Molina Healthcare of Florida
Drug Formulary
2013
Administered by
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.
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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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- 866-4724585.
Provider-related questions may be addressed by calling the Molina Provider Services 1-866-422-2541.
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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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
Carbamazepine
Cyclosporine
Digoxin
Levothyroxine
Phenytoin
Warfarin
Brand Name
Tegretol
Sandimmune, Neoral
Lanoxin
Synthroid or Levoxyl
Dilantin
Coumadin
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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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.
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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ANALGESICS
NARCOTIC ANALGESICS
G
G
G
G
G
G
G
G
G
G
G
PA
G
G
G
APAP/Codeine tablets
APAP/Hydrocodone 500/2.5
APAP/Hydrocodone 325/5
APAP/Hydrocodone 500/5
APAP/Hydrocodone 325/7.5
APAP/Hydrocodone 500/7.5
APAP/Hydrocodone 500/10
APAP/Hydrocodone 500-7.5/15ml
Butalbital/ASA/Codeine
Codeine Sulfate
Hydromorphone
Hydromorphone 8mg
Meperidine
Methadone
Morphine Sulfate SR
G
PA
G,PA
Oxycodone/APAP 5/500
Oxycodone/APAP 10/400
Oxycodone/APAP 2.5/325
Oxycodone/APAP 10/325
Oxycodone/APAP 10/650
G
Oxycodone/ASA
G
Oxycodone
G
Propoxyphene/APAP 100/650
PA
Propoxy HCL CAP 65MG
G
Propoxyphene
PA, QL Oxycodone SR
G, QL Tramadol
G, PA Fentanyl transdermal patches
PA
Hydromorphone 8 mg
PA
Morphine Sulfate 200MG ER
PA
Propoxy HCL 65mg
G,PA Tramadol ER 300mg
PA
Tramadol ER 200mg
PA
Hydrocodone/APAP 2.5/500mg
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
TYLENOL/CODEINE TABLETS
LORTAB 2.5/500
LORTAB 5/325
LORTAB 5/500
LORTAB 7.5/325
LORTAB 7.5/500
LORTAB 10/500
LORTAB ELIXIR
FIORINAL/CODEINE
CODEINE
DILAUDID
DEMEROL
DOLOPHINE
MS CONTIN
TYLOX
MAGNACET
PERCODAN
OXY IR
DARVON
OXYCONTIN
ULTRAM (qty limit #120/mo)
DURAGESIC
ULTRAM ER 300mg
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Non-narcotic analgesics
(See JOINT/CONNECTIVE TISSUE/MUSCULOSKELETAL AGENTS)
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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ANTIHISTAMINE DRUGS
Single Entity Antihistamine
G
G
G
G
G, A
Diphenhydramine 50mg
Clemastine
Cyproheptadine tablets
Hydroxyzine HCl
Promethazine
BENADRYL
G
PA
G
G, ST
PA
Cetirizine HCL
Cetirizine 5mg/10mg Chewable
Loratadine
Fexofenadine
Claritin 5mg Chewable
ZYRTEC *OTC
CLARITIN *OTC
ALLEGRA
ST- Requires prior claim for Zyrtec OTC and/or Claritin OTC

Covered under OTC benefit
Antihistamine/Decongestant
G
Chlorpheniramine/Methscopolamine/Phenylep
hrine
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
G
Guaifenesin/P-Ephed HCL
Pseudoephedrine/Guaifenesin
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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ANTI-INFECTIVE AGENTS
Aminoglycosides
G
PA
Neomycin Sulfate
Tobramycin/NA Chloride 0.2%
TOBI
Antifungal Antibiotics
G
Griseofulvin Microsize & Ultramicrosize
G
G
G
Ketoconazole
Clotrimazole
Fluconazole
G,PA Itraconazole
G,PA Terbinafine
G, PA Voriconazole
GRIS-PEG, GRIFULVIN V, FULVICIN U/F,
FULVICIN P/G
MYCELEX TROCHE
DIFLUCAN
SPORANOX
LAMISIL
VFEND
Antihelmintics
G
Mebendazole
Albendazole
Ivermectin
Thiabendazole
Praziquantel
ALBENZA
STROMECTOL
BILTRICIDE
Antimalarial Agents - Products covered for treatment of active disease only
G
G
G
Chloroquine Phosphate
Hydroxychloroquine
Paromomycin
Iodoquinol
Primaquine
Pyrimethamine
Sulfadoxine/Pyrimethamine
G,PA Mefloquine
PA
Thalidomide
PA
Halofantrine HCL
ARALEN
PLAQUENIL
PRIMAQUINE
DARAPRIM
Antituberculosis Agents
G
G
G
Ethambutol HCl
Isoniazid
Pyrazinamide
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
MYAMBUTOL
INH
PYRAZINAMIDE
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G
G
G
PA
Rifampin
Dapsone
Isoniazid/Rifampin
Isoniazid/Pyrazinamide/Rifampin
Rifabutin
RIFADIN
DAPSONE
RIFAMATE
RIFATER
MYCOBUTIN
Antivirals
G
Acyclovir
G
Rimantadine
G
Famciclovir
G
Valacyclovir
PA,QL Oseltamivir Phosphate
G, PA Ganciclovir
PA
Valganciclovir
ZOVIRAX
FLUMADINE
FAMVIR
VALTREX
TAMIFLU
CYTOVENE
VALCYTE
ST
HIV-ANTIRETROVIRAL agents—All oral anti-retrovirals are covered with
confirmation of diagnosis( HIV or other FDA approved indications)
Hepatitis Antivirals
Adefovir
Entecavir
Epivir HBV
Telbivudine
G,PA Ribavirin
PA
Boceprevir
HEPSERA
BARACLUDE
EPIVIR HBV
TYZEKA
COPEGUS, REBETOL
VICTRELIS
Cephalosporins
ST
ST
G
G
G
G,ST
G,ST
ST
G,ST
G,ST
Cefaclor (all strengths)
Cefaclor ER 500mg
Cefadroxil
Cephalexin
Cefpodoxime Proxetil
Cefuroxime (all forms and strengths)
Cefprozil (all forms and strengths)
Cefixime (all forms and strengths)
Cefdinir (all forms and strengths)
Zinacef Inj
ST-
Requires prior use of Amoxil or Augmentin
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
KEFLEX
CEFTIN
SUPRAX
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Erythromycins/Macrolides
G
G
G
G
G
G
Erythromycin Base Enteric Coat
Erythromycin Base
Erythromycin Estolate
Erythromycin Ethylsuccinate
Erythromycin Stearate
Clarithromycin
Dirithromycin
Erythromycin, delayed-release
G, QL Azithromycin
PA
Azithromycin 600mg tabs
PA
Azithromycin Inj all strengths
ERY-TAB
E.E.S., ERY-PED
ERYTHROCIN
BIAXIN (Not XL)
PCE
ZITHROMAX (Z-MAX excluded)
Fluoroquinolones
G
Ciprofloxacin
ST,QL Levofloxacin
PA
Sparfloxacin
CIPRO
LEVAQUIN (max #20 day supply)
ST- Requires prior claim for ciprofloxacin, otherwise PA required
Penicillins
G
G
G
G
G
Amoxicillin
Ampicillin
Dicloxacillin
Penicillin V potassium
Amoxicillin/Clavulanate
AUGMENTIN
Sulfonamides
G
G
Sulfamethoxazole/Trimethoprim
Sulfasalazine
BACTRIM, DS
AZULFIDINE
Tetracyclines
G,A
G,A
G,A
G,A
G,A
Demeclocycline
Doxycycline capsules
Doxycycline Hyclate tablets
Minocycline
Tetracycline capsules
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
VIBRAMYCIN
MINOCIN
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Miscellaneous Anti-infectives
G
G
G
Clindamycin
Erythromycin/Sulfisoxazole
Metronidazole
Nitrofurantoin
G
Nitrofurantoin Macrocrystals
G
Trimethoprim
G
Nitrofurantoin
Pentamidine
Atovaquone
G,PA Vancomycin oral
PA
Linezolid
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
CLEOCIN ORAL (150mg only)
FLAGYL (375mg, 750 mg ER excluded)
FURADANTIN Oral Suspension
MACRODANTIN
MACROBID
PENTAM 300
MEPRON
VANCOCIN
ZYVOX oral
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ANTINEOPLASTICS
All FDA-approved oral antineoplastics are covered.
The following medications require prior authorization:
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Imatinib
Gefitinib
Lenalidomide
Dasatinib
Erlotinib
Bexarotene
Lapatinib Ditosylate
Thalidomide
capecitabine
Vorinostat
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
GLEEVEC
IRESSA
REVLIMID
SPRYCEL
TARCEVA
TARGRETIN
TYKERB
THALOMID
XELODA
ZOLINZA
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ANTITUSSIVES, EXPECTORANTS, AND MUCOLYTIC AGENTS
Antitussives - Narcotic
G
G
G
G
G
Hydrocodone/Guaifenesin
Codeine /Guaifenesin
Hydrocodone/Homatropine
Promethazine/Codeine liquid
Promethazine/Phenylephrine/Codeine
Antitussives - Non-narcotic
G
G
Benzonatate
Promethazine/DM
TESSALON PERLES
Expectorants
G
G
Guaifenesin
Potassium Iodide
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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BIOTECHNOLOGY AGENTS
Myeloid Stimulants
PA
PA
PA
Filgrastim
Pegfilgrastim
Sargramostim
NEUPOGEN
NEULASTA
LEUKINE
Erythroid Stimulants
PA
PA
Epoetin Alfa
Oprelvekin
PROCRIT
NEUMEGA
Interferons
PA
PA
PA
PA
PA
Interferon alfa-2b
interferon beta-1A
Peginterferon alfa 2B
Peginterferon alfa 2A
Interferon beta-1B
INTRON-A
AVONEX
PEG-INTRON
PEGASYS
EXTAVIA
Other Biotechnological Agents
G, PA
PA
PA
PA
G, PA
PA
G, PA
Ribavirin
Adalimumab
Etanercept
Growth Hormone
Octreotide
Glatiramer Acetate
Enoxaparin
REBETOL, COPEGUS
HUMIRA
ENBREL
TEV-TROPIN
SANDOSTATIN
COPAXONE
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.
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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CARDIOVASCULAR DRUGS
Angiotensin Converting Enzyme (ACE) Inhibitors
G
G
G
PA
G
Captopril, -HCT
Lisinopril, -HCT
Benazepril, -HCT
Fosinopril, -HCT 10/12.5 and 20/125mg
Quinapril, -HCT (all strengths)
Enalapril, -HCT
ZESTRIL, ZESTORETIC
LOTENSIN, HCT
ACCUPRIL, ACCURETIC
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
G
G
G
Disopyramide, CR
Quinidine Gluconate
Quinidine Sulfate SR
Sotalol
BETAPACE, -AF
Anti-Dysrhythmic Agents “Lidocaine Type”
G
G
G
G
PA
Amiodarone
Mexiletine
Moricizine Hcl
Flecainide
Propafenone
Propafenone
Dronedarone hcl
CORDARONE
MEXITIL
TAMBOCOR
RYTHMOL
RYTHMOL SR
MULTAQ
Anti-Dysrhythmic Agents “Procaine Type”
G
Procainamide, SR
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
PRONESTYL, PROCAN SR
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Antilipidemic Agents
G
Colestipol
Niacin
G,PA Cholestyramine Pow 4gm and 4gm lite
G
Gemfibrozil
G
Lovastatin
G
Simvastatin
G
Pravastatin
PA
Ezetimibe/Simvastatin
G,PA Fenofibrate
COLESTID
NIASPAN
QUESTRAN, QUESTRAN LIGHT
LOPID
MEVACOR
ZOCOR (*PA on 80mg strength only)
PRAVACHOL
VYTORIN
TRICOR
PA
G,ST
PA
PA
PA
G,PA
LIPITOR
TRICOR 145MG AND 48MG
TRIGLIDE 50MG, 160MG
FENOGLIDE 40MG AND 120MG
ANTARA 43MG AND 130MG
Prevalite Pow 4GM
Atorvastatin
Fenofibrate
Fenofibrate
Fenofibrate
Fenofibrate
ST- Requires 60 days (2 fills) prior claim for Simvastatin
*PA Required –Use Simvastatin 40mg
Beta-Adrenergic Antagonists “Non-selective”
G
G
G
Nadolol
Propranolol, SR
Timolol
CORGARD
Beta-Adrenergic Antagonists “Selective”
G
G
G
G
G
PA
Acebutolol
Atenolol
Pindolol
Penbutolol
Metoprolol SR
Carvedilol
Metoprolol/HCTZ (all strengths)
SECTRAL
TENORMIN
LEVATOL
TOPROL XL
COREG (not –CR)
Calcium Channel Blockers
G
G
G
G
G
Diltiazem, SR
Diltiazem XR
Diltiazem Hcl
Isradipine
Nicardipine
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
CARDIZEM, CD
DILACOR XR
TIAZAC
DYNACIRC
CARDENE
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G
G
G
G
PA
Nifedipine
Nifedipine SR
Verapamil
Verapamil SR
Felodipine ER 2.5MG,5MG,10MG
Isradipine
G
Amlodipine
G, PA Nimodipine
PA
ADALAT CC
CALAN
CALAN SR
DYNACIRC CR
NORVASC
NIMOTOP
DYNACIRC CR 10MG
Cardiac Glycosides
G
Digoxin (generic not mandatory)
LANOXIN
Centrally Acting Antihypertensives
G
G
G
G
G
Clonidine
Guanabenz Acetate
Guanfacine
Methyldopa
Reserpine
Metyrosine
G, PA Clonidine Patches
CATAPRES
TENEX
RESERPINE
CATAPRES-TTS
Combination Alpha-Beta Antagonist
G
Labetalol
Hemorheologic Agents – Anticoagulants
G
Warfarin (generic not mandatory)
COUMADIN
Hemorheologic Agents – Antiplatelets
G
G
PA
PA
Aspirin 81mg enteric coated
Dipyridamole
Clopidogrel
Prasugrel
ASPIRIN
PERSANTINE
PLAVIX
EFFIENT
Other Hemorrheologic Agents
G
G
Aminocaproic Acid
Pentoxifylline
AMICAR
TRENTAL
Pheochromocytoma Agents
Phenoxybenzamine
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
DIBENZYLINE
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Vasodilator Antihypertensives
G
G
G
G
G
G
Hydralazine
Hydralazine Hcl/HCTZ
Minoxidil (oral only)
Prazosin
Terazosin
Doxazosin
VARIOUS
HYTRIN
CARDURA
Vasodilating Agents
G
G
G
G
G
G
G
Isosorbide Dinitrate, SR
Isosorbide mononitrate (extended release)
Nitroglycerin ointment
Nitroglycerin, SR
Nitroglycerin sublingual Spray
Nitroglycerin patches
Ergoloid Mesylates
ISORDIL, DILATRATE SR
IMDUR
NITROL OINTMENT
NITRO-BID
NITROSTAT SUBLINGUAL SPRAY
NITRO-DUR, TRANSDERM NITRO
HYDERGINE
Antihypertensives, Misc.
PA
PA
Bosentan
Ambrisentan
TRACLEER*
LETAIRIS*
* Distribution may be limited to specialty pharmacy at the discretion of Molina.
Combination Antihypertensives
G
Atenolol/Chlorthalidone
G
G
G
Clonidine/Chlorthalidone
Propranolol Hctz
Metoprolol Tartrate/Hctz
Hctz/Timolol
G
Bendroflumethiazide/Nadolol
G,PA Benazepril Hcl/Amlodipine (all strengths)
PA
Amlodipine/Valsartan
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
TENORETIC
INDERIDE, LA
LOPRESSOR HCT
CORZIDE
LOTREL
EXFORGE
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CENTRAL NERVOUS SYSTEM AGENTS
Antidepressants
G
G
G
G
G
G
G
G
G
G
PA
G
G
PA
G
G
G
G
PA
G
G
PA
G
G
G
ST
G
Amitriptyline
Amitriptyline Hcl/Cl-Diazepox Hcl
Amoxapine
Bupropion-SR
Clomipramine
Desipramine
Doxepin
Fluoxetine
Imipramine HCL
Imipramine Pamoate
Imipramine Pam Cap 75,100mg
Maprotiline
Mirtazapine
Mirtazapine 15mg,30mg ODT
Nortriptyline
Perphenazine/Amitriptyline
Protriptyline HCL
Trazodone
Trazodone 300mg
Trimipramine Maleate
Paroxetine
Paroxetine ER12.5,25,37.5mg
Citalopram
Sertraline
Fluvoxamine Maleate
Venlafaxine tables all strengths
Venlafaxine SR
WELLBUTRIN, SR (“-XL” excluded)
ANAFRANIL
NORPRAMIN
PROZAC (10mg and 20mg only)
TOFRANIL
TOFRANIL-PM
REMERON, REMERON SOLTAB
PAMELOR
TRIAVIL
VIVACTIL
SURMONTIL
PAXIL (Not CR)
CELEXA
ZOLOFT
EFFEXOR
EFFEXOR XR
Note: PA required for members under 6 years
Antimanic Agents
G
G
G
Lithium Carbonate
Lithium Citrate
Lithium Carbonate SR
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
CITRATE
LITHOBID
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Antipsychotic Agents
G
G
G
G
G
G
G
G
G
Chlorpromazine
Fluphenazine
Haloperidol
Loxapine
Loxapine Hcl
Perphenazine
Thioridazine
Thiothixene
Trifluoperazine
Molindone
Pimozide
G
Clozapine
PA,A
Aripiprazole
G,ST, A Olanzapine
G,ST,A Quetiapine
PA,A
Quetiapine
G,A
Risperidone
G,ST,A Ziprasidone
HALDOL
LOXITANE
NAVANE
ORAP
CLOZARIL*
ABILIFY* (under age 10 requires a PA)
ZYPREXA* (under age 18 requires a PA)
SEROQUEL* (under 16 requires a PA)
SEROQUEL XR (under 16 requires a PA)
RISPERDAL* (under age 5 requires a PA)
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
G
G
G
G
G
G
G
PA
G
Alprazolam
Chlordiazepoxide
Clorazepate
Diazepam
Estazolam
Flurazepam
Lorazepam
Temazepam
Temazepam 7.5mg
Triazolam
Quazepam
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
XANAX
TRANXENE
VALIUM
PROSOM
ATIVAN
RESTORIL
DORAL
- 21 -
Monoamine Oxidase Inhibitors
G
G
Phenelzine
Tranylcypromine
NARDIL
PARNATE
Respiratory and Cerebral Stimulants
G
G
G
G,A
G
G
FA
G,A
A
PA

Dextroamphetamine tablets
Methylphenidate,ER
Amphetamine /D-Amphet
Amphetamine /D-Amphet XR
Methamphetamine
Dextroamphetamine ER
Methylphenidate ER
Methylphenidate ER
Atomoxetine
Lisdexamfetamine
DEXEDRINE
RITALIN, SR
ADDERALL
ADDERALL XR (<6 and >18 requires a PA)
DESOXYN
DEXEDRINE SPANSULES
METADATE CD
CONCERTA (<6 and >18 requires a PA)
STRATTERA* (<6 and >18 requires a PA)
Vyvanse (all strengths)
Monotherapy only
Miscellaneous Central Nervous System Agents
PA
G
G
G
PA
G,QL
G
PA
Buspirone 30mg and 7.5mg
Disulfiram
Hydroxyzine HCl, Pamoate
Meprobamate
Oxazepam (all strengths)
Zaleplon
Zolpidem
Naltrexone
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
ANTABUSE
VISTARIL
SONATA (quantity limit 15/30 days)
AMBIEN
- 22 -
ELECTROLYTIC, CALORIC, AND WATER BALANCE
Ammonia Detoxicants
G
Lactulose
Electrolyte Depleters
G
G
Calcium Acetate
Sodium Polystyrene Sulfonate
PHOS-LO
SPS
Loop Diuretics
G
G
G
Bumetanide
Furosemide
Torsemide
Ethacrynic Acid
LASIX
DEMADEX
EDECRIN
Potassium Chloride Formulations
G
G
G
G
Potassium Chloride
Potassium Chloride
Potassium Chloride
Potassium Chloride Effervescent tablets
KLOR-CON
Potassium Sparing Diuretics
G
G
G
G
G
PA
Amiloride
Amiloride/HCTZ
Spironolactone
Spironolactone/HCTZ
Triamterene/HCTZ
Triamt/HCTZ 50/25MG
ALDACTONE
ALDACTAZIDE
DYAZIDE, MAXZIDE
Thiazide and Related Diuretics
G
G
PA
G
G
Chlorthalidone
Indapamide
Hydrochlorothiazide 12.5mg tab
Hydrochlorothiazide Liquid /pediatric
Metolazone
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
ZAROXOLYN
- 23 -
ENDOCRINE AGENTS
Androgens
G
Danazol
Oxandrolone
Testolactone
OXANDRIN
Estrogens
G
Esterified Estrogens
Esterified Estrogens
G
Estropipate
Conjugated Estrogens/Medroxyprogesterone
Conjugated Estrogens
G, QL Estradiol patch
QL
Estradiol patch
QL
Estradiol patch
QL
Estradiol patch
QL
Estradiol patch
QL
Estradiol/Noreth AC
ESTRATAB, -HS
MENEST
CREAM
PREMPHASE, PREMPRO
PREMARIN, CREAM
CLIMARA (quantity limit 4/mo)
CLIMARA PRO (quantity limit 4/mo)
ALORA (quantity limit 8/mo)
ESTRADERM (quantity limit 8/mo)
COMBIPATCH (quantity limit 8/mo)
Insulins
QL
QL
QL
QL
FA
Human Insulin
Insulin Lispro
Insulin Glargine
Insulin Aspart
Apidra Inj
HUMULIN, NOVOLIN
HUMALOG, 50/50, 75/25
LANTUS
NOVOLOG, NOVOLOG MIX 70/30
Glucagon
Glucagon
GLUCAGON KIT
LHRH Agonists
PA
Leuprolide Acetate
LUPRON DEPOT
Oral Antidiabetics
G
G
G
G
G
G
Chlorpropamide
Glipizide
Glyburide
Glyburide, micronized
Tolazamide
Tolbutamide
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
DIABINESE
GLUCOTROL, XL
DIABETA
PRESTAB
- 24 -
G
G
G
Glimepiride
Metformin, ER
Acarbose
Repaglinide
G
Nateglinide
G,ST Pioglitazone
G,ST Pioglitazone/metformin
G
Pioglitazone/glimepiride
ST
Sitagliptin
ST
Sitagliptin/metformin
ST
Linagliptin/metformin
ST
Linagliptin
AMARYL
GLUCOPHAGE
PRECOSE
PRANDIN
STARLIX
ACTOS
ACTOPLUS-MET
DUETACT
JANUVIA
JANUMET
JENTADUETO
TRADJENTA
ST- Requires prior claim for metformin
Misc. Devices
Blood Glucose Monitoring Kit
Blood Glucose Test Strips
Acetone test strips
TRUE RESULT (limit one/year)
TRUE TEST
KETOSTIX
Osteoporosis Agents
G
ST
PA
Alendronate
Risedronate Sodium
Tiludronate Disodium
FOSAMAX
ACTONEL
SKELID
ST- Requires prior claim for Fosamax (alendronate)
Thyroid Agents – All Brands Covered, Generic NOT Mandatory
G
G
G
Levothyroxine
Thyroid, Desuccated
Liothyronine
Liotrix
LEVOXYL, SYNTHROID
ARMOUR THYROID
CYTOMEL
THYROLAR
Antithyroid Agents
G
G
Propylthiouracil
Methimazole
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
PTU
TAPAZOLE
- 25 -
Other Endocrine Agents
G
G
G
Megestrol
Tamoxifen
Etidronate
Raloxifene Hcl
G
Anastrozole
G
Bicalutamide
Estramustine
G
Flutamide
G,PA Desmopressin Acetate
PA
Nafarelin Acetate
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
MEGACE
EVISTA
ARIMIDEX
CASODEX
EMCYT
DDAVP, STIMATE
SYNAREL
- 26 -
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
Miotics
G
G
Carbachol
Pilocarpine
Echothiophate Iodide
ISOPTO CARBACHOL
ISOPTO CARPINE
PHOSPHOLINE IODIDE
Mydriatics
G
G
G
G
G
G
Atropine Sulfate
Cyclopentolate
Dipivefrin
Epinephrine/Pilocarpine
Homatropine
Scopolamine
Tropicamide
CYCLOGYL
ISO-HOMATROPINE
ISO-HYOSCINE
Nasal Corticosteroids
A
A
PA,A
PA,A
Fluticasone nasal spray
Flunisolide nasal spray
Mometasone nasal spray
Triamcinolone nasal
FLONASE
NASALIDE
NASONEX
NASACORT AQ
*ST- Requires prior claim for fluticasone nasal spray
Miscellaneous Nasal Products
G
Cromolyn Sodium
G,PA Azelastine
G
Ipratropium
NASALCROM OTC
ASTELIN
ATROVENT nasal
Ophthalmic Antibiotics
G
G
G
G
G
G
G
G
G
G
Bacitracin
Bacitracin/Polymyxin B Sulfate
Gentamicin
HC/Neosporin/Polymyxin
Neomycin/Gramicidin/Polymyxin
Neomycin/Polymyxin/Bacitracin
Polymyxin B/Trimethoprim
Sodium Sulfacetamide/Prednisolone SP
Sulfacetamide Sodium
Erythromycin Opth oint
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
BACITRACIN O.O.
NEOSPORIN
NEOSPORIN O.O.
POLYTRIM
BLEPH-10
- 27 -
G
G
G
PA
Tobramycin
Ofloxacin
Sodium Sulfacetamide/PrednisoloneAC
Tobramycin/dexamethasone
Gatifloxacin Ophth.
TOBREX
OCUFLOX
BLEPHAMIDE, S.O.P.
TOBRADEX
ZYMAR
Ophthalmic Anti-inflammatory Agents
G
G
G
PA
G
G
G
G
G
Dexamethasone/Neomycin/Polymyxin
Dexamethasone
Diclofenac
Diclofenac 25mg and 100mg ER
Fluorometholone
Fluorometholone Acetate
Flurbiprofen
Prednisone Acetate
Prednisone Phosphate
Neomycin/Polymyxin/Prednisolone
Ketorolac
Rimexolone
MAXITROL
VOLTAREN OPHTH
FML OPHTH SUSP
FLAREX
OCUFEN
PRED MILD, FORTE
INFLAMASE
POLY-PRED
ACULAR, LS
VEXOL
Ophthalmic Antivirals
G
Trifluridine
VIROPTIC
Ophthalmic “Non-selective” Beta Blockers
G
G
G
Levobunolol
Timolol Maleate
Timolol
Metipranolol
BETAGAN
TIMOPTIC
BETIMOL
OPTIPRANOLOL
Ophthalmic “Selective” Beta Blockers
Betaxolol
BETOPTIC-S
Ophthalmic Vasoconstrictors
G
G
Naphazoline
Naphazoline/Pheniramine
NAPHCON OTC
NAPHCON-A OTC
Miscellaneous Antiglaucoma Ophthalmics
G
G
Apraclonidine
Carteolol Hcl
Brimonidine 0.2%
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
IOPIDINE
- 28 -
G
G
Brimonidine 0.15%, 0.1%
Brinzolamide
Travoprost
Latanoprost
Dorzolamide HCL/Timolol
Brimonidine/Timolol
ALPHAGAN-P
AZOPT
TRAVATAN Z
XALATAN
COSOPT
COMBIGAN
Miscellaneous Ophthalmics
G
Ketotifen
Lodoxamide
ST
Olopatadine HCL
G, ST Azelastine
PA
Cyclosporine
PA
Alomide Sol 0.1%
ZADITOR OTC
ALOMIDE
PATANOL, PATADAY
OPTIVAR
RESTASIS
ST- Requires prior claim for Zaditor OTC (ketotifen)
Oral Antiglaucoma Agents
G,PA Acetazolamide 500mg
G
Methazolamide
G
Acetazolamide SR
DIAMOX CR
Oral Anesthetics
G
Lidocaine Viscous
Otic Agents
G
G
G
G
PA
Acetic Acid 2%/HC 1% Otic
Acetic Acid 2% Otic
Benzocaine/Antipyrine Otic
HC/Neosporin/Polymyxin Otic soln, susp
Ciprofloxacin / dexamethasone
A/B OTIC
CORTISPORIN OTIC
CIPRODEX OTIC (prior authorization not required
for plan-approved ENT)
G, PA Ofloxacin
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
- 29 -
GASTROINTESTINAL DRUGS
Antidiarrheal Agents
G
Diphenoxylate/Atropine
LOMOTIL
Antiemetics
G
G
G
G
PA
G
G
G
Meclizine Hcl
Metoclopramide
Prochlorperazine
Promethazine
Promethazine SUP 50MG
Thiethylperazine
Trimethobenzamide
Trimethobenzamide Hcl/B-Caine
Scopolamine Hydrobromide
G, PA Dronabinol
G, PA Granisetron
G, QL Ondansetron HCL
ANTIVERT
REGLAN
TRANSDERM-SCOP
MARINOL
KYTRIL
ZOFRAN, -ODT (30 tabs per 30 days)
Antispasmodics and GI Motility
G
G
G
G
G
G
Belladonna/Phenobarbital 16mg
Bethanechol
Chlordiazepoxide
Dicyclomine
L-Hyoscyamine
Propantheline
DONNATAL (Extentabs excluded)
URECHOLINE
LIBRIUM
BENTYL
LEVSIN
Digestive Enzymes
Pancrelipase delayed-release
Pancrelipase delayed-release
Pancrelipase delayed-release
CREON
PANCREAZE
ZENPEP
Cathartics and Laxatives
G
G
G
Oral Colon Lavage solution
Docusate Sodium Syrup
Polyethylene Glycol
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
GoLYTELY, NuLYTELY
DIOCTO SYRUP
MIRALAX
- 30 -
H2 Antagonists
G
Cimetidine solution
G
Ranitidine
G,ST Ranitidine Syrup
ST-
ZANTAC (150MG TABLETS)
ZANTAC SYRUP
Requires prior claim for Cimetidine Soln
Other Anti-Ulcer Agents
G
Sucralfate
CARAFATE TABLETS
Proton Pump Inhibitors
G
Omeprazole
G,ST Pantoprazole
G, PA Lansoprazole
Lansoprazole
PRILOSEC *
PROTONIX *
PREVACID*
PREVACID OTC*
ST- Requires prior claim for Omeprazole
* PA required after 6 months continued use of all formulary and non-formulary PPIs
Miscellaneous
G
G
G
G
G
G
Chlorhexidine Gluconate
Hydrocortisone hemorrhoid cream, supp
Pramoxine/HC
Hydrocortisone intrarectal foam
Mesalamine
Mesalamine
Ursodiol
Misoprostol
Mesalamine
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
PERIDEX
PROCTO-CREAM
PROCTOFOAM-HC, ANALPRAM-HC,
CORTIFOAM
ROWASA enema
ACTIGALL
CYTOTEC
ASPRISO
- 31 -
GENITOURINARY AGENTS
Smooth Muscle Relaxants
G
ST
G
Oxybutynin
Tolterodine
Flavoxate
DETROL, -LA
URISPAS
ST- Requires prior claim for oxybutynin
Miscellaneous
G
G
G
G
PA
Phenazopyridine
Methanamine combination
Sodium Citrate/Citric Acid
Finasteride
Pentosan Polysulfate
PYRIDIUM
PROSCAR
ELMIRON
Alpha Blockers
G
G
G
Doxazosin
Terazosin
Tamsulosin
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
CARDURA
FLOMAX
- 32 -
IMMUNOSUPPRESSIVE AGENTS
G
G
G
G
G
Azathioprine
Cyclosporine
Cyclosporine
Cyclosporine Micoremulsion
Mycophenolate mofetil
Tacrolimus
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
IMURAN
SANDIMMUNE
SANDIMMUNE ORAL SOLN
NEORAL
CELLCEPT
PROGRAF
- 33 -
JOINT / CONNECTIVE TISSUE / MUSCULOSKELETAL AGENTS
Adrenal Corticosteroids
G
G
G
G
G
G
G
G
Dexamethasone
Hydrocortisone
Methylprednisolone
Prednisolone
Prednisone
Triamcinolone
Prednisolone
Fludrocortisone
CORTEF
MEDROL
PRELONE SYRUP and Tablets
ORAPRED
Antirheumatics
G
G
Methotrexate
Levocarnitine
Auranofin
Penicillamine
Succimer
Leflunomide
RHEUMATREX
CARNITOR
RIDAURA
CUPRIMINE
CHEMET
ARAVA
Gout Agents
G
G
G
G
Allopurinol
Colchicine
Colchicine/Probenecid
Probenecid
ZYLOPRIM
COLCHICINE
Nonsteroidal Anti-inflammatory Agents
G
G
G
PA
G
G
G
PA
G
G, QL
G
G
G
G
Diclofenac, extended release
Diclofenac Potassium
Etodolac
Etodolac ER 400,500 and 600mg
Flurbiprofen
Ibuprofen
Indomethacin, SR
Indomethacin Cap 75mg
Ketoprofen
Ketorolac
Meclofenamate
Naproxen sodium
Naproxen
Oxaprozin
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
VOLTAREN, -XR
CATAFLAM
ANAPROX
NAPROSYN
DAYPRO
- 34 -
G
G
PA
G
G
G
PA
A
PA
Meloxicam
Piroxicam
Piroxicam 10mg and 20mg
Sulindac
Tolmetin Sodium
Diclofenac/Misoprostol
Nabumetone 500MG AND 750MG
Celecoxib
Naprelan CR 375 and 500mg
MOBIC
FELDENE
CLINORIL
TOLECTIN
ARTHROTEC
CELEBREX (age >65 OK)
Salicylates
G
G
Diflunisal
Choline Magnesium Trisalicylate
Skeletal Muscle Relaxants
G
G
G
G
G
G
G
PA
G
PA
G,PA
G
G
PA
PA
PA
Baclofen
Carisoprodol
Carisoprodol/Aspirin
Chlorzoxazone
Cyclobenzaprine
Methocarbamol
Orphenadrine
Orphenadrine 100MG
Orphenadrine/Aspirin/Caffeine
Metaxalone 400MG
Metaxalone 800MG
Dantrolene
Tizanidine
CYCLOBENZAPRINE 5MG
FEXMID 7.5MG
LIORESAL
SOMA (Soma 250 excluded)
PARAFON FORTE
FLEXERIL
ROBAXIN
NORFLEX
NORGESIC
SKELAXIN
DANTRIUM
ZANAFLEX
ZANAFLEX
Miscellaneous Musculoskeletal Agents
G
G
Neostigmine
Pyridostigmine
Riluzole
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
PROSTIGMIN
MESTINON
RILUTEK
- 35 -
NEUROLOGICAL AGENTS
Anticonvulsants – Barbiturate
G
G
G
Mephobarbital
Phenobarbital
Primidone
MEBARAL
PHENOBARBITAL
MYSOLINE
Anticonvulsants – Benzodiazepine
G
PA
Clonazepam
Diazepam
KLONOPIN (regular tabs only)
DIASTAT
Anticonvulsants – Hydantoin
G
Phenytoin (generic not mandatory)
DILANTIN
Anticonvulsants – Miscellaneous
G
G,QL
G,PA,
QL
G
Carbamazepine (generic not mandatory)
Gabapentin capsules
Gabapentin tablets
Valproic Acid (generic not mandatory)
Methsuximide
G
Ethosuximide
Ethotoin
G
Divalproex
G
Lamotrigine
G,PA Topiramate
TEGRETOL, -XR
NEURONTIN
NEURONTIN
DEPAKENE
CELONTIN
ZARONTIN
PEGANONE
DEPAKOTE, -ER
LAMICTAL
TOPAMAX (prior authorization not required for planapproved neurologists)
G,PA Tiagabine Hcl
GABITRIL (prior authorization not required for planapproved Neurologists)
G
G
G
Levetiracetam
Oxcarbazepine
Zonisamide
KEPPRA
TRILEPTAL
ZONEGRAN
Anti-Parkinson’s Agents
G
G,A
G
G
G
G
A
Amantadine
Benztropine tablets
Bromocriptine
Carbidopa/Levodopa
Carbidopa/Levodopa CR
Selegiline Capsule
Trihexyphenidyl tablets
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
PARLODEL
SINEMET
SINEMET CR
ELDEPRYL
- 36 -
G
G
G
Procyclidine Hcl
Pramipexole
Ropinirole HCL
Tolcapone
Entacapone
KEMADRIN
MIRAPEX
REQUIP
TASMAR
COMTAN
Sympatholytic Agents
G
G
G
G
G
QL, PA
G,QL,P
A
G,QL
G,PA
G, PA
APAP/Butalbital/Caffeine
APAP/Butalbital
APAP/Dichloralphenazone/Isometheptene
ASA/Butalbital/Caffeine
Ergotamine/Caffeine
Ergotamine Tartrate
Eletriptan
Zolmitriptan
ESGIC, FIORICET
PHRENILIN, FORTE
MIDRIN
FIORINAL
CAFERGOT
ERGOSTAT
RELPAX ( 6 per 30 days)
ZOMIG, -ZMT (6 per 30 days)
Sumatriptan oral
IMITREX tabs
(quantity limit of 9 per 45 days)
IMITREX INJECTION
IMITREX NASAL
CAFERGOT
Sumatriptan injection
Sumatriptan nasal spray
Ergotamine / Caffeine
Miscellaneous Neurological Agents
G, PA
PA
G, PA
PA
Donepezil
Memantine
Rivastigmine
Rivastigmine
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
ARICEPT
NAMENDA
EXELON caps
EXELON patch (30 per 30 days)
- 37 -
OBSTETRICAL AND GYNECOLOGICAL AGENTS
Monophasic Oral Contraceptives
G
G
G
G
G
G
G
G
G
G
PA
G
G
Desogestrel 0.15/Ethinyl Estradiol 0.03
Ethynodiol/Ethinyl Estradiol
Levonorgestrel 0.15/Ethinyl Estradiol 0.03
Levonorgestrel 0.15/Ethinyl Estradiol 0.03
Norethindrone 0.5/Ethinyl Estradiol 0.035
Norethindrone 1.0/Ethinyl Estradiol 0.035
Norethindrone 1.0/Mestranol 0.05
Norgestrel 0.3/Ethinyl Estradiol 0.03
Norgestrel 0.5/Ethinyl Estradiol 0.05
Levonorgestrel 0.1/ Ethinyl Estradiol 0.02
Norethindrone Acetate/Ethinyl Estradiol
Noreth A et Estra/Fe Fumarate
drospirenone/ ethinyl estradiol
DESOGEN, ORTHO-CEPT
NORDETTE
ORTHO CYCLEN
MODICON
VARIOUS, ORTHO-NOVUM 1/35
VARIOUS,
LO/OVRAL
LOESTRIN, FE
ESTROSTEP FE
YASMIN
Biphasic Oral Contraceptives
G
G
Norethindrone/Ethinyl Estradiol
Norethindrone-Ethinyl Estradiol
Desogestrel/Ethinyl Estradiol
VARIOUS
ORTHO-NOVUM 10/11
APRI
Triphasic Oral Contraceptives
G
G
G
G
Levonorgestrel/Ethinyl Estradiol
Norethindrone-Ethinyl Estradiol
Norethindrone/Ethinyl Estradiol
Norgestimate-Ethinyl Estradiol
ORTHO-NOVUM 7-7-7
TRI-NORINYL
ORTHO TRI-CYCLEN (Not Lo)
Progestin Only Oral Contraceptives
G
Norethindrone
MICRONOR, NOR-QD
Emergency Oral Contraceptives
G,QL Levonogestrel
NEXT CHOICE (limit 2 Rx per year)
Progestin Agents
G,QL Medroxyprogesterone
G
Norethindrone Acetate
G
Progesterone
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
PROVERA, DEPO PROVERA
AYGESTIN
PROMETRIUM
- 38 -
OB/GYN Anti-infectives
G
G
G
G
G
Nystatin Vaginal Tablets
Triple Sulfa Vaginal
Metronidazole
Terconazole
Clindamycin
METRO-GEL VAGINAL
TERAZOL
CLEOCIN VAGINAL (use oral first)
Miscellaneous
Estradiol Vaginal Cream
Methylergonovine Maleate
PA,QL Etonogestrel/Ethinyl Estradiol
Estradiol
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
ESTRACE
METHERGINE
NUVARING (1per 30 days)
ESTRING
- 39 -
RESPIRATORY AGENTS
Beta 2 Adrenergic Agents (oral)
QL
Albuterol inhaler, soln
QL
QL
QL
QL
G,QL
G,QL
Albuterol inhaler
Albuterol inhaler
Albuterol Sulfate tabs
Pirbuterol Acetate
Metaproterenol tablets, syrup
Terbutaline Sulfate
ALBUTEROL MDI,NEB SOLN(excluding
.63/3ml and 1.25/3ml)
PROAIR HFA MDI
VENTOLIN HFA MDI
PROVENTIL REPETAB
MAXAIR AUTOHALER
Beta 2 Adrenergic Inhalants
G,QL Metaproterenol solution
CT,QL Formoterol fumarate
FA,QL Salmeterol
FORADIL
SEREVENT DISKUS
CT- must be used in conjunction with inhaled steroid. Pharmacy system look-back 45 days with each fill.
Inhaled Bronchial Steroids
QL
PA,QL
QL
G ,QL
ST,QL
ST*,QL
ST,QL
Beclomethasone
Mometasone
Fluticasone
Budesonide respules
Budesonide-Formoterol Fumarate
Salmeterol/Fluticasone
Mometasone/Formoterol
QVAR
ASMANEX( All strengths)
FLOVENT
PULMICORT RESPULES (ages <4 only)
SYMBICORT
ADVAIR
DULERA
ST- Requires prior claims history (in the past 60 days) for inhaled steroid
ST*- Requires prior claims history (in the past 60 days) for inhaled steroid for children 12 years and younger
Respiratory Smooth Muscle Relaxants
G
Theophylline SA (generic not required)
Theophylline SA
THEO-DUR, SLOW-BID
THEO-24
Other Respiratory Agents
G ,QL
G,QL
QL
QL
Cromolyn Sodium solution
Ipratropium Bromide soln
Ipratropium Bromide inhaler
Ipratropium/Albuterol
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
ATROVENT HFA inhaler
COMBIVENT respimat
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A,QL Tiotropium
SPIRIVA HANDIHALER*
PA
G
G, ST
G, FA
PA
PA
STQL
BROVANA
MUCOMYST
ACCOLATE
SINGULAIR
SINGULAIR
PULMOZYME *
ASTEPRO
Arformoterol Tartrate
Acetylcysteine
Zafirlukast
Montelukast Sodium tabs
Montelukast Sodium granules
Dornase Alfa
Azelastine nasal spray
ST- Requires prior claims history (in the past 60 days) for Fluticasone
*Distribution may be limited to specialty pharmacy at the discretion of Molina.
*PA required for members less than 30 years of age
Emergency Respiratory Agents
Epinephrine
EPIPEN, JR
Misc. Respiratory Agents
QL
Inhaler Spacer
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
Any item is formulary up to one per year
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SKIN AND MUCOUS MEMBRANE AGENTS
Anti-Acne Products
G
Benzoyl Peroxide liquid 2.5% 5%,10%; gel
2.5%, 5%; lotion 5%,10%
G
Clindamycin Solution
G,PA Clindamycin Gel
G
PA
G
G, PA
G,PA
PA
G,PA
G
PA
PA
Erythromycin Base/Ethanol
Clindamycin lotion
Erythromycin 2% gel
Erythromycin/Benzoyl Peroxide
Tretinoin Topical
Tretinoin cream/gel
Tretinoin gel
Metronidazole 0.75%
Metronidazole gel 1%
Metronidazole Cream 1%
Tetracycline Topical
G,PA Adapalene
PA
Azelaic Acid
PA
Tretinoin gel
DESQUAM
CLEOCIN T
CLEOCIN T GEL
CLEOCIN T LOTION
BENZAMYCIN
RETIN A (Micro-Gel excluded)
AVITA GEL
METROCREAM, METROLOTION
METROGEL
NORITATE
DIFFERIN
AZELEX
ATRALIN GEL
Oral Anti-Acne Agents
G,PA Isotretinoin
Antifungals
G
G
G
Nystatin topical
Nystatin/Triamcinolone
Clotrimazole 1% Topical Cream
G
G
G,PA
G
Ketoconazole shampoo, cream
Ciclopirox
Ciclopirox 0.77% Gel
Econazole
Naftifine
Oxiconazole cream, lotion
PA
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
CLOTRIMAZOLE
NIZORAL SHAMPOO (not –AD) cream
NAFTIN
OXISTAT
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G
Clotrimazole/Betamethasone
Miconazole nitrate
LOTRISONE
FUNGOID tincture
Anti-Infectives – topical (USE OTC WHEN POSSIBLE)
G
G
G
HC/Neosporin/Polymyxin
Silver Sulfadiazine 1%
Mupirocin
CORTISPORIN cream, oint
SILVADENE cream
BACTROBAN oint
PA
Mupirocin
BACTROBAN Cream 2%
Group 1 Anti-Inflammatory Agents*
G
G
PA
Clobetasol emollient, cream, oint, gel 0.05%
Diflorasone Acetate cream, oint 0.05%
Halobetasol cream, oint
TEMOVATE, -E, CORMAX
ULTRAVATE
Group 2 Anti-Inflammatory Agents*
G
G
G
G
G
G
G
betamethasone dipropionate augmented
Betamethasone valerate oint, cream 0.1%
Desonide
Fluocinolone cream 0.2%
Fluocinonide 0.05%
Triamcinolone acetonide oint 0.1%
Halcinonide cream, oint 0.1%
Prednicarbate
DIPROLENE AF, DIPROLENE
VALISONE
DESOWEN
LIDEX, E
HALOG
DERMATOP
Group 3 Anti-Inflammatory Agents
G, PA Desoximetasone cream
(all strengths)
G
Fluocinolone cream, oint 0.025%
G
Fluticasone cream, oint
PA
Hydrocortisone valerate cream, oint 0.2%
G
Mometasone 0.1%
G
Triamcinolone (0.1%) Lotion
G
Triamcinolone cream, oint 0.1%
TOPICORT
CUTIVATE
WESTCORT
ELOCON
TRIAMCINOLONE
Group 4 Anti-Inflammatory Agents
G
G
Fluocinolone cream, soln 0.01%
Triamcinolone 0.025%
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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Group 5 Anti-Inflammatory Agents
G
G
QL
Hydrocortisone
Alclometasone dipropionate cream, oint
Flurandrenolide (topical)
ACLOVATE
CORDRAN (topical)
Antipruritics and Local Anesthetics
G
Lidocaine topical
XYLOCAINE
Antipsoriatic
G
G
PA
Selenium Sulfide 2.5%
Acitretin
Calcipotriene
Tazarotene
SELSUN
SORIATANE
DOVONEX
TAZORAC
Scabicides
G
G
Permethrin
Permethrin
Crotamiton
G, ST Malathion
NIX OTC
EURAX LOTION
OVIDE
ST- Requires prior claim for a permethrin product
Miscellaneous Topical Skin and Mucous Membrane Agents
G
G
G
G
G
Ammonium lactate
Coal Tar
Amcinonide
Aluminum Chloride Hexahydrate
Podofilox
Podofilox
Sulfactamide lotion
G
Fluorouracil
PA
Acyclovir cream
G, PA Acyclovir ointment
Penciclovir
QL,PA Pimecrolimus Cream
QL,PA Tacrolimus Ointment
PA
Becaplermin
G,PA Imiquimod
PA
Alitretinoin 0.1% gel
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
DRYSOL
CONDYLOX soln
CONDYLOX gel
SEB-PREV
ZOVIRAX CREAM
ZOVIRAX OINT
DENAVIR
ELIDEL 30g tube or less per month
PROTOPIC 30g tube or less per month
REGRANEX
ALDARA
PANRETIN GEL
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Miscellaneous Oral Skin Agents
Methoxsalen
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
OXSORALEN
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VITAMINS
Vitamin A
G
Vitamin A
AQUASOL A
Vitamin B Complex
G
G
Folic Acid
Leucovorin Calcium
Vitamin D
G
G
Calcitriol
Ergocalciferol
ROCALTROL
CALCIFEROL
Vitamin K
Phytonadione
MEPHYTON
Flouride Products
G
Sodium Flouride
LURIDE
Prenatal (RX Only)
Generic Prenatal Multivitamins are all formulary as a 30 day supply. Branded prenatals are nonformulary.
Multivitamins with Fluoride
G
G
G
G
G
G
Multivitamins/fluoride
Multivitamins/fluoride
Multivitamins/fluoride
Multivitamins/fluoride/iron
Vitamins ADC/fluoride
Vitamins ADC/fluoride/iron
POLY-VI-SOL
POLY-VI-SOL with IRON
Mineral Replacements
G
Phosphorus
Potassium Iodide
K-PHOS NEUTRAL
SSKI
Mineral Supplements
G
G
Zinc Sulfate
Ferrous Sulfate
Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
ZINC SULFATE
FERROUS SULFATE
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Molina Healthcare of Florida – September2013
PA = Prior Authorization Required, fax request to 1-866-236-8531
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