Molina Drug Formulary 2013

Molina Healthcare of Florida

Drug Formulary

2013

Administered by

1

DRUG FORMULARY
The Molina Drug Formulary was created to help manage the quality of our members’ pharmacy benefit. The Formulary is the cornerstone for a progressive program of managed care pharmacotherapy. Prescription drug therapy is an integral component of your patient’s comprehensive treatment program. The Formulary was created to ensure that Molina members receive high quality, cost-effective, rational drug therapy.
The Molina Pharmacy and Therapeutics Committee meets quarterly to review and recommend medications for Formulary consideration. This assures that the Formulary remains responsive to physician and patient needs. The Committee is composed of physicians and pharmacists representing various medical specialties. With a primary consideration to provide a safe, effective and comprehensive Formulary, the Committee evaluated all therapeutic categories and has selected the most cost-effective agent(s) in each class. The Committee also uses reference materials from CVS/ Caremark. In addition, the Molina Pharmacy and Therapeutics Committee reviews prior authorization procedures to ensure medications are used safely, following manufacturer’s guidelines and current medical practices.
Please familiarize yourself with the Drug Formulary as you prescribe medications for Molina members. Thank you for your cooperation.
PRESCRIPTION CLAIMS PROCESSOR
Molina has selected CVS Caremark as the Pharmacy Benefit Management (PBM) company to manage the prescription benefit for Molina members.
Questions on processing claims, formulary status or rejected claims may be directed to the CVS Caremark Help Desk at 1-800-791-6856
Membership and eligibility concerns may be addressed by calling the Molina Membership Services at 1- 866-472-4585.
Provider-related questions may be addressed by calling the Molina Provider Services 1-866-422-2541.
PREFACE
USING THE MOLINA DRUG FORMULARY
The Molina Drug Formulary is a listing of preferred drug products eligible for reimbursement by Molina. All medications are listed by generic name. The medications are organized by therapeutic classes. For your convenience, an index by both brand and generic names is located at the end of the Drug Formulary.
G = Generic Available
A= Age Restriction
QL= Quantity Limit
ST= Electronic Step Therapy Required
CT= Electronic Concurrent Therapy Required
PA= Prior Authorization required
INDIVIDUAL PRESCRIPTIONS
Each prescription must legally be prescribed for one individual only. If prescribing for a family, each family member must receive a prescription.
INJECTABLE MEDICATIONS
Injectables (except insulin, Depo-Provera, and other specific medications noted in the Formulary) are generally not eligible for reimbursement under the outpatient prescription drug program without prior authorization.
GENERIC MEDICATIONS
Selected medications have FDA-approved generic equivalents available. The Molina drug endorsement states... “Generic drugs will be dispensed whenever available”.
If the use of a particular brand-name becomes medically necessary as determined by the physician, the physician must contact the Medical Director or his designee for prior authorization.
Molina encourages the use of quality generic products. Only those generic products which have received an “AB” rating by the FDA should be utilized. Physicians are encouraged to write “Brand Only” or “DNS” only when medically necessary.
The Pharmacy and Therapeutics Committee recognizes that certain medications possess narrow therapeutic dose response characteristics. Therefore, the following drugs are not recommended to be generically substituted, unless the patient has been therapeutically maintained on the generic product for a period of time.
Generic Name / Brand Name
Carbamazepine / Tegretol
Cyclosporine / Sandimmune, Neoral
Digoxin / Lanoxin
Levothyroxine / Synthroid or Levoxyl
Phenytoin / Dilantin
Warfarin / Coumadin
NON-COVERED MEDICATIONS
Please note that certain medications are not covered. These include, but are not limited to:

• Appetite Suppressants / anorexiants for weight loss
• Retinoic Acid for Cosmetic Purposes
• Experimental or Investigational Medications
• Progesterone Suppositories
• Convenience Dosage Forms (Transdermal Patches) not listed in the Formulary
• Injectables administered in the physician’s office (other than Depo-Provera)

PRIOR AUTHORIZATION REQUEST PROCEDURE
Prescriptions for medications requiring prior approval or for medications not included on the Molina Drug Formulary may be approved when medically necessary and when Formulary alternatives have demonstrated ineffectiveness. When these exceptional needs arise, the physician may fax a completed “Prior Authorization / Medication Exception Request” form to Molina. The forms may be obtained by calling Molina Healthcare of Florida at
(866) 472-4585.
PRESCRIPTION QUANTITIES
Prescriptions should be written for a therapeutic supply of medications (the amount to appropriately treat a medical condition) up to a maximum of a 30-day supply. Trial quantities may be used when trying new treatments, if appropriate.
TELEPHONE PRESCRIPTIONS
Whenever possible, the member should be given the prescription in writing. This will allow the member to
make use of the most convenient network pharmacy and enable the pharmacy to fill the prescription after
normal office hours.

Analgesics

Narcotic Analgesics

G / APAP/Codeine tablets / TYLENOL/CODEINE TABLETS
G
G / APAP/Hydrocodone 500/2.5
APAP/Hydrocodone 325/5 / LORTAB 2.5/500
LORTAB 5/325
G
G / APAP/Hydrocodone 500/5
APAP/Hydrocodone 325/7.5 / LORTAB 5/500
LORTAB 7.5/325
G
G / APAP/Hydrocodone 500/7.5
APAP/Hydrocodone 500/10 / LORTAB 7.5/500
LORTAB 10/500
G / APAP/Hydrocodone 500-7.5/15ml / LORTAB ELIXIR
G / Butalbital/ASA/Codeine / FIORINAL/CODEINE
G / CodeineSulfate / CODEINE
G / Hydromorphone / DILAUDID
PA / Hydromorphone 8mg
G / Meperidine / DEMEROL
G / Methadone / DOLOPHINE
G / Morphine Sulfate SR / MS CONTIN
G / Oxycodone/APAP 5/500 / TYLOX
PA / Oxycodone/APAP 10/400 / MAGNACET
G,PA / Oxycodone/APAP 2.5/325
Oxycodone/APAP 10/325
Oxycodone/APAP 10/650
G / Oxycodone/ASA / PERCODAN
G / Oxycodone / OXY IR
G / Propoxyphene/APAP 100/650
PA / PropoxyHCL CAP 65MG
G / Propoxyphene / DARVON
PA, QL / Oxycodone SR / OXYCONTIN
G, QL / Tramadol / ULTRAM (qty limit #120/mo)
G, PA / Fentanyl transdermal patches / DURAGESIC
PA / Hydromorphone 8 mg
PA / Morphine Sulfate 200MG ER
PA / Propoxy HCL 65mg
G,PA / Tramadol ER 300mg / ULTRAM ER 300mg
PA / Tramadol ER 200mg
PA / Hydrocodone/APAP 2.5/500mg

Non-narcotic analgesics

(See JOINT/CONNECTIVE TISSUE/MUSCULOSKELETAL AGENTS)

Antihistamine Drugs

Single Entity Antihistamine

G / Diphenhydramine 50mg / BENADRYL
G / Clemastine
G / Cyproheptadine tablets
G / Hydroxyzine HCl
G, A / Promethazine
G / Cetirizine HCL / ZYRTEC *OTC
PA / Cetirizine 5mg/10mg Chewable
G / Loratadine / CLARITIN *OTC
G, ST / Fexofenadine / ALLEGRA
PA / Claritin 5mg Chewable

ST-Requires prior claim for Zyrtec OTC and/or Claritin OTC

• Covered under OTC benefit

Antihistamine/Decongestant

G / Chlorpheniramine/Methscopolamine/Phenylephrine
G / Chlorpheniramine/Pseudoephedrine Ext-rel
G / Promethazine/Phenylephrine
G / Pseudoephedrine Tan/Chlor-Tan
G / Brompheniramine/Pseudoephedrine ext-rel.
G / Pseudoephedrine Hcl/Carbinox Mal
Pseudoephedrine Hcl/Acrivastine / SEMPREX-D
G / Loratadine/Pseudoephedrine / CLARITIN-D OTC
G / Cetirizine/Pseudoephedrine / ZYRTEC-D OTC
G, ST / Fexofenadine/ Pseudoephedrine / ALLEGRA-D

ST-Requires prior claim for Zyrtec, -D OTC and/or Claritin, -D OTC

Decongestant

G / Guaifenesin/P-Ephed HCL
G / Pseudoephedrine/Guaifenesin

Anti-infective Agents

Aminoglycosides

G / Neomycin Sulfate
PA / Tobramycin/NA Chloride 0.2% / TOBI

Antifungal Antibiotics

G / GriseofulvinMicrosizeUltramicrosize / GRIS-PEG, GRIFULVIN V, FULVICIN U/F, FULVICIN P/G
G / Ketoconazole
G / Clotrimazole / MYCELEX TROCHE
G / Fluconazole / DIFLUCAN
G,PA / Itraconazole / SPORANOX
G,PA / Terbinafine / LAMISIL
G, PA / Voriconazole / VFEND

Antihelmintics

G / Mebendazole
Albendazole / ALBENZA
Ivermectin / STROMECTOL
Thiabendazole
Praziquantel / BILTRICIDE

Antimalarial Agents - Products covered for treatment of active disease only

G / Chloroquine Phosphate / ARALEN
G / Hydroxychloroquine / PLAQUENIL
G / Paromomycin
Iodoquinol
Primaquine / PRIMAQUINE
Pyrimethamine / DARAPRIM
Sulfadoxine/Pyrimethamine
G,PA / Mefloquine
PA / Thalidomide
PA / Halofantrine HCL

Antituberculosis Agents

G / EthambutolHCl / MYAMBUTOL
G / Isoniazid / INH
G / Pyrazinamide / PYRAZINAMIDE
G / Rifampin / RIFADIN
G / Dapsone / DAPSONE
G / Isoniazid/Rifampin / RIFAMATE
Isoniazid/Pyrazinamide/Rifampin / RIFATER
PA / Rifabutin / MYCOBUTIN

Antivirals

G / Acyclovir / ZOVIRAX
G / Rimantadine / FLUMADINE
G / Famciclovir / FAMVIR
G / Valacyclovir / VALTREX
PA,QL / Oseltamivir Phosphate / TAMIFLU
G, PA / Ganciclovir / CYTOVENE
PA / Valganciclovir / VALCYTE
ST HIV-ANTIRETROVIRAL agents—All oral anti-retrovirals are covered with confirmation of diagnosis( HIV or other FDA approved indications)
Hepatitis Antivirals
Adefovir / HEPSERA
Entecavir / BARACLUDE
Epivir HBV / EPIVIR HBV
Telbivudine / TYZEKA
G,PA
PA / Ribavirin
Boceprevir / COPEGUS, REBETOL
VICTRELIS

Cephalosporins

ST / Cefaclor (all strengths)
ST / Cefaclor ER 500mg
G / Cefadroxil
G / Cephalexin / KEFLEX
G / CefpodoximeProxetil
G,ST / Cefuroxime (all forms and strengths) / CEFTIN
G,ST / Cefprozil (all forms and strengths)
ST / Cefixime (all forms and strengths) / SUPRAX
G,ST / Cefdinir (all forms and strengths)
G,ST
ST- / ZinacefInj
Requires prior use of Amoxil or Augmentin

Erythromycins/Macrolides

G / Erythromycin Base Enteric Coat / ERY-TAB
G / Erythromycin Base
G / Erythromycin Estolate
G / Erythromycin Ethylsuccinate / E.E.S., ERY-PED
G / Erythromycin Stearate / ERYTHROCIN
G / Clarithromycin / BIAXIN (Not XL)
Dirithromycin
Erythromycin, delayed-release / PCE
G, QL / Azithromycin / ZITHROMAX (Z-MAX excluded)
PA / Azithromycin 600mg tabs
PA / Azithromycin Inj all strengths

Fluoroquinolones

G / Ciprofloxacin / CIPRO
ST,QL / Levofloxacin / LEVAQUIN (max #20 day supply)
PA / Sparfloxacin

ST-Requires prior claim for ciprofloxacin, otherwise PA required

Penicillins

G / Amoxicillin
G / Ampicillin
G / Dicloxacillin
G / Penicillin V potassium
G / Amoxicillin/Clavulanate / AUGMENTIN

Sulfonamides

G / Sulfamethoxazole/Trimethoprim / BACTRIM, DS
G / Sulfasalazine / AZULFIDINE

Tetracyclines

G,A / Demeclocycline
G,A / Doxycycline capsules / VIBRAMYCIN
G,A / Doxycycline Hyclatetablets
G,A / Minocycline / MINOCIN
G,A / Tetracycline capsules

Miscellaneous Anti-infectives

G / Clindamycin / CLEOCIN ORAL (150mg only)
G / Erythromycin/Sulfisoxazole
G / Metronidazole / FLAGYL (375mg, 750 mg ER excluded)
Nitrofurantoin / FURADANTIN Oral Suspension
G / NitrofurantoinMacrocrystals / MACRODANTIN
G / Trimethoprim
G / Nitrofurantoin / MACROBID
Pentamidine / PENTAM 300
Atovaquone / MEPRON
G,PA / Vancomycin oral / VANCOCIN
PA / Linezolid / ZYVOX oral

Antineoplastics

All FDA-approved oral antineoplastics are covered.

The following medications require prior authorization:

PA / Imatinib / GLEEVEC
PA / Gefitinib / IRESSA
PA / Lenalidomide / REVLIMID
PA / Dasatinib / SPRYCEL
PA / Erlotinib / TARCEVA
PA / Bexarotene / TARGRETIN
PA / LapatinibDitosylate / TYKERB
PA / Thalidomide / THALOMID
PA / capecitabine / XELODA
PA / Vorinostat / ZOLINZA

Antitussives, Expectorants, and Mucolytic Agents

Antitussives - Narcotic

G
G / Hydrocodone/Guaifenesin
Codeine /Guaifenesin
G / Hydrocodone/Homatropine
G / Promethazine/Codeine liquid
G / Promethazine/Phenylephrine/Codeine

Antitussives - Non-narcotic

G / Benzonatate / TESSALON PERLES
G / Promethazine/DM

Expectorants

G / Guaifenesin
G / Potassium Iodide

Biotechnology Agents

Myeloid Stimulants

PA / Filgrastim / NEUPOGEN
PA / Pegfilgrastim / NEULASTA
PA / Sargramostim / LEUKINE

Erythroid Stimulants

PA / Epoetin Alfa / PROCRIT
PA / Oprelvekin / NEUMEGA

Interferons

PA / Interferon alfa-2b / INTRON-A
PA / interferon beta-1A / AVONEX
PA / Peginterferonalfa 2B / PEG-INTRON
PA
PA / Peginterferonalfa 2A
Interferon beta-1B / PEGASYS
EXTAVIA

Other Biotechnological Agents

G, PA / Ribavirin / REBETOL, COPEGUS
PA / Adalimumab / HUMIRA
PA / Etanercept / ENBREL
PA / Growth Hormone / TEV-TROPIN
G, PA / Octreotide / SANDOSTATIN
PA / Glatiramer Acetate / COPAXONE
G, PA / Enoxaparin / LOVENOX (7 days available at retail without PA)

Note: Prior authorization of these agents may require completion of specific forms which will be automatically faxed to the prescriber under the standard prior authorization procedure (see Overview section). Distribution may be limited to specialty pharmacy at the discretion of Molina.

Cardiovascular Drugs

Angiotensin Converting Enzyme (ACE) Inhibitors

G / Captopril, -HCT
G / Lisinopril, -HCT / ZESTRIL, ZESTORETIC
G / Benazepril, -HCT / LOTENSIN, HCT
PA / Fosinopril, -HCT 10/12.5 and 20/125mg
Quinapril, -HCT (all strengths) / ACCUPRIL, ACCURETIC
G / Enalapril, -HCT / VASOTEC, VASERETIC

Angiotensin Receptor Blockers

PA / Olmesartan, Olmesartan/HCTZ / BENICAR, HCT
ST / Losartan, Losartan HCTZ / LOSARTAN, HCT

ST-Requires prior claim for an ACE inhibitor

ST-Requires prior claim for Losartan

Anti-Dysrhythmic Agents

G / Disopyramide, CR
G / Quinidine Gluconate
G / Quinidine Sulfate SR
G / Sotalol / BETAPACE, -AF

Anti-Dysrhythmic Agents “Lidocaine Type”

G / Amiodarone / CORDARONE
G / Mexiletine / MEXITIL
MoricizineHcl
G / Flecainide / TAMBOCOR
G / Propafenone / RYTHMOL
PA / Propafenone
Dronedaronehcl / RYTHMOL SR
MULTAQ

Anti-Dysrhythmic Agents “Procaine Type”

G / Procainamide, SR / PRONESTYL, PROCAN SR

Antilipidemic Agents

G
G,PA / Colestipol
Niacin
CholestyraminePow 4gm and 4gm lite / COLESTID
NIASPAN
QUESTRAN, QUESTRAN LIGHT
G / Gemfibrozil / LOPID
G
G / Lovastatin
Simvastatin / MEVACOR
ZOCOR (*PA on 80mg strength only)
G / Pravastatin / PRAVACHOL
PA / Ezetimibe/Simvastatin / VYTORIN
G,PA / Fenofibrate / TRICOR
PA / PrevalitePow 4GM
G,ST / Atorvastatin / LIPITOR
PA / Fenofibrate / TRICOR 145MG AND 48MG
PA / Fenofibrate / TRIGLIDE 50MG, 160MG
PA / Fenofibrate / FENOGLIDE 40MG AND 120MG
G,PA / Fenofibrate / ANTARA 43MG AND 130MG

ST-Requires 60 days (2 fills) prior claim for Simvastatin

*PA Required –Use Simvastatin 40mg

Beta-Adrenergic Antagonists “Non-selective”

G / Nadolol / CORGARD
G / Propranolol, SR
G / Timolol

Beta-Adrenergic Antagonists “Selective”

G / Acebutolol / SECTRAL
G / Atenolol / TENORMIN
G / Pindolol
Penbutolol / LEVATOL
G / Metoprolol SR / TOPROL XL
G / Carvedilol / COREG (not –CR)
PA / Metoprolol/HCTZ (all strengths)

Calcium Channel Blockers

G / Diltiazem, SR / CARDIZEM, CD
G / Diltiazem XR / DILACOR XR
G / DiltiazemHcl / TIAZAC
G / Isradipine / DYNACIRC
G / Nicardipine / CARDENE
G / Nifedipine
G / Nifedipine SR / ADALAT CC
G / Verapamil / CALAN
G / Verapamil SR / CALAN SR
PA / Felodipine ER 2.5MG,5MG,10MG
Isradipine / DYNACIRC CR
G / Amlodipine / NORVASC
G, PA / Nimodipine / NIMOTOP
PA / DYNACIRC CR 10MG

Cardiac Glycosides

G / Digoxin (generic not mandatory) / LANOXIN

Centrally Acting Antihypertensives

G / Clonidine / CATAPRES
G / Guanabenz Acetate
G / Guanfacine / TENEX
G / Methyldopa
G / Reserpine / RESERPINE
Metyrosine
G, PA / Clonidine Patches / CATAPRES-TTS

Combination Alpha-Beta Antagonist

G / Labetalol

Hemorheologic Agents– Anticoagulants

G / Warfarin (generic not mandatory) / COUMADIN

Hemorheologic Agents– Antiplatelets

G / Aspirin 81mg enteric coated / ASPIRIN
G / Dipyridamole / PERSANTINE
PA / Clopidogrel / PLAVIX
PA / Prasugrel / EFFIENT

Other Hemorrheologic Agents

G / Aminocaproic Acid / AMICAR
G / Pentoxifylline / TRENTAL

Pheochromocytoma Agents

Phenoxybenzamine / DIBENZYLINE

Vasodilator Antihypertensives

G / Hydralazine
G / Hydralazine Hcl/HCTZ / VARIOUS
G / Minoxidil (oral only)
G / Prazosin
G / Terazosin / HYTRIN
G / Doxazosin / CARDURA

Vasodilating Agents

G / IsosorbideDinitrate, SR / ISORDIL, DILATRATE SR
G / Isosorbidemononitrate (extended release) / IMDUR
G / Nitroglycerin ointment / NITROL OINTMENT
G / Nitroglycerin, SR / NITRO-BID
G / Nitroglycerin sublingual Spray / NITROSTAT SUBLINGUAL SPRAY
G / Nitroglycerin patches / NITRO-DUR, TRANSDERM NITRO
G / ErgoloidMesylates / HYDERGINE

Antihypertensives, Misc.

PA / Bosentan / TRACLEER*
PA / Ambrisentan / LETAIRIS*

* Distribution may be limited to specialty pharmacy at the discretion of Molina.

Combination Antihypertensives

G / Atenolol/Chlorthalidone / TENORETIC
G / Clonidine/Chlorthalidone
G / Propranolol Hctz / INDERIDE, LA
G / Metoprolol Tartrate/Hctz / LOPRESSOR HCT
Hctz/Timolol
G / Bendroflumethiazide/Nadolol / CORZIDE
G,PA / Benazepril Hcl/Amlodipine (all strengths) / LOTREL
PA / Amlodipine/Valsartan / EXFORGE

Central Nervous System Agents

Antidepressants

G / Amitriptyline
G / Amitriptyline Hcl/Cl-DiazepoxHcl
G / Amoxapine
G / Bupropion-SR / WELLBUTRIN, SR (“-XL” excluded)
G / Clomipramine / ANAFRANIL
G / Desipramine / NORPRAMIN
G / Doxepin
G / Fluoxetine / PROZAC (10mg and 20mg only)
G / Imipramine HCL / TOFRANIL
G / Imipramine Pamoate / TOFRANIL-PM
PA / Imipramine Pam Cap 75,100mg
G / Maprotiline
G / Mirtazapine / REMERON, REMERON SOLTAB
PA / Mirtazapine 15mg,30mg ODT
G / Nortriptyline / PAMELOR
G / Perphenazine/Amitriptyline / TRIAVIL
G / Protriptyline HCL / VIVACTIL
G / Trazodone
PA / Trazodone 300mg
G / Trimipramine Maleate / SURMONTIL
G / Paroxetine / PAXIL (Not CR)
PA / Paroxetine ER12.5,25,37.5mg
G / Citalopram / CELEXA
G / Sertraline / ZOLOFT
G / Fluvoxamine Maleate
ST / Venlafaxine tables all strengths / EFFEXOR
G / Venlafaxine SR / EFFEXOR XR

Note: PA required for members under 6 years

Antimanic Agents

G / Lithium Carbonate
G / Lithium Citrate / CITRATE
G / Lithium Carbonate SR / LITHOBID

Antipsychotic Agents

G / Chlorpromazine
G / Fluphenazine
G / Haloperidol / HALDOL
G / Loxapine / LOXITANE
G / LoxapineHcl
G / Perphenazine
G / Thioridazine
G / Thiothixene / NAVANE
G / Trifluoperazine
Molindone
Pimozide / ORAP
G / Clozapine / CLOZARIL*
PA,A / Aripiprazole / ABILIFY* (under age 10 requires a PA)
G,ST, A / Olanzapine / ZYPREXA* (under age 18 requires a PA)
G,ST,A
PA,A / Quetiapine
Quetiapine / SEROQUEL* (under 16 requires a PA)
SEROQUEL XR (under 16 requires a PA)
G,A / Risperidone / RISPERDAL* (under age 5 requires a PA)
G,ST,A / Ziprasidone / GEODON* (under age 16 requires a PA)

Use of >1 atypical at the same time not permitted. Medications should be prescribed for FDA-approved indications and age groups only.

• ST – Requires prior claim for Risperidone

Barbiturates

G / Phenobarbital

Benzodiazepines

G / Alprazolam / XANAX
G / Chlordiazepoxide
G / Clorazepate / TRANXENE
G / Diazepam / VALIUM
G / Estazolam / PROSOM
G / Flurazepam
G / Lorazepam / ATIVAN
G / Temazepam / RESTORIL
PA / Temazepam 7.5mg
G / Triazolam
Quazepam / DORAL

Monoamine Oxidase Inhibitors

G / Phenelzine / NARDIL
G / Tranylcypromine / PARNATE

Respiratory and Cerebral Stimulants

G / Dextroamphetamine tablets / DEXEDRINE
G / Methylphenidate,ER / RITALIN, SR
G / Amphetamine /D-Amphet / ADDERALL
G,A / Amphetamine /D-Amphet XR / ADDERALL XR (<6 and >18 requires a PA)
G / Methamphetamine / DESOXYN
G / DextroamphetamineER / DEXEDRINE SPANSULES
FA / Methylphenidate ER / METADATE CD
G,A / Methylphenidate ER / CONCERTA (<6 and >18 requires a PA)
A / Atomoxetine / STRATTERA* (<6 and >18 requires a PA)
PA / Lisdexamfetamine / Vyvanse(all strengths)

Monotherapy only

Miscellaneous Central Nervous System Agents

PA / Buspirone 30mg and 7.5mg
G / Disulfiram / ANTABUSE
G / Hydroxyzine HCl, Pamoate / VISTARIL
G / Meprobamate
PA / Oxazepam (all strengths)
G,QL / Zaleplon / SONATA (quantity limit 15/30 days)
G / Zolpidem / AMBIEN
PA / Naltrexone

Electrolytic, Caloric, And Water Balance

Ammonia Detoxicants

G / Lactulose

Electrolyte Depleters

G / Calcium Acetate / PHOS-LO
G / Sodium Polystyrene Sulfonate / SPS

Loop Diuretics

G / Bumetanide
G / Furosemide / LASIX
G / Torsemide / DEMADEX
Ethacrynic Acid / EDECRIN

Potassium Chloride Formulations

G / Potassium Chloride / KLOR-CON
G / Potassium Chloride
G / Potassium Chloride
G / Potassium Chloride Effervescent tablets

Potassium Sparing Diuretics

G / Amiloride
G / Amiloride/HCTZ
G / Spironolactone / ALDACTONE
G / Spironolactone/HCTZ / ALDACTAZIDE
G / Triamterene/HCTZ / DYAZIDE, MAXZIDE
PA / Triamt/HCTZ 50/25MG

Thiazide and Related Diuretics

G / Chlorthalidone
G / Indapamide
PA / Hydrochlorothiazide 12.5mg tab
G / Hydrochlorothiazide Liquid /pediatric
G / Metolazone / ZAROXOLYN

Endocrine Agents

Androgens

Danazol
G / Oxandrolone / OXANDRIN
Testolactone

Estrogens

G / Esterified Estrogens / ESTRATAB, -HS
Esterified Estrogens / MENEST
G / Estropipate / CREAM
Conjugated Estrogens/Medroxyprogesterone / PREMPHASE, PREMPRO
Conjugated Estrogens / PREMARIN, CREAM
G, QL / Estradiol patch / CLIMARA (quantity limit 4/mo)
QL / Estradiol patch / CLIMARA PRO (quantity limit 4/mo)
QL / Estradiol patch / ALORA (quantity limit 8/mo)
QL / Estradiol patch
QL / Estradiol patch / ESTRADERM (quantity limit 8/mo)
QL / Estradiol/Noreth AC / COMBIPATCH (quantity limit 8/mo)

Insulins

QL / Human Insulin / HUMULIN, NOVOLIN
QL / Insulin Lispro / HUMALOG, 50/50, 75/25
QL / Insulin Glargine / LANTUS
QL / Insulin Aspart / NOVOLOG, NOVOLOG MIX 70/30
FA / ApidraInj

Glucagon

Glucagon / GLUCAGON KIT

LHRH Agonists

PA / Leuprolide Acetate / LUPRON DEPOT

Oral Antidiabetics

G / Chlorpropamide / DIABINESE
G / Glipizide / GLUCOTROL, XL
G / Glyburide / DIABETA
G / Glyburide, micronized / PRESTAB
G / Tolazamide
G / Tolbutamide
G / Glimepiride / AMARYL
G / Metformin, ER / GLUCOPHAGE
G / Acarbose / PRECOSE
Repaglinide / PRANDIN
G / Nateglinide / STARLIX
G,ST / Pioglitazone / ACTOS
G,ST / Pioglitazone/metformin / ACTOPLUS-MET
G / Pioglitazone/glimepiride / DUETACT
ST / Sitagliptin / JANUVIA
ST / Sitagliptin/metformin / JANUMET
ST
ST / Linagliptin/metformin
Linagliptin / JENTADUETO
TRADJENTA

ST-Requires prior claim for metformin

Misc. Devices

Blood Glucose Monitoring Kit / TRUE RESULT (limit one/year)
Blood Glucose Test Strips / TRUE TEST
Acetone test strips / KETOSTIX

Osteoporosis Agents

G / Alendronate / FOSAMAX
ST / Risedronate Sodium / ACTONEL
PA / Tiludronate Disodium / SKELID

ST-Requires prior claim for Fosamax (alendronate)

Thyroid Agents – All Brands Covered, Generic NOT Mandatory

G / Levothyroxine / LEVOXYL, SYNTHROID
G / Thyroid, Desuccated / ARMOUR THYROID
G / Liothyronine / CYTOMEL
Liotrix / THYROLAR

Antithyroid Agents

G / Propylthiouracil / PTU
G / Methimazole / TAPAZOLE

Other Endocrine Agents

G / Megestrol / MEGACE
G / Tamoxifen
G / Etidronate
RaloxifeneHcl / EVISTA
G / Anastrozole / ARIMIDEX
G / Bicalutamide / CASODEX
Estramustine / EMCYT
G / Flutamide
G,PA / Desmopressin Acetate / DDAVP, STIMATE
PA / Nafarelin Acetate / SYNAREL

Eye, Ear, Nose, and Throat (EENT) Preparations

Miotics

G / Carbachol / ISOPTO CARBACHOL
G / Pilocarpine / ISOPTO CARPINE
Echothiophate Iodide / PHOSPHOLINE IODIDE

Mydriatics

G / Atropine Sulfate
G / Cyclopentolate / CYCLOGYL
G / Dipivefrin
Epinephrine/Pilocarpine
G / Homatropine / ISO-HOMATROPINE
G / Scopolamine / ISO-HYOSCINE
G / Tropicamide

Nasal Corticosteroids

A / Fluticasone nasal spray / FLONASE
A / Flunisolide nasal spray / NASALIDE
PA,A / Mometasone nasal spray / NASONEX
PA,A / Triamcinolone nasal / NASACORT AQ

*ST- Requires prior claim for fluticasone nasal spray