benefit. Drugs on the Preferred Medication List that may

require a PA for coverage are indicated in the Prior Authorization column following the product name. Your

doctor or health care provider can request a prior authorization by completing the appropriate Prior

Authorization Form at www.floridablue.com.


Florida Blue January 2015 Healthy Kids Medication Drug Guide IV

Responsible Quantity

Drugs included in this program allow a maximum quantity per time period. Quantity limits are typically developed

based upon FDA-approved Drug labeling and nationally recognized therapeutic clinical guidelines. Responsible

Quantity Program Drugs are indicated in the Quantity Limits column following the product name. In cases where a

larger quantity of a Responsible Quantity Drug is medically required, your doctor or health care provider can request

an authorization by completing the Quantity Limit Authorization Form at www.floridablue.com. Florida Blue

reserves the right to change the Drugs and the quantity limits subject to the Responsible Quantity Program at any

time and for any reason.

Responsible Steps

Drugs included in this program are not covered unless you first try another designated or prerequisite Drug.

Responsible Steps Program Drugs are indicated in the Responsible Steps column following the product name.

If you cannot use the prerequisite Drug for medical reasons, your doctor or health care provider may request

prior authorization for an override by completing the appropriate Responsible Step Authorization Form at

www.floridablue.com. If the prior authorization request is approved, coverage will be provided for the Responsible

Step Drug. Florida Blue reserves the right to change the Drugs subject to the Responsible Step program at any time

and for any reason.

Covered over-the-counter (OTC) products

Your Pharmacy benefit provides coverage for certain OTC Drugs, if your doctor or health care provider prescribes

them. However, only those OTC Drugs designated on the PML with “OTC” following the product name are eligible

for coverage. Florida Blue reserves the right to change the OTC Drugs covered at any time and for any reason.

Patient Protection Affordable Care Act (PPACA) Mandated Coverage

Preventive Medications

The Patient Protection and Affordable Care Act (PPACA) provide for members to receive coverage for certain

preventive care services, medications, and immunizations at no out-of-pocket costs based on recommendations

from the U.S. Preventive Services Task Force (USPSTF). These USPSTF recommendations include services that

have been shown to be important in preventing disease as well as providing for additional women’s services such as

FDA-approved contraception.

Immunizations

Certain vaccines which are covered under your Wellness Benefits can be administered by Pharmacists that are

certified. Not all pharmacies provide services for vaccine administration. It is important to contact the pharmacy

prior to your visit to ensure availability and administration of the vaccine.

Oral Chemotherapy Drugs Oral chemotherapy drugs are drugs prescribed by a physician to kill or slow the growth of cancerous cells in a manner consistent with the national accepted standards of practice. A list of these drugs can be found at: Oral Chemotherapy Drug List


http://www.bcbsfl.com/DocumentLibrary/Providers/Content/RxF_ChemoParity.pdf

http://www.bcbsfl.com/DocumentLibrary/Providers/Content/RxF_ChemoParity.pdf

V Florida Blue January 2015 Healthy Kids Medication Drug Guide

Women’s Preventive Services

As a result of the expanded PPACA Preventive Services benefits for women’s services, certain generic

contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) are

covered at no cost share when purchased at a participating pharmacy.

Lists of drugs and devices included in the Preventive Medications, Immunizations and Women’s Preventive Services

can be found at www.floridablue.com


Florida Blue January 2015 Healthy Kids Medication Drug Guide VI

Notice

This Healthy Kids Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits,

exclusions, limitations, or conditions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy

Program Endorsement. In the event of any inconsistencies between the Healthy Kids Medication Guide and the

provisions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement, the

provisions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement shall

control to the extent necessary to effectuate the intent of Florida Blue.

2015

TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication

2 = Preferred Brand Drugs * = May not be covered – see endorsement

Florida Blue January 2015 Healthy Kids Medication Drug Guide 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

ANTI-INFECTIVE DRUGS

PENICILLINS

AMOXICILLIN chew tabs, 250 mg 2

amoxicillin/potassiumclavulanate (Augmentin)

1

amoxicillin/potassiumclavulanate ext-release (Augmentin XR)

1

amoxicillin, NP = chew tabs,125 mg

1

ampicillin caps 1

AMPICILLIN susp 2

AUGMENTIN susp, 125 mg/5 mL 2

dicloxacillin 1

penicillin v potassium 1

CEPHALOSPORINS

cefaclor caps 1

cefadroxil 1

cefdinir 1

cefpodoxime 1

cefprozil 1

cefuroxime (Ceftin) 1

cephalexin, NP = tabs (Keflex) 1

MACROLIDES

azithromycin susp,tabs (Zithromax)

1

clarithromycin (Biaxin) 1

clarithromycin ext-release (BiaxinXL)

1

ERY-TAB 2

ERYTHROMYCIN BASE 2

erythromycin delayed-releasecaps

1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

ERYTHROMYCINETHYLSUCCINATE

2

ZITHROMAX packets 2

TETRACYCLINES

demeclocycline 1

doxycycline hyclatecaps (Vibramycin)

1

doxycycline hyclate tabs 1

doxycyclinemonohydrate (Adoxa, Monodox)

1

minocycline (Dynacin, Minocin) 1

TETRACYCLINE 2

FLUOROQUINOLONES

ciprofloxacin (Cipro) 1

ciprofloxacin ext-release (CiproXR)

1

levofloxacin (Levaquin) 1

ofloxacin 200 mg, 300 mg 1

SULFONAMIDES

SULFADIAZINE 2

AMINOGLYCOSIDES

BETHKIS 2 Xneomycin sulfate 1

paromomycin 1

TOBI PODHALER 2 Xtobramycin (Tobi) 1 XTUBERCULOSIS

ethambutol (Myambutol) 1

ISONIAZID syrup 2

isoniazid tabs 1

PRIFTIN 2

pyrazinamide 1

rifabutin (Mycobutin) 1

2015



2 Florida Blue January 2015 Healthy Kids Medication Drug Guide

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

RIFAMATE 2

rifampin (Rifadin) 1

FUNGAL INFECTIONS

fluconazole (Diflucan) 1

flucytosine (Ancobon) 1

griseofulvin microsize (GrifulvinV)

1

itraconazole (Sporanox) 1 •NOXAFIL 2 •nystatin oral 1

SPORANOX soln 2 •terbinafine (Lamisil) 1 •voriconazole (Vfend) 1 •VIRAL INFECTIONS

Cytomegalovirus

VALCYTE 2

Hepatitis

adefovir (Hepsera) 1

BARACLUDE soln 2

entecavir (Baraclude) 1

EPIVIR HBV soln 2

INTRON-A 2 Xlamivudine (Epivir HBV) 1

OLYSIO 2 X •PEGASYS 2 X •RIBATAB 2 X •ribavirin (Copegus, Rebetol) 1 X •SOVALDI 2 X •Herpes

acyclovir (Zovirax) 1

famciclovir (Famvir) 1

valacyclovir (Valtrex) 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

HIV/AIDS

abacavir (Ziagen) 1 •abacavir/lamivudine/

zidovudine (Trizivir)1 •

APTIVUS 2 •ATRIPLA 2 •COMPLERA 2 •CRIXIVAN 2 •didanosine delayed-

release (Videx EC)1 •

EDURANT 2 •EMTRIVA 2 •EPIVIR soln 2 •EPZICOM 2 •FUZEON 2 X •INTELENCE 2 •INVIRASE 2 •ISENTRESS 2 •KALETRA 2 •lamivudine (Epivir) 1 •lamivudine/zidovudine (Combivir) 1 •LEXIVA 2 •NEVIRAPINE susp 2 •nevirapine tabs (Viramune) 1 •nevirapine ext-release (Viramune

XR)1 •

NORVIR 2 •PREZISTA tabs 2 •RESCRIPTOR 2 •REYATAZ 2 •SELZENTRY 2 •stavudine (Zerit) 1 •

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

STRIBILD 2 •SUSTIVA 2 •TIVICAY 2 •TRUVADA 2 •VIDEX 2 •VIRACEPT 2 •VIRAMUNE susp 2 •VIRAMUNE XR 100 mg 2 •VIREAD 2 •ZIAGEN soln 2 •zidovudine (Retrovir) 1 •Influenza

TAMIFLU 2 •MALARIA

atovaquone/proguanil (Malarone) 1

chloroquine phosphate (Aralen) 1

DARAPRIM 2

hydroxychloroquine (Plaquenil) 1

mefloquine 1

PRIMAQUINE 2

WORM INFECTIONS

ALBENZA 2

BILTRICIDE 2

ivermectin (Stromectol) 1

OTHER ANTI-INFECTIVES

ALINIA 2

CAYSTON 2

clindamycin (Cleocin, CleocinPediatric)

1

colistimethate (Coly-Mycin M) 1

DAPSONE 2

erythromycin/sulfisoxazole 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

metronidazole oral (Flagyl) 1

NEBUPENT 2

PRIMSOL 2

SIVEXTRO tabs 2 • •sulfamethoxazole/

trimethoprim (Bactrim)1

trimethoprim 1

vancomycin (Vancocin) 1

XIFAXAN 550 mg 2 • •YODOXIN 2

ZYVOX 2 • •IMMUNIZING AGENTS

FLU VACCINES, NP = FLUBLOK 2 •GAMMAGARD LIQUID 2 X •GAMMAKED 2 X •GAMUNEX-C 2 X •HIZENTRA 2 X •MENACTRA 2

MENOMUNE-A/C/Y/W-135 2

MENVEO 2

PNEUMOVAX 23 2

PREVNAR 13 2

ZOSTAVAX 2

CANCER DRUGS

ACTIMMUNE 2 XAFINITOR 2 X • •AFINITOR DISPERZ 2 X • •ALKERAN tabs 2

anastrozole (Arimidex) 1

bicalutamide (Casodex) 1

BOSULIF 2 X • •capecitabine (Xeloda) 1 X • •

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

CAPRELSA 2 X • •COMETRIQ 2 X • •CYCLOPHOSPHAMIDE tabs 2

EMCYT 2

ERIVEDGE 2 X • •ETOPOSIDE caps 2

exemestane (Aromasin) 1

FARESTON 2

flutamide 1

GILOTRIF 2 X • •GLEEVEC 2 X • •HEXALEN 2 XHYCAMTIN caps 2 X •hydroxyurea (Hydrea) 1

ICLUSIG 2 X • •IMBRUVICA 2 X • •INLYTA 2 X • •JAKAFI 2 X • •letrozole (Femara) 1

LEUCOVORIN CALCIUM tabs,10 mg, 15 mg

2

leucovorin calcium tabs, 5 mg,25 mg

1

LEUKERAN 2

leuprolide acetate 1 X •LOMUSTINE 2

LYSODREN 2 XMATULANE 2 Xmegestrol (Megace) 1

MEKINIST 2 X • •mercaptopurine (Purinethol) 1

MESNEX tabs 2

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

methotrexate 1

MYLERAN 2

NEXAVAR 2 X • •NILANDRON 2

POMALYST 2 X • •PURIXAN 2 XSPRYCEL 2 X • •STIVARGA 2 X • •SUTENT 2 X • •SYLATRON 2 XTABLOID 2

TAFINLAR 2 X • •tamoxifen 1

TARCEVA 2 X • •TARGRETIN caps 2 X •TASIGNA 2 X • •temozolomide (Temodar) 1 X • •tretinoin caps 1 X •TYKERB 2 X • •VOTRIENT 2 X • •XALKORI 2 X • •XTANDI 2 X • •ZELBORAF 2 X • •ZOLINZA 2 X • •ZYDELIG 2 X •ZYKADIA 2 X • •ZYTIGA 2 X • •HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDS

budesonide ext-release (EntocortEC)

1

CORTISONE 2

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

dexamethasone elixir; tabs,0.5 mg, 0.75 mg, 1.5 mg, 4 mg,6 mg

1

DEXAMETHASONE soln; tabs,1 mg, 2 mg

2

fludrocortisone 1

hydrocortisone (Cortef) 1

methylprednisolone (Medrol) 1

prednisolone (Prelone) 1

prednisolone sodiumphosphate (Orapred)

1

prednisolone sodium phosphatesoln, 5 mg/5 mL

1

PREDNISONE soln, 5 mg/5 mL;tabs, 50 mg; NP = dose packs

2

prednisone tabs, 1 mg, 2.5 mg,5 mg, 10 mg, 20 mg

1

MALE HORMONES

ANDRODERM 2 • •ANDROGEL 2 • •danazol 1

ESTROGENS

CLIMARA PRO 2 •DIVIGEL 2 •estradiol patches (Climara) 1 •estradiol tabs (Estrace) 1

estradiol/norethindroneacetate (Activella)

1

estropipate 0.75 mg, 1.5 mg 1

MENEST 2

PREMARIN 2

PREMPHASE 2

PREMPRO 2

PROGESTINS

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

medroxyprogesterone acetatetabs (Provera)

1

norethindrone acetate (Aygestin) 1

progesteronemicronized (Prometrium)

1

BIRTH CONTROL

ELLA 2

levonorgestrel (Plan B, Plan BOne-Step)

1

norelgestromin/ethinylestradiol (Ortho Evra)

1

oral contraceptives –all generics

1

DIABETES

acarbose (Precose) 1

BYDUREON 2 • •BYETTA inj 2 • •glimepiride (Amaryl) 1

glipizide (Glucotrol) 1

glipizide ext-release (Glucotrol XL) 1

glipizide/metformin 1

GLUCAGON EMERGENCY inj kit 2

glyburide (Micronase) 1

glyburide micronized (Glynase) 1

glyburide/metformin (Glucovance) 1

GLYBURIDE, distributor of Diabeta 2

INVOKAMET 2 • •INVOKANA 2 • •JANUMET 2 • •JANUMET XR 2 • •JANUVIA 2 • •KOMBIGLYZE XR 2 • •metformin (Glucophage) 1

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

metformin ext-release (Glucophage XR)

1

metformin ext-releaseOSM (Fortamet)

1

nateglinide (Starlix) 1

ONGLYZA 2 • •pioglitazone (Actos) 1 •pioglitazone/metformin (Actoplus

Met)1 •

PROGLYCEM 2

repaglinide (Prandin) 1

SYMLINPEN inj 2

Insulins

Rapid-Acting Insulins

NOVOLOG inj 2

Short-Acting Insulins

NOVOLIN R inj 2

RELION R inj 2

Intermediate-Acting Insulins

NOVOLIN N inj 2

NOVOLIN 70/30 inj 2

NOVOLOG MIX 70/30 inj 2

Basal Insulins

LANTUS inj 2

LEVEMIR inj 2

THYROID REGULATION

levothyroxine (Synthroid) 1

liothyronine (Cytomel) 1

methimazole (Tapazole) 1

propylthiouracil 1

SYNTHROID 2

GROWTH HORMONE

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

INCRELEX 2 X •NORDITROPIN 2 X •OTHER HORMONES AND RELATED DRUGS

alendronate tabs, 5 mg, 10 mg,35 mg, 70 mg (Fosamax)

1 •

cabergoline 1

calcitonin-salmon (Miacalcin) 1

calcitriol (Rocaltrol) 1

desmopressin inj, nasal,tabs (DDAVP)

1

ibandronate (Boniva) 1 •levocarnitine (Carnitor) 1

methylergonovine 1

octreotide (Sandostatin) 1 X •ORFADIN 2 X •paricalcitol (Zemplar) 1

raloxifene (Evista) 1

risedronate (Actonel) 1 •SENSIPAR 2

SOMAVERT 2 XSTIMATE 2

SYNAREL 2 XHEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS

benazepril (Lotensin) 1

benazepril/hydrochlorothiazide (LotensinHCT)

1

captopril 1

CAPTOPRIL/HYDROCHLOROTHIAZIDE25-15 mg, 50-15 mg

2

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

enalapril (Vasotec) 1

enalapril/hydrochlorothiazide (Vaseretic)

1

fosinopril 1

fosinopril/hydrochlorothiazide 1

lisinopril (Prinivil, Zestril) 1

lisinopril/hydrochlorothiazide (Prinzide,Zestoretic)

1

moexipril (Univasc) 1

moexipril/hydrochlorothiazide (Uniretic)

1

perindopril (Aceon) 1

quinapril (Accupril) 1

quinapril/hydrochlorothiazide (Accuretic)

1

ramipril (Altace) 1

trandolapril (Mavik) 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS

irbesartan (Avapro) 1 •irbesartan/

hydrochlorothiazide (Avalide)1 •

losartan (Cozaar) 1 •losartan/

hydrochlorothiazide (Hyzaar)1 •

valsartan (Diovan) 1 •valsartan/

hydrochlorothiazide (DiovanHCT)

1 •

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral) 1

atenolol (Tenormin) 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

atenolol/chlorthalidone (Tenoretic)

1

bisoprolol (Zebeta) 1

bisoprolol/hydrochlorothiazide (Ziac)

1

carvedilol (Coreg) 1

labetalol (Trandate) 1

metoprolol succinate ext-release (Toprol XL)

1

metoprolol tartrate (Lopressor) 1

nadolol (Corgard) 1

pindolol 1

propranolol ext-release (InderalLA)

1

PROPRANOLOL soln, 20 mg/5 mL 2

propranolol tabs 1

PROPRANOLOL/HYDROCHLOROTHIAZIDE80-25 mg

2

TIMOLOL tabs 2

CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS

amlodipine (Norvasc) 1

amlodipine/benazepril (Lotrel) 1

amlodipine/valsartan (Exforge) 1 •diltiazem (Cardizem) 1

diltiazem ext-release (CardizemCD, Tiazac)

1

felodipine ext-release 1

ISRADIPINE caps, 2.5 mg 2

nifedipine ext-release (Adalat CC,Procardia XL)

1

NISOLDIPINE ext-release 25.5 mg 2

VERAPAMIL 40 mg 2

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

verapamil 80 mg, 120 mg (Calan) 1

verapamil ext-release (Calan SR,Isoptin SR, Verelan, Verelan PM)

1

CHEST PAIN

ISOSORBIDE DINITRATE tabs,30 mg

2

isosorbide dinitrate tabs, 5 mg,10 mg, 20 mg (Isordil)

1

isosorbide mononitrate (Monoket) 1

isosorbide mononitrate ext-release (Imdur)

1

NITRO-BID 2

nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr (Nitro-Dur)

1

NITROSTAT 2

CHOLESTEROL LOWERING

atorvastatin (Lipitor) 1 •cholestyramine (Questran,

Questran Light)1

colestipol (Colestid) 1

CRESTOR 2 • •fenofibrate (Lofibra, Tricor) 1 •fenofibrate micronized (Lofibra) 1 •fenofibric acid delayed-

release (Trilipix)1 •

gemfibrozil (Lopid) 1 •lovastatin (Mevacor) 1 •niacin ext-release (Niaspan) 1

pravastatin (Pravachol) 1 •simvastatin (Zocor) 1 •WELCHOL 2

FLUID RETENTION

ACETAZOLAMIDE 125 mg 2

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

acetazolamide 250 mg 1

acetazolamide ext-release (Diamox Sequels)

1

amiloride 1

amiloride/hydrochlorothiazide 1

bumetanide 1

chlorothiazide 500 mg 1

CHLORTHALIDONE 25 mg, 50 mg 2

furosemide, NP = soln, 8 mg/mL (Lasix)

1

hydrochlorothiazidecaps (Microzide)

1

hydrochlorothiazide tabs 1

indapamide 1

methazolamide (Neptazane) 1

metolazone (Zaroxolyn) 1

spironolactone (Aldactone) 1

spironolactone/hydrochlorothiazide (Aldactazide)

1

torsemide (Demadex) 1

triamterene/hydrochlorothiazide,NP = caps, 50-25 mg (Dyazide,Maxzide, Maxzide-25)

1

HEART RHYTHM

amiodarone (Cordarone) 1

disopyramide (Norpace) 1

flecainide 1

mexiletine 1

propafenone (Rythmol) 1

propafenone ext-release (RythmolSR)

1

quinidine gluconate ext-release 1

QUINIDINE SULFATE ext-release 2

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

QUINIDINE SULFATE 200 mg 2

quinidine sulfate 300 mg 1

sotalol (Betapace, Betapace AF) 1

OTHER HEART RELATED DRUGS

amlodipine/atorvastatin (Caduet) 1

clonidine (Catapres, Catapres-TTS)

1

DIGOXIN soln 2

digoxin tabs (Lanoxin) 1

doxazosin (Cardura) 1

eplerenone (Inspra) 1

guanfacine (Tenex) 1

hydralazine 1

LETAIRIS 2 X • •methyldopa 1

midodrine (Proamatine) 1

minoxidil 1

OPSUMIT 2 X • •prazosin (Minipress) 1

sildenafil (Revatio) 1 X • •terazosin 1

TRACLEER 2 X • •VENTAVIS 2 X • •ERECTILE DYSFUNCTION

LEVITRA* 2

ALLERGIC REACTION KITS

EPIPEN inj 2

EPIPEN-JR inj 2

RESPIRATORY DRUGS

ANTIHISTAMINES

cyproheptadine 1

loratadine (Claritin – OTC) 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

promethazine 1

NASAL PRODUCTS

azelastine (Astepro) 1 •flunisolide 25 mcg/

spray (Flunisolide)1 •

fluticasone propionate (Flonase) 1 •ipratropium (Atrovent) 1 •triamcinolone (Nasacort AQ) 1 •COUGH/COLD/ALLERGY

acetylcysteine 1

loratadine/pseudoephedrine (Claritin-D –OTC)

1

ASTHMA/COPD

albuterol 1

ATROVENT HFA 2 •budesonide (Pulmicort Respules) 1

COMBIVENT RESPIMAT 2 •cromolyn sodium inhal soln 1

DULERA 2 •FORADIL AEROLIZER 2 •ipratropium inhal soln 1

ipratropium/albuterol (Duoneb) 1

levalbuterol, NP =1.25 mg/0.5 mL (Xopenex)

1

montelukast (Singulair) 1 •PROAIR HFA 2 •PULMICORT FLEXHALER 2 •PULMICORT RESPULES

1 mg/2 mL2

QVAR 2 •SPIRIVA HANDIHALER 2 •SPIRIVA RESPIMAT 2 •

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

SYMBICORT 2 •terbutaline 1

theophylline ext-release 1

VENTOLIN HFA 2 •zafirlukast (Accolate) 1 •OTHER RESPIRATORY DRUGS

KALYDECO 2 X • •PULMOZYME 2 XGASTROINTESTINAL DRUGS

LAXATIVES

lactulose 1

PEG – electrolytes forsoln (Colyte, Golytely, Nulytely)

1

ULCER/GERD

CARAFATE susp 2

cimetidine 1

dicyclomine caps, tabs (Bentyl) 1

famotidine (Pepcid) 1

glycopyrrolate (Robinul) 1

hyoscyamine (Anaspaz, Levsin,Levsin/SL)

1

hyoscyamine ext-release (Levbid) 1

lansoprazole delayed-release (Prevacid)

1 •

methscopolamine (Pamine,Pamine Forte)

1

misoprostol (Cytotec) 1

OMEPRAZOLE (Prilosec OTC) 2

omeprazole delayed-release (Prilosec)

1 •

pantoprazole delayed-release (Protonix)

1 •

PROPANTHELINE 15 mg 2

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

ranitidine (Zantac) 1

sucralfate (Carafate) 1

SYMAX DUOTAB 2

NAUSEA AND VOMITING

EMEND caps, therapy pack 2 •granisetron 1 •meclizine 1

ondansetron (Zofran, Zofran ODT) 1 •ondansetron tabs, 24 mg 1 •trimethobenzamide (Tigan) 1

DIGESTIVE ENZYMES– Pancreatic enzyme products:

CREON 2

ZENPEP 2

OTHER GASTROINTESTINAL DRUGS

ASACOL HD 2

balsalazide (Colazal) 1

calcium acetate (Eliphos, Phoslo) 1

CANASA 2

CHENODAL 2

DELZICOL 2

diphenoxylate/atropinetabs (Lomotil)

1

lactulose 1

LIALDA 2

loperamide 1

mesalamine 1

metoclopramide (Reglan) 1

PENTASA 2

RENVELA 2

sulfasalazine (Azulfidine) 1

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

sulfasalazine delayed-release (Azulfidine EN-Tabs)

1

ursodiol (Actigall, Urso 250, UrsoForte)

1

GENITOURINARY DRUGS

URINARY TRACT INFECTIONS

nitrofurantoin (Furadantin) 1

nitrofurantoinmacrocrystalline (Macrodantin)

1

nitrofurantoin monohydrate/macrocrystalline (Macrobid)

1

URINARY TRACT SPASMS

oxybutynin 1 •oxybutynin ext-release (Ditropan

XL)1 •

tolterodine (Detrol) 1 •tolterodine ext-release (Detrol LA) 1 •VESICARE 2 •VAGINAL PRODUCTS

AVC 2

CLEOCIN supp 2

clindamycin (Cleocin) 1

metronidazole (MetroGel-Vaginal) 1

PREMARIN 2

terconazole (Terazol) 1

VAGIFEM 2

OTHER GENITOURINARY DRUGS

alfuzosin ext-release (Uroxatral) 1

CYSTAGON 2

finasteride (Proscar) 1

K-PHOS NO. 2 2

potassium citrate ext-release (Urocit-K)

1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

potassium citrate/citricacid (Polycitra-K)

1

sodium citrate/citric acid (Shohl's) 1

tamsulosin (Flomax) 1

CENTRAL NERVOUS SYSTEM DRUGS

ANXIETY

alprazolam (Xanax) 1

alprazolam ext-release (XanaxXR)

1

buspirone 1

DIAZEPAM oral soln, 1 mg/mL 2

diazepam tabs (Valium) 1

hydroxyzine hcl 1

hydroxyzine pamoate 25 mg,50 mg (Vistaril)

1

lorazepam (Ativan) 1

lorazepam conc (LorazepamIntensol)

1

DEPRESSION

amitriptyline 1

bupropion (Wellbutrin) 1 •bupropion ext-release (Wellbutrin

SR, Wellbutrin XL)1 •

citalopram (Celexa) 1 •clomipramine (Anafranil) 1

desipramine (Norpramin) 1

doxepin 1

DOXEPIN 75 mg 2

duloxetine delayed-release (Cymbalta)

1 •

escitalopram (Lexapro) 1 •fluoxetine, 60 mg not

covered (Prozac)1 •

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

fluvoxamine 1 •imipramine hcl (Tofranil) 1

mirtazapine (Remeron, RemeronSolTab)

1 •

nortriptyline caps (Pamelor) 1

paroxetine hcl (Paxil) 1 •paroxetine hcl ext-release (Paxil

CR)1 •

PAXIL susp 2 • •phenelzine (Nardil) 1

sertraline (Zoloft) 1 •tranylcypromine (Parnate) 1

trazodone 1

venlafaxine 1 •venlafaxine ext-release

caps (Effexor XR)1 •

VENLAFAXINE ext-release tabs,225 mg

2 • •

venlafaxine ext-release tabs,37.5 mg, 75 mg, 150 mg

1 •

PSYCHOTIC AND BIPOLAR DISORDERS

chlorpromazine 1

clozapine (Clozaril) 1 •fluphenazine hcl tabs 1

haloperidol lactate oral soln 1

haloperidol tabs 1

LITHIUM soln 2

lithium carbonate 1

LITHIUM CARBONATE caps,600 mg

2

lithium carbonate ext-release300 mg (Lithobid)

1

lithium carbonate ext-release450 mg

1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

loxapine (Loxitane) 1

olanzapine (Zyprexa, ZyprexaZydis)

1 •

perphenazine 1

prochlorperazine 1

quetiapine (Seroquel) 1 •risperidone (Risperdal, Risperdal

M-Tab)1 •

SEROQUEL XR 2 •thiothixene 1

trifluoperazine 1

ziprasidone (Geodon) 1 •SLEEP AIDS

estazolam 1

phenobarbital soln; tabs,16.2 mg, 32.4 mg

1

PHENOBARBITAL tabs, 15 mg,30 mg, 60 mg, 64.8 mg, 100 mg;NP = 97.2 mg

2

temazepam (Restoril) 1

zaleplon (Sonata) 1 •zolpidem (Ambien) 1 •zolpidem ext-release (Ambien CR) 1 •HYPERACTIVITY/NARCOLEPSY

amphetamine/dextroamphetamine (Adderall)

1 • •

amphetamine/dextroamphetamine ext-release (Adderall XR)

1 • •

caffeine citrate (Cafcit) 1

dextroamphetamine 1 • •dextroamphetamine ext-

release (Dexedrine Spansule)1 • •

methylphenidate tabs (Ritalin) 1 • •

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

methylphenidate ext-releasecaps; tabs, 20 mg (MetadateCD, Ritalin LA)

1 • •

modafinil (Provigil) 1 • •MULTIPLE SCLEROSIS

BETASERON 2 X • •COPAXONE 2 X • •PLEGRIDY 2 X • •REBIF 2 X • •TECFIDERA 2 X • •OTHER CENTRAL NERVOUS SYSTEM DRUGS

acamprosate delayed-release (Campral)

1

disulfiram (Antabuse) 1

donepezil (Aricept, Aricept ODT) 1

EXELON patches 2

galantamine (Razadyne) 1

galantamine ext-release (Razadyne ER)

1

naltrexone (ReVia) 1

rivastigmine (Exelon) 1

TOBACCO CESSATION

bupropion ext-release (Zyban) 1

CHANTIX* 2

NICOTROL INHALER* 2

NICOTROL NS* 2

PAIN RELIEF DRUGS

NON-NARCOTIC DRUGS

butalbital/acetaminophen 1 •butalbital/acetaminophen/

caffeine (Esgic, Fioricet)1 •

butalbital/aspirin/caffeinecaps (Fiorinal)

1 •

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

salsalate 1

NARCOTIC DRUGS

acetaminophen/codeine (Tylenolw/Codeine)

1 •

buprenorphine 1 • •buprenorphine/naloxone 1 • •butalbital/aspirin/caffeine/

codeine (Fiorinal w/Codeine)1 •

butorphanol nasal 1 •fentanyl (Duragesic) 1 •fentanyl (Actiq) 1 • •hydrocodone/acetaminophen,

NP = soln, 10-325 mg/15 mL1 •

hydrocodone/ibuprofen (Ibudone,Reprexain, Vicoprofen)

1 •

hydromorphone soln,tabs (Dilaudid)

1 •

methadone conc, soln 1 •methadone tabs (Dolophine) 1 •morphine sulfate conc, soln 1 •morphine sulfate ext-

release (Avinza, Kadian, MSContin)

1 •

MORPHINE SULFATE tabs 2 •oxycodone 1 •oxycodone/

acetaminophen (Percocet)1 •

oxycodone/acetaminophen caps,5-500 mg

1 •

oxycodone/aspirin (Percodan) 1 •OXYCONTIN 2 •ROXICET soln 2 •SUBOXONE film 2 • •tramadol (Ultram) 1 •

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

tramadol ext-release (Ultram ER) 1 •tramadol/

acetaminophen (Ultracet)1 •

RHEUMATOID AND OSTEOARTHRITIS

diclofenac potassium (Cataflam) 1

diclofenac sodium delayed-release

1

diclofenac sodium ext-release (Voltaren-XR)

1

ENBREL 2 X • •etodolac 1

etodolac ext-release 1

flurbiprofen 1

HUMIRA 2 X • •ibuprofen 1

indomethacin 1

ketoprofen 1

leflunomide (Arava) 1

MELOXICAM susp 2

meloxicam tabs (Mobic) 1

nabumetone 1

naproxen (Naprosyn) 1

naproxen delayed-release (EC-Naprosyn)

1

naproxen sodium (Anaprox) 1

oxaprozin (Daypro) 1

piroxicam (Feldene) 1

SIMPONI 2 X • •sulindac 1

MIGRAINE HEADACHES

acetaminophen/isometheptene/dichloralphenazone

1

IMITREX nasal 2 •

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

naratriptan (Amerge) 1 •rizatriptan (Maxalt, Maxalt-MLT) 1 •sumatriptan auto-injector;

cartridge; inj, 6 mg/0.5 mL;tabs (Imitrex)

1 •

SUMATRIPTAN inj, 4 mg/0.5 mL 2 •GOUT

allopurinol (Zyloprim) 1

COLCRYS 2

probenecid 1

probenecid/colchicine 1

NEUROMUSCULAR DRUGS

SEIZURES

carbamazepine (Tegretol) 1

carbamazepine ext-release (Carbatrol, Tegretol-XR)

1

clonazepam (Klonopin) 1

DIASTAT 2

DILANTIN caps 2

divalproex delayed-release (Depakote, DepakoteSprinkles)

1

divalproex ext-release (DepakoteER)

1

ethosuximide (Zarontin) 1

gabapentin (Neurontin) 1

lamotrigine (Lamictal) 1

levetiracetam (Keppra) 1

oxcarbazepine (Trileptal) 1

phenytoin (Dilantin) 1

phenytoin sodium ext-release (Dilantin, Phenytek)

1

primidone (Mysoline) 1

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

SABRIL 2

topiramate (Topamax, TopamaxSprinkle)

1

valproic acid (Depakene) 1

zonisamide (Zonegran) 1

PARKINSON'S DISEASE

amantadine caps, syrup 1

AMANTADINE tabs 2

benztropine 1

bromocriptine (Parlodel) 1

carbidopa/levodopa (Parcopa,Sinemet)

1

carbidopa/levodopa ext-release (Sinemet CR)

1

entacapone (Comtan) 1

pramipexole (Mirapex) 1

ropinirole (Requip) 1

selegiline caps (Eldepryl) 1

selegiline tabs 1

trihexyphenidyl 1

MUSCLE RELAXANTS

baclofen 1

chlorzoxazone (Parafon Forte) 1

cyclobenzaprine 1

DANTROLENE 100 mg 2

dantrolene 25 mg,50 mg (Dantrium)

1

metaxalone (Skelaxin) 1

methocarbamol (Robaxin) 1

orphenadrine citrate ext-release 1

orphenadrine/aspirin/caffeine25-385-30 mg

1

tizanidine (Zanaflex) 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

OTHER NEUROMUSCULAR DRUGS

MESTINON syrup 2

MESTINON TIMESPAN 2

PROSTIGMIN tabs 2

pyridostigmine (Mestinon) 1

riluzole (Rilutek) 1

SUPPLEMENTS

VITAMINS

ergocalciferol (Drisdol) 1

MEPHYTON 2

MULTIVITAMINS

PRENATAL MULTIVITAMINS/FOLIC ACID

2

MINERALS AND ELECTROLYTES

potassium bicarbonate/chlorideeffervescent tabs, 25 mEq

1

potassium chloride packets;soln

1

potassium chloride ext-release,NP = 20 mEq

1

potassium phosphate/sodiumphosphates (K-Phos Neutral)

1

SODIUM FLUORIDE tabs, 2.2 mg 2

sodium fluoride, NP = tabs,1.1 mg (Luride)

1

BLOOD MODIFYING DRUGS

anagrelide (Agrylin) 1

ARANESP 2 X •cilostazol (Pletal) 1

CINRYZE 2 X •clopidogrel (Plavix) 1

cyanocobalamin inj 1

dipyridamole (Persantine) 1

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

DROXIA 2

ELIQUIS 2 •enoxaparin inj (Lovenox) 1 •FIRAZYR 2 X •folic acid tabs, 1 mg 1

LEUKINE 2 XNEULASTA 2 X • •NEUPOGEN 2 X •pentoxifylline ext-release (Trental) 1

PRADAXA 2 •PROCRIT 2 X •warfarin (Coumadin) 1

XARELTO 2 •ZAVESCA 2 X •COAGULATION FACTORS

ADVATE 2 X •ALPHANATE/VWF 2 X •ALPHANINE SD 2 X •ALPROLIX 2 X •BEBULIN/VH 2 X •BENEFIX 2 X •CORIFACT 2 X •ELOCTATE 2 X •FEIBA NF 2 X •HELIXATE FS 2 X •HEMOFIL M 2 X •HUMATE-P 2 X •KOATE-DVI 2 X •KOGENATE FS 2 X •MONOCLATE-P 2 X •MONONINE 2 X •NOVOSEVEN/RT 2 X •

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

PROFILNINE SD 2 X •RECOMBINATE 2 X •RIXUBIS 2 X •TRETTEN 2 X •WILATE 2 X •XYNTHA/SOLOFUSE 2 X •TOPICAL PRODUCTS

EYE

Anti-infectives

BACITRACIN oint 2

bacitracin/polymyxin B oint 1

ciprofloxacin soln (Ciloxan) 1

erythromycin oint 1

gentamicin oint, soln (Garamycin) 1

NATACYN 2

neomycin/polymyxin B/bacitracin oint

1

neomycin/polymyxin B/gramicidin soln (Neosporin)

1

ofloxacin soln (Ocuflox) 1

polymyxin B/trimethoprimsoln (Polytrim)

1

sulfacetamide sodiumsoln (Bleph-10)

1

tobramycin soln (Tobrex) 1

trifluridine soln (Viroptic) 1

VIGAMOX 2

Steroids and Combination Products

dexamethasone sodiumphosphate soln

1

fluorometholone susp, 0.1% (FMLLiquifilm)

1

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

neomycin/polymyxin B/bacitracin/hydrocortisone oint

1

neomycin/polymyxin B/dexamethasone oint,susp (Maxitrol)

1

prednisolone acetate susp (PredForte)

1

sulfacetamide sodium/prednisolone soln

1

TOBRADEX oint 2

tobramycin/dexamethasonesusp (Tobradex)

1

Glaucoma

brimonidine soln,0.15% (Alphagan P)

1

brimonidine soln, 0.2% 1

carteolol soln 1

dorzolamide soln (Trusopt) 1

dorzolamide/timolol maleatesoln (Cosopt)

1

latanoprost soln (Xalatan) 1 •levobunolol soln, 0.5% (Betagan) 1

pilocarpine soln (Isopto Carpine) 1

timolol maleate soln (Timoptic,Timoptic-XE)

1

Other Eye Products

ATROPINE SULFATE oint 2

atropine sulfate soln (IsoptoAtropine)

1

azelastine soln (Optivar) 1

cromolyn sodium soln 1

cyclopentolate soln (Cyclogyl) 1

diclofenac soln (Voltaren) 1

flurbiprofen soln (Ocufen) 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

homatropine soln (IsoptoHomatropine)

1

ketorolac soln (Acular, Acular LS) 1

tropicamide soln (Mydriacyl) 1

EAR

acetic acid soln 1

ACETIC ACID/ALUMINUMACETATE soln

2

benzocaine/antipyrine soln 1

CIPRODEX 2

hydrocortisone/acetic acidsoln (Vosol HC)

1

neomycin/polymyxin B/hydrocortisone soln,susp (Cortisporin)

1

ofloxacin soln 1

MOUTH AND THROAT (LOCAL)

cevimeline (Evoxac) 1

chlorhexidine rinse (Peridex) 1

clotrimazole troche 1

lidocaine viscous 1

nystatin susp 1

pilocarpine (Salagen) 1

triamcinolone paste 1

ANORECTAL AGENTS

hydrocortisone acetate crm,supp (Anusol-HC, Proctocort)

1

hydrocortisoneenema (Cortenema)

1

PROCTOFOAM HC 2

SKIN CONDITIONS/PRODUCTS

Acne

adapalene* (Differin) 1

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

CLARAVIS 30 mg 2

clindamycin (Cleocin-T) 1

clindamycin/benzoylperoxide (Benzaclin, Duac)

1

erythromycin (Erygel) 1

erythromycin pads, soln 1

erythromycin/benzoylperoxide (Benzamycin)

1

FINACEA 2

isotretinoin 10 mg, 20 mg,40 mg – Amnesteem, Claravis,Myorisan, Zenatane

1

metronidazole (Metrocream,Metrogel, Metrolotion)

1

sulfacetamide sodium (Klaron) 1

sulfacetamide sodium/sulfur, NP= susp, 10-5% (Plexion)

1

TAZORAC* 2 •tretinoin microsphere* (Retin-A

Micro)1

tretinoin* (Retin-A) 1

Anti-infectives

ciclopirox crm, gel, shampoo,susp (Loprox)

1

ciclopirox soln, 8% (Penlac) 1 •econazole 1

ketoconazole (Nizoral) 1

mupirocin (Bactroban) 1

nystatin topical 1

silver sulfadiazine (Silvadene) 1

ZOVIRAX crm 2

Corticosteroids

alclometasone (Aclovate) 1

betamethasone dipropionate 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

betamethasone dipropionate,augmented (Diprolene)

1

betamethasone valerate 1

clobetasol (Olux, Temovate) 1

desonide (Desowen) 1

desoximetasone crm, 0.25%; gel;oint, 0.25% (Topicort)

1

diflorasone oint 1

fluocinolone (Derma-Smoothe/FS,Synalar)

1

fluocinonide 1

fluticasone propionate (Cutivate) 1

halobetasol (Ultravate) 1

hydrocortisone topical 1

hydrocortisonevalerate (Westcort)

1

mometasone (Elocon) 1

nystatin/triamcinolone 1

triamcinolone, NP = oint, 0.5% 1

Other Skin Products

acitretin (Soriatane) 1

calcipotriene (Dovonex) 1 •diclofenac sodium (Solaraze) 1

fluorouracil (Efudex) 1

imiquimod (Aldara) 1

lidocaine jelly, 2%; oint, 5%;soln, 4% (Xylocaine)

1

lidocaine patches (Lidoderm) 1

lidocaine/prilocaine crm (Emla) 1

lindane 1

malathion (Ovide) 1

permethrin crm 1

podofilox (Condylox) 1

2015




Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

selenium sulfide 2.5% 1

STELARA 2 X • •VALCHLOR 2 XMISCELLANEOUS CATEGORIES

DIABETIC SUPPLIES

BLOOD GLUCOSE METERS –BAYER BREEZE 2

2

BLOOD GLUCOSE METERS –BAYER CONTOUR

2

BLOOD GLUCOSE METERS –BAYER CONTOUR NEXT/EZ/LINK/USB

2

INSULIN PEN NEEDLES –NOVOFINE, NOVOTWIST,OTHER VARIOUSMANUFACTURERS

2

LANCET DEVICES – VARIOUSMANUFACTURERS

2

LANCETS – VARIOUSMANUFACTURERS

2

SYRINGES/NEEDLES – VARIOUSMANUFACTURERS – for self-injectable drug administration

2

TEST DISCS – BAYER BREEZE 2 2 •TEST STRIPS – BAYER

CONTOUR/NEXT2 •

MISCELLANEOUS DRUGS

azathioprine (Imuran) 1

CELLCEPT oral susp 2

CHEMET 2

CUPRIMINE 2

cyclosporine (Sandimmune) 1

cyclosporine modified caps,25 mg, 100 mg; soln (Neoral)

1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r A

utho

rizat

ion

Qua

nitit

y Li

mits

Res

pons

ible

Ste

ps

CYCLOSPORINE modified caps,50 mg

2

EXJADE 2 Xmycophenolate mofetil (Cellcept) 1

mycophenolate sodium delayed-release (Myfortic)

1

naloxone inj, 0.4 mg/mL 1

RAPAMUNE soln 2

REVLIMID 2 X • •sirolimus (Rapamune) 1

sodium polystyrene sulfonate 1

tacrolimus (Prograf) 1

THALOMID 2 X • •ZORTRESS 2

2015


INDEX

A

abacavir.............................................................................. 2abacavir/lamivudine/zidovudine.......................................2acamprosate delayed-release........................................ 13acarbose............................................................................. 5acebutolol...........................................................................7acetaminophen/codeine..................................................13acetaminophen/isometheptene/dichloralphenazone....................................................... 14

ACETAZOLAMIDE 125 mg.................................................8acetazolamide 250 mg...................................................... 8acetazolamide ext-release................................................ 8ACETIC ACID/ALUMINUM ACETATE ear soln................ 17acetic acid ear soln.........................................................17acetylcysteine.................................................................... 9acitretin.............................................................................18ACTIMMUNE....................................................................... 3acyclovir oral..................................................................... 2adapalene......................................................................... 17adefovir...............................................................................2ADVATE............................................................................ 16AFINITOR............................................................................ 3AFINITOR DISPERZ........................................................... 3ALBENZA............................................................................ 3albuterol..............................................................................9alclometasone..................................................................18alendronate tabs, 5 mg, 10 mg, 35 mg, 70 mg................6alfuzosin ext-release....................................................... 11ALINIA................................................................................. 3ALKERAN tabs....................................................................3allopurinol........................................................................ 14ALPHANATE/VWF............................................................ 16ALPHANINE SD................................................................ 16alprazolam........................................................................ 11alprazolam ext-release....................................................11ALPROLIX......................................................................... 16amantadine caps, syrup................................................. 15AMANTADINE tabs........................................................... 15amiloride.............................................................................8amiloride/hydrochlorothiazide......................................... 8amiodarone........................................................................ 8amitriptyline..................................................................... 11amlodipine..........................................................................7amlodipine/atorvastatin.................................................... 9amlodipine/benazepril....................................................... 7amlodipine/valsartan......................................................... 7amoxicillin, NP = chew tabs, 125 mg.............................. 1amoxicillin/potassium clavulanate.................................. 1amoxicillin/potassium clavulanate ext-release...............1AMOXICILLIN chew tabs, 250 mg...................................... 1amphetamine/dextroamphetamine................................ 12amphetamine/dextroamphetamine ext-release.............12

ampicillin caps...................................................................1AMPICILLIN susp................................................................1anagrelide.........................................................................15anastrozole.........................................................................3ANDRODERM..................................................................... 5ANDROGEL.........................................................................5APTIVUS............................................................................. 2ARANESP..........................................................................15ASACOL HD......................................................................10atenolol............................................................................... 7atenolol/chlorthalidone..................................................... 7atorvastatin........................................................................ 8atovaquone/proguanil....................................................... 3ATRIPLA..............................................................................2ATROPINE SULFATE eye oint......................................... 17atropine sulfate eye soln................................................17ATROVENT HFA.................................................................9AUGMENTIN susp, 125 mg/5 mL.......................................1AVC................................................................................... 11azathioprine......................................................................19azelastine eye soln..........................................................17azelastine nasal................................................................. 9azithromycin susp, tabs................................................... 1

B

bacitracin/polymyxin B eye oint.................................... 16BACITRACIN eye oint.......................................................16baclofen............................................................................ 15balsalazide........................................................................10BARACLUDE soln...............................................................2BEBULIN/VH..................................................................... 16benazepril........................................................................... 6benazepril/hydrochlorothiazide........................................6BENEFIX........................................................................... 16benzocaine/antipyrine ear soln......................................17benztropine...................................................................... 15betamethasone dipropionate......................................... 18betamethasone dipropionate, augmented.................... 18betamethasone valerate..................................................18BETASERON.....................................................................13BETHKIS............................................................................. 1bicalutamide.......................................................................3BILTRICIDE......................................................................... 3bisoprolol........................................................................... 7bisoprolol/hydrochlorothiazide........................................ 7BLOOD GLUCOSE METERS – BAYER BREEZE 2.........19BLOOD GLUCOSE METERS – BAYER CONTOUR........ 19BLOOD GLUCOSE METERS – BAYER CONTOURNEXT/EZ/LINK/USB........................................................ 19

BOSULIF............................................................................. 3brimonidine eye soln, 0.15%..........................................17brimonidine eye soln, 0.2%............................................17bromocriptine...................................................................15budesonide.........................................................................9budesonide ext-release.....................................................4bumetanide.........................................................................8

2015


buprenorphine................................................................. 13buprenorphine/naloxone.................................................13bupropion......................................................................... 11bupropion ext-release.....................................................11bupropion ext-release – smoking deterrent..................13buspirone......................................................................... 11butalbital/acetaminophen............................................... 13butalbital/acetaminophen/caffeine.................................13butalbital/aspirin/caffeine/codeine.................................13butalbital/aspirin/caffeine caps...................................... 13butorphanol nasal........................................................... 13BYDUREON........................................................................ 5BYETTA inj..........................................................................5

C

cabergoline.........................................................................6caffeine citrate................................................................. 12calcipotriene.....................................................................18calcitonin-salmon.............................................................. 6calcitriol.............................................................................. 6calcium acetate................................................................10CANASA............................................................................ 10capecitabine....................................................................... 3CAPRELSA..........................................................................4captopril..............................................................................6CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-15 mg,50-15 mg........................................................................... 6

CARAFATE susp...............................................................10carbamazepine.................................................................14carbamazepine ext-release.............................................14carbidopa/levodopa.........................................................15carbidopa/levodopa ext-release.....................................15carteolol eye soln............................................................17carvedilol............................................................................ 7CAYSTON........................................................................... 3cefaclor caps..................................................................... 1cefadroxil............................................................................1cefdinir................................................................................1cefpodoxime.......................................................................1cefprozil.............................................................................. 1cefuroxime..........................................................................1CELLCEPT oral susp........................................................ 19cephalexin, NP = tabs.......................................................1cevimeline........................................................................ 17CHANTIX........................................................................... 13CHEMET............................................................................19CHENODAL.......................................................................10chlorhexidine oral rinse..................................................17chloroquine phosphate.....................................................3chlorothiazide 500 mg...................................................... 8chlorpromazine................................................................ 12CHLORTHALIDONE 25 mg, 50 mg....................................8chlorzoxazone..................................................................15cholestyramine.................................................................. 8ciclopirox crm, gel, shampoo, susp.............................. 18ciclopirox soln................................................................. 18

cilostazol.......................................................................... 15cimetidine......................................................................... 10CINRYZE........................................................................... 15CIPRODEX........................................................................ 17ciprofloxacin ext-release.................................................. 1ciprofloxacin eye soln.................................................... 16ciprofloxacin oral.............................................................. 1citalopram.........................................................................11CLARAVIS 30 mg............................................................. 18clarithromycin.................................................................... 1clarithromycin ext-release................................................1CLEOCIN supp..................................................................11CLIMARA PRO....................................................................5clindamycin/benzoyl peroxide....................................... 18clindamycin oral................................................................ 3clindamycin topical......................................................... 18clindamycin vaginal crm................................................ 11clobetasol......................................................................... 18clomipramine................................................................... 11clonazepam...................................................................... 14clonidine............................................................................. 9clopidogrel....................................................................... 15clotrimazole troche......................................................... 17clozapine.......................................................................... 12COLCRYS......................................................................... 14colestipol............................................................................ 8colistimethate.....................................................................3COMBIVENT RESPIMAT....................................................9COMETRIQ......................................................................... 4COMPLERA.........................................................................2COPAXONE...................................................................... 13CORIFACT........................................................................ 16CORTISONE....................................................................... 4CREON..............................................................................10CRESTOR........................................................................... 8CRIXIVAN............................................................................2cromolyn sodium eye soln.............................................17cromolyn sodium inhal soln............................................ 9CUPRIMINE.......................................................................19cyanocobalamin inj......................................................... 15cyclobenzaprine...............................................................15cyclopentolate eye soln..................................................17CYCLOPHOSPHAMIDE tabs..............................................4cyclosporine.....................................................................19cyclosporine modified caps, 25 mg, 100 mg; soln.......19CYCLOSPORINE modified caps, 50 mg.......................... 19cyproheptadine.................................................................. 9CYSTAGON.......................................................................11

D

danazol............................................................................... 5DANTROLENE 100 mg.....................................................15dantrolene 25 mg, 50 mg................................................15DAPSONE........................................................................... 3DARAPRIM..........................................................................3DELZICOL......................................................................... 10

2015


demeclocycline.................................................................. 1desipramine......................................................................11desmopressin inj, nasal, tabs..........................................6desonide........................................................................... 18desoximetasone crm, 0.25%; gel; oint, 0.25%.............. 18dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4mg, 6 mg.......................................................................... 5

dexamethasone sodium phosphate eye soln............... 16DEXAMETHASONE soln; tabs, 1 mg, 2 mg....................... 5dextroamphetamine.........................................................12dextroamphetamine ext-release.....................................12DIASTAT............................................................................14DIAZEPAM oral soln, 1 mg/mL.........................................11diazepam tabs..................................................................11diclofenac eye soln......................................................... 17diclofenac potassium......................................................14diclofenac sodium delayed-release...............................14diclofenac sodium ext-release....................................... 14diclofenac sodium gel.................................................... 18dicloxacillin........................................................................ 1dicyclomine caps, tabs...................................................10didanosine delayed-release..............................................2diflorasone oint............................................................... 18DIGOXIN soln......................................................................9digoxin tabs....................................................................... 9DILANTIN caps................................................................. 14diltiazem............................................................................. 7diltiazem ext-release......................................................... 7diphenoxylate/atropine tabs...........................................10dipyridamole.................................................................... 15disopyramide..................................................................... 8disulfiram..........................................................................13divalproex delayed-release.............................................14divalproex ext-release.....................................................14DIVIGEL...............................................................................5donepezil.......................................................................... 13dorzolamide/timolol maleate eye soln...........................17dorzolamide eye soln......................................................17doxazosin........................................................................... 9doxepin............................................................................. 11DOXEPIN 75 mg...............................................................11doxycycline hyclate caps................................................. 1doxycycline hyclate tabs..................................................1doxycycline monohydrate................................................ 1DROXIA............................................................................. 16DULERA.............................................................................. 9duloxetine delayed-release.............................................11

E

econazole......................................................................... 18EDURANT........................................................................... 2ELIQUIS.............................................................................16ELLA.................................................................................... 5ELOCTATE........................................................................16EMCYT................................................................................ 4EMEND caps, therapy pack..............................................10

EMTRIVA.............................................................................2enalapril.............................................................................. 7enalapril/hydrochlorothiazide...........................................7ENBREL............................................................................ 14enoxaparin inj.................................................................. 16entacapone.......................................................................15entecavir............................................................................. 2EPIPEN inj...........................................................................9EPIPEN-JR inj..................................................................... 9EPIVIR HBV soln................................................................ 2EPIVIR soln......................................................................... 2eplerenone..........................................................................9EPZICOM............................................................................ 2ergocalciferol................................................................... 15ERIVEDGE.......................................................................... 4ERY-TAB............................................................................. 1erythromycin/benzoyl peroxide..................................... 18erythromycin/sulfisoxazole.............................................. 3ERYTHROMYCIN BASE.....................................................1erythromycin delayed-release caps................................ 1ERYTHROMYCIN ETHYLSUCCINATE.............................. 1erythromycin eye oint.....................................................16erythromycin gel............................................................. 18erythromycin topical pads, soln.................................... 18escitalopram.....................................................................11estazolam......................................................................... 12estradiol/norethindrone acetate.......................................5estradiol patches...............................................................5estradiol tabs..................................................................... 5estropipate 0.75 mg, 1.5 mg.............................................5ethambutol......................................................................... 1ethosuximide....................................................................14etodolac............................................................................ 14etodolac ext-release........................................................14ETOPOSIDE caps...............................................................4EXELON patches.............................................................. 13exemestane........................................................................ 4EXJADE.............................................................................19

F

famciclovir..........................................................................2famotidine.........................................................................10FARESTON......................................................................... 4FEIBA NF.......................................................................... 16felodipine ext-release........................................................7fenofibrate.......................................................................... 8fenofibrate micronized......................................................8fenofibric acid delayed-release........................................8fentanyl lozenges............................................................ 13fentanyl patches.............................................................. 13FINACEA........................................................................... 18finasteride.........................................................................11FIRAZYR........................................................................... 16flecainide............................................................................ 8fluconazole......................................................................... 2flucytosine..........................................................................2

2015


fludrocortisone.................................................................. 5flunisolide 25 mcg/spray.................................................. 9fluocinolone..................................................................... 18fluocinonide..................................................................... 18fluorometholone eye susp, 0.1%................................... 16fluorouracil....................................................................... 18fluoxetine, 60 mg not covered....................................... 11fluphenazine hcl tabs......................................................12flurbiprofen eye soln.......................................................17flurbiprofen tabs..............................................................14flutamide.............................................................................4fluticasone propionate nasal............................................9fluticasone propionate topical....................................... 18FLU VACCINES, NP = FLUBLOK...................................... 3fluvoxamine......................................................................12folic acid tabs, 1 mg....................................................... 16FORADIL AEROLIZER....................................................... 9fosinopril............................................................................ 7fosinopril/hydrochlorothiazide......................................... 7furosemide, NP = soln, 8 mg/mL..................................... 8FUZEON.............................................................................. 2

G

gabapentin........................................................................14galantamine......................................................................13galantamine ext-release..................................................13GAMMAGARD LIQUID........................................................3GAMMAKED........................................................................3GAMUNEX-C.......................................................................3gemfibrozil..........................................................................8gentamicin eye oint, soln............................................... 16GILOTRIF............................................................................ 4GLEEVEC............................................................................4glimepiride..........................................................................5glipizide.............................................................................. 5glipizide/metformin............................................................5glipizide ext-release.......................................................... 5GLUCAGON EMERGENCY inj kit...................................... 5glyburide.............................................................................5GLYBURIDE, distributor of Diabeta.................................... 5glyburide/metformin.......................................................... 5glyburide micronized........................................................ 5glycopyrrolate.................................................................. 10granisetron....................................................................... 10griseofulvin microsize.......................................................2guanfacine..........................................................................9

H

halobetasol.......................................................................18haloperidol lactate oral soln.......................................... 12haloperidol tabs...............................................................12HELIXATE FS................................................................... 16HEMOFIL M...................................................................... 16HEXALEN............................................................................ 4HIZENTRA...........................................................................3homatropine eye soln..................................................... 17

HUMATE-P........................................................................ 16HUMIRA.............................................................................14HYCAMTIN caps................................................................. 4hydralazine......................................................................... 9hydrochlorothiazide caps.................................................8hydrochlorothiazide tabs..................................................8hydrocodone/acetaminophen, NP = soln, 10-325 mg/15mL....................................................................................13

hydrocodone/ibuprofen.................................................. 13hydrocortisone/acetic acid ear soln..............................17hydrocortisone acetate rectal crm, supp...................... 17hydrocortisone enema....................................................17hydrocortisone oral...........................................................5hydrocortisone topical....................................................18hydrocortisone valerate..................................................18hydromorphone soln, tabs.............................................13hydroxychloroquine.......................................................... 3hydroxyurea....................................................................... 4hydroxyzine hcl............................................................... 11hydroxyzine pamoate 25 mg, 50 mg............................. 11hyoscyamine.................................................................... 10hyoscyamine ext-release................................................10

I

ibandronate........................................................................ 6ibuprofen.......................................................................... 14ICLUSIG.............................................................................. 4IMBRUVICA.........................................................................4imipramine hcl................................................................. 12imiquimod.........................................................................18IMITREX nasal.................................................................. 14INCRELEX...........................................................................6indapamide.........................................................................8indomethacin................................................................... 14INLYTA................................................................................ 4INSULIN PEN NEEDLES – NOVOFINE, NOVOTWIST,OTHER VARIOUS MANUFACTURERS......................... 19

INTELENCE.........................................................................2INTRON-A........................................................................... 2INVIRASE............................................................................ 2INVOKAMET........................................................................5INVOKANA.......................................................................... 5ipratropium/albuterol.........................................................9ipratropium inhal soln...................................................... 9ipratropium nasal.............................................................. 9irbesartan........................................................................... 7irbesartan/hydrochlorothiazide........................................ 7ISENTRESS........................................................................ 2ISONIAZID syrup.................................................................1isoniazid tabs.....................................................................1ISOSORBIDE DINITRATE tabs, 30 mg.............................. 8isosorbide dinitrate tabs, 5 mg, 10 mg, 20 mg............... 8isosorbide mononitrate.....................................................8isosorbide mononitrate ext-release.................................8isotretinoin 10 mg, 20 mg, 40 mg – Amnesteem,Claravis, Myorisan, Zenatane....................................... 18

2015


ISRADIPINE caps, 2.5 mg.................................................. 7itraconazole........................................................................2ivermectin...........................................................................3

J

JAKAFI.................................................................................4JANUMET............................................................................5JANUMET XR..................................................................... 5JANUVIA..............................................................................5

K

KALETRA............................................................................ 2KALYDECO....................................................................... 10ketoconazole crm, shampoo.......................................... 18ketoprofen........................................................................ 14ketorolac eye soln...........................................................17KOATE-DVI....................................................................... 16KOGENATE FS.................................................................16KOMBIGLYZE XR............................................................... 5K-PHOS NO. 2..................................................................11

L

labetalol.............................................................................. 7lactulose........................................................................... 10lactulose........................................................................... 10lamivudine.......................................................................... 2lamivudine.......................................................................... 2lamivudine/zidovudine...................................................... 2lamotrigine....................................................................... 14LANCET DEVICES – VARIOUS MANUFACTURERS...... 19LANCETS – VARIOUS MANUFACTURERS.................... 19lansoprazole delayed-release.........................................10LANTUS inj..........................................................................6latanoprost eye soln....................................................... 17leflunomide.......................................................................14LETAIRIS.............................................................................9letrozole.............................................................................. 4LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg................... 4leucovorin calcium tabs, 5 mg, 25 mg............................ 4LEUKERAN......................................................................... 4LEUKINE........................................................................... 16leuprolide acetate..............................................................4levalbuterol neb soln, NP = 1.25 mg/0.5 mL................... 9LEVEMIR inj........................................................................ 6levetiracetam....................................................................14LEVITRA..............................................................................9levobunolol eye soln, 0.5%............................................ 17levocarnitine.......................................................................6levofloxacin oral................................................................ 1levonorgestrel.................................................................... 5levothyroxine..................................................................... 6LEXIVA................................................................................ 2LIALDA.............................................................................. 10lidocaine/prilocaine crm................................................. 18lidocaine jelly, 2%; oint, 5%; soln, 4%.......................... 18lidocaine patches............................................................ 18

lidocaine viscous............................................................ 17lindane.............................................................................. 18liothyronine........................................................................ 6lisinopril..............................................................................7lisinopril/hydrochlorothiazide.......................................... 7lithium carbonate............................................................ 12LITHIUM CARBONATE caps, 600 mg..............................12lithium carbonate ext-release 300 mg........................... 12lithium carbonate ext-release 450 mg........................... 12LITHIUM soln.................................................................... 12LOMUSTINE........................................................................4loperamide........................................................................10loratadine............................................................................9loratadine/pseudoephedrine.............................................9lorazepam conc............................................................... 11lorazepam tabs................................................................ 11losartan...............................................................................7losartan/hydrochlorothiazide........................................... 7lovastatin............................................................................ 8loxapine............................................................................ 12LYSODREN......................................................................... 4

M

malathion..........................................................................18MATULANE......................................................................... 4meclizine...........................................................................10medroxyprogesterone acetate tabs.................................5mefloquine..........................................................................3megestrol............................................................................4MEKINIST............................................................................4MELOXICAM susp............................................................ 14meloxicam tabs............................................................... 14MENACTRA.........................................................................3MENEST..............................................................................5MENOMUNE-A/C/Y/W-135................................................. 3MENVEO............................................................................. 3MEPHYTON...................................................................... 15mercaptopurine..................................................................4mesalamine...................................................................... 10MESNEX tabs..................................................................... 4MESTINON syrup..............................................................15MESTINON TIMESPAN.................................................... 15metaxalone....................................................................... 15metformin........................................................................... 5metformin ext-release....................................................... 6metformin ext-release OSM..............................................6methadone conc, soln.................................................... 13methadone tabs...............................................................13methazolamide...................................................................8methimazole....................................................................... 6methocarbamol................................................................ 15methotrexate...................................................................... 4methscopolamine............................................................ 10methyldopa.........................................................................9methylergonovine..............................................................6methylphenidate ext-release caps; tabs, 20 mg........... 13

2015


methylphenidate tabs......................................................12methylprednisolone...........................................................5metoclopramide............................................................... 10metolazone......................................................................... 8metoprolol succinate ext-release.................................... 7metoprolol tartrate............................................................ 7metronidazole oral............................................................ 3metronidazole topical......................................................18metronidazole vaginal gel.............................................. 11mexiletine........................................................................... 8midodrine........................................................................... 9minocycline........................................................................ 1minoxidil............................................................................. 9mirtazapine.......................................................................12misoprostol...................................................................... 10modafinil...........................................................................13moexipril.............................................................................7moexipril/hydrochlorothiazide......................................... 7mometasone.....................................................................18MONOCLATE-P................................................................ 16MONONINE....................................................................... 16montelukast........................................................................9morphine sulfate conc, soln.......................................... 13morphine sulfate ext-release..........................................13MORPHINE SULFATE tabs..............................................13mupirocin......................................................................... 18mycophenolate mofetil................................................... 19mycophenolate sodium delayed-release...................... 19MYLERAN........................................................................... 4

N

nabumetone..................................................................... 14nadolol................................................................................ 7naloxone inj, 0.4 mg/mL................................................. 19naltrexone.........................................................................13naproxen...........................................................................14naproxen delayed-release.............................................. 14naproxen sodium............................................................ 14naratriptan........................................................................ 14NATACYN..........................................................................16nateglinide..........................................................................6NEBUPENT......................................................................... 3neomycin/polymyxin B/bacitracin/hydrocortisone eyeoint.................................................................................. 17

neomycin/polymyxin B/bacitracin eye oint...................16neomycin/polymyxin B/dexamethasone eye oint,susp.................................................................................17

neomycin/polymyxin B/gramicidin eye soln.................16neomycin/polymyxin B/hydrocortisone ear soln,susp.................................................................................17

neomycin sulfate............................................................... 1NEULASTA........................................................................16NEUPOGEN...................................................................... 16nevirapine ext-release.......................................................2NEVIRAPINE susp.............................................................. 2nevirapine tabs.................................................................. 2

NEXAVAR............................................................................4niacin ext-release.............................................................. 8NICOTROL INHALER....................................................... 13NICOTROL NS..................................................................13nifedipine ext-release........................................................7NILANDRON........................................................................4NISOLDIPINE ext-release 25.5 mg.....................................7NITRO-BID.......................................................................... 8nitrofurantoin................................................................... 11nitrofurantoin macrocrystalline..................................... 11nitrofurantoin monohydrate/macrocrystalline..............11nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr....................................................................................... 8

NITROSTAT........................................................................ 8NORDITROPIN....................................................................6norelgestromin/ethinyl estradiol......................................5norethindrone acetate.......................................................5nortriptyline caps............................................................ 12NORVIR...............................................................................2NOVOLIN 70/30 inj............................................................. 6NOVOLIN N inj....................................................................6NOVOLIN R inj....................................................................6NOVOLOG inj......................................................................6NOVOLOG MIX 70/30 inj....................................................6NOVOSEVEN/RT.............................................................. 16NOXAFIL............................................................................. 2nystatin/triamcinolone.................................................... 18nystatin oral....................................................................... 2nystatin susp................................................................... 17nystatin topical................................................................ 18

O

octreotide........................................................................... 6ofloxacin 200 mg, 300 mg................................................ 1ofloxacin ear soln............................................................17ofloxacin eye soln........................................................... 16olanzapine........................................................................ 12OLYSIO............................................................................... 2OMEPRAZOLE (Prilosec OTC).........................................10omeprazole delayed-release...........................................10ondansetron..................................................................... 10ondansetron tabs, 24 mg............................................... 10ONGLYZA............................................................................6OPSUMIT............................................................................ 9oral contraceptives – all generics................................... 5ORFADIN.............................................................................6orphenadrine/aspirin/caffeine 25-385-30 mg................ 15orphenadrine citrate ext-release....................................15oxaprozin..........................................................................14oxcarbazepine..................................................................14oxybutynin........................................................................11oxybutynin ext-release....................................................11oxycodone........................................................................13oxycodone/acetaminophen caps, 5-500 mg................. 13oxycodone/acetaminophen tabs....................................13oxycodone/aspirin........................................................... 13

2015


OXYCONTIN..................................................................... 13

P

pantoprazole delayed-release........................................ 10paricalcitol..........................................................................6paromomycin..................................................................... 1paroxetine hcl.................................................................. 12paroxetine hcl ext-release.............................................. 12PAXIL susp........................................................................12PEGASYS............................................................................2PEG – electrolytes for soln............................................ 10penicillin v potassium.......................................................1PENTASA.......................................................................... 10pentoxifylline ext-release................................................16perindopril.......................................................................... 7permethrin crm................................................................ 18perphenazine....................................................................12phenelzine........................................................................ 12phenobarbital soln; tabs, 16.2 mg, 32.4 mg..................12PHENOBARBITAL tabs, 15 mg, 30 mg, 60 mg, 64.8 mg,100 mg; NP = 97.2 mg....................................................12

phenytoin..........................................................................14phenytoin sodium ext-release........................................14pilocarpine eye soln........................................................17pilocarpine tabs...............................................................17pindolol...............................................................................7pioglitazone........................................................................6pioglitazone/metformin..................................................... 6piroxicam..........................................................................14PLEGRIDY.........................................................................13PNEUMOVAX 23................................................................ 3podofilox...........................................................................18polymyxin B/trimethoprim eye soln.............................. 16POMALYST......................................................................... 4potassium bicarbonate/chloride effervescent tabs, 25mEq................................................................................. 15

potassium chloride ext-release, NP = 20 mEq..............15potassium chloride packets; soln................................. 15potassium citrate/citric acid...........................................11potassium citrate ext-release.........................................11potassium phosphate/sodium phosphates.................. 15PRADAXA..........................................................................16pramipexole......................................................................15pravastatin..........................................................................8prazosin.............................................................................. 9prednisolone acetate eye susp......................................17prednisolone sodium phosphate oral soln, 15 mg/5mL......................................................................................5

prednisolone sodium phosphate oral soln, 5 mg/5mL......................................................................................5

prednisolone soln, 15 mg/5 mL....................................... 5PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg; NP = dosepacks..................................................................................5

prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg......5PREMARIN crm................................................................ 11PREMARIN tabs..................................................................5

PREMPHASE...................................................................... 5PREMPRO...........................................................................5PRENATAL MULTIVITAMINS/FOLIC ACID......................15PREVNAR 13...................................................................... 3PREZISTA tabs................................................................... 2PRIFTIN...............................................................................1PRIMAQUINE...................................................................... 3primidone......................................................................... 14PRIMSOL.............................................................................3PROAIR HFA...................................................................... 9probenecid....................................................................... 14probenecid/colchicine.....................................................14prochlorperazine..............................................................12PROCRIT...........................................................................16PROCTOFOAM HC.......................................................... 17PROFILNINE SD...............................................................16progesterone micronized..................................................5PROGLYCEM......................................................................6promethazine..................................................................... 9propafenone....................................................................... 8propafenone ext-release...................................................8PROPANTHELINE 15 mg.................................................10PROPRANOLOL/HYDROCHLOROTHIAZIDE 80-25mg...................................................................................... 7

propranolol ext-release.....................................................7PROPRANOLOL soln, 20 mg/5 mL.................................... 7propranolol tabs................................................................ 7propylthiouracil..................................................................6PROSTIGMIN tabs............................................................15PULMICORT FLEXHALER................................................. 9PULMICORT RESPULES 1 mg/2 mL.................................9PULMOZYME.................................................................... 10PURIXAN.............................................................................4pyrazinamide......................................................................1pyridostigmine................................................................. 15

Q

quetiapine.........................................................................12quinapril..............................................................................7quinapril/hydrochlorothiazide.......................................... 7quinidine gluconate ext-release.......................................8QUINIDINE SULFATE 200 mg........................................... 9quinidine sulfate 300 mg.................................................. 9QUINIDINE SULFATE ext-release......................................8QVAR...................................................................................9

R

raloxifene............................................................................6ramipril................................................................................7ranitidine...........................................................................10RAPAMUNE soln.............................................................. 19REBIF................................................................................ 13RECOMBINATE................................................................ 16RELION R inj...................................................................... 6RENVELA.......................................................................... 10repaglinide..........................................................................6

2015


RESCRIPTOR..................................................................... 2REVLIMID..........................................................................19REYATAZ............................................................................ 2RIBATAB............................................................................. 2ribavirin...............................................................................2rifabutin.............................................................................. 1RIFAMATE...........................................................................2rifampin...............................................................................2riluzole.............................................................................. 15risedronate......................................................................... 6risperidone....................................................................... 12rivastigmine......................................................................13RIXUBIS............................................................................ 16rizatriptan......................................................................... 14ropinirole.......................................................................... 15ROXICET soln...................................................................13

S

SABRIL.............................................................................. 15salsalate............................................................................13selegiline caps.................................................................15selegiline tabs..................................................................15selenium sulfide 2.5%.....................................................19SELZENTRY........................................................................2SENSIPAR...........................................................................6SEROQUEL XR................................................................ 12sertraline...........................................................................12sildenafil............................................................................. 9silver sulfadiazine........................................................... 18SIMPONI............................................................................14simvastatin......................................................................... 8sirolimus...........................................................................19SIVEXTRO tabs.................................................................. 3sodium citrate/citric acid................................................11sodium fluoride oral, NP = tabs, 1.1 mg........................15SODIUM FLUORIDE tabs, 2.2 mg....................................15sodium polystyrene sulfonate....................................... 19SOMAVERT.........................................................................6sotalol................................................................................. 9SOVALDI............................................................................. 2SPIRIVA HANDIHALER...................................................... 9SPIRIVA RESPIMAT...........................................................9spironolactone................................................................... 8spironolactone/hydrochlorothiazide................................8SPORANOX soln................................................................ 2SPRYCEL............................................................................ 4stavudine............................................................................ 2STELARA.......................................................................... 19STIMATE............................................................................. 6STIVARGA...........................................................................4STRIBILD.............................................................................3SUBOXONE film............................................................... 13sucralfate..........................................................................10sulfacetamide sodium/prednisolone eye soln..............17sulfacetamide sodium/sulfur, NP = susp, 10-5%..........18sulfacetamide sodium eye soln..................................... 16

sulfacetamide sodium lotn.............................................18SULFADIAZINE................................................................... 1sulfamethoxazole/trimethoprim....................................... 3sulfasalazine.................................................................... 10sulfasalazine delayed-release........................................ 11sulindac............................................................................ 14sumatriptan auto-injector; cartridge; inj, 6 mg/0.5 mL;tabs..................................................................................14

SUMATRIPTAN inj, 4 mg/0.5 mL......................................14SUSTIVA............................................................................. 3SUTENT.............................................................................. 4SYLATRON......................................................................... 4SYMAX DUOTAB..............................................................10SYMBICORT..................................................................... 10SYMLINPEN inj................................................................... 6SYNAREL............................................................................ 6SYNTHROID........................................................................6SYRINGES/NEEDLES – VARIOUS MANUFACTURERS –for self-injectable drug administration..............................19

T

TABLOID............................................................................. 4tacrolimus.........................................................................19TAFINLAR........................................................................... 4TAMIFLU............................................................................. 3tamoxifen............................................................................4tamsulosin........................................................................11TARCEVA............................................................................4TARGRETIN caps............................................................... 4TASIGNA............................................................................. 4TAZORAC..........................................................................18TECFIDERA...................................................................... 13temazepam....................................................................... 12temozolomide.....................................................................4terazosin............................................................................. 9terbinafine.......................................................................... 2terbutaline........................................................................ 10terconazole.......................................................................11TEST DISCS – BAYER BREEZE 2.................................. 19TEST STRIPS – BAYER...................................................19TETRACYCLINE................................................................. 1THALOMID........................................................................ 19theophylline ext-release..................................................10thiothixene........................................................................12timolol maleate eye soln................................................ 17TIMOLOL tabs.....................................................................7TIVICAY...............................................................................3tizanidine.......................................................................... 15TOBI PODHALER............................................................... 1TOBRADEX oint................................................................17tobramycin/dexamethasone eye susp...........................17tobramycin eye soln....................................................... 16tobramycin inhal soln....................................................... 1tolterodine........................................................................ 11tolterodine ext-release.................................................... 11topiramate........................................................................ 15

2015


torsemide............................................................................8TRACLEER..........................................................................9tramadol............................................................................13tramadol/acetaminophen................................................ 14tramadol ext-release....................................................... 14trandolapril......................................................................... 7tranylcypromine...............................................................12trazodone..........................................................................12tretinoin caps.....................................................................4tretinoin crm, gel.............................................................18tretinoin microsphere......................................................18TRETTEN.......................................................................... 16triamcinolone dental paste.............................................17triamcinolone nasal...........................................................9triamcinolone topical, NP = oint, 0.5%.......................... 18triamterene/hydrochlorothiazide, NP = caps, 50-25mg......................................................................................8

trifluoperazine.................................................................. 12trifluridine eye soln......................................................... 16trihexyphenidyl................................................................ 15trimethobenzamide..........................................................10trimethoprim.......................................................................3tropicamide eye soln...................................................... 17TRUVADA............................................................................3TYKERB.............................................................................. 4

U

ursodiol.............................................................................11

V

VAGIFEM...........................................................................11valacyclovir........................................................................ 2VALCHLOR....................................................................... 19VALCYTE............................................................................ 2valproic acid.................................................................... 15valsartan............................................................................. 7valsartan/hydrochlorothiazide..........................................7vancomycin........................................................................ 3venlafaxine....................................................................... 12venlafaxine ext-release caps..........................................12VENLAFAXINE ext-release tabs, 225 mg.........................12venlafaxine ext-release tabs, 37.5 mg, 75 mg, 150mg....................................................................................12

VENTAVIS........................................................................... 9VENTOLIN HFA................................................................ 10VERAPAMIL 40 mg.............................................................7verapamil 80 mg, 120 mg................................................. 8verapamil ext-release........................................................8VESICARE.........................................................................11VIDEX.................................................................................. 3VIGAMOX.......................................................................... 16VIRACEPT...........................................................................3VIRAMUNE susp.................................................................3VIRAMUNE XR 100 mg......................................................3VIREAD............................................................................... 3voriconazole.......................................................................2

VOTRIENT...........................................................................4

W

warfarin.............................................................................16WELCHOL........................................................................... 8WILATE............................................................................. 16

X

XALKORI............................................................................. 4XARELTO.......................................................................... 16XIFAXAN 550 mg................................................................3XTANDI................................................................................4XYNTHA/SOLOFUSE........................................................16

Y

YODOXIN............................................................................ 3

Z

zafirlukast......................................................................... 10zaleplon............................................................................ 12ZAVESCA.......................................................................... 16ZELBORAF..........................................................................4ZENPEP............................................................................ 10ZIAGEN soln....................................................................... 3zidovudine.......................................................................... 3ziprasidone.......................................................................12ZITHROMAX packets..........................................................1ZOLINZA..............................................................................4zolpidem........................................................................... 12zolpidem ext-release....................................................... 12zonisamide....................................................................... 15ZORTRESS....................................................................... 19ZOSTAVAX..........................................................................3ZOVIRAX crm....................................................................18ZYDELIG............................................................................. 4ZYKADIA............................................................................. 4ZYTIGA................................................................................4ZYVOX.................................................................................3

florida blue healthy kids 2015 medication guide for ... · florida blue healthy kids medication...

Documents