Title 19/21 SMI Integrated Plan Drug List
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Title 19/21 SMI Integrated Plan Drug List Updated September 1, 2015 Updated September 1, 2015 Page 1 of 42 What is the Mercy Maricopa Integrated Care Preferred Drug List? A Preferred Drug List is a list of drugs chosen by Mercy Maricopa Integrated Care and a team of doctors and pharmacists; in accordance with the Behavioral Health Drug List from Arizona Department of Health Services, a Division of Behavioral Health Services (ADHS/DBHS). Mercy Maricopa will generally cover drugs listed in our Preferred Drug List as long as they are medically necessary. Prescriptions must also be filled at a Mercy Maricopa network pharmacy, and other plan rules must be followed. The Preferred Drug List begins on page 4. It gives you information about the drugs covered by Mercy Maricopa. The first column of the chart lists the drug that is covered by the plan. Brand name drugs are capitalized (e.g., AMOXIL). Generic drugs are listed in lower case (e.g., amoxicillin). The second column serves as a reference for providing the brand or generic name of the covered drug. The third column lists any requirements for the drug such as prior authorization (PA), quantity limits (QLL), step therapy (ST), Age restrictions (AGE), and other information. Injectable medications require prior authorization unless otherwise noted on the Preferred Drug List. Can the Preferred Drug List change? Yes, Mercy Maricopa Integrated Care may add or take off drugs during the year. To get the latest information about covered drugs, visit our website, www.MercyMaricopa.org, or call Member Services at 1-800-564-5465 or TTY 711. If we take a drug off the Preferred Drug List or add restrictions to it, we will let you know at least 60 days before. Or, if you request a refill and it is no longer covered, you will get a 60-day supply of the drug until your doctor can write you a new prescription. Also, if the Food and Drug Administration says a drug on our Preferred Drug List is unsafe or the drug’s maker takes the drug off the market, we will take the drug off our Preferred Drug List right away and let members who take the drug know. How do I use the Preferred Drug List? The Preferred Drug List begins on page 4. Drugs are grouped depending on the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Medications.” If you know what your drug is used for, look for the category name in the list that begins on page 18. Then look under the category name for your drug. Are there any other restrictions on coverage? Some drugs may have additional requirements or limits on coverage. These may include: • Prior Authorization: Mercy Maricopa may require prior authorization for certain drugs on the Preferred Drug List. This means that your doctor will need to get approval from us before you can fill some of your prescriptions. If approval isn’t given, Mercy Maricopa Integrated Care will not cover the drug. • Quantity Limits: For certain drugs, Mercy Maricopa limits the amount of the drug it will cover. For example, we provide 60 pills in 30 days per prescription for Lisinopril 40 mg. Please refer to the quantity limit levels list at the end of this document. • Step Therapy: In some cases, Mercy Maricopa requires you to try certain drugs first to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat your medical condition, Mercy Maricopa Integrated Care may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Updated September 1, 2015 2 You can find out if your drug has any additional requirements or limits by looking in the third column of the list. All brand-named drugs are subject to non-formulary status when generics are available. Key: Abbreviations: Cap = Capsule Chew = Chewable Conc = Concentrate DR = Delayed Release Elix = Elixir ER = Extended Release IM = Intermuscular INJ = Injectable IR = Immediate Release LA = Long Acting ODT = Oral Disintegrating Tablet PA – Prior Authorization required QLL – Quantity Limit Levels apply SL = Sublingual SOLN = Solution SR = Sustained Release Susp = Suspension Syr = Syrup STEP = Step Therapy Tab = Tablet TD = Transdermal XL = Extended Release What if my drug is not on the Preferred Drug List? If your drug is not on this Preferred Drug List, you should first call your doctor and ask if your drug is covered. If we do not cover it, you have two options: • Ask your doctor to prescribe a similar drug that is covered. • Your doctor can ask Mercy Maricopa to make an exception and cover your drug through the prior authorization process. What are generic drugs? Mercy Maricopa Integrated Care covers both brand name and generic drugs. Generic drugs usually cost less and are approved by the Food and Drug Administration (FDA). Generic drugs are listed in lower-case (e.g., amoxicillin). Brand name drugs are capitalized (e.g., AMOXIL). Mail order pharmacy service You can use our network mail order pharmacy service, CVS Caremark, to fill prescriptions for what are called “maintenance” drugs. These are drugs that you take on a regular basis for a chronic or long-term medical condition. These are the only drugs available through our mail order service. For more information on mail order pharmacy services, call Member Services. For more information For more detailed information about your Mercy Maricopa Integrated Care prescription drug coverage, please review your Member Handbook. If you have questions about Mercy Maricopa Integrated Care, please call Member Services at 1-800-564-5465. Or visit www.MercyMaricopa.org. Updated September 1, 2015 3 Preferred drug list COVERED DRUG ANESTHETICS TOPICAL ANESTHETICS lidocaine hcl topical cream, ointment, solution lidocaine hcl viscous lidocaine-prilocaine topical Lidocaine 5% Topical Patch ANTIINFECTIVES CEPHALOSPORINS Cefaclor cefaclor er Cefadroxil Cefdinir cefpodoxime proxetil Cefprozil Cefuroxime Cephalexin 250mg, 500mg Ceftriaxone cefuroxime axetil SUPRAX CLINDAMYCINS Clindamycin ERYTHROMYCINS ERY-TAB Erythromycin erythromycin ethylsuccinate erythromycin w/sulfisoxazole OTHER MACROLIDES Azithromycin clarithromycin, er PENICILLINS amox tr-potassium clavulanate Amoxicillin Ampicillin Dicloxacillin penicillin v potassium SULFONAMIDES sulfamethoxazole/trimethoprim Sulfadiazine TETRACYCLINES Demeclocycline Updated September 1, 2015 REFERENCE DRUG NAME REQUIREMENTS/LIMITS Xylocaine Xylocaine Emla Lidoderm Ceclor Ceclor Duricef Omnicef Vantin Cefzil Ceftin Keflex Rocephin Ceftin QLL=2 grams/Rx QLL= 1 tab/Rx Cleocin Eryc E.E.S. Pediazole Zithromax Biaxin, Biaxin XL Augmentin Amoxil Principen Veetids Septra 4 COVERED DRUG doxycycline hyclate, hyclate DR, monohydrate minocycline hcl tetracycline hcl URINARY ANTIINFECTIVES nitrofurantoin25 MG/5 ML SUSPENSION MACRODANTIN (25 MG ONLY) methenamine hippurate nitrofurantoin macrocrystal Nitrofurantoin suspension 25mg/ml Trimethoprim QUINOLONES ciprofloxacin oral suspension ciprofloxacin er ciprofloxacin hcl ofloxacin Levofloxacin TOPICAL ANTIBACTERIAL DRUGS bacitracin ointment bacitracin/polymyxin B Erythromycin gentamicin sulfate mupirocin ointment, cream neomycin/bacitracin/polymyxin B silver sulfadiazine sulfacetamide sodium ORAL ANTIFUNGAL DRUGS clotrimazole Fluconazole Flucytosine griseofulvin microsize griseofulvin ultramicrosize Itraconazole Ketoconazole NOXAFIL ORAL SUSPENSION Nystatin SPORANOX (ORAL SOLUTION) Terbinafine Voriconazole VAGINAL ANTIFUNGALS Clotrimazole nystatin Updated September 1, 2015 REFERENCE DRUG NAME Adoxa, Doryx, Periostat, Vibramycin Dynacin Sumycin REQUIREMENTS/LIMITS FURADANTIN Macrodantin Furadantin CIPRO ORAL SUSPENSION Cipro XR Cipro Floxin Levaquin Polysporin Eryderm Genoptic Bactroban Neosporin Silvadene Ovace QLL = 30/30days Mycelex Diflucan Ancobon GRIFULVIN V GRIS-PEG Sporanox Nizoral PA PA, QLL = 600ml/30days Mycostatin Lamisil Vfend QLL #90 per 365 days PA Mycelex Mycostatin 5 COVERED DRUG REFERENCE DRUG NAME Terconazole Terazol OTHER TOPICAL ANTIFUNGALS Ciclopirox Loprox/Penlac Clotrimazole Lotrimin econazole nitrate Spectazole Ketoconazole Nizoral Miconazole Nystatin Mycostatin Terbinafine Lamisil Tolnaftate TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB. clotrimazole/betamethasone Lotrisone nystatin w/triamcinolone Mycolog II ANTIRETROVIRALS & PROTEASE INHIBITORS abacavir tablet Ziagen abacavir Sulfate-LamivudineTrizivir Zidovudine 300mg-150mg-300mg APTIVUS ATRIPLA COMPLERA CRIXIVAN Didanosine Videx EC EDURANT EMTRIVA EPIVIR oral solution EPZICOM FUZEON INTELENCE INVIRASE ISENTRESS KALETRA lamivudine 100mg, 150mg, 300mg lamivudine-zidovudine 150mg-300mg LEXIVA nevirapine tablets, oral suspension NORVIR PREZISTA RESCRIPTOR REYATAZ SELZENTRY Stavudine STRIBILD Updated September 1, 2015 REQUIREMENTS/LIMITS COVERED FOR ID SPECIALISTS; ALL OTHERS REQUIRE PA Epivir, HBV Combivir Viramune Zerit 6 COVERED DRUG SUSTIVA TIVICAY TRIUMEQ TRUVADA TYBOST VIDEX ORAL SOLUTION VIRACEPT VIRAMUNE XR VIREAD VITEKTA ZIAGEN oral solution Zidovudine OTHER ANTIINFECTIVE DRUGS atovaquone suspension CLEOCIN (100 MG VAGINAL OVULE) Dapsone vancomycin capsules ZYVOX OTHER ANTIVIRAL DRUGS Acyclovir acyclovir 5% ointment adefovir dipivoxil amantadine hcl Entecavir EPIVIR HBV 100mg tab, oral solution Famciclovir foscarnet injection Ganciclovir HARVONI INFERGEN INTRON A PEGINTRON PEGINTRON REDIPEN PEGASYS Rimantadine REBETOL (ORAL SOLUTION) REFERENCE DRUG NAME REQUIREMENTS/LIMITS PA Mepron COVERED FOR ID SPECIALISTS; ALL OTHERS REQUIRE PA Vancocin pulvules QLL=40 caps/30 days PA Zovirax Zovirax ointment HEPSERA Symmetrel BARACLUDE QLL=60 caps or tabs/30 days PA Famvir Foscavir Cytovene RELENZA Ribavirin PA PA PA PA PA PA PA PA QLL = 30/30days PA; MUST BE ON INTERFERON QLL/Rx=20 inhalation diskus/Rx PA SOVALDI PA Updated September 1, 2015 Flumadine 7 TAMIFLU COVERED DRUG REFERENCE DRUG NAME TYZEKA valacyclovir VALCYTE Cidofovir injection ZOVIRAX (5% CREAM) ANTITUBERCULOSIS DRUGS Ethambutol Isoniazid isoniazid-rifampin PRIFTIN Pyrazinamide Rifabutin Rifampin AMEBICIDES YODOXIN ANTHELMINTICS Albenza Biltricide Mebendazole ivermectin PLASMODICIDES atovaquone-proguanil chloroquine phosphate COARTEM DARAPRIM hydroxychloroquine sulfate Mefloquine Primaquine Quinine sulfate TRICHOMONOCIDES Metronidazole AMINOGLYCOSIDES Neomycin Paromomycin Tobramycin Updated September 1, 2015 Valtrex VISTIDE INJECTION REQUIREMENTS/LIMITS QLL/Rx=75mg: 10 capsules /Rx 45mg: 10 capsules /Rx 30mg: 20 capsules/Rx 6mg/ml oral suspension 3 bottles/Rx COVERED FOR GASTROENTEROLOGISTS OR ID SPECIALISTS; ALL OTHERS REQUIRE PA 500 mg tablet QLL=60 tabs/30 days 1 gram tablet QLL=30 tabs/30 days PA PA Myambutol Nydrazid Isonarif, Rifamate Mycobutin Rifadin Stromectol Malarone Aralen Plaquenil Lariam Qualaquin Flagyl TOBI PA 8 COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS MEDICATIONS WITHIN THIS CLASS ARE COVERED FOR FDA APPROVED INDICATIONS AND MAY REQUIRE PRIOR AUTHORIZATION. ALL INJECTABLE MEDICATIONS WITHIN THIS CLASS REQUIRE PRIOR AUTHORIZATION. ACTIMMUNE PA ALKERAN TABS Anastrozole Arimidex Azathioprine Imuran Bicalutamide Casodex Capecitabine Xeloda PA CELLCEPT INJECTION PA COSENTYX PA cyclophosphamide Cytoxan PA (INJECTABLE ONLY) Cyclosporine Neoral PA (INJECTABLE ONLY) DEPO-PROVERA 400mg/ml (INJ) PA ELIGARD (INJ) PA ENBREL PA Exemestane Aromasin Fluorouracil Adrucil PA (INJECTABLE ONLY) Flutamide GLEEVEC PA HUMIRA PA Hydroxyurea Hydrea IRESSA PA Leflunomide Arava Letrozole Femara leucovorin tablets LEUPROLIDE PA LUPRON Depot PA megestrol acetate Megace Mercaptopurine Purinethol MESNEX TABLETS ONLY methotrexate 2.5mg Tab Trexall methotrexate INJ PA mycophenolate mofetil Cellcept Mycophenolic Acid 180mg & 360mg Myfortic Delayed-Release mitoxantrone [INJ] NOVANTRONE PA Octreotide Sandostatin PA ORENCIA PA REMICADE PA REVLIMID PA sirolimus Rapamune STIVARGA PA Updated September 1, 2015 9 COVERED DRUG TABLOID Tacrolimus tamoxifen citrate TARCEVA THALOMID Tretinoin VELCADE VOTRIENT ZOLADEX [INJ] ZOLINZA AUTONOMIC AND CNS MEDICATIONS ANALGESICS acetaminophen aspirin, enteric-coated aspirin buffered aspirin enteric-coated aspirin tramadol hcl tramadol ER tramadol hcl-acetaminophen CLASS II NARCOTICS fentanyl patches fentanyl lozenges hydrocodone-acetaminophen hydrocodone bit-ibuprofen hydromorphone hcl Meperidine methadone hcl morphine sulfate morphine sulfate ER tablets oxycodone-acetaminophen oxycodone-aspirin oxycodone hcl REFERENCE DRUG NAME Prograf Nolvadex Vesinoid PA PA PA PA PA COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA Tylenol OTC Bufferin, Ascriptin Ecotrin Ultram Ultram ER Ultracet QLL=240 tabs/30 days QLL= 30/30days QLL= 4 grams APAP/day Duragesic Actiq Vicodin, Lortab Vicoprofen Dilaudid Demerol Dolophine MS Contin QLL=15 patches/30 days QLL=90 lozenges /30 days QLL= 4 grams APAP/day QLL=240 tabs/30 days QLL =180 tabs/30 days QLL=180 tabs/30 days QLL=180 tabs/30 days Percocet QLL=240 tabs/30 days QLL=240 tabs/30 days QLL for 5 mg=240 tabs/30 days, 10 mg, 15 mg, 20 mg, or 30 mg=180 tabs/30 days PA/QLL=90 tabs/30 days STEP, QLL = #240/30days STEP, QLL= #60/30days Oxyir OXYCONTIN oxymorphone IR Opana IR oxymorphone ER Opana ER CLASS III NARCOTICS acetaminophen-codeine Tylenol #3 butalbital/aspirin/caffeine with Fiorinal with Codeine codeine DRUGS TO PREVENT AND TREAT HEADACHES Updated September 1, 2015 REQUIREMENTS/LIMITS QLL= 4 grams APAP/day QLL = 240/30days 10 COVERED DRUG butalbital/acetaminophen/caffeine butalbital/aspirin/caffeine ergotamine tartrate/caffeine ergoloid mesylates ERGOMAR Naratriptan Rizatriptan Sumatriptan sumatriptan INJ dihyrdoergotamine nasal spray MIGERGOT Suppository RELPAX ANXIOLYTICS alprazolam IR REFERENCE DRUG NAME Esgic/Fioricet/Triad Fiorinal, Fortabs Cafergot Hydergine REQUIREMENTS/LIMITS Amerge Maxalt Imitrex QLL= 9 tabs/30 days QLL= 12 tabs/30 days QLL= 6 nasal sprays/30 days; 9 tabs/30 days QLL=4 vials/30 days; 1 kit/30 days QLL=8 units/30 days QLL = 12/30days QLL=6 tabs/30 days Imitrex MIGRANAL QLL = 180/30days Xanax 0.25/0.5/1mg = #120 2mg = #60 QLL 120 ml/30 days 0.25/0.5/1mg = #120 2mg = #60 0.5/1mg = #120 2/3mg = #60 alprazolam intensol solution alprazolam ODT alprazolam XR buspirone hcl chlordiazepoxide hcl clorazepate dipotassium diazepam 2.5 mg, 10 mg, 20 mg rectal gel Diazepam diazepam intensol Lorazepam lorazepam intensol Oxazepam Meprobamate SEDATIVE/HYPNOTIC DRUGS Estazolam flurazepam hcl Eszopiclone Temazepam Triazolam ROZEREM Zaleplon zolpidem tabs Updated September 1, 2015 XanaxXR Buspar Librium Tranxene T-Tab Diastat QLL=2 pkgs/30 days Valium Diazepam Intensol Ativan QLL = 120/30days 240ml 0.5/1 mg = #120 2mg = #90 90ml/30 days Lorazepam Intensol Serax Various QLL=30 tabs/30 days QLL=30 caps/30 days QLL = 30/30days QLL=30 caps/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 caps/30 days QLL 5mg=60 tabs/30 days, QLL 10mg=30 tabs/30 days Dalmane LUNESTA Restoril Halcion ramelteon Sonata Ambien 11 COVERED DRUG Zolpidem ER INTERMEZZO SL / EDULAR ZOLPIMIST ANTIMANIA DRUGS lithium carbonate lithium carbonate ER Tab REFERENCE DRUG NAME Ambien CR zolpidem SL Tab zolpidem oral spray REQUIREMENTS/LIMITS PA PA PA Eskalith/CR Covered for RBHA Psych Providers all others require a PA Covered for RBHA Psych Providers all others require a PA Covered for RBHA Psych Providers all others require a PA Lithobid lithium oral solution CARBAMAZEPINES carbamazepine, ER Tab carbamazepine ER Cap oxcarbazepine tablets, suspension Carbamazepine XR ANTICONVULSANT/BENZODIAZEPINES clonazepam tab clonazepam ODT HYDANTOINS phenytoin sodium, ER DILANTIN 30 MG EXTENDED RELEASE phenytoin extended release capsules VALPROIC ACID AND DERIVATIVES divalproex divalproex sodium ER, delayedrelease valproic acid ANTICONVULSANT BARBITURATES Phenobarbital Primidone OTHER ANTICONVULSANTS BANZEL CELONTIN Ethosuximide Felbamate gabapentin Tab, Cap, Soln, Sprinkles gabapentin ER Tab gabapentin Tab GABITRIL 12 mg, 16 mg lamotrigine Updated September 1, 2015 Epitol, Tegretol Tegretol XR Carbatrol, Equetro Trileptal TEGRETOL XR Klonopin 0.5/1mg = #120 2mg = #60 0.125/0.25/0.5/1mg = #120 2mg = #60 Klonopin ODT Dilantin, ER, infatabs PHENYTEK Depakote Depakote ER, DelayedRelease Depakene Mysoline PA Felbatol Neurontin HORIZANT GRALISE PA PA QLL=60 tabs/30 days QLL = 60 tabs/ 30 days Lamictal 12 COVERED DRUG lamotrigine ER Tab levetiracetam, -ER LYRICA gabapentin solution ONFI tiagabine 2 mg, 4 mg Topiramate VIMPAT Zonisamide ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS Mirtazapine, - ODT REFERENCE DRUG NAME REQUIREMENTS/LIMITS Lamictal XR Keppra, Keppra XR QLL = 30/30days PA NEURONTIN SOLUTION MONOAMINE OXIDASE INHIBITORS (MAOIs) PA QLL=60 tabs/30 days Gabitril Topamax PA QLL=180 units/30 days Zonegran Remeron Remeron SolTab seligilene EMSAM Isocarboxazid Marplan phenelzine sulfate Nardil tranylcypromine sulfate Parnate NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIs) budeprion SR Wellbutrin SR bupropion IR, Wellbutrin, QLL = 30/30 Days COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA QLL = #60/30days QLL= #60/30 days Bupropion XL Wellbutrin XL QLL= #30/30 days bupropion hbr ER TAB APLENZIN PA TRICYCLIC ANTIDEPRESSANTS & RELATED NON-SELECTIVE REUPTAKE INHIBITORS amitriptyline hcl tab Elavil Amoxapine Clomipramine Anafranil desipramine hcl tab Norpramin doxepin hcl Tab, Conc Sinequan SILENOR PA imipramine hcl Tab, Cap Tofranil maprotiline hcl Various nortriptyline hcl Cap, Soln Pamelor protriptyline hcl Vivactil trimipramine Surmontil SELECTIVE SEROTONIN REUPTAKE INHIBITORS citalopram Tab, Soln Celexa QLL= 30 tabs/30 days Solution QLL = 300 ml/30 days Escitalopram Tab, Soln Lexapro QLL = 30/30days Solution QLL = 300 ml/30 days Updated September 1, 2015 13 COVERED DRUG fluoxetine hcl Cap, Tab, Soln REFERENCE DRUG NAME Prozac fluoxetine hcl DR Cap Prozac Weekly fluvoxamine maleate Luvox fluvoxamine maleate ER Cap paroxetine hcl Susp, Tab Luvox CR Paxil paroxetine ER Paxil CR PEXEVA sertraline hcl Soln, Tab Zoloft VIIBRYD SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIs) nefazodone trazodone hcl Desyrel REQUIREMENTS/LIMITS QLL 10 mg=30 tabs,caps/30 days; 20 mg = 120 tabs,caps/30 days 40 mg= 60 tabs,caps/ 30 days Soln=600 ml/30 days PA QLL = #1 pkg/28days QLL 100 mg=90 tabs/30 days; 50 mg=60 tabs/30 days; 25 mg= 30 tabs/30 days QLL = 30 caps/ 30 days QLL=60 tabs/30 days; 40 mg= #45/30 days Suspension = #900ml/30days 12.5 mg QLL = 30 tabs/30 days; 25 mg QLL = 60 tabs/30 days 37.5 mg =30 tabs/30 days PA QLL 10 MG= #180/30days 20 MG=#90/30days 30 MG=#60/30days 40 MG=#45/30days QLL for 25 mg=30 tabs/30 days 50/100 mg = 60 tabs/30days soln = #75 ml/30days PA QLL= #60/30days 40mg QLL = #30/30days QLL= #120/30days 300mg QLL = #60/30days SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) desvenlafaxine PRISTIQ QLL = 30/30days duloxetine hcl CYMBALTA QLL = 60 caps/30 days venlafaxine hcl Tab Effexor QLL = 90 tabs/ 30 days venlafaxine hcl ER Tab, Cap Effexor ER QLL=60 tabs or caps/30 days COMBINATION MEDICATIONS USED FOR THE TREATMENT OF BPAD fluoxetine hcl /olanzapine Symbyax QLL = #30/30 days; ANTIPSYCHOTICS Covered for RBHA Providers, All others require PA, PA Required for child < 6 FIRST GENERATION ANTIPYSYCHOTICS Haloperidol tab, Susp Haldol haloperidol decanoate Haldol Suspension for Injection Updated September 1, 2015 14 COVERED DRUG REFERENCE DRUG NAME loxapine succinate Loxitane ORAP pimozide thiothixene Navane SECOND GENERATION ANTIPSYCHOTICS ABILIFY Tab Abilify ABILIFY, - ODT, solution ABILIFY MAINTENA clozapine Tab Clozaril clozapine ODT Tab FazaClo FANAPT INVEGA INVEGA SUSTENNA LATUDA olanzapine olanzapine ODT quetiapine Tab Zyprexa Zyprexa Zydis Seroquel SEROQUEL XR risperidone RISPERDAL CONSTA Risperdal M-TAB SAPHRIS Updated September 1, 2015 Risperdal REQUIREMENTS/LIMITS QLL = #30/30 days PA QLL = #30/30days Solution QLL = #480ml/30days PA 25mg QLL = #360/30days 50mg QLL = #90/30days 100mg QLL = #270/30days 200mg QLL = #90/30days Suspension QLL = #240ml/30days QLL = 12.5mg, 25mg = #360, 100mg = #270, 150mg, 200mg = #90 PA QLL = 1mg,2mg,4mg #60 6mg,8mg,10mg, 12mg #30 Titration pack = #1 PA PA PA QLL = #60/30days 120mg QLL = #30/30days 2.5mg, 5mg QLL = # 30 tabs/30 days 7.5mg, 10mg, 15mg, 20mg QLL = #30/30days QLL = #30/30 days 25 mg, 50 mg QLL = #30/30 days 100 mg, 200 mg, 300 mg, 400 mg QLL = #60/30 days PA QLL = #30/30days 0.25 mg, 0.5 mg, 1 mg, 2 mg, QLL = #90/30 days; 3 mg QLL = #60/30 days; 4 mg QLL = #60/30 days Solution QLL = #240ml/30days QLL = #2 inj/28 days 0.25mg, 0.5mg, 1mg QLL = #90/30 days; 2mg, 3mg, 4mg QLL = #60/30days PA; QLL = #60/30 days 15 COVERED DRUG REFERENCE DRUG NAME ziprasidone hcl Geodon PHENOTHIAZINE ANTIPSYCHOTICS chlorpromazine hcl Various fluphenazine decanoate Inj Prolixin fluphenazine hcl Tab, Susp, Elix Prolixin perphenazine Tab Trilafon thioridazine hcl Tab Mellaril trifluoperazine hcl Tab Stelazine ANTIVERTIGO AND ANTIEMETIC DRUGS ANZEMET DICLEGIS granisetron Kytril meclizine ondansetron, -ODT 4mg, 8mg, oral solution ondansetron 24mg prochlorperazine maleate promethazine hcl trimethobenzamide 250 mg, 300 mg capsules, 200 mg suppositories EMEND ANTIPARKINSON ANTICHOLINERGIC DRUGS benztropine mesylate trihexyphenidyl OTHER ANTIPARKINSON DRUGS bromocriptine mesylate carbidopa/levodopa carbidopa/levodopa/entacapone PA QLL = maximum 120 tabs COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA Zofran, -ODT QL 4mg: #180/30days QL 8mg: #90/30days QL Solution #150ml/30days PA Zofran Compazine Phenergan Tigan QLL=6 tabs/30 days Cogentin Artane Parlodel Sinemet Stalevo EMSAM seligilene entacapone pramipexole ropinirole selegiline DRUGS FOR MULTIPLE SCLEROSIS AVONEX BETASERON COPAXONE 20mg, 40mg GILENYA Comtan Mirapex Requip Updated September 1, 2015 REQUIREMENTS/LIMITS Qll = #60/30 days COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA QLL=270 tabs/30 days COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA QLL=90 tabs/30 days PA PA PA PA 16 COVERED DRUG REFERENCE DRUG NAME REBIF CNS STIMULANT DRUGS PA Required for child < 6 amphetamine/dextroamphetamine, Adderall, extended-release Adderall XR DAYTRANA Dextroamphetamine, ER Cap VYVANSE dexmethylphenidate hcl dexmethylphenidate ER FOCALIN XR 25mg and 35mg Methylin Tabs, Chew Tabs methylphenidate CD methylphenidate er, sr methylphenidate hcl methylphenidate suspension QUILLIVANT XR methylphenidate Dexedrine, Dexedrine Spansule lisdexamfetamine dimesylate Focalin Focalin XR Cap dexmethylphenidate ER Ritalin, Ritalin SR Metadate CD Concerta, Ritalin-LA, Ritalin-SR Ritalin Methylin Suspension Methylphenidate susp RITALIN LA 10mg ANTIDEMENTIA DRUGS donepezil 5MG, 10 MG (23 MG IS NON-FORMULARY) donepezil ODT EXELON PATCH galantamine, -ER memantine rivastigmine capsules SMOKING CESSATION DRUGS bupropion SR buproban CHANTIX Updated September 1, 2015 REQUIREMENTS/LIMITS PA Immediate release QLL= 5/7.5/10/12.5mg= #90 15/20/30mg = #60 XR QLL=30 caps/30 days PA Spansule QLL = #60/30 days; IR QLL = #90/30 days QLL = #30/30 days QLL = #60/30 days QLL = #30/30 days QLL = #30/30 days QLL= #90/30 days QLL = #30/30days QLL=#30/30 days Children under 6 yrs require a PA; QLL= #90 /30 days QLL= 900ml/30days PA; Children under 6 yrs require a PA QLL = 900ml/30days Children under 6 yrs require a PA; QLL=#30/30 days Aricept QLL=30 tabs/30 days Aricept ODT QLL=30 tabs/30 days PA PA; galantamine QLL=60 tabs/30 days galantamine ER QLL=30 caps/30 days Razadyne, Razadyne ER Namenda Exelon Zyban PA; QLL=60 caps/30 days MONTHLY QLL=60 tabs/30 days; COVERED FOR 90 DAYS/ 6 MONTH PERIOD MONTHLY COMBINED QLL=0.5 mg,1 17 COVERED DRUG REFERENCE DRUG NAME nicotine gum OTC nicotine lozenge OTC nicotine patch OTC NICOTROL CARTRIDGE NICOTROL NASAL SPRAY OTHER ADHD DRUGS PA Required for child < 6 STRATTERA SUBSTANCE ABUSE OPIATE AGONISTS/PARTIAL AGONISTS Subutex buprenorphine hcl SL Tab buprenorphine hcl /naloxone SL Tab Suboxone SUBOXONE FILM buprenorphine hcl / naloxone methadone Dolophine OPIATE ANTAGONISTS naltrexone Revia VIVITROL naltrexone INJ MISCELLANEOUS AGENTS Updated September 1, 2015 REQUIREMENTS/LIMITS mg=60 tabs/30 days; QLL=1 starter pack/month; COVERED FOR 90 DAYS/ 6 MONTH PERIOD MONTHLY QLL 2 MG=660 pieces/30 days; MONTHLY QLL 4 MG=330 pieces/30 days; COVERED FOR 90 DAYS/ 6 MONTH PERIOD MONTHLY QLL=324 lozenges/30 days; COVERED FOR 90 DAYS/ 6 MONTH PERIOD MONTHLY QLL=30 patches/30 days; COVERED FOR 90 DAYS/ 6 MONTH PERIOD MONTHLY QLL=3 boxes/30 days; COVERED FOR 90 DAYS/ 6 MONTH PERIOD MONTHLY QLL=15 bottle/30 days; COVERED FOR 90 DAYS/ 6 MONTH PERIOD QLL = #30/30 days Covered for RBHA PROIVDERS All others require a PA QLL = #90/30 days Covered for RBHA/PROVIDERS. All others require a PA QLL = #90/30 days PA; can only be prescribed by RBHAPROVIDERS QLL = #90/30 days Covered for Opioid Treatment Program (OTP) Providers only Covered for RBHA/Suboxone certified Physicians. All others require a PA; QLL = #30/30 days Covered for RBHA/Suboxone certified Physicians. All others require a PA 18 COVERED DRUG acamprosate DR Tab disulfiram OTHER CNS DRUGS caffeine citrate oral solution phentermine pyridostigmine CARDIOVASCULAR MEDICATIONS CARDIAC GLYCOSIDES digoxin LANOXIN CALCIUM ANTAGONISTS amlodipine cartia xt diltiazem er diltiazem hcl diltia xt dilt-CD felodipine er isradipine Matzim LA nicardipine hcl nifediac cc nifedical xl nifedipine, er nimodipine Nisoldipine verapamil, er CARBONIC ANHYDRASE INHIBITORS acetazolamide, -ER LOOP DIURETICS bumetanide furosemide torsemide THIAZIDE AND RELATED DRUGS chlorthalidone chlorothiazide hydrochlorothiazide indapamide metolazone Updated September 1, 2015 REFERENCE DRUG NAME CAMPRAL Antabuse REQUIREMENTS/LIMITS Adipex PA Lanoxin Norvasc Cardizem CD Tiazac/Taztia XT Cardizem Cardizem CD Cardizem CD Plendil Dynacirc Cardizem LA Cardene Procardia Procardia XL Nimotop Sular Verelan/Calan/Calan SR QLL= 30 tabs/30 days QLL=60 caps/30 days QLL=60 caps or tabs/30 days QLL=120 tabs/30 days QLL=60 caps/30 days QLL=60 caps/30 days QLL = 60/30days QLL = 90/30days QLL=90/30 days Extended Release QLL=90/30 days QLL=60 tabs/30 days QLL for Immediate Release=120 units/30days; QLL for Extended Release=60 units/30 days Diamox Bumex Lasix Demadex Microzide Lozol Zaroxolyn 19 COVERED DRUG REFERENCE DRUG NAME methyclothiazide Aquatensen, Enduron POTASSIUM SPARING DIURETICS amiloride amiloride hcl w/hctz Midamor eplerenone Inspra spironolactone Aldactone spironolactone w/hctz Aldactazide triamterene w/hctz Maxzide/Diazide BETA-ADRENERGIC ANTAGONIST DRUGS acebutolol atenolol Tenormin bisoprolol fumarate Zebeta carvedilol Coreg labetalol hcl Normodyne/Trandate metoprolol succinate Toprol XL metoprolol tartrate Lopressor nadolol Corgard pindolol propranolol, er Inderal/LA timolol maleate VASODILATOR ANTIHYPERTENSIVES doxazosin mesylate Cardura hydralazine hcl Apresoline minoxidil prazosin hcl terazosin hcl REQUIREMENTS/LIMITS PA QLL=30 tabs/30 days Minipress Hytrin QLL 1mg, 2mg, 5mg=30/30 days; QLL 10 mg=60/30 days CENTRALLY ACTING ANTIHYPERTENSIVES clonidine patches Catapres TTS clonidine tablets Catapres guanfacine hcl Tenex guanfacine ER INTUNIV clonidine ER KAPVAY ANGIOTENSIN CONVERTING ENZYME INHIBITORS benazepril hcl Lotensin captopril Capoten enalapril maleate Vasotec fosinopril sodium Monopril lisinopril Prinivil/Zestril moexipril hcl perindopril Updated September 1, 2015 PA QLL = #30/30 days QLL=30 tabs/30 days; 40 mg=60 tabs/30 days Univasc Aceon 20 COVERED DRUG REFERENCE DRUG NAME quinapril hcl Accupril ramipril Altace trandolapril Mavik ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR BENICAR HCT valsartan valsartan HCTZ irbesartan losartan Losartan HCT OTHER ANTIHYPERTENSIVES amlodipine/benazepril Amlodipine/valsartan Amlodipine/valsartan w hctz atenolol w/chlorthalidone benazepril hcl w/hctz bisoprolol fumarate w/hctz captopril w/hctz enalapril maleate w/hctz fosinopril w/hctz lisinopril w/hctz methyldopa w/hctz metoprolol w/hctz moexipril w/hctz nadolol-bendroflumethiazide propranolol hcl w/hctz quinapril w/hctz NITRATES isosorbide dinitrate isosorbide mononitrate nitro-bid ointment nitroglycerin (patch, sublingual tablet,) NITROSTAT OTHER VASODILATING DRUGS ADCIRCA epoprostenol LETAIRIS Updated September 1, 2015 Diovan Diovan-HCT Avapro Cozaar HYZAAR REQUIREMENTS/LIMITS STEP; COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA; QLL=30 tabs/30 days STEP; COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA; QLL=30 tabs/30 days ; QLL=60 tabs/30 days; QLL=30 tabs/30 days Lotrel EXFORGE EXFORGE HCT Tenoretic Lotensin HCT Ziac Capozide Vaseretic Monopril HCT Prinzide/Zestoretic QLL = 30/30days QLL = 30/30days Lopressor HCT Uniretic Corzide Inderide Quinaretic Isochron/Isordil Imdur/Ismo/Monoket Nitro-Dur/Nitrostat PA PA PA Flolan 21 COVERED DRUG REMODULIN sildenafil TRACLEER TYVASO VENTAVIS CLASS 1A ANTIARRHYTHMICS disopyramide quinidine gluconate quinidine sulfate CLASS 1B ANTIARRHYTHMICS mexiletine CLASS 1C ANTIARRHYTHMICS flecainide acetate propafenone hcl, SR 12hr OTHER ANTIARRHYTHMICS amiodarone MULTAQ RANEXA sotalol TIKOSYN HYPOLIPOPROTEINEMICS cholestyramine, -light colestipol hcl fenofibrate 54mg, 67mg, 134mg, 160mg, 200mg fenofibrate 48 mg, 145 mg fenofibric acid gemfibrozil OTC niacin Niacin tab CR ZETIA HMG-COA REDUCTASE INHIBITORS atorvastatin fluvastatin lovastatin pravastatin simvastatin Updated September 1, 2015 REFERENCE DRUG NAME REQUIREMENTS/LIMITS PA COVERED WHEN PRESCRIBED BY CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA; QLL=90 tabs/30 days PA PA PA Revatio Norpace Mexitil Tambocor Rythmol, Rythmol SR Pacerone Betapace COVERED FOR CARDIOLOGISTS; ALL OTHERS REQUIRE PA PA PA Questran, Questran Light Colestid Lofibra Tricor Trilipix Lopid QLL = #60/30days SLO NIACIN OTC STEP Lipitor Lescol Mevacor QLL=30 tabs/30 days QLL=30 caps/30 days QLL=30 tabs/30 days; 40 mg=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days Pravachol Zocor 22 COVERED DRUG LESCOL XL OTHER CARDIOVASCULAR DRUGS midodrine pentoxifylline DERMATOLOGICAL MEDICATIONS TOPICAL CORTICOSTEROID DRUGS alclometasone dipropionate amcinonide betamethasone dipropionate betamethasone valerate CAPEX SHAMPOO clobetasol propionate CORDRAN TAPE desonide desoximetasone diflorasone diacetate fluocinolone cream, solution fluocinolone body oil, scalp oil fluocinonide 0.05%: fluticasone propionate halobetasol hydrocortisone hydrocortisone butyrate hydrocortisone valerate mometasone furoate prednicarbate triamcinolone acetonide ANTIPRURITIC DRUGS hydroxyzine hcl hydroxyzine pamoate ANTIACNE DRUGS adapalene cream, gel amnesteem benzoyl peroxide benzoyl peroxide-erythromycin 5%3% gel claravis clindamycin phosphate erythromycin metronidazole cream, gel, lotion salicylic acid cream, gel, lotion, sod.sulfacetamide/sulfur Updated September 1, 2015 REFERENCE DRUG NAME REQUIREMENTS/LIMITS QLL=30 tabs/30 days ProAmatine Trental Aclovate Diprolene Beta-Val Clobevate/Temovate Desowen/Lokara Topicort Apexicon/Maxiflor/Psorcon Synalar Derma-Smoothe FS Oil Cutivate Ultravate Ala-Cort/Cetacort/Hytone Locoid Westcort Elocon Dermatop Kenalog Differin Accutane Benzamycin Accutane Cleocin T/Clindamax A/T/S / Emgel/Erycette Metrocream, Metrogel, Metrolotion Avar/Plexion 23 COVERED DRUG REFERENCE DRUG NAME Accutane Avita/Retin-A sotret tretinoin KERATOLYTIC DRUGS CONDYLOX GEL podofilox solution Condylox ANTIPSORIASIS AND ANTIECZEMA DRUGS calcipotriene cream, ointment, scalp Dovonex solution coal tar DOAK TAR DISTILLATE DRITHO-SCALP POLYTAR selenium sulfide Selseb sulfacetamide sodium Carmol Scalp VECTICAL OINTMENT ORAL DERMATOLOGICAL DRUGS METHOXSALEN RAPID CAP 10 MG OXSORALEN ULTRA TOPICAL DERMATOLOGICAL DRUGS ammonium lactate OTC lotion, cream Lac-Hydrin FLUOROPLEX fluorouracil Efudex capsaicin OTC CARAC aluminum chloride 20% DRYSOL 20% ELIDEL REQUIREMENTS/LIMITS QLL = 45 gm/30 days COVERED FOR AGE 2 THROUGH10; STEP FOR ALL OTHERS QLL=30 gm/30 days HYPERCARE 20% aluminum chloride imiquimod 5% cream Aldara SANTYL urea 40% cream, 50% ointment wart remover (salicylic acid 17%) Occlusal-HP SCABICIDES/PEDICULICIDES cumulative QLL = 454gm per 180days EURAX malathion 0.5% lotion Ovide spinosad 0.9% TOPICAL SUSPENSION NATROBA permethrin 5% cream Elimite piperonyl butoxide/pyrethrins OTC Rid shampoo pyrethrin 0.33% OTC shampoo SKLICE PA, QLL = 1 pkg per 180days QLL = 1 pkg per 180days STEP; QLL=240ml/30 days QLL = 2 pkg per 180days QLL = 1 pkg per 180days QLL = 1 pkg per 180days STEP QLL = 1 pkg per 180days QLL = 2 pkg per 180days ULESFIA 5% LOTION Updated September 1, 2015 24 COVERED DRUG REFERENCE DRUG NAME EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE EAR antipyrine/benzocaine otic Benzotic/Otogesic acetic acid, -HC otic carbamide peroxide Debrox CIPRO HC CIPRODEX OTIC neomycin/polymixin/hydrocortisone ofloxacin DRUGS AFFECTING THE NOSE azelastine Astelin flunisolide Nasarel fluticasone propionate Flonase fluticasone OTC ipratropium bromide Atrovent NASONEX OTC Nasacort Allergy 24 hour spray OTC oxymetazoline nasal spray triamcinolone acetonide nasal Nasacort AQ DRUGS AFFECTING THE THROAT AND MOUTH ABREVA APHTHASOL chlorhexidine gluconate 0.12% rinse Peridex DENAVIR doxycycline hyclate, hyclate DR, Adoxa, Doryx, Periostat, monohydrate Vibramycin pilocarpine hcl Salagen Saliva substitute Salivart Spray triamcinolone acetonide Kenalog in Orabase ENDOCRINE MEDICATIONS ORAL HYPOGLYCEMIC DRUGS acarbose Precose chlorpropamide Diabinese glimepiride Amaryl glipizide, er Glucotrol, XL glipizide-metformin Metaglip glyburide, -micro Diabeta/Micronase glyburide-metformin Glucovance JANUMET, JANUMET XR JANUVIA metformin Glucophage metformin ER 500mg, 750mg Glucophage XR (generics for Glucophage XR only) Updated September 1, 2015 REQUIREMENTS/LIMITS STEP/QLL=2 bottles/30 days PA STEP STEP 25 COVERED DRUG nateglinide PRANDIMET repaglinide tolazamide tolbutamide INSULIN SENSITIZERS AVANDAMET AVANDARYL AVANDIA DUETACT pioglitazone pioglitazone-metformin GLUCOSE ELEVATING DRUGS GLUCAGON glucose chewable tablets OTC INSULIN HUMULIN 50/50 HUMULIN N PEN HUMULIN R (500 U/ML VIAL) HUMULIN 70/30 NOVOLIN 70/30 NOVOLIN R NOVOLIN N NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 FLEXPEN LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR PEN OTHER GLUCOSE-LOWERING DRUGS BYETTA VICTOZA GLUCOCORTICOID DRUGS cortisone dexamethasone hydrocortisone hydrocortisone injection methylprednisolone methylprednisolone injection prednisolone prednisone Updated September 1, 2015 REFERENCE DRUG NAME Starlix REQUIREMENTS/LIMITS Prandin QLL=60 tabs/30 days QLL=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=90 tabs/30 days Actos Actoplus Met PA PA PA PA STEP STEP Cortef Solu-Cortef Medrol Solu-Medrol Prelone Sterapred PA PA 26 COVERED DRUG REFERENCE DRUG NAME prednisolone sodium phosphate, ORAPRED, -ODT ODT triamcinolone INJ Kenalog GROWTH HORMONES AND RELATED AGENTS INCRELEX NORDITROPIN NORDITROPIN NORDIFLEX NUTROPIN NUTROPIN AQ SEROSTIM TEV-TROPIN MINERALOCORTICOID DRUGS fludrocortisone acetate Florinef THYROID SUPPLEMENTS ARMOUR THYROID levothroid levothyroxine sodium Levothyroid / Synthroid Levoxyl levothyroid liothyronine Cytomel thyroid, dessicated Armour Thyroid unithroid Synthroid ANTITHYROID DRUGS methimazole Tapazole propylthiouracil ANDROGEN DRUGS ANDRODERM PATCH ANDROGEL ANDROXY danazol fluoxymesterone METHITEST TESTIM testosterone cypionate injection (200 mg/ml only) testosterone enanthate injection OTHER ENDOCRINE DRUGS alendronate sodium Fosamax cabergoline calcitonin nasal spray desmopressin acetate Updated September 1, 2015 Dostinex Miacalcin DDAVP/Minirin REQUIREMENTS/LIMITS PA PA PA PA PA PA PA PA PA PA PA PA PA QLL 35 mg or 70 mg=4 tabs/30 days; QLL 5 mg,10 mg, 40 mg=30 tabs/30 days COVERED FOR ENDO; ALL OTHERS REQUIRE PA QLL=90 tabs/30 days 27 COVERED DRUG etidronate fortical nasal spray KUVAN MIACALCIN (INJ) zoledronic solution(INJ) SENSIPAR REFERENCE DRUG NAME Didronel RECLAST (INJ) GASTROINTESTINAL MEDICATIONS ANTIDIARRHEAL DRUGS bismuth subsalicylate Kaopectate diphenoxylate w/atropine Lomotil loperamide hcl Imodium ANTISPASMODICS/DRUGS AFFECT GI MOTILITY dicyclomine hcl Bentyl glycopyrrolate tablets Robinul hyoscyamine Nulev/Levbrel metoclopramide hcl Reglan ANTIULCER DRUGS cimetidine tablets Tagamet famotidine tablets Pepcid nizatidine tablets Axid ranitidine tablets, syrup, solution Zantac OTHER ANTIULCER DRUGS misoprostol Cytotec sucralfate Carafate CARAFATE SUSPENSION PROTON PUMP INHIBITORS First-lansoprazole 3mg/ml oral suspension First-omeprazole 2mg/ml oral suspension lansoprazole Cap Prevacid, omeprazole RX, omeprazole OTC Prilosec, OTC Prilosec pantoprazole LAXATIVES AND CATHARTICS bisacodyl constulose Updated September 1, 2015 REQUIREMENTS/LIMITS Protonix PA PA PA COVERED FOR NEPHROLOGIST; ALL OTHERS REQUIRE PA QLL = 240tabs/30day, 1200ml/30days QLL=30 caps or tabs/30 days omeprazole 10mg QLL=30 caps/30 days, omeprazole 20mg QLL=120 caps or tabs/30 days, omeprazole 40mg QLL=270 caps/30 days. QLL=30 tabs/30 days 28 COVERED DRUG DOCUSOL ENEMA docusate ENEMEEZ ENEMA OTC FLEET BISACODYL ENEMA KONSYL D OTC MIRALAX OTC polyethylene glycol 3350 powder for solution psyllium OTC SENOKOT OTC (brand and generic OTC dosage forms covered) SORBITOL OTC 70% ORAL SOLN OTHER GI DRUGS OTC aluminum hydroxide gel AMITIZA antacids ASACOL HD balsalazide belladonna alkaloids-opium budesonide CANASA CORTIFOAM CREON LIPASE 3,000; 6,000; 12,000; 24,000 UNITS Delzicol DIPENTUM hydrocortisone 1%, 2.5% rectal cream hydrocortisone rectal enema suspension hydrocortisone with pramoxine rectal cream IPECAC SYRUP LINZESS mesalamine enema NULYTELY WITH FLAVOR PACKS PANCREAZE PANCRELIPASE 5,000 UNITS PEG 3350 ELECTROLYTE SOLUTION PENTASA PramCort 1%-1% Topical Cream Pramosone 1%-1% Topical Cream Updated September 1, 2015 REFERENCE DRUG NAME REQUIREMENTS/LIMITS Colace QLL=510 gm/30 days QLL=527 gm/30 days Metamucil Alternagel QLL=60 caps/30 days Mylanta, Maalox Colazal QLL=270 caps/30 days Entocort EC QLL=90 caps/30 days Proctocort 1%, Proctosol-HC 2.5% Colocort/ Cortenema Pramcort, Pramosone 145mcg Capsule QLL= 60/30days 290mcg Capsule QLL= 30/30days Rowasa 29 COVERED DRUG Proctocort 1%, Procto Pak Proctocream- HC, PROCTOFOAM-HC Proctosol-HC, Proctozone-HC propantheline sulfasalazine ULTRESA LIPASE 13,800 unit, 20,700 unit, 23,000 unit ursodiol ZENPEP 5,000U; 10,000U, 15,000U, 20,000U IMMUNOLOGICALS AND VACCINES GARDASIL REFERENCE DRUG NAME Azulfidine Actigall RHOGAM WINRHO MUSCULOSKELETAL MEDICATIONS SALICYLATES AND RELATED DRUGS aspirin choline magnesium trisalicylate diflunisal Dolobid salsalate Disalcid NON-STEROIDAL ANTIINFLAMMATORY AGENTS celecoxib CELEBREX diclofenac sodium Voltaren diclofenac ER Voltaren XR etodolac Lodine/Lodine XL fenoprofen flurbiprofen Anasaid ibuprofen Motrin, Advil indomethacin Indocin SR ketoprofen Orudis/Oruvail ketorolac Toradol meclofenamate meloxicam Mobic nabumetone Relafen naproxen Naprosyn, Aleve oxaprozin Daypro piroxicam Feldene sulindac Clinoril tolmetin OTHER DRUGS FOR ARTHRITIS RIDAURA Updated September 1, 2015 REQUIREMENTS/LIMITS COVERED BY AHCCCS (THROUGH MEDICAL BENEFIT) for MALES AND FEMALES THROUGH AGE 26 STEP QLL=20 tabs/30 days COVERED FOR RHEUMATOLOGIST; 30 COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS ALL OTHERS REQUIRE PA DRUGS TO PREVENT AND TREAT GOUT allopurinol Zyloprim colchicine / probenecid colchicine 0.6mg COLCRYS probenecid ULORIC DIRECT MUSCLE RELAXANTS baclofen tizanidine hcl tablets, capsules 2mg, Zanaflex tablets, capsules 4mg CNS MUSCLE RELAXANTS carisoprodol Soma cyclobenzaprine hcl Flexeril dantrolene capsule Dantrium methocarbamol Robaxin metaxalone Skelaxin OTHER MUSCULOSKELETAL MEDICATIONS riluzole Rilutek PA QLL=120 tabs/30 days QLL=120 tabs/30 days QLL=120 tabs/30 days QLL=120 tabs/30 days COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA NUTRITION, BLOOD MODIFIERS, ELECTROLYTES, ENZYME REPLACEMENT THERAPEUTIC VITAMINS & MINERALS alpha-tocopherol Vitamin E – Various CALCIFEROL Drisdol calcitriol Calcijex/Rocaltrol calcium acetate capsules, tablets Phoslo calcium carbonate, - with vitamin D Tums/Maalox, Calcitrate +D, Caltrate +D calcium citrate Citracal OTC cholecalciferol Vitamin D3 Vitamin B12 500mcg, 1000mcg tab Vitamin B12 cyanocobalamin [inj] PA ergocalciferol Vitamin D2 ferrous gluconate ferrous sulfate folic acid Iron up liquid OTC Fish Oil (omega-3 fatty acids) levocarnitine COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA magnesium oxide tablets multivitamin with fluoride poly-vitamin drops, -w iron drops QLL=1 bottle/30 days Updated September 1, 2015 31 COVERED DRUG NEPHROCAPS paricalcitol REFERENCE DRUG NAME REQUIREMENTS/LIMITS ZEMPLAR COVERED FOR NEPHROLOGIST; ALL OTHERS REQUIRE PA PHOS-NAK, K-PHOS NEUTRAL TABLETS pyridoxine Vitamin B6 - Various sodium bicarbonate sodium fluoride drops, chewable tablets, tablets thiamine Vitamin B1 - Various POTASSIUM SUPPLEMENTS citric acid/sodium citrate oral soln Bicitra klor con, klor con m, klor con effervescent potassium citrate ER potassium chloride caps, tabs, oral K-Dur/Klotrix solution SHOHL’S MODIFIED POTASSIUM REMOVING RESINS sodium polystyrene sulfonate Kayexalate ORAL ANTICOAGULANTS PRADAXA Eliquis warfarin sodium Coumadin Xarelto HEPARINS heparin sodium [inj] (heparin lock flush solution not covered) LOW-MOLECULAR WEIGHT HEPARINS (LMWH) enoxaparin [inj] Lovenox QLL=60 caps/30 days 10 DAYS W/O PA (10 DAYS=20 SYRINGES) 10 DAYS W/O PA (10 DAYS=10 SYRINGES) FRAGMIN [inj] ANTIPLATELET DRUGS BRILINTA cilostazol clopidogrel dipyridamole ticlopidine hcl HEMOSTATICS aminocaproic acid MEPHYTON HEMATOPOIETIC AGENTS Updated September 1, 2015 PA, QLL = 60/30 days Pletal Plavix Persantine Ticlid QLL=30 tabs/30 days Amicar 32 COVERED DRUG EPOGEN, PROCRIT PROMACTA NEUPOGEN NEULASTA BLOOD DETOXICANTS AURYXIA enulose generlac lactulose FOSRENOL RENAGEL sevelamer OTHER BLOOD MODIFIERS anagrelide ARCALYST SOLIRIS REFERENCE DRUG NAME REQUIREMENTS/LIMITS PA PA PA PA PA PA RENVELA Agrylin PA COVERED FOR HEMATOLOGIST; ALL OTHERS REQUIRE PA ENZYME REPLACEMENTS CEREZYME PA ELAPRASE PA SUCRAID PA OBSTETRICAL & GYNECOLOGICAL MEDICATIONS PRENATAL VITAMINS QLL=100 tabs/90 days for single prenatal vitamins; QLL=60/30 days for combo pack prenatal vitamins complete natal DHA CONCEPT DHA fe plus tablet prenatal advantage (prenatal AD) prenatal low iron SELECT-OB, SELECT-OB + DHA trinate vinatal forte vinate II vinate az vinate calcium vinate gt vinate one vinate m vinate ultra vitafol-ob vitafol-pn OB/GYN TOPICAL ANTIINFECTIVES AVC vaginal cream Updated September 1, 2015 33 COVERED DRUG REFERENCE DRUG NAME CLEOCIN OVULE clindamycin 2% vaginal cream Clindamax metronidazole 0.75% vaginal gel MetroGel miconazole vaginal suppositories, cream MONISTAT 3 and 7 OTC VAGINAL CREAM AND COMBINATION PACK ESTROGEN DRUGS CENESTIN estradiol tablets Estrace estradiol transdermal patch Climara estropipate Ogen/Ortho-Est ESTRACE VAGINAL CREAM ESTRING FEMRING MENEST PREMARIN PREMARIN CREAM VAGIFEM Estradiol Dis (twice weekly) patch VIVELLE DOT ESTROGEN/PROGESTIN COMBINATIONS CLIMARA PRO COMBIPATCH estradiol/norethindrone acetate Activella 0.5mg-0.1mg 0.5mg-0.1mg, 1 mg-0.5 mg Activella1 mg-0.5mg Norethindrone acetate/ ethinyl Femhrt estradiol 0.5mg/2.5mcg PREFEST PREMPHASE PREMPRO SELECTIVE ESTROGEN RECEPTOR MODULATOR raloxifene Evista PROGESTIN DRUGS medroxyprogesterone acetate Provera norethindrone acetate Aygestin progesterone capsule Prometrium OTHER OB/GYN DRUGS METHERGINE TABLETS OPHTHALMIC MEDICATIONS OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS bacitracin ophth ointment bacitracin/polymixin ophth ointment AK-Poly Bac ciprofloxacin hcl (ophth drops) Ciloxan Updated September 1, 2015 REQUIREMENTS/LIMITS QLL=4 patches/30 days QLL=8 patches/30 days QLL = 30/30days QLL for injection=1/90 days 34 COVERED DRUG REFERENCE DRUG NAME CILOXAN OPTHALMIC OINTMENT erythromycin gatifloxacin 0.5% ophthalmic solution ZYMAXID gentamicin sulfate Garamycin/Gentak levofloxacin 0.5% ophth soln Quixin neomycin/polymyxin/bacitracin Neosporin neomycin/polymyxin/gramicidin ofloxacin Ocuflox polymyxin/trimethoprim Polytrim sulfacetamide sodium Bleph-10 tobramycin sulfate Tobrex TOBREX OINTMENT VIGAMOX OPHTHALMIC CORTICOSTEROID DRUGS dexamethasone PRED MILD prednisolone Omnipred/Pred Forte fluorometholone FML FORTE OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS bacitracin/neomycin/polymixinB/ hydrocortisone BLEPHAMIDE DROPS, OINT. neomycin/polymixin/hydrocortisone Cortisporin neomycin/polymyxin/dexamethasone Methadex/Maxitrol Neomycin/bacitracin/polymixin B/hydrocortisone prednisolone/sulfacetamide prednisolone/gentamicin sulfate Pred G TOBRADEX OINTMENT tobramycin/dexamethasone susp Tobradex ANTIGLAUCOMA DRUGS acetazolamide, -ER AZOPT BETOPTIC S betaxolol hcl 0.5% brimonidine tartrate Alphagan, Alphagan P carteolol hcl COMBIGAN dorzolamide Trusopt dorzolamide/timolol Cosopt ISOPTO CARBACHOL latanoprost Xalatan Updated September 1, 2015 REQUIREMENTS/LIMITS QLL = 5mL (2 bottles)/ 30 days 35 COVERED DRUG levobunolol hcl LUMIGAN methazolamide metipranolol PHOSPHOLINE IODIDE pilocarpine hcl timolol maleate travoprost TRAVATAN Z ZIOPTAN OTHER OPHTHALMIC DRUGS artificial tears drops, ointment atropine sulfate cromolyn sodium cyclopentolate diclofenac sodium flurbiprofen sodium ISOPTO HOMATROPINE ISOPTO HYOSCINE ketorolac tromethamine ketotifen MUROCOLL-2 naphazoline 0.1% eye drops naphazoline/pheniramine NATACYN NEVANAC PATANOL phenylephrine REFRESH TEARS, LIQUIGEL (15 ML AND 30 ML BOTTLE ONLY) RESTASIS SYSTANE (15 ML AND 30 ML BOTTLE ONLY) trifluridine tropicamide ketotifen fumarate ophthalmic solution RESPIRATORY MEDICATIONS BETA-2 ADRENERGIC DRUGS albuterol sulfate (inhalation soln, syrup, tablet) FORADIL metaproterenol Updated September 1, 2015 REFERENCE DRUG NAME Betagan REQUIREMENTS/LIMITS Optipranolol Isopto Carpine Timoptic/Timoptic-XE Travatan PA Isopto Atropine Crolom Cyclogyl Voltaren Ocufen Acular, Acular LS AK-Con, Naphcon-Forte Naphcon A, Opcon A PA Tropicacyl ZADITOR OTC PA 36 COVERED DRUG PROAIR HFA PROVENTIL HFA SEREVENT DISKUS terbutaline VENTOLIN HFA INHALED CORTICOSTEROIDS ADVAIR DISKUS ADVAIR HFA ASMANEX budesonide respules 0.25 mg/2 ml, 0.50 mg/2 ml DULERA FLOVENT DISKUS FLOVENT HFA PULMICORT 1 MG/2 ML RESPULES PULMICORT FLEXHALER/INHALER QVAR SYMBICORT LEUKOTRIENE MODIFIERS montelukast 4mg, 5mg 10mg tablets, 4mg granules zafirlukast METHYL XANTHINE DRUGS theophylline, er OTHER DRUGS FOR ASTHMA ATROVENT (INHALER) COMBIVENT RESPIMAT cromolyn sodium nebulizer soln Epinephrine 0.3mg/0.3ml and 0.15mg/0.15ml ipratropium bromide ipratropium bromide/albuterol inhalation soln sodium chloride 0.9% nebulizer solution OTC OTHER RESPIRATORY DRUGS ARALAST NP, PROLASTIN ESBRIET PULMOZYME TUDORZA PRESSAIR sodium chloride 3%, 7% for inhalation SPIRIVA, SPIRIVA RESPIMAT Updated September 1, 2015 REFERENCE DRUG NAME REQUIREMENTS/LIMITS QLL= 2 inhalers/30 days QLL= 2 inhalers/30 days QLL= 2 inhalers/30 days Pulmicort Respules QLL=120 ml/30 days (60 respules/30 days) QLL=120 ml/30 days (60 respules/30 days) QLL=1 inhaler or flexhaler/30 days Singulair QLL=30/30 days Accolate QLL=60 tabs/30 days EPIPEN, EPIPEN JR PA PA PA HYPERSAL QLL=1pkg/30 days 37 COVERED DRUG REFERENCE DRUG NAME tobramycin inhalation solution TOBI ANTIHISTAMINES AND DECONGESTANTS ALLEGRA 30mg/5ml fexofenadine 30mg/5ml Suspension Suspension brompheniramine Bromax ER tablets brompheniramine maleate carbinoxamine cetirizine, cetirizine-D OTC OTC Zyrtec chlorpheniramine maleate clemastine fumarate cyproheptadine hcl diphenhydramine hcl fexofenadine tablets, fexofenadine-D Tavist Periactin Benadryl Allegra hydroxyzine hcl Atarax hydroxyzine pamoate cap Vistaril loratadine, loratadine-D OTC OTC Claritin,Claritin D pseudoephedrine Sudafed Vazol oral solution brompheniramine maleate ANTIHISTAMINE/DECONGESTANT COMBINATIONS brompheniramine/phenylephrine promethazine vc plain syrup Phenergan VC (promethazine-phenylephrine) Sildec syrup Rondec, Cardec syrup (brompheniramine/pseudoephedrine) Virdec drops Rondec drops (chlorpheniramine/phenylephrine) ANTITUSSIVE AND EXPECTORANT DRUGS benzonatate Tessalon brompheniramine-dm-phenylephrine Alahist-DM brompheniramine-dmSildec DM pseudoephedrine CHERATUSSIN AC OTC (guaifensin-codeine) CHERATUSSIN DAC OTC (guaifensin-pseudoephed-codeine) DELSYM SUSPENSION guaifenesin plain syrup, MUCINEX ER Robitussin guaifenesin w/codeine syrup Tussi-Organidin NR guaifenesin-dm syrup, MUCINEX DM Robitussin DM ER guaifenesin-dm-pseudoephedrine Robitussin CF Updated September 1, 2015 REQUIREMENTS/LIMITS PA cetirizine-D QLL=60 tabs/30 days cetirizine syrup QLL= 300ml/30Days 30mg, 60mg QLL= 60 tabs/30 days; 180mg QLL=30 tabs/30 days loratadine-D QLL=#30 tabs/30 QLL=120 tabs/30 days QLL=90 capsules/30 days QLL=480ml/30 days QLL=480ml/30 days 38 COVERED DRUG REFERENCE DRUG NAME Guaifenesin / dextromethorphan / Robitussin PE phenylephrine guaifenesin-phenylephrine Despec hydrocodone-homatropine Hycodan,Hydromet MUCINEX D ER (guaifenesin-pseudoephedrine) NoHist-DM syrup Rondec DM (chlorpheniramine-dmphenylephrine) promethazine-codeine Phenergan w/Codeine promethazine vc w/codeine syrup Phenergan VC w/Codeine (promethazine-phenylephrinecodeine) promethazine-dm Phenergan DM Virdec-DM drops Rondec-DM drops (chlorpheniramine-dmphenylephrine) TOXICOLOGY MEDICATIONS acetylcysteine CUPRIMINE UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS DRUGS flavoxate Urispas oxybutynin chloride Ditropan oxybutynin chloride er Ditropan XL tolterodine Detrol Tolterodine ER Detrol LA trospium Sanctura trospium ER Sanctura XR CHOLINERGIC STIMULANTS bethanechol chloride Urecholine URINARY ANESTHETICS phenazopyridine hcl Pyridium/Urodol OTHER GENITOURINARY PRODUCTS alfuzosin Uroxatral CYTRA, K ELMIRON finasteride Proscar K-PHOS potassium citrate tamsulosin Flomax MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES Updated September 1, 2015 REQUIREMENTS/LIMITS QLL=480ml/30 days STEP STEP QLL=60 tabs/30 days STEP, QLL = 30 tabs/30 days QLL=60 caps/30 days 39 COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS TEST STRIPS COMBINED QLL=150 TEST STRIPS/30 DAYS MICROLET LANCING DEVICE/LANCETS AUTOJECT 2 INJECTION DEVICE insulin syringes ONE TOUCH DELICA LANCETS ONE TOUCH SURESOFT LANCETS ONE TOUCH TEST STRIPS, CONTROL Combined QLL for test strips= SOLUTION 204 strips/30 days ONE TOUCH ULTRA2, ULTRALINK, Combined QLL for test strips= ULTRAMINI, ULTRASMART, VERIO 204 strips/30 days GLUCOMETERS/TEST STRIPS ONE TOUCH ULTRASOFT LANCETS CHEMSTRIP KETOSTIX OTHER SUPPLIES AEROCHAMBER, MICROCHAMBER, QLL=2/year OPTICHAMBER ALCOHOL PREP PADS REPRODUCTIVE HEALTH* *Family planning services are administered by Aetna Medicaid Administrators, LLC. COVERED CONTRACEPTIVES ALTAVERA NORDETTE-28 APRI DESOGEN ARANELLE TRI-NORINYL AVIANE ALESSE-28 AZURETTE MIRCETTE BALZIVA OVCON-35 CAMILA NOR-Q-D CAZIANT CYCLESSA CESIA CYCLESSA CRYSELLE LO/OVRAL-28 CYCLAFEM 1-35 ORTHO-NOVUM 1/35 CYCLAFEM 7/7/7 ORTHO-NOVUM 7/7/7 QL: 1 tab (1pack)/month ELLA 3 tabs (3 pack)/year EMOQUETTE DESOGEN ENPRESSE TRI-LEVLEN 28 ERRIN NOR-Q-D GIANVI TAB 3-0.02MG YAZ-28 GILDESS FE1-20 LOESTRIN FE 1/20 GILDESS FE 1.5-30 LOESTRIN FE 1.5/30 INTROVALE- 91 tablet pack SEASONALE JOLESSA - 91 tablet pack SEASONALE Updated September 1, 2015 40 COVERED DRUG JOLIVETTE JUNEL 1/20 JUNEL 1.5/30 JUNEL FE 1/20 JUNEL FE 1.5/30 KARIVA KELNOR 1/35 LEENA LESSINA Levonorgestrel/Ethinyl Estradiol 0.15mg-0.03mg Tablet REFERENCE DRUG NAME NOR-Q-D LOESTRIN 1/20 LOESTRIN 1.5/30 LOESTRIN FE 1/20 LOESTRIN FE MIRCETTE DEMULEN 1/35-28 TRI-NORINYL ALESSE-28 SEASONALE LEVONORGESTREL 0.75MG LEVORA-28 LORYNA TAB 3-0.02MG LOW-OGESTREL LUTERA MARLISSA-28 MICROGESTIN 1/20 MICROGESTIN 1.5/30 MICROGESTIN FE 1/20 MICROGESTIN FE 1.5/30 MONONESSA MYZILRA-28 NECON NECON NECON 1/35 NECON NECON 7/7/7 PLAN B NORDETTE-28 YAZ-28 LO/OVRAL-28 ALESSE-28 NORDETTE-28 LOESTRIN LOESTRIN LOESTRIN FE 1/20 LOESTRIN FE ORTHO-CYCLEN TRI-LEVLEN 28 MODICON NECON ORTHO-NOVUM 1/35 NORINYL 1+50 ORTHO-NOVUM 7/7/7 NEXT CHOICE PLAN B NEXT CHOICE ONE DOSE NORA-BE NORTREL NORTREL 1/35 NORTREL OGESTREL PLAN B ONE STEP NOR-Q-D MODICON ORTHO-NOVUM 1/35 ORTHO-NOVUM OVRAL-28 PLAN B ONE STEP PORTIA PREVIFEM QUASENSE 91 tablet pack NORDETTE-28 ORTHO-CYCLEN SEASONALE Updated September 1, 2015 REQUIREMENTS/LIMITS QL: 2 tabs (1pack)/month 6 tabs (3 pack)/year QL: 2 tabs (1pack)/month 6 tabs (3 pack)/year QL: 2 tabs (1pack)/month 6 tabs (3 pack)/year QL: 2 tabs (1pack)/month 6 tabs (3 pack)/year 41 COVERED DRUG RECLIPSEN SOLIA SPRINTEC SRONYX TILIA FE TRINESSA TRI-PREVIFEM TRI-SPRINTEC TRIVORA-28 VELIVET VESTURA TAB 3-0.02MG VIORELE XULANE PATCH OCELLA 28 ZENCHENT ZOVIA 1/35E ZOVIA 1/50E IMPLANTS AND IUDS MIRENA IUD IMPLANON IMPLANT NEXPLANON IMPLANT SKYLA INTRAVAGINAL CONTRACEPTION NUVARING INJECTABLE CONTRACEPTION Medroxyprogesterone acetate 150mg OTHER PRODUCTS- MISC. DIAPHRAGMS OTC CONDOMS Spermacidal Foam / Jelly Updated September 1, 2015 REFERENCE DRUG NAME DESOGEN DESOGEN ORTHO-CYCLEN ALESSE-28 ESTROSTEP FE ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN TRI-LEVLEN 28 CYCLESSA YAZ-28 MIRCETTE Ortho Evra YASMIN 28 OVCON-35 DEMULEN 1/35-28 DEMULEN 1/50-21 REQUIREMENTS/LIMITS QL: 3 patches / month DEPO-PROVERA MPA QLL = 1 per 90days Various Various Various 42
