If you have questions about AmeriHealth Caritas PA prescription drug coverage:
• Members please call 1-888-991-7200, TTY users should call 1-888-987-5704.
• Prescribers and Pharmacists please call 1-866-610-2774.
F
GA
NF
QL
PA
AL
ST
GR
OTC
Status and Restriction Definitions
Formulary Drug
Non-Preferred Brand Drug - Preferred Generic is Available
Non-Formulary Drug - Prior Authorization is Required
Maximum Quantity Limit Allowed
Prior Authorization Required (Yes)
Age Restriction (Minimum /Maximum)
Step Therapy Required (Yes)
Gender Restriction (Male / Female)
Over-The-Counter Medication (Yes)
AmeriHealth Caritas PA Formulary Medication List 2015
Brand Name
Generic Name
Notes and Restrictions
►5-ALPHA-REDUCTASE INHIBITORS
FINASTERIDE
Status PA ST QL AL AL GR
max min max m/f
(Gender M)
F
M
(Gender M)
GA
M
FINASTERIDE
PROSCAR
FINASTERIDE
►5-HT3 RECEPTOR ANTAGONISTS
ANZEMET
(100MG) QL 5 QY per 30 DY PA Required 100MG
F
Y
5
(50MG) QL 5 QY per 30 DY PA Required 50MG
F
Y
5
NF
Y
DOLASETRON MESYLATE
ANZEMET
DOLASETRON MESYLATE
GRANISETRON HCL
PA Required 1MG
GRANISETRON HCL
F
ONDANSETRON HCL
ONDANSETRON HCL
F
ONDANSETRON ODT
ONDANSETRON
ZOFRAN
GA
ONDANSETRON HCL
ZOFRAN ODT
GA
ONDANSETRON
►ADAMANTANES (CNS)
F
AMANTADINE HCL
AMANTADINE HYDROCHLORIDE
►ADRENALS
CORTEF
GA
HYDROCORTISONE
F
CORTISONE ACETATE
CORTISONE ACETATE
F
DEXAMETHASONE
DEXAMETHASONE
F
DEXAMETHASONE INTENSOL
DEXAMETHASONE
ENTOCORT EC
PA Required 3MG
NF
Y
BUDESONIDE
FLUDROCORTISONE ACETATE
F
FLUDROCORTISONE ACETATE
MEDROL
GA
METHYLPREDNISOLONE
MEDROL DOSEPAK
GA
METHYLPREDNISOLONE
METHYLPREDNISOLONE
F
METHYLPREDNISOLONE
METHYLPREDNISOLONE DOSE PACK
F
METHYLPREDNISOLONE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 1 of 73
Brand Name
Generic Name
Notes and Restrictions
ORAPRED
Status PA ST QL AL AL GR
max min max m/f
GA
PREDNISOLONE SODIUM PHOSPHATE
F
PREDNISOLONE
PREDNISOLONE ANHYDROUS
F
PREDNISOLONE SODIUM PHOSPHATE
PREDNISOLONE SODIUM PHOSPHATE
F
PREDNISONE
PREDNISONE
F
PREDNISONE INTENSOL
PREDNISONE
PRELONE
GA
PREDNISOLONE ANHYDROUS
►ALCOHOL DETERRENTS
ANTABUSE
GA
DISULFIRAM
F
DISULFIRAM
DISULFIRAM
►ALKALINIZING AGENTS
F
CITRIC ACID/SODIUM CITRATE
CITRIC ACID; SODIUM CITRATE
F
POTASSIUM CITRATE ER
POTASSIUM CITRATE
UROCIT-K 10
GA
POTASSIUM CITRATE
UROCIT-K 5
GA
POTASSIUM CITRATE
►ALLYLAMINES
LAMISIL
(250MG) QL 90 DS per 365 DY
GA
90
(250MG) QL 90 DS per 365 DY
F
90
(0.15MG/0.15ML) QL 2 QY per 30 DY
F
2
(0.3MG/0.3ML) QL 2 QY per 30 DY
F
2
TERBINAFINE HYDROCHLORIDE
TERBINAFINE HCL
TERBINAFINE HYDROCHLORIDE
►ALPHA- AND BETA-ADRENERGIC AGONISTS
AUVI-Q
EPINEPHRINE
AUVI-Q
EPINEPHRINE
F
EPINEPHRINE HCL
EPINEPHRINE HYDROCHLORIDE
EPIPEN 2-PAK
(0.3MG/0.3ML) QL 2 QY per 30 DY
F
2
(0.15MG/0.3ML) QL 2 QY per 30 DY
F
2
OTC 60MG TABS
F
OTC 12.5MG/5ML; 120MG/5ML; 5MG/5ML SYRP
F
EPINEPHRINE
EPIPEN-JR 2-PAK
EPINEPHRINE
PSEUDOEPHEDRINE HCL
PSEUDOEPHEDRINE HYDROCHLORIDE
►ALPHA-ADRENERGIC AGONISTS
DONATUSSIN
CHLOPHEDIANOL HYDROCHLORIDE; GUAIFENESIN; PHENYLEPHRINE
HYDROCHLORIDE
►ALPHA-ADRENERGIC AGONISTS (EENT)
ALPHAGAN P
GA
BRIMONIDINE TARTRATE
BRIMONIDINE TARTRATE
F
BRIMONIDINE TARTRATE
►ALPHA-ADRENERGIC BLOCKING AGENTS
CARDURA
GA
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
F
DOXAZOSIN MESYLATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 2 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
MINIPRESS
GA
PRAZOSIN HYDROCHLORIDE
F
PRAZOSIN HCL
PRAZOSIN HYDROCHLORIDE
F
TERAZOSIN HCL
TERAZOSIN HCL
►AMEBICIDES
PAROMOMYCIN SULFATE
(250MG) QL 10 DS per 30 DY PA Required 250MG
F
Y
10
PAROMOMYCIN SULFATE
F
YODOXIN
IODOQUINOL
►AMINOPENICILLINS
F
AMOXICILLIN
AMOXICILLIN
F
AMOXICILLIN/CLAVULANATE POTASSIUM
AMOXICILLIN; CLAVULANIC ACID
AMOXICILLIN/CLAVULANATE POTASSIUM
Augmentin 125/5ml & 250mg/5ml are not on formulary
F
Augmentin 125/5ml & 250mg/5ml are not on formulary
F
AMOXICILLIN; CLAVULANIC ACID
AMOXICILLIN/CLAVULANATE POTASSIUM
AMOXICILLIN; POTASSIUM CLAVULANATE
F
AMPICILLIN
AMPICILLIN
AUGMENTIN
GA
AMOXICILLIN; CLAVULANIC ACID
►AMMONIA DETOXICANTS
F
LACTULOSE
LACTULOSE
►AMPHETAMINES
ADDERALL
Prior authorization required for members age 21 and older. PA Required GA
Y
20
Y
20
Y
20
Y
20
Y
20
Y
20
Y
20
F
Y
20
F
Y
20
F
Y
20
F
Y
20
F
Y
20
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 1.25MG; 1.25MG; 1.25MG; 1.25MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL
Prior authorization required for members age 21 and older. PA Required GA
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 1.875MG; 1.875MG; 1.875MG; 1.875MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL
Prior authorization required for members age 21 and older. PA Required GA
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 2.5MG; 2.5MG; 2.5MG; 2.5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL
Prior authorization required for members age 21 and older. PA Required GA
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 3.125MG; 3.125MG; 3.125MG; 3.125MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL
Prior authorization required for members age 21 and older. PA Required GA
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 3.75MG; 3.75MG; 3.75MG; 3.75MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL
Prior authorization required for members age 21 and older. PA Required GA
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 5MG; 5MG; 5MG; 5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL
Prior authorization required for members age 21 and older. PA Required GA
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 7.5MG; 7.5MG; 7.5MG; 7.5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL XR
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 1.25MG; 1.25MG; 1.25MG; 1.25MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL XR
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 2.5MG; 2.5MG; 2.5MG; 2.5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL XR
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 3.75MG; 3.75MG; 3.75MG; 3.75MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL XR
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 5MG; 5MG; 5MG; 5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
ADDERALL XR
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 6.25MG; 6.25MG; 6.25MG; 6.25MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 3 of 73
Brand Name
Generic Name
ADDERALL XR
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
Y
20
F
Y
20
F
Y
20
F
Y
20
F
Y
20
F
Y
20
F
Y
20
F
Y
20
Prior authorization required for members age 21 and older. PA Required GA
10MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required GA
15MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required GA
5MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 7.5MG; 7.5MG; 7.5MG; 7.5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
AMPHETAMINE/DEXTROAMPHETAMINE
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 1.25MG; 1.25MG; 1.25MG; 1.25MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
AMPHETAMINE/DEXTROAMPHETAMINE
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 1.875MG; 1.875MG; 1.875MG; 1.875MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
AMPHETAMINE/DEXTROAMPHETAMINE
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 2.5MG; 2.5MG; 2.5MG; 2.5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
AMPHETAMINE/DEXTROAMPHETAMINE
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 3.125MG; 3.125MG; 3.125MG; 3.125MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
AMPHETAMINE/DEXTROAMPHETAMINE
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 3.75MG; 3.75MG; 3.75MG; 3.75MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
AMPHETAMINE/DEXTROAMPHETAMINE
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 5MG; 5MG; 5MG; 5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
AMPHETAMINE/DEXTROAMPHETAMINE
Prior authorization required for members age 21 and older. PA Required
AMPHETAMINE ASPARTATE; AMPHETAMINE SULFATE; DEXTROAMPHETAMINE 7.5MG; 7.5MG; 7.5MG; 7.5MG (Max Age 20)
SACCHARATE; DEXTROAMPHETAMINE SULFATE
DEXEDRINE
DEXTROAMPHETAMINE SULFATE
DEXEDRINE
DEXTROAMPHETAMINE SULFATE
DEXEDRINE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE ER
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE ER
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE ER
DEXTROAMPHETAMINE SULFATE
VYVANSE
LISDEXAMFETAMINE DIMESYLATE
VYVANSE
LISDEXAMFETAMINE DIMESYLATE
VYVANSE
LISDEXAMFETAMINE DIMESYLATE
VYVANSE
LISDEXAMFETAMINE DIMESYLATE
VYVANSE
LISDEXAMFETAMINE DIMESYLATE
VYVANSE
LISDEXAMFETAMINE DIMESYLATE
Prior authorization required for members age 21 and older. PA Required
10MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
5MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
10MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
15MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
5MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
20MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
30MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
40MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
50MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
60MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
70MG (Max Age 20)
F
Y
20
►ANALGESICS AND ANTIPYRETICS, MISC.
F
BUTALBITAL/ACETAMINOPHEN
ACETAMINOPHEN; BUTALBITAL
F
BUTALBITAL/ACETAMINOPHEN/CAFFEINE
ACETAMINOPHEN; BUTALBITAL; CAFFEINE
ED-APAP
OTC 160MG/5ML LIQD
F
ACETAMINOPHEN
ESGIC
GA
ACETAMINOPHEN; BUTALBITAL; CAFFEINE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 4 of 73
Brand Name
Generic Name
Notes and Restrictions
MARTEN-TAB
Status PA ST QL AL AL GR
max min max m/f
GA
ACETAMINOPHEN; BUTALBITAL
PAIN RELIEF
OTC 650MG TBCR
F
OTC 160MG/5ML LIQD
F
(Gender M)
F
M
(Gender M)
F
M
ACETAMINOPHEN
Q-PAP
ACETAMINOPHEN
►ANDROGENS
ANDROGEL
TESTOSTERONE
ANDROGEL PUMP
TESTOSTERONE
F
ANDROID
METHYLTESTOSTERONE
F
ANDROXY
FLUOXYMESTERONE
DANAZOL
PA Required 100MG
F
Y
PA Required 200MG
F
Y
PA Required 50MG
F
Y
DANAZOL
DANAZOL
DANAZOL
DANAZOL
DANAZOL
FORTESTA
GA
TESTOSTERONE
F
METHITEST
METHYLTESTOSTERONE
TESTIM
PA Required 1%
NF
Y
TESTOSTERONE
F
TESTOSTERONE
TESTOSTERONE
TESTOSTERONE ENANTHATE
(200MG/ML) QL 1 QY per 30 DY
F
1
TESTOSTERONE ENANTHATE
F
TESTRED
METHYLTESTOSTERONE
►ANGIOTENSIN II RECEPTOR ANTAGONISTS
ATACAND
CANDESARTAN CILEXETIL
ATACAND
CANDESARTAN CILEXETIL
ATACAND
CANDESARTAN CILEXETIL
ATACAND
CANDESARTAN CILEXETIL
AVALIDE
HYDROCHLOROTHIAZIDE; IRBESARTAN
AVALIDE
HYDROCHLOROTHIAZIDE; IRBESARTAN
AVAPRO
IRBESARTAN
AVAPRO
IRBESARTAN
AVAPRO
IRBESARTAN
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (16MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (32MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (4MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (8MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (12.5MG; 150MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (12.5MG; 300MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (150MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (75MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (16MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (32MG TABS)
F
Y
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Brand Name
Generic Name
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE
CANDESARTAN CILEXETIL; HYDROCHLOROTHIAZIDE
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE
CANDESARTAN CILEXETIL; HYDROCHLOROTHIAZIDE
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE
CANDESARTAN CILEXETIL; HYDROCHLOROTHIAZIDE
COZAAR
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (4MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (8MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (16MG; 12.5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (32MG; 12.5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (32MG; 25MG TABS)
F
Y
Generic 90-days
GA
LOSARTAN POTASSIUM
DIOVAN
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (160MG TABS)
GA
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (320MG TABS)
GA
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (40MG TABS)
GA
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (80MG TABS)
GA
Y
VALSARTAN
DIOVAN HCT
Requires ST with losartan or losartan/hydrochlorothiazide
GA
VALSARTAN
DIOVAN
VALSARTAN
DIOVAN
VALSARTAN
DIOVAN
HYDROCHLOROTHIAZIDE; VALSARTAN
HYZAAR
Generic 90-days
GA
HYDROCHLOROTHIAZIDE; LOSARTAN POTASSIUM
IRBESARTAN
IRBESARTAN
IRBESARTAN
IRBESARTAN
IRBESARTAN
IRBESARTAN
IRBESARTAN/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; IRBESARTAN
IRBESARTAN/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; IRBESARTAN
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (150MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (300MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (75MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (12.5MG; 150MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (12.5MG; 300MG TABS)
F
Y
F
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM
F
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; LOSARTAN POTASSIUM
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (160MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (320MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (40MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide or
valsartan/hydrochlorothiazide (80MG TABS)
F
Y
VALSARTAN
VALSARTAN/HYDROCHLOROTHIAZIDE
Requires ST with losartan or losartan/hydrochlorothiazide
F
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
VALSARTAN
HYDROCHLOROTHIAZIDE; VALSARTAN
►ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
ACCUPRIL
GA
QUINAPRIL HCL
ACCURETIC
GA
HYDROCHLOROTHIAZIDE; QUINAPRIL HCL
ACEON
GA
PERINDOPRIL ERBUMINE
BENAZEPRIL HCL
F
BENAZEPRIL HCL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 6 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE
BENAZEPRIL HCL; HYDROCHLOROTHIAZIDE
F
CAPTOPRIL
CAPTOPRIL
F
CAPTOPRIL/HYDROCHLOROTHIAZIDE
CAPTOPRIL; HYDROCHLOROTHIAZIDE
F
ENALAPRIL MALEATE
ENALAPRIL MALEATE
F
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE
ENALAPRIL MALEATE; HYDROCHLOROTHIAZIDE
F
FOSINOPRIL SODIUM
FOSINOPRIL SODIUM
F
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE
FOSINOPRIL SODIUM; HYDROCHLOROTHIAZIDE
LISINOPRIL
Generic 90-days
F
LISINOPRIL
F
LISINOPRIL/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; LISINOPRIL
LOTENSIN
GA
BENAZEPRIL HCL
LOTENSIN HCT
GA
BENAZEPRIL HCL; HYDROCHLOROTHIAZIDE
MAVIK
GA
TRANDOLAPRIL
F
MOEXIPRIL HCL
MOEXIPRIL HYDROCHLORIDE
F
MOEXIPRIL/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; MOEXIPRIL HYDROCHLORIDE
F
PERINDOPRIL ERBUMINE
PERINDOPRIL ERBUMINE
PRINIVIL
Generic 90-days
GA
LISINOPRIL
F
QUINAPRIL HCL
QUINAPRIL HCL
F
QUINAPRIL/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; QUINAPRIL HCL
F
TRANDOLAPRIL
TRANDOLAPRIL
UNIRETIC
GA
HYDROCHLOROTHIAZIDE; MOEXIPRIL HYDROCHLORIDE
UNIVASC
GA
MOEXIPRIL HYDROCHLORIDE
VASERETIC
GA
ENALAPRIL MALEATE; HYDROCHLOROTHIAZIDE
VASOTEC
Generic 90-days
GA
ENALAPRIL MALEATE
ZESTORETIC
GA
HYDROCHLOROTHIAZIDE; LISINOPRIL
ZESTRIL
Generic 90-days
GA
LISINOPRIL
►ANTACIDS AND ADSORBENTS
ALUMINUM HYDROXIDE
OTC 320MG/5ML SUSP
F
OTC 400MG/5ML; 400MG/5ML; 40MG/5ML SUSP
F
OTC 200MG/5ML; 200MG/5ML; 20MG/5ML SUSP
F
OTC 750MG CHEW
F
ALUMINUM HYDROXIDE
ANTACID ANTI-GAS MAXIMUM STRENGTH
ALUMINUM HYDROXIDE; MAGNESIUM HYDROXIDE; SIMETHICONE
ANTACID PLUS ANTI-GAS RELIEF
ALUMINUM HYDROXIDE; MAGNESIUM HYDROXIDE; SIMETHICONE
CALCIUM ANTACID EXTRA STRENGTH
CALCIUM CARBONATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 7 of 73
Brand Name
Generic Name
CHEWABLE ANTACID
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
OTC 500MG CHEW
F
OTC 500MG CAPS
F
OTC 500MG TABS
F
OTC 250MG TABS
F
OTC 400MG TABS
F
OTC 420MG TABS
F
OTC 325MG TABS
F
OTC 650MG TABS
F
OTC 500MG CHEW
GA
OTC 1000MG CHEW
GA
CALCIUM CARBONATE
MAGNESIUM
MAGNESIUM OXIDE
MAGNESIUM
MAGNESIUM OXIDE
MAGNESIUM OXIDE
MAGNESIUM OXIDE
MAGNESIUM OXIDE
MAGNESIUM OXIDE
MAGNESIUM OXIDE
MAGNESIUM OXIDE
SODIUM BICARBONATE
SODIUM BICARBONATE
SODIUM BICARBONATE
SODIUM BICARBONATE
TUMS
CALCIUM CARBONATE
TUMS ULTRA 1000
CALCIUM CARBONATE
URO-MAG
OTC 140MG CAPS
F
MAGNESIUM OXIDE
►ANTHELMINTICS
F
ALBENZA
ALBENDAZOLE
F
BILTRICIDE
PRAZIQUANTEL
F
STROMECTOL
IVERMECTIN
►ANTIALLERGIC AGENTS
ALAWAY
(0.03%) QL 1 QY per 30 DYOTC 0.03% SOLN
F
1
KETOTIFEN FUMARATE
ASTELIN
GA
AZELASTINE HYDROCHLORIDE
F
ASTEPRO
AZELASTINE HYDROCHLORIDE
F
AZELASTINE HCL
AZELASTINE HYDROCHLORIDE
(0.03%) QL 1 QY per 30 DYOTC 0.03% SOLN
F
Requires trial and failure or intolerance to Zaditor OTC or Alaway
OTC.(0.20%) QL 1 QY per 30 DY (0.20% SOLN)
F
OLOPATADINE HYDROCHLORIDE
ZADITOR
(0.03%) QL 1 QY per 30 DYOTC 0.03% SOLN
F
KETOTIFEN FUMARATE
1
KETOTIFEN FUMARATE
PATADAY
Y
1
1
KETOTIFEN FUMARATE
►ANTIBACTERIALS (EENT)
F
BACITRACIN/POLYMYXIN B
BACITRACIN ZINC; POLYMYXIN B SULFATE
BLEPH-10
GA
SULFACETAMIDE SODIUM
CILOXAN
GA
CIPROFLOXACIN HCL
CIPRODEX
CIPROFLOXACIN HCL; DEXAMETHASONE
CORTISPORIN
Requires trial and failure or intolerance to ofloxacin otic drops or
prescribing provider is an ear, eye, nose and throat (EENT) physician. PA
Required 0.3%; 0.1% (0.3%; 0.1% SUSP)
NF
Y
Y
GA
HYDROCORTISONE; NEOMYCIN SULFATE; POLYMYXIN B SULFATE
GENTAK
F
GENTAMICIN SULFATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 8 of 73
Brand Name
Generic Name
Notes and Restrictions
MAXITROL
Status PA ST QL AL AL GR
max min max m/f
GA
DEXAMETHASONE; NEOMYCIN SULFATE; POLYMYXIN B SULFATE
F
MOXEZA
MOXIFLOXACIN HYDROCHLORIDE
F
NEOMYCIN/BACITRACIN/POLYMYXIN
BACITRACIN ZINC; NEOMYCIN SULFATE; POLYMYXIN B SULFATE
NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE
F
BACITRACIN ZINC; HYDROCORTISONE ACETATE; NEOMYCIN SULFATE; POLYMYXIN
B SULFATE
F
NEOMYCIN/POLYMYXIN/DEXAMETHASONE
DEXAMETHASONE; NEOMYCIN SULFATE; POLYMYXIN B SULFATE
F
NEOMYCIN/POLYMYXIN/GRAMICIDIN
GRAMICIDIN; NEOMYCIN SULFATE; POLYMYXIN B SULFATE
F
NEOMYCIN/POLYMYXIN/HYDROCORTISONE
HYDROCORTISONE; NEOMYCIN SULFATE; POLYMYXIN B SULFATE
NEOSPORIN
GA
GRAMICIDIN; NEOMYCIN SULFATE; POLYMYXIN B SULFATE
OCUFLOX
GA
OFLOXACIN
F
POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE
POLYMYXIN B SULFATE; TRIMETHOPRIM SULFATE
POLYTRIM
GA
POLYMYXIN B SULFATE; TRIMETHOPRIM SULFATE
F
SULFACETAMIDE SODIUM
SULFACETAMIDE SODIUM
F
SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM
PREDNISOLONE SODIUM PHOSPHATE; SULFACETAMIDE SODIUM
TOBRADEX
GA
DEXAMETHASONE; TOBRAMYCIN SULFATE
F
TOBRAMYCIN SULFATE
TOBRAMYCIN
F
TOBRAMYCIN/DEXAMETHASONE
DEXAMETHASONE; TOBRAMYCIN SULFATE
TOBREX
Formulary Drug
F
Formulary Drug
GA
TOBRAMYCIN
TOBREX
TOBRAMYCIN
VIGAMOX
PA Required 0.50%
F
Y
MOXIFLOXACIN HYDROCHLORIDE
►ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
BACTROBAN
Cream requires prior authorization.
GA
MUPIROCIN
BENZACLIN
GA
BENZOYL PEROXIDE; CLINDAMYCIN PHOSPHATE
BENZAMYCIN
GA
BENZOYL PEROXIDE; ERYTHROMYCIN
CLEOCIN-T
GA
CLINDAMYCIN PHOSPHATE
F
CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PHOSPHATE
F
CLINDAMYCIN/BENZOYL PEROXIDE
BENZOYL PEROXIDE; CLINDAMYCIN PHOSPHATE
DOUBLE ANTIBIOTIC
OTC 500UNIT/GM; 10000UNIT/GM OINT
F
BACITRACIN ZINC; POLYMYXIN B SULFATE
ERY
F
ERYTHROMYCIN
ERYTHROMYCIN/BENZOYL PEROXIDE
F
BENZOYL PEROXIDE; ERYTHROMYCIN
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 9 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
GENTAMICIN SULFATE
GENTAMICIN SULFATE
METROGEL
Generic available for the 0.75% strength.
F
METRONIDAZOLE
METROGEL-VAGINAL
GA
METRONIDAZOLE
F
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
Generic available for the 0.75% strength.
F
METRONIDAZOLE
F
METRONIDAZOLE VAGINAL
METRONIDAZOLE
MUPIROCIN
Cream requires prior authorization.
F
MUPIROCIN
POLYSPORIN
OTC 500UNIT/GM; 10000UNIT/GM OINT
GA
BACITRACIN ZINC; POLYMYXIN B SULFATE
►ANTICHOLINERGIC AGENTS (CNS)
F
BENZTROPINE MESYLATE
BENZTROPINE MESYLATE
F
TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL HYDROCHLORIDE
►ANTICONVULSANTS, MISCELLANEOUS
BANZEL
PA Required 200MG
NF
Y
PA Required 400MG
NF
Y
RUFINAMIDE
BANZEL
RUFINAMIDE
CARBAMAZEPINE
F
CARBAMAZEPINE
CARBAMAZEPINE ER
F
CARBAMAZEPINE
DEPAKENE
GA
VALPROATE SODIUM
DEPAKENE
GA
VALPROIC ACID
DEPAKOTE
GA
DIVALPROEX SODIUM
DEPAKOTE ER
GA
DIVALPROEX SODIUM
DEPAKOTE SPRINKLES
GA
DIVALPROEX SODIUM
DIVALPROEX SODIUM
F
DIVALPROEX SODIUM
DIVALPROEX SODIUM DR
F
DIVALPROEX SODIUM
DIVALPROEX SODIUM ER
F
DIVALPROEX SODIUM
GABAPENTIN
F
GABAPENTIN
KEPPRA
GA
LEVETIRACETAM
LAMICTAL
GA
LAMOTRIGINE
LAMICTAL CHEWABLE DISPERSIBLE
GA
LAMOTRIGINE
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE
F
LAMOTRIGINE
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT
TAKING VALPROATE
F
LAMOTRIGINE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 10 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
LAMICTAL STARTER/TAKING VALPROATE
LAMOTRIGINE
F
LAMOTRIGINE
LAMOTRIGINE
F
LEVETIRACETAM
LEVETIRACETAM
NEURONTIN
GA
GABAPENTIN
OXCARBAZEPINE
OXCARBAZEPINE
Diagnosis of seizure disorder required. Seizure disorder ICD-9 codes=
345.0, 345.1, 345.2, 345.3, 345.4, 345.5, 345.6, 345.7, 345.8, 345.9 and
780.3
TEGRETOL
F
GA
CARBAMAZEPINE
TEGRETOL-XR
Formulary Drug
F
Formulary Drug
GA
CARBAMAZEPINE
TEGRETOL-XR
CARBAMAZEPINE
TOPAMAX
GA
TOPIRAMATE
TOPAMAX SPRINKLE
GA
TOPIRAMATE
F
TOPIRAMATE
TOPIRAMATE
TRILEPTAL
OXCARBAZEPINE
VALPROIC ACID
Diagnosis of seizure disorder required. Seizure disorder ICD-9 codes=
345.0, 345.1, 345.2, 345.3, 345.4, 345.5, 345.6, 345.7, 345.8, 345.9 and
780.3
GA
F
VALPROATE SODIUM
VALPROIC ACID
F
VALPROIC ACID
►ANTIDEPRESSANTS, MISCELLANEOUS
BUDEPRION SR
F
BUPROPION HCL
BUPROBAN
F
BUPROPION HCL
BUPROPION HCL
F
BUPROPION HCL
BUPROPION HCL SR
F
BUPROPION HCL
BUPROPION HCL XL
F
BUPROPION HCL
MIRTAZAPINE
F
MIRTAZAPINE
MIRTAZAPINE ODT
F
MIRTAZAPINE
REMERON
GA
MIRTAZAPINE
REMERON SOLTAB
GA
MIRTAZAPINE
WELLBUTRIN
GA
BUPROPION HCL
WELLBUTRIN SR
GA
BUPROPION HCL
WELLBUTRIN XL
GA
BUPROPION HCL
ZYBAN
GA
BUPROPION HCL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 11 of 73
Brand Name
Generic Name
Notes and Restrictions
►ANTIDIARRHEA AGENTS
Status PA ST QL AL AL GR
max min max m/f
F
DIPHENOXYLATE/ATROPINE
ATROPINE SULFATE; DIPHENOXYLATE HYDROCHLORIDE
LOMOTIL
GA
ATROPINE SULFATE; DIPHENOXYLATE HYDROCHLORIDE
F
LOPERAMIDE HCL
LOPERAMIDE HYDROCHLORIDE
PEPTO-BISMOL
OTC 262MG CHEW
GA
OTC 262MG/15ML SUSP
GA
BISMUTH SUBSALICYLATE
PEPTO-BISMOL
BISMUTH SUBSALICYLATE
PINK BISMUTH
OTC 262MG CHEW
F
OTC 262MG/15ML SUSP
F
BISMUTH SUBSALICYLATE
STOMACH RELIEF
BISMUTH SUBSALICYLATE
►ANTIDOTES
F
LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM
►ANTIEMETICS, MISCELLANEOUS
F
EMEND
APREPITANT
EMEND
(40MG) QL 1 QY per 30 DY
F
1
APREPITANT
F
EMEND (In a Dose Pack)
APREPITANT
TRANSDERM-SCOP
PA Required 1.5MG
NF
Y
SCOPOLAMINE
►ANTIFUNGALS, MISCELLANEOUS
F
GRIFULVIN V
GRISEOFULVIN
F
GRISEOFULVIN MICROSIZE
GRISEOFULVIN
F
GRISEOFULVIN ULTRAMICROSIZE
GRISEOFULVIN ULTRAMICROSIZE
GRIS-PEG
Formulary Drug
GA
Formulary Drug
F
GRISEOFULVIN ULTRAMICROSIZE
GRIS-PEG
GRISEOFULVIN ULTRAMICROSIZE
►ANTIGOUT AGENTS
F
ALLOPURINOL
ALLOPURINOL
ZYLOPRIM
GA
ALLOPURINOL
►ANTIHISTAMINES (GI DRUGS)
ANTIVERT
GA
MECLIZINE HYDROCHLORIDE
MECLIZINE HCL
OTC 12.5MG TABS
F
OTC 25MG TABS
F
MECLIZINE HYDROCHLORIDE
MECLIZINE HCL
MECLIZINE HYDROCHLORIDE
PROCHLORPERAZINE
F
PROCHLORPERAZINE
PROCHLORPERAZINE EDISYLATE
F
PROCHLORPERAZINE EDISYLATE
PROCHLORPERAZINE MALEATE
F
PROCHLORPERAZINE MALEATE
TIGAN
GA
TRIMETHOBENZAMIDE HYDROCHLORIDE
Coverage by AmeriHealth First
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Page 12 of 73
Brand Name
Generic Name
TRAVEL SICKNESS
Notes and Restrictions
OTC 25MG CHEW
Status PA ST QL AL AL GR
max min max m/f
F
MECLIZINE HYDROCHLORIDE
F
TRIMETHOBENZAMIDE HCL
TRIMETHOBENZAMIDE HYDROCHLORIDE
►ANTI-INFLAMMATORY AGENTS (GI DRUGS)
F
BALSALAZIDE DISODIUM
BALSALAZIDE DISODIUM
F
CANASA
MESALAMINE (5-ASA)
COLAZAL
GA
BALSALAZIDE DISODIUM
F
DELZICOL
MESALAMINE (5-ASA)
F
DIPENTUM
OLSALAZINE SODIUM
F
LIALDA
MESALAMINE (5-ASA)
F
MESALAMINE
MESALAMINE (5-ASA)
F
PENTASA
MESALAMINE (5-ASA)
►ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
AMCINONIDE
F
AMCINONIDE
ANUSOL-HC
GA
HYDROCORTISONE
F
AUGMENTED BETAMETHASONE DIPROPIONATE
AUGMENTED BETAMETHASONE DIPROPIONATE
F
BETAMETHASONE DIPROPIONATE
BETAMETHASONE DIPROPIONATE
F
BETAMETHASONE VALERATE
BETAMETHASONE VALERATE
F
CLOBETASOL PROPIONATE
CLOBETASOL PROPIONATE
F
CLOBETASOL PROPIONATE EMOLLIENT
CLOBETASOL PROPIONATE
F
DESONIDE
DESONIDE
F
DESOXIMETASONE
DESOXIMETASONE
F
DIFLORASONE DIACETATE
DIFLORASONE DIACETATE
DIPROLENE
GA
AUGMENTED BETAMETHASONE DIPROPIONATE
DIPROLENE AF
GA
AUGMENTED BETAMETHASONE DIPROPIONATE
ELOCON
GA
MOMETASONE FUROATE
ELOCON
(0.10%) QL 45 QY per 30 DY
GA
45
MOMETASONE FUROATE
FLUOCINOLONE ACETONIDE
F
FLUOCINOLONE ACETONIDE
FLUOCINONIDE
F
FLUOCINONIDE
FLUOCINONIDE-E
F
FLUOCINONIDE
HYDROCORTISONE
F
HYDROCORTISONE
Coverage by AmeriHealth First
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Page 13 of 73
Brand Name
Generic Name
HYDROCORTISONE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
OTC 1% LOTN
F
HYDROCORTISONE
F
HYDROCORTISONE IN ABSORBASE
HYDROCORTISONE
F
HYDROCORTISONE VALERATE
HYDROCORTISONE VALERATE
F
MOMETASONE FUROATE
MOMETASONE FUROATE
MOMETASONE FUROATE
(0.10%) QL 45 QY per 30 DY
F
45
MOMETASONE FUROATE
F
PROCTOFOAM HC
HYDROCORTISONE ACETATE; PRAMOXINE HYDROCHLORIDE
TEMOVATE
GA
CLOBETASOL PROPIONATE
TEMOVATE E
GA
CLOBETASOL PROPIONATE
TOPICORT
GA
DESOXIMETASONE
F
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE
Pays at point of sale for members less than 4 years of age. PA Required
55MCG/ACT
WESTCORT
NF
Y
GA
HYDROCORTISONE VALERATE
►ANTILIPEMIC AGENTS, MISCELLANEOUS
NIACIN
OTC 100MG TABS
F
OTC 250MG TABS
F
OTC 500MG TABS
F
OTC 50MG TABS
F
OTC 250MG CPCR
F
OTC 500MG CPCR
F
OTC 1000MG TBCR
F
OTC 250MG TBCR
F
OTC 500MG TBCR
F
OTC 750MG TBCR
F
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN
NIACIN ER
NIACIN
NIACIN ER
NIACIN
NIACIN TR
NIACIN
NIACIN TR
NIACIN
NIACIN TR
NIACIN
NIACIN TR
NIACIN
NIACOR
F
NIACIN
►ANTIMALARIALS
ARALEN
GA
CHLOROQUINE PHOSPHATE
CHLOROQUINE PHOSPHATE
F
CHLOROQUINE PHOSPHATE
DARAPRIM
F
PYRIMETHAMINE
HYDROXYCHLOROQUINE SULFATE
F
HYDROXYCHLOROQUINE SULFATE
MEFLOQUINE HCL
F
MEFLOQUINE HCL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 14 of 73
Brand Name
Generic Name
Notes and Restrictions
PLAQUENIL
Status PA ST QL AL AL GR
max min max m/f
GA
HYDROXYCHLOROQUINE SULFATE
F
PRIMAQUINE PHOSPHATE
PRIMAQUINE PHOSPHATE
►ANTIMANIC AGENTS
F
LITHIUM
LITHIUM
F
LITHIUM CARBONATE
LITHIUM CARBONATE
F
LITHIUM CARBONATE ER
LITHIUM CARBONATE
LITHOBID
GA
LITHIUM CARBONATE
►ANTIMUSCARINICS
DETROL
GA
TOLTERODINE TARTRATE
DETROL LA
Formulary Drug
GA
Formulary Drug
F
TOLTERODINE TARTRATE
DETROL LA
TOLTERODINE TARTRATE
F
OXYBUTYNIN CHLORIDE
OXYBUTYNIN CHLORIDE
F
OXYBUTYNIN CHLORIDE ER
OXYBUTYNIN CHLORIDE
F
TOLTERODINE TARTRATE
TOLTERODINE TARTRATE
F
TOLTERODINE TARTRATE ER
TOLTERODINE TARTRATE
TOVIAZ
(4MG TB24)
F
Y
(8MG TB24)
F
Y
FESOTERODINE FUMARATE
TOVIAZ
FESOTERODINE FUMARATE
TROSPIUM CHLORIDE
F
TROSPIUM CHLORIDE
►ANTIMUSCARINICS/ANTISPASMODICS
ATROVENT HFA
F
IPRATROPIUM BROMIDE
BENTYL
GA
DICYCLOMINE HYDROCHLORIDE
COMBIVENT
F
ALBUTEROL SULFATE; IPRATROPIUM BROMIDE
COMBIVENT RESPIMAT
F
ALBUTEROL SULFATE; IPRATROPIUM BROMIDE
DICYCLOMINE HCL
F
DICYCLOMINE HYDROCHLORIDE
GLYCOPYRROLATE
F
GLYCOPYRROLATE
HYOSCYAMINE SULFATE
F
HYOSCYAMINE SULFATE
HYOSCYAMINE SULFATE ER
F
HYOSCYAMINE SULFATE
LEVBID
GA
HYOSCYAMINE SULFATE
PROPANTHELINE BROMIDE
F
PROPANTHELINE BROMIDE
ROBINUL
GA
GLYCOPYRROLATE
ROBINUL FORTE
GA
GLYCOPYRROLATE
Coverage by AmeriHealth First
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Page 15 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
SPIRIVA HANDIHALER
TIOTROPIUM BROMIDE MONOHYDRATE
F
TUDORZA PRESSAIR
ACLIDINIUM BROMIDE
►ANTIMYCOBACTERIALS, MISCELLANEOUS
F
DAPSONE
DAPSONE
►ANTINEOPLASTIC AGENTS
F
ALKERAN
MELPHALAN
ANASTROZOLE
(Gender F)
F
F
(Gender F)
GA
F
ANASTROZOLE
ARIMIDEX
ANASTROZOLE
F
BICALUTAMIDE
BICALUTAMIDE
CASODEX
(Gender M)
GA
M
BICALUTAMIDE
F
CEENU
LOMUSTINE
F
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
F
DROXIA
HYDROXYUREA
F
EMCYT
ESTRAMUSTINE PHOSPHATE SODIUM
FARESTON
Must have documented intolerence to tamoxifen. PA Required 60MG
F
Y
TOREMIFENE CITRATE
FEMARA
(2.5MG) QL 1 QY per 1 DY
GA
1
LETROZOLE
FLUTAMIDE
(Gender M)
F
M
FLUTAMIDE
F
HEXALEN
ALTRETAMINE
HYDREA
GA
HYDROXYUREA
F
HYDROXYUREA
HYDROXYUREA
LETROZOLE
(2.5MG) QL 1 QY per 1 DY
F
1
LETROZOLE
F
LEUKERAN
CHLORAMBUCIL
F
LYSODREN
MITOTANE
F
MATULANE
PROCARBAZINE HYDROCHLORIDE
MEGACE ES
(625MG/5ML) QL 150 QY per 30 DY
F
150
MEGESTROL ACETATE
MEGACE ORAL
GA
MEGESTROL ACETATE
MEGESTROL ACETATE
F
MEGESTROL ACETATE
MERCAPTOPURINE
F
MERCAPTOPURINE
METHOTREXATE
F
METHOTREXATE
METHOTREXATE SODIUM
F
METHOTREXATE SODIUM
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 16 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
MYLERAN
BUSULFAN
RHEUMATREX
GA
METHOTREXATE SODIUM
F
TABLOID
THIOGUANINE
TAMOXIFEN CITRATE
(Gender F)
F
F
TAMOXIFEN CITRATE
F
TREXALL
METHOTREXATE SODIUM
►ANTIPROTOZOALS, MISCELLANEOUS
FLAGYL
GA
METRONIDAZOLE
MEPRON
PA Required 750MG/5ML
F
OTC 1% OINT
F
Y
ATOVAQUONE
►ANTIPRURITICS AND LOCAL ANESTHETICS
DIBUCAINE
DIBUCAINE
F
LIDOCAINE
LIDOCAINE HYDROCHLORIDE
LIDOCAINE
PA Required 5%
NF
Y
LIDOCAINE
LIDOCAINE/PRILOCAINE
(2.5%; 2.5%) QL 30 QY per 30 DY
F
30
LIDOCAINE; PRILOCAINE
LIDODERM
PA Required 5%
NF
Y
LIDOCAINE
NUPERCAINAL
OTC 1% OINT
F
DIBUCAINE
PHENAZOPYRIDINE HCL
F
PHENAZOPYRIDINE HYDROCHLORIDE
PYRIDIUM
GA
PHENAZOPYRIDINE HYDROCHLORIDE
►ANTIPSYCHOTICS, MISCELLANEOUS
LOXAPINE SUCCINATE
F
LOXAPINE SUCCINATE
LOXITANE
GA
LOXAPINE SUCCINATE
ORAP
F
PIMOZIDE
►ANTITHYROID AGENTS
METHIMAZOLE
F
METHIMAZOLE
PROPYLTHIOURACIL
F
PROPYLTHIOURACIL
SSKI
F
POTASSIUM IODIDE
TAPAZOLE
GA
METHIMAZOLE
►ANTITUBERCULOSIS AGENTS
ETHAMBUTOL HCL
F
ETHAMBUTOL HYDROCHLORIDE
ISONIAZID
F
ISONIAZID
MYCOBUTIN
F
RIFABUTIN
PYRAZINAMIDE
F
PYRAZINAMIDE
RIFADIN
GA
RIFAMPIN
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 17 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
RIFAMPIN
RIFAMPIN
►ANTITUSSIVES
F
BENZONATATE
BENZONATATE
F
BROMFED DM
BROMPHENIRAMINE MALEATE; DEXTROMETHORPHAN HYDROBROMIDE;
PSEUDOEPHEDRINE HYDROCHLORIDE
CHERATUSSIN AC
OTC 10MG/5ML; 100MG/5ML SYRP
F
OTC 10MG/5ML; 100MG/5ML; 30MG/5ML SOLN
F
CODEINE PHOSPHATE; GUAIFENESIN
CHERATUSSIN DAC
CODEINE PHOSPHATE; GUAIFENESIN; PSEUDOEPHEDRINE HYDROCHLORIDE
F
HYDROCODONE/HOMATROPINE
HOMATROPINE METHYLBROMIDE; HYDROCODONE BITARTRATE
M-END DMX
OTC 0.667MG/5ML; 10MG/5ML; 20MG/5ML LIQD
F
DEXBROMPHENIRAMINE MALEATE; DEXTROMETHORPHAN HYDROBROMIDE;
PSEUDOEPHEDRINE HYDROCHLORIDE
F
PROMETHAZINE VC/CODEINE
CODEINE PHOSPHATE; PHENYLEPHRINE HYDROCHLORIDE; PROMETHAZINE
HYDROCHLORIDE
F
PROMETHAZINE/CODEINE
CODEINE PHOSPHATE; PROMETHAZINE HYDROCHLORIDE
F
PROMETHAZINE/DEXTROMETHORPHAN
DEXTROMETHORPHAN HYDROBROMIDE; PROMETHAZINE HYDROCHLORIDE
F
PROMETHAZINE-DM
DEXTROMETHORPHAN HYDROBROMIDE; PROMETHAZINE HYDROCHLORIDE
ROBAFEN DM
OTC 10MG/5ML; 100MG/5ML SYRP
F
DEXTROMETHORPHAN HYDROBROMIDE; GUAIFENESIN
TESSALON PERLES
GA
BENZONATATE
F
TUSSIGON
HOMATROPINE METHYLBROMIDE; HYDROCODONE BITARTRATE
►ANTIVIRALS (EENT)
F
TRIFLURIDINE
TRIFLURIDINE
VIROPTIC
GA
TRIFLURIDINE
►ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
DENAVIR
(1%) QL 5 QY per 30 DY
F
5
PENCICLOVIR
►ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.
AMBIEN
GA
ZOLPIDEM TARTRATE
AMBIEN CR
PA Required 12.5MG
NF
Y
PA Required 6.25MG
NF
Y
ZOLPIDEM TARTRATE
AMBIEN CR
ZOLPIDEM TARTRATE
F
BUSPIRONE HCL
BUSPIRONE HYDROCHLORIDE
F
DROPERIDOL
DROPERIDOL
EDLUAR
PA Required 10MG
NF
Y
PA Required 5MG
NF
Y
ZOLPIDEM TARTRATE
EDLUAR
ZOLPIDEM TARTRATE
HYDROXYZINE HCL
F
HYDROXYZINE HYDROCHLORIDE
HYDROXYZINE PAMOATE
F
HYDROXYZINE PAMOATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 18 of 73
Brand Name
Generic Name
LUNESTA
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
PA Required 1MG
NF
Y
PA Required 2MG
NF
Y
PA Required 3MG
NF
Y
ESZOPICLONE
LUNESTA
ESZOPICLONE
LUNESTA
ESZOPICLONE
F
MEPROBAMATE
MEPROBAMATE
ROZEREM
RAMELTEON
Requires trial and failure or intolerance to zolpidem or zaleplon. Note:
F
Can be approved as first line agent if there is a history of substance abuse
(8MG TABS)
SONATA
Y
GA
ZALEPLON
VISTARIL
GA
HYDROXYZINE PAMOATE
F
ZALEPLON
ZALEPLON
F
ZOLPIDEM TARTRATE
ZOLPIDEM TARTRATE
►ASTRINGENTS
DRYSOL
GA
ALUMINUM CHLORIDE
F
HYPERCARE
ALUMINUM CHLORIDE
►ATYPICAL ANTIPSYCHOTICS
F
ABILIFY
ARIPIPRAZOLE
F
ABILIFY DISCMELT
ARIPIPRAZOLE
CLOZAPINE
CLOZAPINE
CLOZARIL
CLOZAPINE
FANAPT
Only Teva products covered - NDCs starting "00093". **A pharmacy
override can be placed if the pharmacy states they cannot get an
adequate supply of the preferred TEVA generic**
F
Only Teva products covered - NDCs starting "00093". **A pharmacy
override can be placed if the pharmacy states they cannot get an
adequate supply of the preferred TEVA generic**
GA
F
ILOPERIDONE
FANAPT TITRATION PACK (In a Dose Pack)
F
ILOPERIDONE
GEODON
GA
ZIPRASIDONE HYDROCHLORIDE
LATUDA
F
LURASIDONE HYDROCHLORIDE
OLANZAPINE
F
OLANZAPINE
QUETIAPINE FUMARATE
F
QUETIAPINE FUMARATE
RISPERDAL
GA
RISPERIDONE
RISPERIDONE
F
RISPERIDONE
SAPHRIS
F
ASENAPINE MALEATE
SEROQUEL
GA
QUETIAPINE FUMARATE
ZIPRASIDONE HCL
F
ZIPRASIDONE HYDROCHLORIDE
ZYPREXA
GA
OLANZAPINE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 19 of 73
Brand Name
Generic Name
Notes and Restrictions
►AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX
Status PA ST QL AL AL GR
max min max m/f
(0.5MG) QL 360 QY per 365 DY Min Age 18
F
360
18
(1MG) QL 360 QY per 365 DY Min Age 18
F
360
18
(0) QL 360 QY per 365 DY Min Age 18
F
360
18
VARENICLINE TARTRATE
CHANTIX
VARENICLINE TARTRATE
CHANTIX STARTING MONTH PAK (In a Dose Pack)
VARENICLINE TARTRATE
NICODERM CQ
OTC 14MG/24HR PT24
GA
OTC 21MG/24HR PT24
GA
OTC 7MG/24HR PT24
GA
OTC 2MG GUM
GA
OTC 4MG GUM
GA
NICOTINE
NICODERM CQ
NICOTINE
NICODERM CQ
NICOTINE
NICORETTE
NICOTINE POLACRILEX
NICORETTE
NICOTINE POLACRILEX
NICOTINE
OTC 14MG/24HR PT24
F
OTC 21MG/24HR PT24
F
OTC 2MG GUM
F
OTC 2MG LOZG
F
OTC 4MG GUM
F
OTC 4MG LOZG
F
OTC 7MG/24HR PT24
F
NICOTINE
NICOTINE
NICOTINE
NICOTINE POLACRILEX
NICOTINE POLACRILEX
NICOTINE POLACRILEX
NICOTINE POLACRILEX
NICOTINE POLACRILEX
NICOTINE POLACRILEX
NICOTINE POLACRILEX
NICOTINE POLACRILEX
NICOTINE TRANSDERMAL SYSTEM
NICOTINE
F
NICOTROL INHALER
NICOTINE
NICOTROL NS
(10MG/ML) QL 60 QY per 30 DY
F
60
NICOTINE
►AZOLES
DIFLUCAN
GA
FLUCONAZOLE
DIFLUCAN
(150MG) QL 2 QY per 30 DY
GA
2
FLUCONAZOLE
F
FLUCONAZOLE
FLUCONAZOLE
FLUCONAZOLE
(150MG) QL 2 QY per 30 DY
F
2
FLUCONAZOLE
VFEND
PA Required 200MG
NF
Y
PA Required 40MG/ML
NF
Y
PA Required 50MG
NF
Y
VORICONAZOLE
VFEND
VORICONAZOLE
VFEND
VORICONAZOLE
►AZOLES (SKIN & MUCOUS MEMBRANE)
F
CLOTRIMAZOLE
CLOTRIMAZOLE
CLOTRIMAZOLE
OTC 1% CREA
F
(0.05%; 1%) QL 15 QY per 34 DY
F
CLOTRIMAZOLE
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE
15
BETAMETHASONE DIPROPIONATE; CLOTRIMAZOLE
KETOCONAZOLE
F
KETOCONAZOLE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 20 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
KETOCONAZOLE
Prior 4 week therapy with selenium sulfide or ketoconazole 1% shampoo
(OTC). (2% SHAM)
LOTRIMIN AF
OTC 1% CREA
GA
(0.05%; 1%) QL 15 QY per 34 DY
GA
KETOCONAZOLE
Y
CLOTRIMAZOLE
LOTRISONE
15
BETAMETHASONE DIPROPIONATE; CLOTRIMAZOLE
F
MICONAZOLE 3
MICONAZOLE NITRATE
MICONAZOLE NITRATE
OTC 2% CREA
F
MICONAZOLE NITRATE
MONISTAT 1
OTC 6.50% OINT
GA
TIOCONAZOLE
NIZORAL
KETOCONAZOLE
Prior 4 week therapy with selenium sulfide or ketoconazole 1% shampoo GA
(OTC). (2% SHAM)
►BARBITURATES (ANTICONVULSANTS)
MYSOLINE
Y
GA
PRIMIDONE
F
PRIMIDONE
PRIMIDONE
►BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
PHENOBARBITAL
F
PHENOBARBITAL
►BASIC LOTIONS AND LINIMENTS
LAC-HYDRIN
GA
LACTIC ACID
LAC-HYDRIN
GA
AMMONIUM LACTATE
F
LACLOTION
AMMONIUM LACTATE
►BASIC OINTMENTS AND PROTECTANTS
F
AMMONIUM LACTATE
LACTIC ACID
F
AMMONIUM LACTATE
AMMONIUM LACTATE
AMMONIUM LACTATE
OTC 12% LOTN
F
LACTIC ACID
►BENZODIAZEPINES (ANTICONVULSANTS)
F
CLONAZEPAM
CLONAZEPAM
KLONOPIN
GA
CLONAZEPAM
►BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
ALPRAZOLAM
F
ALPRAZOLAM
ATIVAN
GA
LORAZEPAM
CHLORDIAZEPOXIDE HCL
Brand name product can not be approved. Excluded from DPW coverage. F
CHLORDIAZEPOXIDE HYDROCHLORIDE
CLORAZEPATE DIPOTASSIUM
F
CLORAZEPATE DIPOTASSIUM
DIASTAT ACUDIAL
DIAZEPAM
DIASTAT ACUDIAL
DIAZEPAM
DIASTAT PEDIATRIC
DIAZEPAM
Coverage by AmeriHealth First
Last updated copy:11/20/2014
Diastat is supplied as a twin pack (kit), 2 doses per pack. The approvable GA
quantity limit is 4 doses/month = 2 kits/month.(10MG) QL 2 QY per 30 DY
PA Required 10MG
Y
2
Diastat is supplied as a twin pack (kit), 2 doses per pack. The approvable GA
quantity limit is 4 doses/month = 2 kits/month.(20MG) QL 2 QY per 30 DY
PA Required 20MG
Y
2
Diastat is supplied as a twin pack (kit), 2 doses per pack. The approvable GA
quantity limit is 4 doses/month = 2 kits/month.(2.5MG) QL 2 QY per 30 DY
PA Required 2.5MG
Y
2
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Page 21 of 73
Brand Name
Generic Name
DIAZEPAM
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Brand name product can not be approved. Excluded from DPW coverage. F
DIAZEPAM
DIAZEPAM
DIAZEPAM
DIAZEPAM
DIAZEPAM
DIAZEPAM
DIAZEPAM
Supplied as a twin pack (kit), 2 doses per pack. The approvable quantity
limit is 4 doses/month = 2 kits/month.(10MG) QL 2 QY per 30 DY
F
2
Supplied as a twin pack (kit), 2 doses per pack. The approvable quantity
limit is 4 doses/month = 2 kits/month.(2.5MG) QL 2 QY per 30 DY
F
2
Supplied as a twin pack (kit), 2 doses per pack. The approvable quantity
limit is 4 doses/month = 2 kits/month.(20MG) QL 2 QY per 30 DY
F
2
F
ESTAZOLAM
ESTAZOLAM
HALCION
GA
TRIAZOLAM
F
LORAZEPAM
LORAZEPAM
F
OXAZEPAM
OXAZEPAM
RESTORIL
GA
TEMAZEPAM
F
TEMAZEPAM
TEMAZEPAM
TRANXENE T
GA
CLORAZEPATE DIPOTASSIUM
F
TRIAZOLAM
TRIAZOLAM
XANAX
GA
ALPRAZOLAM
►BENZYLAMINES (SKIN & MUCOUS MEMBRANE)
LOTRIMIN ULTRA
OTC 1% CREA
F
BUTENAFINE HYDROCHLORIDE
MENTAX
Lotrimin Ultra (OTC) is preferred.
GA
BUTENAFINE HYDROCHLORIDE
►BETA-ADRENERGIC BLOCKING AGENTS
ATENOLOL
Generic 90-days
F
ATENOLOL
BETAPACE
GA
SOTALOL HYDROCHLORIDE
BETAPACE AF
GA
SOTALOL HYDROCHLORIDE
BISOPROLOL FUMARATE
F
BISOPROLOL FUMARATE
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE
F
BISOPROLOL FUMARATE; HYDROCHLOROTHIAZIDE
CARVEDILOL
F
CARVEDILOL
COREG
GA
CARVEDILOL
CORGARD
GA
NADOLOL
CORZIDE
GA
BENDROFLUMETHIAZIDE; NADOLOL
INDERAL LA
GA
PROPRANOLOL HYDROCHLORIDE
LABETALOL HCL
F
LABETALOL HYDROCHLORIDE
LOPRESSOR
GA
METOPROLOL TARTRATE
LOPRESSOR HCT
GA
HYDROCHLOROTHIAZIDE; METOPROLOL TARTRATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 22 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
METOPROLOL SUCCINATE ER
METOPROLOL SUCCINATE
F
METOPROLOL TARTRATE
METOPROLOL TARTRATE
F
METOPROLOL/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; METOPROLOL TARTRATE
F
NADOLOL
NADOLOL
F
NADOLOL/BENDROFLUMETHIAZIDE
BENDROFLUMETHIAZIDE; NADOLOL
F
PINDOLOL
PINDOLOL
F
PROPRANOLOL HCL
PROPRANOLOL HYDROCHLORIDE
F
PROPRANOLOL HCL ER
PROPRANOLOL HYDROCHLORIDE
F
PROPRANOLOL/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; PROPRANOLOL HYDROCHLORIDE
F
SOTALOL HCL
SOTALOL HYDROCHLORIDE
F
SOTALOL HCL (AF)
SOTALOL HYDROCHLORIDE
TENORMIN
Generic 90-days
GA
ATENOLOL
TIMOLOL MALEATE
F
TIMOLOL MALEATE
TOPROL XL
GA
METOPROLOL SUCCINATE
TRANDATE
GA
LABETALOL HYDROCHLORIDE
ZEBETA
GA
BISOPROLOL FUMARATE
ZIAC
GA
BISOPROLOL FUMARATE; HYDROCHLOROTHIAZIDE
►BETA-ADRENERGIC BLOCKING AGENTS (EENT)
BETAGAN
GA
LEVOBUNOLOL HYDROCHLORIDE
CARTEOLOL HCL
F
CARTEOLOL HCL
LEVOBUNOLOL HCL
F
LEVOBUNOLOL HYDROCHLORIDE
TIMOLOL MALEATE OPHTHALMIC GEL FORMING
F
TIMOLOL MALEATE
TIMOPTIC
GA
TIMOLOL MALEATE
TIMOPTIC OCUDOSE
F
TIMOLOL MALEATE
TIMOPTIC-XE
GA
TIMOLOL MALEATE
►BIGUANIDES
GLUCOPHAGE
GA
METFORMIN HYDROCHLORIDE
GLUCOPHAGE XR
GA
METFORMIN HYDROCHLORIDE
METFORMIN HCL
F
METFORMIN HYDROCHLORIDE
METFORMIN HCL ER
F
METFORMIN HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 23 of 73
Brand Name
Generic Name
Notes and Restrictions
►BILE ACID SEQUESTRANTS
Status PA ST QL AL AL GR
max min max m/f
F
CHOLESTYRAMINE
CHOLESTYRAMINE
F
CHOLESTYRAMINE LIGHT
CHOLESTYRAMINE
COLESTID
GA
COLESTIPOL HYDROCHLORIDE
F
COLESTIPOL HCL
COLESTIPOL HYDROCHLORIDE
F
PREVALITE
CHOLESTYRAMINE
QUESTRAN
GA
CHOLESTYRAMINE
QUESTRAN LIGHT
GA
CHOLESTYRAMINE
F
WELCHOL
COLESEVELAM HYDROCHLORIDE
►BONE RESORPTION INHIBITORS
F
ALENDRONATE SODIUM
ALENDRONATE SODIUM
DIDRONEL
GA
ETIDRONATE DISODIUM
F
ETIDRONATE DISODIUM
ETIDRONATE DISODIUM
FOSAMAX
Generic 90-days
GA
ALENDRONATE SODIUM
►BUTYROPHENONES
HALOPERIDOL
F
HALOPERIDOL LACTATE
HALOPERIDOL
F
HALOPERIDOL
HALOPERIDOL DECANOATE
F
HALOPERIDOL DECANOATE
HALOPERIDOL LACTATE
F
HALOPERIDOL LACTATE
►CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
CALAN
GA
VERAPAMIL HYDROCHLORIDE
CALAN SR
GA
VERAPAMIL HYDROCHLORIDE
CARDIZEM
GA
DILTIAZEM HYDROCHLORIDE
CARDIZEM CD
GA
DILTIAZEM HYDROCHLORIDE
DILACOR XR
GA
DILTIAZEM HYDROCHLORIDE
DILTIAZEM CD
F
DILTIAZEM HYDROCHLORIDE
DILTIAZEM HCL
F
DILTIAZEM HYDROCHLORIDE
DILTIAZEM HCL ER
F
DILTIAZEM HYDROCHLORIDE
DILT-XR
F
DILTIAZEM HYDROCHLORIDE
ISOPTIN SR
GA
VERAPAMIL HYDROCHLORIDE
TAZTIA XT
F
DILTIAZEM HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 24 of 73
Brand Name
Generic Name
Notes and Restrictions
TIAZAC
Status PA ST QL AL AL GR
max min max m/f
GA
DILTIAZEM HYDROCHLORIDE
F
VERAPAMIL HCL
VERAPAMIL HYDROCHLORIDE
F
VERAPAMIL HCL ER
VERAPAMIL HYDROCHLORIDE
F
VERAPAMIL HCL SR
VERAPAMIL HYDROCHLORIDE
VERELAN
GA
VERAPAMIL HYDROCHLORIDE
►CALORIC AGENTS
GLUCOSE
OTC 4GM CHEW
F
OTC 4GM CHEW
F
DEXTROSE (ANHYDROUS)
SM GLUCOSE
DEXTROSE (ANHYDROUS)
►CARBONIC ANHYDRASE INHIBITORS (EENT)
F
ACETAZOLAMIDE
ACETAZOLAMIDE
ACETAZOLAMIDE ER
PA Required 500MG
F
Y
ACETAZOLAMIDE
COSOPT
GA
DORZOLAMIDE HYDROCHLORIDE; TIMOLOL MALEATE
DIAMOX
PA Required 500MG
GA
Y
ACETAZOLAMIDE
F
DORZOLAMIDE HCL
DORZOLAMIDE HYDROCHLORIDE
F
DORZOLAMIDE HCL/TIMOLOL MALEATE
DORZOLAMIDE HYDROCHLORIDE; TIMOLOL MALEATE
TRUSOPT
GA
DORZOLAMIDE HYDROCHLORIDE
►CARDIOTONIC AGENTS
F
DIGOX
DIGOXIN
LANOXIN
GA
DIGOXIN
►CARIOSTATIC AGENTS
CLINPRO 5000
(Max Age 20)
F
20
Maximum Age is 10 years (Max Age 10)
F
10
(Max Age 20)
F
20
(Max Age 20)
GA
20
(Max Age 20)
F
20
OTC 0.04% SOLN (Max Age 20)
F
20
(Max Age 20)
GA
20
(Max Age 20)
F
20
(Max Age 20)
GA
20
(Max Age 20)
GA
20
(Max Age 20)
F
20
SODIUM FLUORIDE
DENTA 5000 PLUS
SODIUM FLUORIDE
FLUORITAB
SODIUM FLUORIDE
LURIDE
SODIUM FLUORIDE
NEUTRAL SODIUM FLUORIDE
SODIUM FLUORIDE
PHOS FLUR
SODIUM FLUORIDE
PREVIDENT
SODIUM FLUORIDE
PREVIDENT 5000 BOOSTER
SODIUM FLUORIDE
PREVIDENT 5000 PLUS
SODIUM FLUORIDE
PREVIDENT FLUORIDE
SODIUM FLUORIDE
SF
SODIUM FLUORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 25 of 73
Brand Name
Generic Name
SF 5000 PLUS
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
(Max Age 20)
F
20
(Max Age 20)
F
20
SODIUM FLUORIDE
SODIUM FLUORIDE
SODIUM FLUORIDE
►CATHARTICS AND LAXATIVES
F
AMITIZA
LUBIPROSTONE
COLYTE-FLAVOR PACKS
GA
POLYETHYLENE GLYCOL; POTASSIUM CHLORIDE; SODIUM BICARBONATE; SODIUM
CHLORIDE; SODIUM SULFATE
DOCUSATE CALCIUM
OTC 240MG CAPS
F
OTC 5MG TBEC
F
DOCUSATE CALCIUM
FLEET LAXATIVE
BISACODYL
F
GAVILYTE-G
POLYETHYLENE GLYCOL; POTASSIUM CHLORIDE; SODIUM BICARBONATE; SODIUM
CHLORIDE; SODIUM SULFATE
GOLYTELY
GA
POLYETHYLENE GLYCOL; POTASSIUM CHLORIDE; SODIUM BICARBONATE; SODIUM
CHLORIDE; SODIUM SULFATE
LAXATIVE
OTC 10MG SUPP
F
OTC 400MG/5ML SUSP
F
BISACODYL
MILK OF MAGNESIA
MAGNESIUM HYDROXIDE
F
MINERAL OIL HEAVY
MINERAL OIL
MIRALAX
OTC POWD
GA
POLYETHYLENE GLYCOL
NATURAL FIBER THERAPY
OTC 30.90% POWD
F
OTC 48.57% POWD
F
PSYLLIUM
NATURAL FIBER THERAPY
PSYLLIUM
NULYTELY/FLAVOR PACKS
GA
POLYETHYLENE GLYCOL; POTASSIUM CHLORIDE; SODIUM BICARBONATE; SODIUM
CHLORIDE
F
PEG 3350/ELECTROLYTES
POLYETHYLENE GLYCOL; POTASSIUM CHLORIDE; SODIUM BICARBONATE; SODIUM
CHLORIDE; SODIUM SULFATE
F
POLYETHYLENE GLYCOL 3350
POLYETHYLENE GLYCOL
POLYETHYLENE GLYCOL 3350
OTC POWD
F
OTC 8.6MG TABS
F
OTC 50MG; 8.6MG TABS
F
OTC 60MG/15ML SYRP
F
OTC 100MG CAPS
F
OTC 240MG CAPS
F
POLYETHYLENE GLYCOL
SENNA
SENNOSIDES
SENNA S
DOCUSATE SODIUM; SENNOSIDES
SILACE
DOCUSATE SODIUM
STOOL SOFTENER
DOCUSATE SODIUM
STOOL SOFTENER LAXATIVE DC
DOCUSATE CALCIUM
F
TRILYTE
POLYETHYLENE GLYCOL; POTASSIUM CHLORIDE; SODIUM BICARBONATE; SODIUM
CHLORIDE
►CELL STIMULANTS AND PROLIFERANTS
RETIN-A
TRETINOIN
RETIN-A
TRETINOIN
Coverage by AmeriHealth First
Last updated copy:11/20/2014
Pays at point of sale for members less than 21 years old. PA Required
0.01%
GA
Y
Pays at point of sale for members less than 21 years old. PA Required
0.03%
GA
Y
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Brand Name
Generic Name
RETIN-A
TRETINOIN
RETIN-A
TRETINOIN
RETIN-A MICRO
TRETINOIN
TRETINOIN
TRETINOIN
TRETINOIN
TRETINOIN
TRETINOIN
TRETINOIN
TRETINOIN
TRETINOIN
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Pays at point of sale for members less than 21 years old. PA Required
0.05%
GA
Y
Pays at point of sale for members less than 21 years old. PA Required
0.10%
GA
Y
Pays at point of sale for members less than 21 years old. PA Required
0.04%
GA
Y
Pays at point of sale for members less than 21 years old. PA Required
0.01%
F
Y
Pays at point of sale for members less than 21 years old. PA Required
0.03%
F
Y
Pays at point of sale for members less than 21 years old. PA Required
0.05%
F
Y
Pays at point of sale for members less than 21 years old. PA Required
0.10%
F
Y
►CENTRAL ALPHA-AGONISTS
CATAPRES
Generic 90-days
GA
Generic 90-days
GA
Generic 90-days
GA
Generic 90-days
GA
Generic 90-days
F
CLONIDINE HYDROCHLORIDE
CATAPRES-TTS-1
CLONIDINE HYDROCHLORIDE
CATAPRES-TTS-2
CLONIDINE HYDROCHLORIDE
CATAPRES-TTS-3
CLONIDINE HYDROCHLORIDE
CLONIDINE HCL
CLONIDINE HYDROCHLORIDE
F
CLORPRES
CHLORTHALIDONE; CLONIDINE HYDROCHLORIDE
F
GUANFACINE HCL
GUANFACINE HCL
F
METHYLDOPA
METHYLDOPA
F
METHYLDOPA/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; METHYLDOPA
TENEX
GA
GUANFACINE HCL
►CENTRAL NERVOUS SYSTEM AGENTS, MISC.
NAMENDA
Min Age 18
F
18
Min Age 18
F
18
Min Age 18
F
18
Min Age 18
F
18
Prior authorization required for members age 21 and older. PA Required
100MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
10MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
18MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
25MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
40MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
60MG (Max Age 20)
F
Y
20
MEMANTINE HYDROCHLORIDE
NAMENDA TITRATION PAK (In a Dose Pack)
MEMANTINE HYDROCHLORIDE
NAMENDA XR
MEMANTINE HYDROCHLORIDE
NAMENDA XR TITRATION PACK
MEMANTINE HYDROCHLORIDE
STRATTERA
ATOMOXETINE HYDROCHLORIDE
STRATTERA
ATOMOXETINE HYDROCHLORIDE
STRATTERA
ATOMOXETINE HYDROCHLORIDE
STRATTERA
ATOMOXETINE HYDROCHLORIDE
STRATTERA
ATOMOXETINE HYDROCHLORIDE
STRATTERA
ATOMOXETINE HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Brand Name
Generic Name
STRATTERA
ATOMOXETINE HYDROCHLORIDE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Prior authorization required for members age 21 and older. PA Required
80MG (Max Age 20)
►CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
CARISOPRODOL
F
Y
20
F
CARISOPRODOL
F
CHLORZOXAZONE
CHLORZOXAZONE
F
CYCLOBENZAPRINE HCL
CYCLOBENZAPRINE HYDROCHLORIDE
F
METHOCARBAMOL
METHOCARBAMOL
ROBAXIN
GA
METHOCARBAMOL
ROBAXIN-750
GA
METHOCARBAMOL
SOMA
GA
CARISOPRODOL
F
TIZANIDINE HCL
TIZANIDINE HYDROCHLORIDE
ZANAFLEX
GA
TIZANIDINE HYDROCHLORIDE
►CHLORAMPHENICOL
F
CHLORAMPHENICOL SODIUM SUCCINATE
CHLORAMPHENICOL SODIUM SUCCINATE
►CHOLELITHOLYTIC AGENTS
ACTIGALL
GA
URSODIOL
URSO 250
GA
URSODIOL
URSO FORTE
GA
URSODIOL
F
URSODIOL
URSODIOL
►CHOLESTEROL ABSORPTION INHIBITORS
F
VYTORIN
EZETIMIBE; SIMVASTATIN - HIGH DOSE (40 MG & HIGHER)
F
VYTORIN
EZETIMIBE; SIMVASTATIN
F
ZETIA
EZETIMIBE
►CLASS IA ANTIARRHYTHMICS
F
DISOPYRAMIDE PHOSPHATE
DISOPYRAMIDE PHOSPHATE
NORPACE
GA
DISOPYRAMIDE PHOSPHATE
NORPACE CR
GA
DISOPYRAMIDE PHOSPHATE
F
QUINIDINE GLUCONATE CR
QUINIDINE GLUCONATE
F
QUINIDINE SULFATE
QUINIDINE SULFATE
F
QUINIDINE SULFATE ER
QUINIDINE SULFATE
►CLASS IB ANTIARRHYTHMICS
F
MEXILETINE HCL
MEXILETINE HYDROCHLORIDE
►CLASS IC ANTIARRHYTHMICS
FLECAINIDE ACETATE
Formulary Drug
GA
FLECAINIDE ACETATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Brand Name
Generic Name
FLECAINIDE ACETATE
Notes and Restrictions
Formulary Drug
Status PA ST QL AL AL GR
max min max m/f
F
FLECAINIDE ACETATE
F
PROPAFENONE HCL
PROPAFENONE HCL
RYTHMOL
GA
PROPAFENONE HCL
►CLASS III ANTIARRHYTHMICS
F
AMIODARONE HCL
AMIODARONE HCL
CORDARONE
GA
AMIODARONE HCL
MULTAQ
PA Required 400MG
NF
Y
DRONEDARONE HYDROCHLORIDE
PACERONE
F
AMIODARONE HCL
►CONTRACEPTIVES
APRI
F
DESOGESTREL; ETHINYL ESTRADIOL
ARANELLE
F
ETHINYL ESTRADIOL; NORETHINDRONE
AVIANE
F
ETHINYL ESTRADIOL; LEVONORGESTREL
BALZIVA
F
ETHINYL ESTRADIOL; NORETHINDRONE
CAMILA
F
NORETHINDRONE
CAMRESE
F
ETHINYL ESTRADIOL; LEVONORGESTREL
CESIA
F
DESOGESTREL; ETHINYL ESTRADIOL
CRYSELLE-28
F
ETHINYL ESTRADIOL; NORGESTREL
CYCLESSA
GA
DESOGESTREL; ETHINYL ESTRADIOL
DESOGEN
GA
DESOGESTREL; ETHINYL ESTRADIOL
ENPRESSE-28
F
ETHINYL ESTRADIOL; LEVONORGESTREL
ERRIN
F
NORETHINDRONE
ESTROSTEP FE
GA
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
FEMCON FE
GA
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE
INTROVALE
GA
ETHINYL ESTRADIOL; LEVONORGESTREL
JOLESSA
F
ETHINYL ESTRADIOL; LEVONORGESTREL
JOLIVETTE
F
NORETHINDRONE
JUNEL 1.5/30
F
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
JUNEL 1/20
F
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
JUNEL FE 1.5/30
F
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
JUNEL FE 1/20
F
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 29 of 73
Brand Name
Generic Name
KARIVA
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
DESOGESTREL; ETHINYL ESTRADIOL
KELNOR 1/35
F
ETHINYL ESTRADIOL; ETHYNODIOL DIACETATE
KURVELO
F
ETHINYL ESTRADIOL; LEVONORGESTREL
LEENA
F
ETHINYL ESTRADIOL; NORETHINDRONE
LESSINA
F
ETHINYL ESTRADIOL; LEVONORGESTREL
LEVONORGESTREL/ETHINYL ESTRADIOL
GA
ETHINYL ESTRADIOL; LEVONORGESTREL
LEVORA 0.15/30-28
F
ETHINYL ESTRADIOL; LEVONORGESTREL
LOESTRIN 1.5/30-21
GA
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
LOESTRIN 1/20-21
GA
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
LOESTRIN 24 FE
F
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
LOESTRIN FE 1.5/30
GA
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
LOESTRIN FE 1/20
GA
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
LOW-OGESTREL
F
ETHINYL ESTRADIOL; NORGESTREL
LUTERA
F
ETHINYL ESTRADIOL; LEVONORGESTREL
MICROGESTIN 1.5/30
F
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
MICROGESTIN 1/20
F
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
MICROGESTIN FE
F
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
MICROGESTIN FE 1.5/30
F
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
MIRCETTE
GA
DESOGESTREL; ETHINYL ESTRADIOL
MODICON
GA
ETHINYL ESTRADIOL; NORETHINDRONE
MONONESSA
F
ETHINYL ESTRADIOL; NORGESTIMATE
NECON 1/35
F
ETHINYL ESTRADIOL; NORETHINDRONE
NECON 1/50-28
F
MESTRANOL; NORETHINDRONE
NECON 10/11-28
F
ETHINYL ESTRADIOL; NORETHINDRONE
NECON 7/7/7
F
ETHINYL ESTRADIOL; NORETHINDRONE
NEXT CHOICE
F
LEVONORGESTREL
NEXT CHOICE ONE DOSE
F
LEVONORGESTREL
NORA-BE
F
NORETHINDRONE
NORINYL 1+35
GA
ETHINYL ESTRADIOL; NORETHINDRONE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Brand Name
Generic Name
NOR-QD
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
NORETHINDRONE
NORTREL 0.5/35 (28)
F
ETHINYL ESTRADIOL; NORETHINDRONE
NORTREL 1/35
F
ETHINYL ESTRADIOL; NORETHINDRONE
NORTREL 7/7/7
F
ETHINYL ESTRADIOL; NORETHINDRONE
NUVARING
F
ETHINYL ESTRADIOL; ETONOGESTREL
OCELLA
F
DROSPIRENONE; ETHINYL ESTRADIOL
OGESTREL
GA
ETHINYL ESTRADIOL; NORGESTREL
ORTHO EVRA
F
ETHINYL ESTRADIOL; NORELGESTROMIN
ORTHO MICRONOR
GA
NORETHINDRONE
ORTHO TRI-CYCLEN
GA
ETHINYL ESTRADIOL; NORGESTIMATE
ORTHO TRI-CYCLEN LO
F
ETHINYL ESTRADIOL; NORGESTIMATE
ORTHO-NOVUM 1/35
GA
ETHINYL ESTRADIOL; NORETHINDRONE
OVCON-35
GA
ETHINYL ESTRADIOL; NORETHINDRONE
PLAN B
GA
LEVONORGESTREL
PLAN B ONE-STEP
GA
LEVONORGESTREL
PORTIA-28
F
ETHINYL ESTRADIOL; LEVONORGESTREL
QUASENSE
F
ETHINYL ESTRADIOL; LEVONORGESTREL
RECLIPSEN
F
DESOGESTREL; ETHINYL ESTRADIOL
SEASONIQUE
GA
ETHINYL ESTRADIOL; LEVONORGESTREL
SOLIA
F
DESOGESTREL; ETHINYL ESTRADIOL
SPRINTEC 28
F
ETHINYL ESTRADIOL; NORGESTIMATE
SRONYX
F
ETHINYL ESTRADIOL; LEVONORGESTREL
TILIA FE
F
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE ACETATE
TRINESSA
F
ETHINYL ESTRADIOL; NORGESTIMATE
TRI-NORINYL 28
GA
ETHINYL ESTRADIOL; NORETHINDRONE
TRI-SPRINTEC
F
ETHINYL ESTRADIOL; NORGESTIMATE
TRIVORA-28
F
ETHINYL ESTRADIOL; LEVONORGESTREL
VELIVET
F
DESOGESTREL; ETHINYL ESTRADIOL
YASMIN 28
GA
DROSPIRENONE; ETHINYL ESTRADIOL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
ZENCHENT FE
ETHINYL ESTRADIOL; FERROUS FUMARATE; NORETHINDRONE
F
ZOVIA 1/35E
ETHINYL ESTRADIOL; ETHYNODIOL DIACETATE
F
ZOVIA 1/50E
ETHINYL ESTRADIOL; ETHYNODIOL DIACETATE
►CORTICOSTEROIDS (EENT)
BECONASE AQ
PA Required 42MCG/SPRAY
NF
Y
BECLOMETHASONE DIPROPIONATE
F
DEXAMETHASONE SODIUM PHOSPHATE
DEXAMETHASONE SODIUM PHOSPHATE
FLONASE
GA
FLUTICASONE PROPIONATE
F
FLUOROMETHOLONE
FLUOROMETHOLONE
F
FLUTICASONE PROPIONATE
FLUTICASONE PROPIONATE
F
FML
FLUOROMETHOLONE
F
FML FORTE
FLUOROMETHOLONE
FML LIQUIFILM
GA
FLUOROMETHOLONE
F
MAXIDEX
DEXAMETHASONE
NASACORT ALLERGY 24HR
OTC 55MCG/ACT AERO
F
TRIAMCINOLONE ACETONIDE
NASACORT AQ
Pays at point of sale for members less than 4 years of age. PA Required
55MCG/ACT
NF
Y
TRIAMCINOLONE ACETONIDE
OMNARIS
PA Required 50MCG/ACT
NF
Y
CICLESONIDE
PRED FORTE
GA
PREDNISOLONE ACETATE
F
PRED MILD
PREDNISOLONE ACETATE
F
PREDNISOLONE ACETATE
PREDNISOLONE ACETATE
RHINOCORT AQUA
PA Required 32MCG/ACT
NF
Y
PA Required 27.5MCG/SPRAY
NF
Y
BUDESONIDE
VERAMYST
FLUTICASONE FUROATE
►COUMARIN DERIVATIVES
COUMADIN
GA
WARFARIN SODIUM
F
WARFARIN SODIUM
WARFARIN SODIUM
►CYCLOOXYGENASE-2 (COX-2) INHIBITORS
CELEBREX
CELECOXIB
CELEBREX
CELECOXIB
CELEBREX
CELECOXIB
CELEBREX
CELECOXIB
Requires prior use of 2 NSAIDs in previous 30 days, current anticoagulant F
therapy, or documented GI disease. (100MG CAPS)
Y
Requires prior use of 2 NSAIDs in previous 30 days, current anticoagulant
therapy, or documented GI disease. (200MG CAPS)
F
Y
Requires prior use of 2 NSAIDs in previous 30 days, current anticoagulant
therapy, or documented GI disease. (400MG CAPS)
F
Y
Requires prior use of 2 NSAIDs in previous 30 days, current anticoagulant
therapy, or documented GI disease. (50MG CAPS)
F
Y
OTC SOLN
F
►DEVICES
ACCU-CHEK AVIVA
ACCU-CHEK AVIVA
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 32 of 73
Brand Name
Generic Name
ACCU-CHEK FASTCLIX LANCETDEVICE KIT
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
OTC KIT
F
OTC MISC
F
OTC KIT
F
OTC MISC
F
OTC KIT
F
OTC LIQD
F
OTC MISC
F
OTC MISC
F
OTC KIT
F
OTC MISC
F
ACCU-CHEK FASTCLIX LANCETDEVICE KIT
ACCU-CHEK FASTCLIX LANCETS
ACCU-CHEK FASTCLIX LANCETS
ACCU-CHEK MULTICLIX LANC ET DEVICE KIT
ACCU-CHEK MULTICLIX LANC ET DEVICE KIT
ACCU-CHEK MULTICLIX LANCETS
ACCU-CHEK MULTICLIX LANCETS
ACCU-CHEK NANO SMARTVIEW
ACCU-CHEK NANO SMARTVIEW
ACCU-CHEK SMARTVIEW CONTROL
ACCU-CHEK SMARTVIEW CONTROL
ACCU-CHEK SOFT TOUCH LANCETS
ACCU-CHEK SOFT TOUCH LANCETS
ACCU-CHEK SOFTCLIX LANCETDEVICE
ACCU-CHEK SOFTCLIX LANCETDEVICE
ACCU-CHEK SOFTCLIX LANCETDEVICE KIT
ACCU-CHEK SOFTCLIX LANCETDEVICE KIT
ACCU-CHEK SOFTCLIX LANCETS
ACCU-CHEK SOFTCLIX LANCETS
OPTICHAMBER FACE MASK/LARGE
() QL 2 QY per 365 DYOTC MISC
GA
2
() QL 2 QY per 365 DYOTC MISC
GA
2
() QL 2 QY per 365 DYOTC MISC
GA
2
OPTICHAMBER FACE MASK/LARGE
OPTICHAMBER FACE MASK/MEDIUM
OPTICHAMBER FACE MASK/MEDIUM
OPTICHAMBER FACE MASK/SMALL
OPTICHAMBER FACE MASK/SMALL
►DIABETES MELLITUS
ACCU-CHEK AVIVA PLUS
OTC KIT
F
ACCU-CHEK AVIVA PLUS
ACCU-CHEK AVIVA PLUS
DIAGNOSTIC TEST
ACCU-CHEK SMARTVIEW STRIPS
DIAGNOSTIC TEST
Quantity Limit Clarification: Non-insulin users-50 strips per 25 days. Insulin F
users-100 strips per 25 days. Gestational diabetes-300 strips per 30
days.OTC STRP
Quantity Limit Clarification: Non-insulin users-50 strips per 25 days. Insulin F
users-100 strips per 25 days. Gestational diabetes-300 strips per 30
days.OTC STRP
►DIGESTANTS
F
CREON
AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASE
F
PANCRELIPASE
AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASE
ZENPEP
Formulary Drug
GA
Formulary Drug
F
AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASE
ZENPEP
AMYLASE (DIASTASE); LIPASE (AS PANCRELIPASE); PROTEASE
►DIHYDROPYRIDINES
ADALAT CC
GA
NIFEDIPINE
F
AMLODIPINE BESYLATE
AMLODIPINE BESYLATE
AMLODIPINE BESYLATE/VALSARTAN
AMLODIPINE BESYLATE; VALSARTAN
AMLODIPINE BESYLATE/VALSARTAN
AMLODIPINE BESYLATE; VALSARTAN
AMLODIPINE BESYLATE/VALSARTAN
AMLODIPINE BESYLATE; VALSARTAN
AMLODIPINE BESYLATE/VALSARTAN
AMLODIPINE BESYLATE; VALSARTAN
EXFORGE
AMLODIPINE BESYLATE; VALSARTAN
Coverage by AmeriHealth First
Last updated copy:11/20/2014
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (10MG; 160MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (10MG; 320MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (5MG; 160MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (5MG; 320MG TABS)
F
Y
GA
Y
Formulary Drug Requires ST with losartan or
losartan/hydrochlorothiazide (5MG; 160MG TABS)
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Brand Name
Generic Name
Notes and Restrictions
EXFORGE
AMLODIPINE BESYLATE; VALSARTAN
EXFORGE
AMLODIPINE BESYLATE; VALSARTAN
EXFORGE
AMLODIPINE BESYLATE; VALSARTAN
EXFORGE HCT
AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE; VALSARTAN
EXFORGE HCT
AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE; VALSARTAN
EXFORGE HCT
AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE; VALSARTAN
EXFORGE HCT
AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE; VALSARTAN
EXFORGE HCT
AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE; VALSARTAN
Status PA ST QL AL AL GR
max min max m/f
Formulary Drug Requires ST with losartan, losartan/hydrochlorothiazide, F
or valsartan/hydrochlorothiazide (10MG; 160MG TABS)
Y
Formulary Drug Requires ST with losartan, losartan/hydrochlorothiazide, F
or valsartan/hydrochlorothiazide (10MG; 320MG TABS)
Y
Formulary Drug Requires ST with losartan, losartan/hydrochlorothiazide, F
or valsartan/hydrochlorothiazide (5MG; 320MG TABS)
Y
Requires ST with losartan or losartan/hydrochlorothiazide (10MG;
12.5MG; 160MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (10MG; 25MG; 160MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (10MG; 25MG; 320MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (5MG; 12.5MG; 160MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (5MG; 25MG; 160MG TABS)
F
Y
F
NIFEDIAC CC
NIFEDIPINE
F
NIFEDICAL XL
NIFEDIPINE
F
NIFEDIPINE
NIFEDIPINE
F
NIFEDIPINE ER
NIFEDIPINE
F
NISOLDIPINE
NISOLDIPINE
NORVASC
Generic 90-days
GA
AMLODIPINE BESYLATE
PROCARDIA
GA
NIFEDIPINE
PROCARDIA XL
GA
NIFEDIPINE
SULAR
GA
NISOLDIPINE
►DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
Requires prior use of a preferred metformin or insulin. (1000MG; 50MG
TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (500MG; 50MG
TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (1000MG; 100MG F
TB24)
Y
Requires prior use of a preferred metformin or insulin. (1000MG; 50MG
TB24)
F
Y
Requires prior use of a preferred metformin or insulin. (500MG; 50MG
TB24)
F
Y
METFORMIN HYDROCHLORIDE; SITAGLIPTIN PHOSPHATE
JANUVIA
Requires prior use of a preferred metformin or insulin. (100MG TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (25MG TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (50MG TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (2.5MG; 1000MG
TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (2.5MG; 500MG
TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (2.5MG; 850MG
TABS)
F
Y
JANUMET
METFORMIN HYDROCHLORIDE; SITAGLIPTIN PHOSPHATE
JANUMET
METFORMIN HYDROCHLORIDE; SITAGLIPTIN PHOSPHATE
JANUMET XR
METFORMIN HYDROCHLORIDE; SITAGLIPTIN PHOSPHATE
JANUMET XR
METFORMIN HYDROCHLORIDE; SITAGLIPTIN PHOSPHATE
JANUMET XR
SITAGLIPTIN PHOSPHATE
JANUVIA
SITAGLIPTIN PHOSPHATE
JANUVIA
SITAGLIPTIN PHOSPHATE
JENTADUETO
LINAGLIPTIN; METFORMIN HYDROCHLORIDE
JENTADUETO
LINAGLIPTIN; METFORMIN HYDROCHLORIDE
JENTADUETO
LINAGLIPTIN; METFORMIN HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 34 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Requires prior use of a preferred metformin or insulin. (1000MG; 2.5MG
TB24)
F
Y
Requires prior use of a preferred metformin or insulin. (1000MG; 5MG
TB24)
F
Y
Requires prior use of a preferred metformin or insulin. (500MG; 5MG
TB24)
F
Y
METFORMIN HYDROCHLORIDE; SAXAGLIPTIN HYDROCHLORIDE
ONGLYZA
Requires prior use of a preferred metformin or insulin. (2.5MG TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (5MG TABS)
F
Y
Requires prior use of a preferred metformin or insulin. (5MG TABS)
F
Y
KOMBIGLYZE XR
METFORMIN HYDROCHLORIDE; SAXAGLIPTIN HYDROCHLORIDE
KOMBIGLYZE XR
METFORMIN HYDROCHLORIDE; SAXAGLIPTIN HYDROCHLORIDE
KOMBIGLYZE XR
SAXAGLIPTIN HYDROCHLORIDE
ONGLYZA
SAXAGLIPTIN HYDROCHLORIDE
TRADJENTA
LINAGLIPTIN
►DIRECT FACTOR XA INHIBITORS
F
ELIQUIS
APIXABAN
F
XARELTO
RIVAROXABAN
►DIRECT THROMBIN INHIBITORS
F
PRADAXA
DABIGATRAN ETEXILATE MESYLATE
►DIRECT VASODILATORS
F
HYDRALAZINE HCL
HYDRALAZINE HYDROCHLORIDE
F
MINOXIDIL
MINOXIDIL
►DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ARAVA
GA
LEFLUNOMIDE
F
LEFLUNOMIDE
LEFLUNOMIDE
►DOPAMINE PRECURSORS
F
CARBIDOPA/LEVODOPA
CARBIDOPA ANHYDROUS; LEVODOPA
F
CARBIDOPA/LEVODOPA ER
CARBIDOPA ANHYDROUS; LEVODOPA
SINEMET
GA
CARBIDOPA ANHYDROUS; LEVODOPA
SINEMET CR
GA
CARBIDOPA ANHYDROUS; LEVODOPA
►EENT ANTI-INFECTIVES, MISCELLANEOUS
F
ACETASOL HC
ACETIC ACID; HYDROCORTISONE
F
ACETIC ACID
ACETIC ACID
F
ACETIC ACID/ALUMINUM ACETATE
ACETIC ACID; ALUMINUM ACETATE
F
CHLORHEXIDINE GLUCONATE ORAL RINSE
CHLORHEXIDINE GLUCONATE
PERIOGARD
GA
CHLORHEXIDINE GLUCONATE
►EENT DRUGS, MISCELLANEOUS
F
APRACLONIDINE
APRACLONIDINE HYDROCHLORIDE
ARTIFICIAL TEARS
OTC 1.40% SOLN
F
POLYVINYL ALCOHOL
ATROVENT
GA
IPRATROPIUM BROMIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 35 of 73
Brand Name
Generic Name
IOPIDINE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Formulary Drug
F
Formulary Drug
GA
APRACLONIDINE HYDROCHLORIDE
IOPIDINE
APRACLONIDINE HYDROCHLORIDE
F
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE
TEARS NATURALE
OTC 0.1%; 0.3% SOLN
F
OTC 0.01%; 0; 0.05%; 0.3% SOLN
F
DEXTRAN 70; HYDROXYPROPYL METHYLCELLULOSE
TEARS NATURALE II
BENZALKONIUM CHLORIDE; DEXTRAN 70; EDETIC ACID; HYDROXYPROPYL
METHYLCELLULOSE
►EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
ACULAR
GA
KETOROLAC TROMETHAMINE
ACULAR LS
GA
KETOROLAC TROMETHAMINE
F
FLURBIPROFEN SODIUM
FLURBIPROFEN SODIUM
F
KETOROLAC TROMETHAMINE
KETOROLAC TROMETHAMINE
OCUFEN
GA
FLURBIPROFEN SODIUM
►ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS
BROMOCRIPTINE MESYLATE
F
BROMOCRIPTINE MESYLATE
CABERGOLINE
PA Required 0.5MG
F
Y
CABERGOLINE
PARLODEL
GA
BROMOCRIPTINE MESYLATE
►ERYTHROMYCINS
F
ERYTHROMYCIN/SULFISOXAZOLE
ERYTHROMYCIN; SULFISOXAZOLE
►ESTROGEN AGONIST-ANTAGONISTS
EVISTA
(Gender F)
F
F
RALOXIFENE HYDROCHLORIDE
►ESTROGENS
CLIMARA
GA
ESTRADIOL
ESTRACE
GA
ESTRADIOL
F
ESTRADIOL
ESTRADIOL
F
ESTROPIPATE
ESTROPIPATE
FEMHRT LOW DOSE
(Gender F)
F
F
(Gender F)
F
F
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
JINTELI
ETHINYL ESTRADIOL; NORETHINDRONE ACETATE
F
MENEST
ESTROGENS, ESTERIFIED
PREMARIN
(Gender F)
F
F
(Gender F)
F
F
(Gender F)
F
F
ESTROGENS, CONJUGATED
PREMPHASE
ESTROGENS, CONJUGATED; MEDROXYPROGESTERONE ACETATE
PREMPRO
ESTROGENS, CONJUGATED; MEDROXYPROGESTERONE ACETATE
VIVELLE-DOT
F
ESTRADIOL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 36 of 73
Brand Name
Generic Name
Notes and Restrictions
►ETHANOLAMINE DERIVATIVES
BANOPHEN
OTC 12.5MG/5ML LIQD
Status PA ST QL AL AL GR
max min max m/f
F
DIPHENHYDRAMINE HYDROCHLORIDE
F
CLEMASTINE FUMARATE
CLEMASTINE FUMARATE
CLEMASTINE FUMARATE
OTC 1.34MG TABS
F
CLEMASTINE FUMARATE
F
DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE HYDROCHLORIDE
DIPHENHYDRAMINE HCL
OTC 25MG CAPS
F
OTC 25MG TABS
F
OTC 50MG CAPS
F
OTC 50MG TABS
F
OTC 25MG TABS
F
OTC 25MG TABS
F
OTC 100MG/5ML SYRP
F
OTC 100MG/5ML; 5MG/5ML LIQD
F
OTC 600MG TB12
F
OTC 600MG TB12
GA
DIPHENHYDRAMINE HYDROCHLORIDE
DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE HYDROCHLORIDE
DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE HYDROCHLORIDE
NIGHTTIME SLEEP AID
DIPHENHYDRAMINE HYDROCHLORIDE
SLEEP AID
DOXYLAMINE SUCCINATE
SM SLEEP AID
DOXYLAMINE SUCCINATE
►EXPECTORANTS
COUGH SYRUP
GUAIFENESIN
DESPEC
GUAIFENESIN; PHENYLEPHRINE HYDROCHLORIDE
GUAIFENESIN ER
GUAIFENESIN
MUCINEX
GUAIFENESIN
MUCINEX D
OTC 600MG; 60MG TB12
F
OTC 10MG/5ML; 100MG/5ML; 5MG/5ML SYRP
F
OTC 10MG/5ML; 100MG/5ML; 5MG/5ML LIQD
GA
GUAIFENESIN; PSEUDOEPHEDRINE HYDROCHLORIDE
ROBAFEN CF COUGH & COLD
DEXTROMETHORPHAN HYDROBROMIDE; GUAIFENESIN; PHENYLEPHRINE
HYDROCHLORIDE
ROBITUSSIN COUGH/COLD CF
DEXTROMETHORPHAN HYDROBROMIDE; GUAIFENESIN; PHENYLEPHRINE
HYDROCHLORIDE
►FIBRIC ACID DERIVATIVES
FENOFIBRATE
F
FENOFIBRATE
FENOFIBRATE MICRONIZED
F
FENOFIBRATE
GEMFIBROZIL
F
GEMFIBROZIL
LOFIBRA
GA
FENOFIBRATE
LOPID
GA
GEMFIBROZIL
TRICOR
F
FENOFIBRATE
►FIBROMYALGIA AGENTS
SAVELLA
F
MILNACIPRAN HYDROCHLORIDE
SAVELLA TITRATION PACK
F
MILNACIPRAN HYDROCHLORIDE
►FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
CYPROHEPTADINE HCL
F
CYPROHEPTADINE HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 37 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
►FIRST GENERATION CEPHALOSPORINS
F
CEFADROXIL
CEFADROXIL MONOHYDRATE
F
CEPHALEXIN
CEPHALEXIN MONOHYDRATE
F
CEPHALEXIN
CEPHALEXIN
KEFLEX
GA
CEPHALEXIN
►GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
BACLOFEN
F
BACLOFEN
►GI DRUGS, MISCELLANEOUS
F
LINZESS
LINACLOTIDE
►GLYCOGENOLYTIC AGENTS
GLUCAGEN HYPOKIT
(1MG) QL 2 QY per 30 DY
F
2
(1MG) QL 2 QY per 30 DY
F
2
GLUCAGON HYDROCHLORIDE (RDNA)
GLUCAGON EMERGENCY KIT
GLUCAGON RDNA (HUMAN RECOMBINANT)
►GLYCOPEPTIDES
VANCOCIN HCL
Requires trial and failure or intolerance to metronidazole (125MG CAPS) GA
Y
Requires trial and failure or intolerance to metronidazole (250MG CAPS) GA
Y
VANCOMYCIN HYDROCHLORIDE
VANCOCIN HCL
VANCOMYCIN HYDROCHLORIDE
VANCOMYCIN HCL
Requires trial and failure or intolerance to metronidazole (125MG CAPS)
F
Y
Requires trial and failure or intolerance to metronidazole (250MG CAPS)
F
Y
VANCOMYCIN HYDROCHLORIDE
VANCOMYCIN HCL
VANCOMYCIN HYDROCHLORIDE
►GOLD COMPOUNDS
F
RIDAURA
AURANOFIN
►HEAVY METAL ANTAGONISTS
F
CHEMET
SUCCIMER
EXJADE
PA Required 125MG
NF
Y
PA Required 250MG
NF
Y
PA Required 500MG
NF
Y
DEFERASIROX
EXJADE
DEFERASIROX
EXJADE
DEFERASIROX
►HEMORRHEOLOGIC AGENTS
F
PENTOXIFYLLINE ER
PENTOXIFYLLINE
►HEMOSTATICS
AMINOCAPROIC ACID
PA Required 25%
F
Y
PA Required 500MG
F
Y
AMINOCAPROIC ACID
AMINOCAPROIC ACID
AMINOCAPROIC ACID
►HEPARINS
ENOXAPARIN SODIUM
F
ENOXAPARIN SODIUM
HEPARIN SODIUM
F
HEPARIN SODIUM (PORCINE)
►HISTAMINE H2-ANTAGONISTS
CIMETIDINE
F
CIMETIDINE
CIMETIDINE HCL
F
CIMETIDINE HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 38 of 73
Brand Name
Generic Name
FAMOTIDINE
Notes and Restrictions
Generic 90-days
Status PA ST QL AL AL GR
max min max m/f
F
FAMOTIDINE
FAMOTIDINE
OTC 10MG TABS Generic 90-days
F
FAMOTIDINE
F
NIZATIDINE
NIZATIDINE
PEPCID
Generic 90-days
GA
FAMOTIDINE
RANITIDINE 75
OTC 75MG TABS
F
RANITIDINE HYDROCHLORIDE
F
RANITIDINE HCL
RANITIDINE HYDROCHLORIDE
ZANTAC
Generic 90-days
GA
RANITIDINE HYDROCHLORIDE
►HIV ENTRY AND FUSION INHIBITORS
F
SELZENTRY
MARAVIROC
►HIV INTEGRASE INHIBITORS
F
ISENTRESS
RALTEGRAVIR POTASSIUM
F
TIVICAY
DOLUTEGRAVIR SODIUM
►HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
EDURANT
F
RILPIVIRINE HYDROCHLORIDE
F
INTELENCE
ETRAVIRINE
F
RESCRIPTOR
DELAVIRDINE MESYLATE
F
SUSTIVA
EFAVIRENZ
F
VIRAMUNE
NEVIRAPINE
F
VIRAMUNE XR
NEVIRAPINE
►HIV NUCLEOSIDE & NUCLEOTIDE RT INHIBITOR
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE
F
ABACAVIR SULFATE; LAMIVUDINE; ZIDOVUDINE
F
ATRIPLA
EFAVIRENZ; EMTRICITABINE; TENOFOVIR DISOPROXIL FUMARATE
COMBIVIR
GA
LAMIVUDINE; ZIDOVUDINE
F
COMPLERA
EMTRICITABINE; RILPIVIRINE HYDROCHLORIDE; TENOFOVIR DISOPROXIL
FUMARATE
F
DIDANOSINE
DIDANOSINE
F
EMTRIVA
EMTRICITABINE
EPIVIR
Formulary Drug
F
Formulary Drug
GA
LAMIVUDINE
EPIVIR
LAMIVUDINE
EPIVIR HBV
F
LAMIVUDINE
EPZICOM
F
ABACAVIR SULFATE; LAMIVUDINE
LAMIVUDINE
F
LAMIVUDINE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 39 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
LAMIVUDINE/ZIDOVUDINE
LAMIVUDINE; ZIDOVUDINE
RETROVIR
GA
ZIDOVUDINE
F
STAVUDINE
STAVUDINE
F
STRIBILD
COBICISTAT; ELVITEGRAVIR; EMTRICITABINE; TENOFOVIR DISOPROXIL FUMARATE
TRIZIVIR
GA
ABACAVIR SULFATE; LAMIVUDINE; ZIDOVUDINE
F
TRUVADA
EMTRICITABINE; TENOFOVIR DISOPROXIL FUMARATE
VIDEX EC
GA
DIDANOSINE
F
VIDEX PEDIATRIC
DIDANOSINE
F
VIREAD
TENOFOVIR DISOPROXIL FUMARATE
ZERIT
GA
STAVUDINE
F
ZIAGEN
ABACAVIR SULFATE
F
ZIDOVUDINE
ZIDOVUDINE
►HIV PROTEASE INHIBITORS
F
APTIVUS
TIPRANAVIR
F
CRIXIVAN
INDINAVIR SULFATE
F
INVIRASE
SAQUINAVIR MESYLATE
F
KALETRA
LOPINAVIR; RITONAVIR
F
LEXIVA
FOSAMPRENAVIR CALCIUM
F
NORVIR
RITONAVIR
F
PREZISTA
DARUNAVIR
F
PREZISTA
DARUNAVIR ETHANOLATE
F
REYATAZ
ATAZANAVIR SULFATE
F
VIRACEPT
NELFINAVIR MESYLATE
►HMG-COA REDUCTASE INHIBITORS
F
ADVICOR
LOVASTATIN; NIACIN
F
ATORVASTATIN CALCIUM
ATORVASTATIN CALCIUM
FLUVASTATIN
FLUVASTATIN SODIUM
FLUVASTATIN
FLUVASTATIN SODIUM
LESCOL
FLUVASTATIN SODIUM
LESCOL
FLUVASTATIN SODIUM
Coverage by AmeriHealth First
Last updated copy:11/20/2014
Requires prior use of simvastatin, pravastatin, lovastatin, or atorvastatin.
(20MG CAPS)
F
Y
Requires prior use of simvastatin, pravastatin, lovastatin, or atorvastatin.
(40MG CAPS)
F
Y
Requires prior use of simvastatin, pravastatin, lovastatin, or atorvastatin. GA
(20MG CAPS)
Y
Requires prior use of simvastatin, pravastatin, lovastatin, or atorvastatin. GA
(40MG CAPS)
Y
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Page 40 of 73
Brand Name
Generic Name
LESCOL XL
FLUVASTATIN SODIUM
LIPITOR
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Requires prior use of simvastatin, pravastatin, lovastatin, or atorvastatin.
(80MG TB24)
Generic 90-days 40MG
F
Y
GA
ATORVASTATIN CALCIUM
LOVASTATIN
Generic 90-days
F
Generic 90-days
GA
LOVASTATIN
MEVACOR
LOVASTATIN
PRAVACHOL
Requires trial and failure of atorvastatin or simvastatin. (20MG TABS)
Generic 90-days
GA
Y
Requires trial and failure of atorvastatin or simvastatin. (40MG TABS)
Generic 90-days
GA
Y
Requires trial and failure of atorvastatin or simvastatin. (80MG TABS)
Generic 90-days
GA
Y
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
Requires trial and failure of atorvastatin or simvastatin. (10MG TABS)
F
Y
Requires trial and failure of atorvastatin or simvastatin. (20MG TABS)
F
Y
Requires trial and failure of atorvastatin or simvastatin. (40MG TABS)
F
Y
Requires trial and failure of atorvastatin or simvastatin. (80MG TABS)
F
Y
PRAVASTATIN SODIUM
PRAVACHOL
PRAVASTATIN SODIUM
PRAVACHOL
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
PRAVASTATIN SODIUM
SIMVASTATIN
Generic 90-days
F
Generic 90-days
F
Generic 90-days
GA
Generic 90-days
GA
SIMVASTATIN - HIGH DOSE (40 MG & HIGHER)
SIMVASTATIN
SIMVASTATIN
ZOCOR
SIMVASTATIN - HIGH DOSE (40 MG & HIGHER)
ZOCOR
SIMVASTATIN
►HYDANTOINS
DILANTIN
GA
PHENYTOIN SODIUM
DILANTIN
GA
PHENYTOIN
F
DILANTIN INFATABS
PHENYTOIN
F
PHENYTOIN
PHENYTOIN
F
PHENYTOIN SODIUM EXTENDED
PHENYTOIN SODIUM
►IMMUNOSUPPRESSIVE AGENTS
F
AZATHIOPRINE
AZATHIOPRINE
CELLCEPT
Formulary Drug
GA
Formulary Drug
F
MYCOPHENOLATE MOFETIL
CELLCEPT
MYCOPHENOLATE MOFETIL
CYCLOSPORINE
F
CYCLOSPORINE
CYCLOSPORINE MODIFIED
F
CYCLOSPORINE
GENGRAF
F
CYCLOSPORINE
IMURAN
GA
AZATHIOPRINE
MYCOPHENOLATE MOFETIL
F
MYCOPHENOLATE MOFETIL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 41 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
NEORAL
GA
CYCLOSPORINE
PROGRAF
GA
TACROLIMUS
SANDIMMUNE
GA
CYCLOSPORINE
F
TACROLIMUS
TACROLIMUS
►INCRETIN MIMETICS
Requires trial of metformin-containing product. (10MCG/0.04ML SOPN)
F
Y
Requires trial of metformin-containing product. (5MCG/0.02ML SOPN)
F
Y
Requires trial and failure of metformin containing product. (18MG/3ML
SOPN)
F
Y
(100UNIT/ML) QL 3 QY per 30 DY
F
3
Quantity limit: 2 boxes (30ml)/month(100UNIT/ML) QL 2 QY per 30 DY
F
2
Requires trial and failure with Apidra.(100UNIT/ML) QL 2 QY per 30 DY
(100UNIT/ML SOCT)
F
Y
2
Requires trial and failure with Apidra.(100UNIT/ML) QL 3 QY per 30 DY
(100UNIT/ML SOLN)
F
Y
3
Requires trial and failure with Apidra.(100UNIT/ML) QL 2 QY per 30 DY
(100UNIT/ML SOPN)
F
Y
2
INSULIN LISPRO
HUMALOG MIX 50/50
(50UNIT/ML; 50UNIT/ML) QL 3 QY per 30 DY
F
3
(50UNIT/ML; 50UNIT/ML) QL 2 QY per 30 DY
F
2
(25UNIT/ML; 75UNIT/ML) QL 3 QY per 30 DY
F
3
(25UNIT/ML; 75UNIT/ML) QL 2 QY per 30 DY
F
2
(30UNIT/ML; 70UNIT/ML) QL 3 QY per 30 DYOTC 30UNIT/ML; 70UNIT/ML F
SUSP
3
INSULIN HUMAN (REGULAR); INSULIN HUMAN, ISOPHANE (NPH)
HUMULIN N
(100UNIT/ML) QL 3 QY per 30 DYOTC 100UNIT/ML SUSP
F
3
(100UNIT/ML) QL 3 QY per 30 DYOTC 100UNIT/ML SOLN
F
3
BYETTA
EXENATIDE
BYETTA
EXENATIDE
VICTOZA
LIRAGLUTIDE
►INSULINS
APIDRA
INSULIN GLULISINE
APIDRA SOLOSTAR
INSULIN GLULISINE
HUMALOG CARTRIDGE
INSULIN LISPRO
HUMALOG VIAL
INSULIN LISPRO
HUMALOG KWIKPEN
INSULIN LISPRO; INSULIN LISPRO PROTAMINE (NPL)
HUMALOG MIX 50/50 KWIKPEN
INSULIN LISPRO; INSULIN LISPRO PROTAMINE (NPL)
HUMALOG MIX 75/25
INSULIN LISPRO; INSULIN LISPRO PROTAMINE (NPL)
HUMALOG MIX 75/25 KWIKPEN
INSULIN LISPRO; INSULIN LISPRO PROTAMINE (NPL)
HUMULIN 70/30
INSULIN HUMAN, ISOPHANE (NPH)
HUMULIN R
INSULIN HUMAN (REGULAR)
F
HUMULIN R U-500 (CONCENTRATED)
INSULIN HUMAN (REGULAR)
LANTUS
(100UNIT/ML) QL 3 QY per 30 DY
F
3
Quantity limit: 2 boxes (30ml)/month(100UNIT/ML) QL 2 QY per 30 DY
F
2
OTC 325MG TABS
F
OTC 90MG TABS
F
OTC 324MG TABS
F
OTC 240MG TABS
F
OTC 324MG TABS
F
INSULIN GLARGINE
LANTUS SOLOSTAR
INSULIN GLARGINE
►IRON PREPARATIONS
FERRETTS
FERROUS FUMARATE
FERROUS FUMARATE
FERROUS FUMARATE
FERROUS FUMARATE 324
FERROUS FUMARATE
FERROUS GLUCONATE
FERROUS GLUCONATE
FERROUS GLUCONATE
FERROUS GLUCONATE
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Brand Name
Generic Name
FERROUS GLUCONATE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
OTC 325MG TABS
F
OTC 15MG/ML SOLN Generic 90-days
F
OTC 220MG/5ML ELIX Generic 90-days
F
OTC 300MG/5ML SYRP Generic 90-days
F
OTC 324MG TBEC Generic 90-days
F
OTC 325MG TBEC Generic 90-days
F
OTC 18MG TBCR Generic 90-days
F
OTC 28MG TABS Generic 90-days
F
OTC 90MG TABS Generic 90-days
F
FERROUS GLUCONATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
IRON
FERROUS FUMARATE
IRON
FERROUS SULFATE
IRON
FERROUS SULFATE
F
MULTIGEN
CALCIUM ASCORBATE ANHYDROUS; CALCIUM THREONATE; CYANOCOBALAMIN;
DESICCATED GASTRIC SUBSTANCE; FERROUS ASPARTO GLYCINATE; SUCCINIC ACID
(BUTANEDIOIC ACID)
F
MULTIGEN FOLIC
CALCIUM ASCORBATE ANHYDROUS; CALCIUM THREONATE; CYANOCOBALAMIN;
FERROUS ASPARTO GLYCINATE; FOLIC ACID; SUCCINIC ACID (BUTANEDIOIC ACID)
F
MULTIGEN PLUS
CALCIUM ASCORBATE ANHYDROUS; CALCIUM THREONATE; CYANOCOBALAMIN;
FERROUS ASPARTO GLYCINATE; FERROUS FUMARATE; FOLIC ACID; SUCCINIC ACID
(BUTANEDIOIC ACID)
SLOW FE
OTC 142MG TBCR Generic 90-days
F
OTC 160MG TBCR Generic 90-days
F
OTC 5% GEL
F
FERROUS SULFATE
SLOW FE
FERROUS SULFATE, DRIED
►KERATOLYTIC AGENTS
ACNE MEDICATION 5
BENZOYL PEROXIDE
F
BENZAC AC WASH
BENZOYL PEROXIDE
BENZOYL PEROXIDE
OTC 10% GEL
F
OTC 10% LIQD
F
BENZOYL PEROXIDE
DESQUAM-X WASH
BENZOYL PEROXIDE
F
LAVOCLEN-4 CREAMY WASH
BENZOYL PEROXIDE
NEUTROGENA ON-THE-SPOT ACNE TREATMENT
OTC 2.50% CREA
F
OTC 2% SHAM
F
BENZOYL PEROXIDE
P&S
SALICYLIC ACID
F
SODIUM SULFACETAMIDE/SULFUR
SULFACETAMIDE SODIUM; SULFUR
F
UREA
UREA (CARBAMIDE)
►KERATOPLASTIC AGENTS
F
DRITHO-CREME HP
ANTHRALIN
►LEUKOTRIENE MODIFIERS
F
MONTELUKAST SODIUM
MONTELUKAST SODIUM
SINGULAIR
Formulary Drug
F
MONTELUKAST SODIUM
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Brand Name
Generic Name
SINGULAIR
Notes and Restrictions
Formulary Drug
Status PA ST QL AL AL GR
max min max m/f
GA
MONTELUKAST SODIUM
►LINCOMYCINS
CLEOCIN
GA
CLINDAMYCIN HYDROCHLORIDE
CLEOCIN PEDIATRIC GRANULES
GA
CLINDAMYCIN PALMITATE HCL
F
CLINDAMYCIN HCL
CLINDAMYCIN HYDROCHLORIDE
F
CLINDAMYCIN PALMITATE HCL
CLINDAMYCIN PALMITATE HCL
►LOCAL ANESTHETICS (EENT)
F
ANTIPYRINE/BENZOCAINE
ANTIPYRINE; BENZOCAINE
F
LIDOCAINE HCL
LIDOCAINE HYDROCHLORIDE
F
LIDOCAINE VISCOUS
LIDOCAINE HYDROCHLORIDE
XYLOCAINE
GA
LIDOCAINE HYDROCHLORIDE
►LOCAL ANTI-INFECTIVES, MISCELLANEOUS
ANTI-DANDRUFF SHAMPOO
OTC 1% SHAM
F
SELENIUM SULFIDE
KLARON
GA
SULFACETAMIDE SODIUM
F
SELENIUM SULFIDE
SELENIUM SULFIDE
SILVADENE
GA
SILVER SULFADIAZINE
F
SILVER SULFADIAZINE
SILVER SULFADIAZINE
F
SODIUM SULFACETAMIDE
SULFACETAMIDE SODIUM
►LOOP DIURETICS
F
BUMETANIDE
BUMETANIDE
DEMADEX
GA
TORSEMIDE
FUROSEMIDE
Generic 90-days
F
Generic 90-days
GA
FUROSEMIDE
LASIX
FUROSEMIDE
F
TORSEMIDE
TORSEMIDE
►MACROLIDES
E.E.S. GRANULES
GA
ERYTHROMYCIN ETHYLSUCCINATE
F
ERY-TAB
ERYTHROMYCIN
F
ERYTHROCIN STEARATE
ERYTHROMYCIN STEARATE
ERYTHROMYCIN
Formulary Drug
GA
Formulary Drug
F
ERYTHROMYCIN
ERYTHROMYCIN
ERYTHROMYCIN
ERYTHROMYCIN BASE
F
ERYTHROMYCIN
ERYTHROMYCIN ETHYLSUCCINATE
F
ERYTHROMYCIN ETHYLSUCCINATE
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Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
►MAST-CELL STABILIZERS
F
CROMOLYN SODIUM
CROMOLYN SODIUM
OTC 5.2MG/ACT AERS
F
Requires prior use of a preferred sulfonylurea, metformin, or insulin.
(120MG TABS)
F
Y
Requires prior use of a preferred sulfonylurea, metformin, or insulin.
(60MG TABS)
F
Y
NATEGLINIDE
STARLIX
Requires prior use of a preferred metformin or insulin. (120MG TABS)
GA
Y
Requires prior use of a preferred metformin or insulin. (60MG TABS)
GA
Y
CROMOLYN SODIUM
CROMOLYN SODIUM
►MEGLITINIDES
NATEGLINIDE
NATEGLINIDE
NATEGLINIDE
NATEGLINIDE
STARLIX
NATEGLINIDE
►MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
ALDACTAZIDE
GA
HYDROCHLOROTHIAZIDE; SPIRONOLACTONE
ALDACTONE
GA
SPIRONOLACTONE
F
SPIRONOLACTONE
SPIRONOLACTONE
F
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; SPIRONOLACTONE
►MIOTICS
ISOPTO CARBACHOL
GA
CARBACHOL
F
PHOSPHOLINE IODIDE
ECHOTHIOPHATE IODIDE
F
PILOCARPINE HCL
PILOCARPINE HYDROCHLORIDE
F
PILOPINE HS
PILOCARPINE HYDROCHLORIDE
►MONOAMINE OXIDASE B INHIBITORS
ELDEPRYL
GA
SELEGILINE HCL
F
SELEGILINE HCL
SELEGILINE HCL
►MONOAMINE OXIDASE INHIBITORS
NARDIL
GA
PHENELZINE SULFATE
PARNATE
GA
TRANYLCYPROMINE SULFATE
F
PHENELZINE SULFATE
PHENELZINE SULFATE
F
TRANYLCYPROMINE SULFATE
TRANYLCYPROMINE SULFATE
►MUCOLYTIC AGENTS
F
ACETYLCYSTEINE
ACETYLCYSTEINE
►MULTIVITAMIN PREPARATIONS
ANIMAL SHAPES + IRON
OTC 60MG; 0; 4.5MCG; 15MG; 0.3MG; 13.5MG; 1.05MG; 1.2MG; 5MG;
F
1.05MG; 15UNIT; 2500UNIT; 400UNIT CHEW
ASCORBIC ACID; BETA CAROTENE; CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC
ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM;
THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A ACETATE
(RETINYL ACETATE); VITAMIN D
CENTRUM
OTC 60MG; 0; 30MCG; 75MCG; 200MG; 10MG; 72MG; 400UNIT; 35MCG; GA
0.5MG; 6MCG; 18MG; 400MCG; 50MG; 2.3MG; 20MG; 5MCG; 20MG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; BORON; CALCIUM; CALCIUM
PANTOTHENATE; CHLORIDE ION; CHOLECALCIFEROL; CHROMIUM PICOLINATE;25MCG; 80MG; 150MCG; 2MG; 1.7MG; 2MG; 10MCG; 45MCG; 55MCG;
CUPRIC SULFATE ANHYDROUS; CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC
10MCG; 1.5MG; 30UNIT; 3500UNIT; 11MG TABS
ACID; MAGNESIUM; MANGANESE SULFATE; NIACINAMIDE; NICKEL SULFA
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Brand Name
Generic Name
CERTAVITE/ANTIOXIDANTS
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
OTC 60MG/15ML; 300MCG/15ML; 10MG/15ML; 25MCG/15ML;
F
6MCG/15ML; 9MG/15ML; 2MG/15ML; 20MG/15ML; 150MCG/15ML;
ASCORBIC ACID; BIOTIN; CALCIUM PANTOTHENATE; CHROMIC CHLORIDE;
2MG/15ML; 1.7MG/15ML; 25MCG/15ML; 1.5MG/15ML; 30UNIT/15ML;
CYANOCOBALAMIN; FERROUS GLUCONATE; MANGANESE CHLORIDE; NIACINAMIDE;
POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5-PHOSPHATE;
3MG/15ML LIQD
SODIUM MOLYBDATE; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACE
CHILDRENS CHEWABLE VITAMINS
OTC 60MG; 4.5MCG; 0.3MG; 13.5MG; 0; 1.2MG; 0; 2500UNIT; 400UNIT;
F
ASCORBIC ACID; CYANOCOBALAMIN; FOLIC ACID; NIACINAMIDE; PYRIDOXINE 15UNIT CHEW
HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; VITAMIN A
(SYNTHETIC); VITAMIN D; VITAMIN E
COMPLETENATE
GA
ASCORBIC ACID; BETA CAROTENE; CHOLECALCIFEROL; CYANOCOBALAMIN;
FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE;
RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA
CVS CHILDRENS CHEWABLE MULTIVITAMIN/IRON
OTC 60MG; 0; 4.5MCG; 400UNIT; 15MG; 300MCG; 13.5MG; 1.05MG;
F
1.2MG; 1.05MG; 15UNIT; 2500UNIT CHEW
ASCORBIC ACID; BETA CAROTENE; CYANOCOBALAMIN; ERGOCALCIFEROL;
FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE;
RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A
DAILY-VITE/IRON/BETA-CAROTENE
OTC 60MG; 0; 10MG; 400UNIT; 6MCG; 18MG; 400MCG; 20MG; 2MG;
F
1.7MG; 1.5MG; 30UNIT; 5000UNIT TABS
ASCORBIC ACID; BETA CAROTENE; CALCIUM PANTOTHENATE; CHOLECALCIFEROL;
CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE
HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DLALPHA; VITAMIN A ACETATE (RETINYL ACETATE)
ELDERTONIC
OTC 13.5%; 2MCG/15ML; 3MG/15ML; 0; 0.7MG/15ML; 7MG/15ML;
F
0.7MG/15ML; 0.6MG/15ML; 0.5MG/15ML; 5MG/15ML ELIX
ALCOHOL, USP; CYANOCOBALAMIN; DEXPANTHENOL; MAGNESIUM; MANGANESE;
NIACIN; PYRIDOXINE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; ZINC SULFATE
(ANHYDROUS)
GERAVIM
OTC 100MG/30ML; 1MCG/30ML; 15MG/30ML; 2MG/30ML; 2MG/30ML;
F
CHOLINE; CYANOCOBALAMIN; FERROUS GLUCONATE; MAGNESIUM CHLORIDE;50MG/30ML; 10MG/30ML; 100MCG/30ML; 1MG/30ML; 2.5MG/30ML;
5MG/30ML; 2MG/30ML LIQD
MANGANESE CHLORIDE; NIACINAMIDE; PANTOTHENIC ACID; POTASSIUM IODIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5 PHOSPHATE SODIUM; THIAMINE
HYDROCHLORIDE; ZINC CHLORIDE
MISSION PRENATAL
OTC 100MG; 50MG; 2MCG; 30MG; 0.4MG; 10MG; 1MG; 3MG; 2MG;
F
F
F
F
F
F
5MG; 4000UNIT; 400UNIT TABS (Gender F)
ASCORBIC ACID; CALCIUM; CYANOCOBALAMIN; FERROUS GLUCONATE; FOLIC ACID;
NIACINAMIDE; PANTOTHENIC ACID; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN;
THIAMINE HYDROCHLORIDE; VITAMIN A (SYNTHETIC); VITAMIN D
MISSION PRENATAL HP
OTC 100MG; 50MG; 2MCG; 30MG; 0.8MG; 10MG; 1MG; 25MG; 2MG;
5MG; 4000UNIT; 400UNIT TABS (Gender F)
ASCORBIC ACID; CALCIUM; CYANOCOBALAMIN; FERROUS GLUCONATE; FOLIC ACID;
NIACINAMIDE; PANTOTHENIC ACID; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN;
THIAMINE HYDROCHLORIDE; VITAMIN A (SYNTHETIC); VITAMIN D
MISSION PRENATAL/FOLIC ACID
OTC 100MG; 50MG; 2MCG; 30MG; 0.8MG; 10MG; 1MG; 10MG; 2MG;
1MG; 4000UNIT; 400UNIT; 0 TABS (Gender F)
ASCORBIC ACID; CALCIUM; CYANOCOBALAMIN; FERROUS GLUCONATE; FOLIC ACID;
NIACINAMIDE; PANTOTHENIC ACID; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN;
THIAMINE HYDROCHLORIDE; VITAMIN A (SYNTHETIC); VITAMIN D; ZINC
F
MULTI VITAMIN/FLUORIDE
ASCORBIC ACID; CHOLECALCIFEROL; CYANOCOBALAMIN; FOLIC ACID;
NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE;
THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A ACETATE
(RETINYL ACETATE)
F
MULTI-VIT/FLUORIDE
ASCORBIC ACID; CHOLECALCIFEROL; CYANOCOBALAMIN; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE
HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A PALMITATE (RETINYL
PALMITATE)
F
MULTI-VIT/FLUORIDE
ASCORBIC ACID; CHOLECALCIFEROL; CYANOCOBALAMIN; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5 PHOSPHATE SODIUM; SODIUM
FLUORIDE; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A
PALMITATE (RETINYL PALMITATE)
F
MULTI-VIT/IRON/FLUORIDE
ASCORBIC ACID; CHOLECALCIFEROL; FERROUS SULFATE; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE
HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A PALMITATE (RETINYL
PALMITATE)
F
MULTIVITAMIN/FLUORIDE
ASCORBIC ACID; CYANOCOBALAMIN; FOLIC ACID; NIACINAMIDE; PYRIDOXINE
HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE HYDROCHLORIDE;
VITAMIN A; VITAMIN D; VITAMIN E
MULTI-VITAMINS
OTC 37.5MG; 1MG; 28.5MG; 400UNIT; 20MG; 0.1MG; 2MG; 1.5MG;
F
ASCORBIC ACID; CALCIUM PANTOTHENATE; CALCIUM PHOSPHATE DIBASIC; 5000UNIT TABS
CHOLECALCIFEROL; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN;
THIAMINE MONONITRATE; VITAMIN A ACETATE (RETINYL ACETATE)
MY-VITALIFE
OTC 60MG; 5000UNIT; 30MCG; 130MG; 10MCG; 2MG; 6MCG; 0.4MG;
F
150MCG; 27MG; 100MG; 2.6MG; 10MCG; 20MG; 10MG; 100MG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; CALCIUM; CHROMIUM; COPPER;
37.5MG; 2MG; 1.7MG; 10MCG; 1.5MG; 1500UNIT; 400UNIT; 30UNIT;
CYANOCOBALAMIN; FOLIC ACID; IODINE; IRON; MANGANESE; MANGANESE
SULFATE; MOLYBDENUM; NIACIN; PANTOTHENIC ACID; PHOSPHORUS; POTASSIUM;
15MG CAPS
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SELENIUM; THIAMINE
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Brand Name
Generic Name
NUTRINATE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
(Gender F)
F
F
ASCORBIC ACID; BETA CAROTENE; CHOLECALCIFEROL; CYANOCOBALAMIN;
FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE;
RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A
ONE DAILY PLUS MINERALS
OTC 60MG; 5000UNIT; 30MCG; 130MG; 10MG; 34MG; 10MCG; 2MG;
F
6MCG; 18MG; 0.4MG; 150MCG; 100MG; 2.5MG; 10MCG; 20MG; 100MG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; CALCIUM; CALCIUM PANTOTHENATE;
37.5MG; 2MG; 1.7MG; 10MCG; 1.5MG; 30UNIT; 1500UNIT; 400UNIT;
CHLORIDE ION; CHROMIUM; CUPRIC SULFATE PENTAHYDRATE; CYANOCOBALAMIN;
FERROUS FUMARATE; FOLIC ACID; IODINE; MAGNESIUM; MANGANESE SULFATE;
15MG TABS
MOLYBDENUM; NIACINAMIDE; PHOSPHORUS; POTASSIUM; P
ONE-A-DAY WOMENS FORMULA
OTC 60MG; 0; 30MCG; 450MG; 5MG; 800UNIT; 120MCG; 2MG; 6MCG;
F
18MG; 400MCG; 50MG; 2MG; 10MG; 25MCG; 2MG; 1.7MG; 20MCG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; CALCIUM; CALCIUM PANTOTHENATE;
1.5MG; 2500UNIT; 30UNIT; 15MG TABS
CHOLECALCIFEROL; CHROMIC CHLORIDE; CUPRIC SULFATE ANHYDROUS;
CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; MAGNESIUM; MANGANESE
SULFATE; NIACINAMIDE; PHYTONADIONE; PYRIDOXINE HYDROCHLORI
PEDIAVIT
OTC 40MG/10ML; 150MCG/10ML; 3MCG/10ML; 200MCG/10ML;
F
10MG/10ML; 9MG/10ML; 5MG/10ML; 0.7MG/10ML; 0.8MG/10ML;
ASCORBIC ACID; BIOTIN; CYANOCOBALAMIN; FOLIC ACID; IRON; NIACIN;
PANTOTHENIC ACID; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE; 0.7MG/10ML; 10UNIT/10ML; 2500UNIT/10ML; 400UNIT/10ML;
TOCOPHEROL, D-ALPHA; VITAMIN A; VITAMIN D; ZINC
8MG/10ML LIQD
POLY-VI-SOL
ASCORBIC ACID; CYANOCOBALAMIN; NIACINAMIDE; PYRIDOXINE
HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; VITAMIN A
(SYNTHETIC); VITAMIN D; VITAMIN E
POLY-VI-SOL/IRON
ASCORBIC ACID; IRON; NIACIN; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN;
THIAMINE HYDROCHLORIDE; VITAMIN A; VITAMIN D; VITAMIN E
POLYVITAMIN
OTC 35MG/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.5MG/ML; GA
1500UNIT/ML; 400UNIT/ML; 5UNIT/ML SOLN (Max Age 3)
3
OTC 35MG/ML; 10MG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.5MG/ML; GA
1500UNIT/ML; 400UNIT/ML; 5UNIT/ML SOLN (Max Age 3)
3
OTC 35MG/ML; 400UNIT/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML;
F
3
F
3
0.6MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML SOLN (Max Age 3)
ASCORBIC ACID; CHOLECALCIFEROL; CYANOCOBALAMIN; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5-PHOSPHATE; THIAMINE
HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A PALMITATE (RETINYL
PALMITATE)
POLYVITAMIN/IRON
OTC 35MG/ML; 400UNIT/ML; 10MG/ML; 8MG/ML; 0.4MG/ML;
0.6MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML SOLN (Max Age 3)
ASCORBIC ACID; CHOLECALCIFEROL; FERROUS SULFATE; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5-PHOSPHATE; THIAMINE
HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A PALMITATE (RETINYL
PALMITATE)
POLYVITAMIN/IRON
OTC 60MG; 400UNIT; 0.8MG; 4.5MCG; 12MG; 0.3MG; 13.5MG; 1.05MG;
F
1.2MG; 0; 1.05MG; 15UNIT; 2500UNIT; 8MG CHEW
ASCORBIC ACID; CHOLECALCIFEROL; CUPRIC OXIDE; CYANOCOBALAMIN; FERROUS
FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE;
RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; TOCOPHERYL
ACET,DL-ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE); ZINC
F
PR NATAL 400
ASCORBIC ACID; BETA CAROTENE; CALCIUM CARBONATE; CHOLECALCIFEROL;
CUPRIC OXIDE; CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA);
EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE; FOLIC ACID; IRON; IRON
PROTEIN SUCCINYLATE; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-
F
PR NATAL 400 EC
ASCORBIC ACID; BETA CAROTENE; CALCIUM CARBONATE; CHOLECALCIFEROL;
CUPRIC OXIDE; CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA);
EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IRON; MAGNESIUM OXIDE;
NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLA
F
PR NATAL 430
ASCORBIC ACID; BETA CAROTENE; CALCIUM CARBONATE; CHOLECALCIFEROL;
CUPRIC OXIDE; CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA);
EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE; FOLIC ACID; IRON; IRON
PROTEIN SUCCINYLATE; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-
F
PRENA1 CHEW/QUATREFOLIC
CHOLECALCIFEROL; FOLIC ACID; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC);
METHYLCOBALAMIN (MECOBALAMIN); PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN
F
PRENATA
ASCORBIC ACID; CHOLECALCIFEROL; CYANOCOBALAMIN; FERROUS FUMARATE;
FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM
ASCORBATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA
PRENATAL
(Gender F)
F
F
F
F
F
F
ASCORBIC ACID; ASCORBYL PALMITATE; BETA CAROTENE; CALCIUM CARBONATE;
CHOLECALCIFEROL; CUPRIC OXIDE; CYANOCOBALAMIN; FERROUS FUMARATE;
FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE
MONONITRATE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A
PRENATAL
OTC 100MG; 200MG; 400UNIT; 4MCG; 0.8MG; 27MG; 18MG; 2.6MG;
ASCORBIC ACID; CALCIUM SULFATE; CHOLECALCIFEROL; CYANOCOBALAMIN; 1.7MG; 1.84MG; 11UNIT; 4000UNIT; 25MG TABS (Gender F)
FOLIC ACID; IRON; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN;
THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A; ZINC OXIDE
PRENATAL 19
(Gender F)
ASCORBIC ACID; BETA CAROTENE; CALCIUM CARBONATE; CALCIUM
PANTOTHENATE; CHOLECALCIFEROL; CYANOCOBALAMIN; FERROUS FUMARATE;
FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE
MONONITRATE; TOCOPHERYL ACET,DL-ALPHA; ZINC OXIDE
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Brand Name
Generic Name
PRENATAL LOW IRON
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
OTC 100MG; 0; 200MG; 400UNIT; 4MCG; 27MG; 0.8MG; 18MG; 2.6MG;
F
F
ASCORBIC ACID; BETA CAROTENE; CALCIUM CARBONATE; CHOLECALCIFEROL;1.7MG; 1.5MG; 4000UNIT; 11MG; 25MG TABS (Gender F)
CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE
HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN A ACETATE
(RETINYL ACETATE); VITAMIN E ACETATE (D-ALPHA); ZINC
PRORENAL QD
OTC 30MG; 15MCG; 2.5MG; 400UNIT; 0.45MG; 1.2MCG; 50MG; 75MG;
F
4MG; 250MG; 400MCG; 10MG; 2.5MG; 1MG; 27.5MCG; 0.75MG; 5UNIT;
ASCORBIC ACID; BIOTIN; CALCIUM PANTOTHENATE; CHOLECALCIFEROL; CUPRIC
4MG CAPS
OXIDE; CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC
ACID (EPA); FERROUS GLUCONATE; FISH OIL; FOLIC ACID; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SELENOMETHIONI
TAB-A-VITE MAXIMUM
OTC 60MG; 0; 30MCG; 162MG; 109MG; 72MG; 400UNIT; 65MCG; 2MG;
F
6MCG; 18MG; 400MCG; 100MG; 3.5MG; 20MG; 5MCG; 10MG; 25MCG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; CALCIUM; CALCIUM PHOSPHATE
80MG; 150MCG; 2MG; 1.7MG; 2MG; 150MCG; 10MCG; 160MCG;
DIBASIC; CHLORIDE ION; CHOLECALCIFEROL; CHROMIC CHLORIDE; CUPRIC
SULFATE ANHYDROUS; CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; 20MCG; 1.5MG; 10MCG; 30UNIT; 2500UNIT; 15MG TABS
MAGNESIUM OXIDE; MANGANESE SULFATE; NIACINAMIDE; NICKEL SULF
THERABASIC-M
OTC 90MG; 1250UNIT; 35MCG; 40MG; 7.5MG; 15MCG; 2MG; 9MCG;
F
400UNIT; 27MG; 0.4MG; 150MCG; 100MG; 5MG; 15MCG; 30MG; 10MG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; CALCIUM; CHLORIDE ION; CHROMIUM;
31MG; 7.5MG; 3MG; 3.4MG; 10MCG; 3MG; 30UNIT; 5000UNIT; 15MG
CUPRIC SULFATE PENTAHYDRATE; CYANOCOBALAMIN; ERGOCALCIFEROL;
FERROUS FUMARATE; FOLIC ACID; IODINE; MAGNESIUM OXIDE; MANGANESE TABS
SULFATE; MOLYBDENUM; NIACINAMIDE; PANTOTHENIC ACID; PHOSPH
THERATRUM COMPLETE 50 PLUS
OTC 60MG; 0; 30MCG; 150MCG; 200MG; 10MG; 72MG; 400UNIT;
F
150MCG; 2MG; 25MCG; 400MCG; 250MCG; 300MCG; 100MG; 2MG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; BORON; CALCIUM; CALCIUM
20MG; 5MCG; 48MG; 10MCG; 80MG; 150MCG; 3MG; 1.7MG; 2MG;
PANTOTHENATE; CHLORIDE ION; CHOLECALCIFEROL; CHROMIUM; COPPER;
CYANOCOBALAMIN; FOLIC ACID; LUTEIN (VEGETABLE ENZYME); LYCOPENE; 75MCG; 20MCG; 1.5MG; 45UNIT; 10MCG; 3500UNIT; 15MG TABS
MAGNESIUM OXIDE; MANGANESE SULFATE; NIACINAMIDE; NICKEL; PHOSPHOR
F
TRIVEEN-DUO DHA
ASCORBIC ACID; BETA CAROTENE; CALCIUM CARBONATE; CHOLECALCIFEROL;
CUPRIC OXIDE; CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA);
EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE; FOLIC ACID; IRON; IRON
PROTEIN SUCCINYLATE; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-
TRI-VI-SOL
OTC 35MG/ML; 400UNIT/ML; 750UNIT/ML SOLN (Max Age 3)
GA
3
ASCORBIC ACID; CHOLECALCIFEROL; VITAMIN A PALMITATE (RETINYL PALMITATE)
TRI-VI-SOL/IRON
OTC 35MG/ML; 10MG/ML; 1500UNIT/ML; 400UNIT/ML SOLN (Max Age 3) F
3
ASCORBIC ACID; IRON; VITAMIN A (SYNTHETIC); VITAMIN D
F
TRI-VIT/FLUORIDE
ASCORBIC ACID; CHOLECALCIFEROL; SODIUM FLUORIDE; VITAMIN A PALMITATE
(RETINYL PALMITATE)
F
TRI-VIT/FLUORIDE/IRON
ASCORBIC ACID; FLUORIDE; IRON; VITAMIN A; VITAMIN D
TRI-VITAMIN
OTC 35MG/ML; 400UNIT/ML; 1500UNIT/ML SOLN (Max Age 3)
F
3
ASCORBIC ACID; CHOLECALCIFEROL; VITAMIN A PALMITATE (RETINYL PALMITATE)
F
TRI-VITAMIN/FLUORIDE
ASCORBIC ACID; SODIUM FLUORIDE; VITAMIN A; VITAMIN D
VITATRUM
OTC 60MG; 0; 45MCG; 108MG; 10MG; 50MG; 400UNIT; 20MCG; 2MG;
F
6MCG; 18MG; 400MCG; 40MG; 1MG; 20MG; 10UNIT; 150MCG; 2MG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; CALCIUM; CALCIUM PANTOTHENATE;
1.7MG; 20MG; 1.5MG; 60UNIT; 3500UNIT; 15MG CHEW
CALCIUM PHOSPHATE DIBASIC; CHOLECALCIFEROL; CHROMIC CHLORIDE; CUPRIC
OXIDE; CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; MAGNESIUM OXIDE;
MANGANESE SULFATE; NIACINAMIDE; PHYTONADIONE; P
VITRUM SENIOR
OTC 60MG; 0; 30MCG; 150MCG; 200MG; 10MG; 48MG; 72MG; 400UNIT; F
150MCG; 2MG; 25MCG; 400MCG; 250MCG; 300MCG; 100MG; 2MG;
ASCORBIC ACID; BETA CAROTENE; BIOTIN; BORON; CALCIUM CARBONATE;
20MG; 5MCG; 10MCG; 80MG; 150MCG; 3MG; 1.7MG; 2MG; 10MCG;
CALCIUM PANTOTHENATE; CALCIUM PHOSPHATE; CHLORIDE ION;
CHOLECALCIFEROL; CHROMIC CHLORIDE; CUPRIC OXIDE; CYANOCOBALAMIN; 75MCG; 20MCG; 1.5MG; 45UNIT; 3500UNIT; 15MG TABS
FOLIC ACID; LUTEIN (VEGETABLE ENZYME); LYCOPENE; MAGNESIUM OXIDE;
MANGA
►MYDRIATICS
F
ATROPINE SULFATE
ATROPINE SULFATE
F
CYCLOPENTOLATE HCL
CYCLOPENTOLATE HYDROCHLORIDE
►NATURAL PENICILLINS
F
PENICILLIN V POTASSIUM
PENICILLIN V POTASSIUM
►NEURAMINIDASE INHIBITORS
RELENZA DISKHALER
QL: One treatment per 6 months(5MG/BLISTER) QL 1 FL per 180 DY
F
1
QL: One treatment per 6 months(30MG) QL 1 FL per 180 DY
F
1
QL: One treatment per 6 months(45MG) QL 1 FL per 180 DY
F
1
ZANAMIVIR
TAMIFLU
OSELTAMIVIR PHOSPHATE
TAMIFLU
OSELTAMIVIR PHOSPHATE
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Brand Name
Generic Name
TAMIFLU
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
QL: One treatment per 6 months(6MG/ML) QL 1 FL per 180 DY
F
1
QL: One treatment per 6 months(75MG) QL 1 FL per 180 DY
F
1
OSELTAMIVIR PHOSPHATE
TAMIFLU
OSELTAMIVIR PHOSPHATE
►NITRATES AND NITRITES
ISORDIL TITRADOSE
GA
ISOSORBIDE DINITRATE
F
ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE
F
ISOSORBIDE DINITRATE ER
ISOSORBIDE DINITRATE
F
ISOSORBIDE MONONITRATE
ISOSORBIDE MONONITRATE
F
ISOSORBIDE MONONITRATE ER
ISOSORBIDE MONONITRATE
NITRO-BID
GA
NITROGLYCERIN
NITRO-DUR
Formulary Drug
F
Formulary Drug
GA
NITROGLYCERIN
NITRO-DUR
NITROGLYCERIN
F
NITROGLYCERIN ER
NITROGLYCERIN
F
NITROGLYCERIN TRANSDERMAL
NITROGLYCERIN
F
NITROSTAT
NITROGLYCERIN
F
NITRO-TIME
NITROGLYCERIN
►NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
MIRAPEX
GA
PRAMIPEXOLE DIHYDROCHLORIDE MONOHYDRATE
F
PRAMIPEXOLE DIHYDROCHLORIDE
PRAMIPEXOLE DIHYDROCHLORIDE MONOHYDRATE
REQUIP
GA
ROPINIROLE HYDROCHLORIDE
F
ROPINIROLE HCL
ROPINIROLE HYDROCHLORIDE
►NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS
CAFERGOT
GA
CAFFEINE; ERGOTAMINE TARTRATE
D.H.E. 45
GA
DIHYDROERGOTAMINE MESYLATE
F
DIBENZYLINE
PHENOXYBENZAMINE HYDROCHLORIDE
F
DIHYDROERGOTAMINE MESYLATE
DIHYDROERGOTAMINE MESYLATE
DIHYDROERGOTAMINE MESYLATE
1 kit (8 vials) per 30 days.(4MG/ML) QL 1 QY per 30 DY
F
1
DIHYDROERGOTAMINE MESYLATE
F
ERGOMAR
ERGOTAMINE TARTRATE
MIGRANAL
1 kit (8 vials) per 30 days.(4MG/ML) QL 1 QY per 30 DY
GA
1
DIHYDROERGOTAMINE MESYLATE
►NUCLEOSIDES AND NUCLEOTIDES
ACYCLOVIR
F
ACYCLOVIR
BARACLUDE
GA
ENTECAVIR MONOHYDRATE
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Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
ENTECAVIR
ENTECAVIR MONOHYDRATE
HEPSERA
PA Required 10MG
NF
Y
ADEFOVIR DIPIVOXIL
F
VALACYCLOVIR HCL
VALACYCLOVIR HCL
VALTREX
GA
VALACYCLOVIR HCL
ZOVIRAX
GA
ACYCLOVIR
ZOVIRAX
ACYCLOVIR
Requires trial and failure or intolerance to a preferred oral antiviral such NF
as acyclovir PA Required 5%
►OPIATE AGONISTS
Y
F
ACETAMINOPHEN/CODEINE
ACETAMINOPHEN; CODEINE PHOSPHATE
F
ACETAMINOPHEN/CODEINE #2
ACETAMINOPHEN; CODEINE PHOSPHATE
F
ACETAMINOPHEN/CODEINE #3
ACETAMINOPHEN; CODEINE PHOSPHATE
F
ACETAMINOPHEN/CODEINE #4
ACETAMINOPHEN; CODEINE PHOSPHATE
AVINZA
PA Required 120MG
NF
Y
PA Required 30MG
NF
Y
PA Required 45MG
NF
Y
PA Required 60MG
NF
Y
PA Required 75MG
NF
Y
PA Required 90MG
NF
Y
MORPHINE SULFATE
AVINZA
MORPHINE SULFATE
AVINZA
MORPHINE SULFATE
AVINZA
MORPHINE SULFATE
AVINZA
MORPHINE SULFATE
AVINZA
MORPHINE SULFATE
F
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE
ACETAMINOPHEN; BUTALBITAL; CAFFEINE; CODEINE PHOSPHATE
F
BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE
ASPIRIN; BUTALBITAL; CAFFEINE; CODEINE PHOSPHATE
DEMEROL
GA
MEPERIDINE HYDROCHLORIDE
DILAUDID
GA
HYDROMORPHONE HYDROCHLORIDE
DOLOPHINE
GA
METHADONE HYDROCHLORIDE
DOLOPHINE HCL
GA
METHADONE HYDROCHLORIDE
DURAGESIC
(100MCG/HR) QL 10 QY per 30 DY
GA
10
(12MCG/HR) QL 10 QY per 30 DY
GA
10
(25MCG/HR) QL 10 QY per 30 DY
GA
10
(50MCG/HR) QL 10 QY per 30 DY
GA
10
(75MCG/HR) QL 10 QY per 30 DY
GA
10
FENTANYL
DURAGESIC
FENTANYL
DURAGESIC
FENTANYL
DURAGESIC
FENTANYL
DURAGESIC
FENTANYL
ENDOCET
ACETAMINOPHEN; OXYCODONE HYDROCHLORIDE
ENDODAN
Only 5/325mg and 5/500mg are formulary. All other strengths require
prior authorization.
F
F
ASPIRIN; OXYCODONE HYDROCHLORIDE
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Page 50 of 73
Brand Name
Generic Name
FENTANYL
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
(100MCG/HR) QL 10 QY per 30 DY
F
10
(12MCG/HR) QL 10 QY per 30 DY
F
10
(25MCG/HR) QL 10 QY per 30 DY
F
10
(50MCG/HR) QL 10 QY per 30 DY
F
10
(75MCG/HR) QL 10 QY per 30 DY
F
10
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FENTANYL
FIORINAL/CODEINE #3
GA
ASPIRIN; BUTALBITAL; CAFFEINE; CODEINE PHOSPHATE
F
HYDROCODONE BITARTRATE/ACETAMINOPHEN
ACETAMINOPHEN; HYDROCODONE BITARTRATE
HYDROCODONE/ACETAMINOPHEN
Formulary Drug
F
ACETAMINOPHEN; HYDROCODONE BITARTRATE
HYDROCODONE/ACETAMINOPHEN
ACETAMINOPHEN; HYDROCODONE BITARTRATE
HYDROCODONE/ACETAMINOPHEN
ACETAMINOPHEN; HYDROCODONE BITARTRATE
HYDROCODONE/ACETAMINOPHEN
ACETAMINOPHEN; HYDROCODONE BITARTRATE
HYDROGESIC
ACETAMINOPHEN; HYDROCODONE BITARTRATE
Formulary Drug Only 5/325, 5/500, 7.5/325, 7.5/500, 7.5/750, 10/325 & GA
10/650mg are formulary. All other strengths require prior authorization.
Formulary Drug Only 5/325, 5/500, 7.5/325, 7.5/500, 7.5/750, 10/325 &
10/650mg are formulary. All other strengths require prior authorization.
F
Formulary Drug Only 5/500, 7.5/500, 7.5/750 & 10/650mg are
formulary. All other strengths require prior authorization.
F
Only 5/325, 5/500, 7.5/325, 7.5/500, 7.5/750, 10/325 & 10/650mg are
formulary. All other strengths require prior authorization.
F
F
HYDROMORPHONE HCL
HYDROMORPHONE HYDROCHLORIDE
KADIAN
Formulary Drug
F
Formulary Drug
GA
Formulary Drug
F
Formulary Drug
GA
MORPHINE SULFATE
KADIAN
MORPHINE SULFATE
LORTAB
ACETAMINOPHEN; HYDROCODONE BITARTRATE
LORTAB
ACETAMINOPHEN; HYDROCODONE BITARTRATE
LORTAB
ACETAMINOPHEN; HYDROCODONE BITARTRATE
LORTAB
ACETAMINOPHEN; HYDROCODONE BITARTRATE
Formulary Drug Only 5/325, 5/500, 7.5/325, 7.5/500, 7.5/750, 10/325 & GA
10/650mg are formulary. All other strengths require prior authorization.
Formulary Drug Only 5/500, 7.5/500, 7.5/750 & 10/650mg are formulary. GA
All other strengths require prior authorization.
F
MEPERIDINE HCL
MEPERIDINE HYDROCHLORIDE
F
METHADONE HCL
METHADONE HYDROCHLORIDE
F
MORPHINE SULFATE
MORPHINE SULFATE
F
MORPHINE SULFATE ER
MORPHINE SULFATE
MS CONTIN
GA
MORPHINE SULFATE
OXYCODONE HCL
Formulary Drug
GA
Formulary Drug
F
Only 5/325mg and 5/500mg are formulary. All other strengths require
prior authorization.
F
Only 5/325mg and 5/500mg are formulary. All other strengths require
prior authorization.
GA
Only 5/325mg and 5/500mg are formulary. All other strengths require
prior authorization.
F
OXYCODONE HYDROCHLORIDE
OXYCODONE HCL
OXYCODONE HYDROCHLORIDE
OXYCODONE/ACETAMINOPHEN
ACETAMINOPHEN; OXYCODONE HYDROCHLORIDE
PERCOCET
ACETAMINOPHEN; OXYCODONE HYDROCHLORIDE
ROXICET
ACETAMINOPHEN; OXYCODONE HYDROCHLORIDE
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Brand Name
Generic Name
Notes and Restrictions
ROXICODONE
Status PA ST QL AL AL GR
max min max m/f
GA
OXYCODONE HYDROCHLORIDE
F
TRAMADOL HCL
TRAMADOL HCL
TYLENOL/CODEINE #4
GA
ACETAMINOPHEN; CODEINE PHOSPHATE
ULTRAM
GA
TRAMADOL HCL
VICOPROFEN
PA Required 7.5MG; 200MG
NF
Y
HYDROCODONE BITARTRATE; IBUPROFEN
F
ZAMICET
ACETAMINOPHEN; HYDROCODONE BITARTRATE
►OPIATE ANTAGONISTS
F
NALTREXONE HCL
NALTREXONE HYDROCHLORIDE
REVIA
GA
NALTREXONE HYDROCHLORIDE
►OPIATE PARTIAL AGONISTS
BUPRENORPHINE HCL
PA Required 2MG
NF
Y
PA Required 8MG
NF
Y
PA Required 2MG; 0.5MG
F
Y
PA Required 8MG; 2MG
F
Y
PA Required 10MG/ML
NF
Y
PA Required 10MCG/HR
NF
Y
PA Required 20MCG/HR
NF
Y
PA Required 5MCG/HR
NF
Y
BUPRENORPHINE HYDROCHLORIDE
BUPRENORPHINE HCL
BUPRENORPHINE HYDROCHLORIDE
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
BUPRENORPHINE HCL/NALOXONE HCL
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
BUTORPHANOL TARTRATE
BUTORPHANOL TARTRATE
BUTRANS
BUPRENORPHINE
BUTRANS
BUPRENORPHINE
BUTRANS
BUPRENORPHINE
F
NALBUPHINE HCL
NALBUPHINE HYDROCHLORIDE
SUBOXONE
PA Required 12MG; 3MG
F
Y
PA Required 2MG; 0.5MG
F
Y
PA Required 4MG; 1MG
F
Y
PA Required 8MG; 2MG
F
Y
PA Required 1.4MG; 0.36MG
F
Y
PA Required 5.7MG; 1.4MG
F
Y
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
SUBOXONE
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
SUBOXONE
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
SUBOXONE
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
ZUBSOLV
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
ZUBSOLV
BUPRENORPHINE HYDROCHLORIDE; NALOXONE HYDROCHLORIDE DIHYDRATE
►ORALLY INHALED PREPARATIONS (STEROIDS)
ASMANEX TWISTHALER 120 METERED DOSES
QL: 1 inhaler per 30 days(220MCG/INH) QL 1 QY per 30 DY
F
1
QL: 1 inhaler per 14 days(220MCG/INH) QL 1 QY per 14 DY
F
1
QL: 1 inhaler per 30 days(220MCG/INH) QL 1 QY per 30 DY
F
1
QL: 1 inhaler per 30 days(110MCG/INH) QL 1 QY per 30 DY
F
1
QL: 1 inhaler per 30 days(220MCG/INH) QL 1 QY per 30 DY
F
1
MOMETASONE FUROATE
ASMANEX TWISTHALER 14 METERED DOSES
MOMETASONE FUROATE
ASMANEX TWISTHALER 30 ME TERED DOSES
MOMETASONE FUROATE
ASMANEX TWISTHALER 30 METERED DOSES
MOMETASONE FUROATE
ASMANEX TWISTHALER 60 METERED DOSES
MOMETASONE FUROATE
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Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
1
QL: Limited to one respule per day. Prior authorization required for twice F
daily dosing.(0.25MG/2ML) QL 60 QY per 30 DY (Max Age 8)
60
8
QL: Limited to two respules per day.(0.5MG/2ML) QL 120 QY per 30 DY
(Max Age 8)
F
120
8
QL: 1 inhaler (13 gram) per 30 days or 2 inhaler (8.8 gram) per 30
days(5MCG/ACT; 200MCG/ACT) QL 13 QY per 30 DY Min Age 12
F
13
12
QL: 1 inhaler (13 gram) per 30 days or 2 inhalers (8.8 gram) per 30
days(5MCG/ACT; 100MCG/ACT) QL 13 QY per 30 DY Min Age 12
F
13
12
FORMOTEROL FUMARATE DIHYDRATE; MOMETASONE FUROATE
FLOVENT DISKUS
QL: 1 inhaler per 30 days(50MCG/BLIST) QL 60 QY per 30 DY
F
60
QL: 2 inhalers per 30 days(100MCG/BLIST) QL 120 QY per 30 DY
F
120
QL: 4 inhalers per 30 days(250MCG/BLIST) QL 4 QY per 30 DY
F
4
QL: 1 inhaler per 30 days(110MCG/ACT) QL 12 QY per 30 DY
F
12
QL: 1 inhaler per 30 days(44MCG/ACT) QL 10.6 QY per 30 DY
F
10.6
QL: 2 inhalers per 30 days(220MCG/ACT) QL 24 QY per 30 DY
F
24
Formulary Drug **Generic Pulmicort will also pay at the point of sale for
claims that meet the requirements. QL: limited to one respule per day.
Prior authorization required for twice daily dosing.(1MG/2ML) QL 60 QY
per 30 DY (Max Age 8)
F
60
8
Formulary Drug QL: Limited to one respule per day. Prior authorization
required for twice daily dosing.(0.25MG/2ML) QL 30 QY per 30 DY (Max
Age 8)
GA
30
8
Formulary Drug QL: Limited to two respules per day.(0.5MG/2ML) QL 60 GA
QY per 30 DY (Max Age 8)
60
8
BUDESONIDE
QVAR
QL: 1 inhaler per 30 days(40MCG/ACT) QL 8.7 QY per 30 DY
F
8.7
QL: 2 inhalers per 30 days(80MCG/ACT) QL 17.4 QY per 30 DY
F
17.4
QL: 1 inhaler per 30 days(160MCG/ACT; 4.5MCG/ACT) QL 10.2 QY per 30
DY
F
10.2
BUDESONIDE; FORMOTEROL FUMARATE DIHYDRATE
SYMBICORT
QL: 1 inhaler per 30 days(80MCG/ACT; 4.5MCG/ACT) QL 10.2 QY per 30 DY F
10.2
ASMANEX TWISTHALER 7 METERED DOSES
QL: 1 inhaler per 7 days(110MCG/INH) QL 1 QY per 7 DY
MOMETASONE FUROATE
BUDESONIDE
BUDESONIDE
BUDESONIDE
BUDESONIDE
DULERA
FORMOTEROL FUMARATE DIHYDRATE; MOMETASONE FUROATE
DULERA
FLUTICASONE PROPIONATE
FLOVENT DISKUS
FLUTICASONE PROPIONATE
FLOVENT DISKUS
FLUTICASONE PROPIONATE
FLOVENT HFA
FLUTICASONE PROPIONATE
FLOVENT HFA
FLUTICASONE PROPIONATE
FLOVENT HFA
FLUTICASONE PROPIONATE
PULMICORT
BUDESONIDE
PULMICORT
BUDESONIDE
PULMICORT
BECLOMETHASONE DIPROPIONATE
QVAR
BECLOMETHASONE DIPROPIONATE
SYMBICORT
BUDESONIDE; FORMOTEROL FUMARATE DIHYDRATE
►OTHER MACROLIDES
AZITHROMYCIN
(100MG/5ML) QL 1 FL per 30 DY
F
1
(1GM) QL 1 FL per 30 DY
F
1
(200MG/5ML) QL 1 FL per 30 DY
F
1
(250MG) QL 6 QY per 30 DY
F
6
(500MG) QL 1 FL per 30 DY
F
1
(600MG) QL 6 QY per 30 DY
F
6
(250MG) QL 1 FL per 30 DY
GA
1
(250MG/5ML) QL 1 FL per 30 DY
GA
1
(500MG) QL 1 FL per 30 DY
GA
1
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
AZITHROMYCIN
BIAXIN
CLARITHROMYCIN
BIAXIN
CLARITHROMYCIN
BIAXIN
CLARITHROMYCIN
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 53 of 73
Brand Name
Generic Name
BIAXIN XL
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
GA
1
(125MG/5ML) QL 1 FL per 30 DY
F
1
(250MG) QL 1 FL per 30 DY
F
1
(250MG/5ML) QL 1 FL per 30 DY
F
1
(500MG) QL 1 FL per 30 DY
F
1
(500MG) QL 1 FL per 30 DY
F
1
(100MG/5ML) QL 1 FL per 30 DY
GA
1
(1GM) QL 1 FL per 30 DY
GA
1
(200MG/5ML) QL 1 FL per 30 DY
GA
1
(250MG) QL 1 FL per 30 DY
GA
1
(500MG) QL 1 FL per 30 DY
GA
1
(600MG) QL 1 FL per 30 DY
GA
1
(500MG) QL 1 FL per 30 DY
GA
1
(250MG) QL 1 FL per 30 DY
GA
1
F
1
(500MG) QL 1 FL per 30 DY
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN
CLARITHROMYCIN ER
CLARITHROMYCIN
ZITHROMAX
AZITHROMYCIN
ZITHROMAX
AZITHROMYCIN
ZITHROMAX
AZITHROMYCIN
ZITHROMAX
AZITHROMYCIN
ZITHROMAX
AZITHROMYCIN
ZITHROMAX
AZITHROMYCIN
ZITHROMAX TRI-PAK
AZITHROMYCIN
ZITHROMAX Z-PAK
AZITHROMYCIN
ZMAX
(2GM) QL 1 QY per 30 DY
AZITHROMYCIN DIHYDRATE
►OTHER MISCELLANEOUS THERAPEUTIC AGENTS
CARNITOR
GA
LEVOCARNITINE
ELMIRON
PA Required 100MG
NF
Y
PENTOSAN POLYSULFATE SODIUM
F
LEVOCARNITINE
LEVOCARNITINE
►OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS
ANAPROX
GA
NAPROXEN SODIUM
ANAPROX DS
GA
NAPROXEN SODIUM
CATAFLAM
GA
DICLOFENAC POTASSIUM
CHILDRENS ADVIL
OTC 50MG/1.25ML SUSP
GA
IBUPROFEN
CHILDRENS IBUPROFEN
OTC 100MG/5ML SUSP
F
OTC 40MG/ML SUSP
F
IBUPROFEN
CHILDRENS IBUPROFEN
IBUPROFEN
DAYPRO
GA
OXAPROZIN
DICLOFENAC POTASSIUM
F
DICLOFENAC POTASSIUM
DICLOFENAC SODIUM DR
F
DICLOFENAC SODIUM
EC-NAPROSYN
GA
NAPROXEN
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 54 of 73
Brand Name
Generic Name
Notes and Restrictions
FELDENE
Status PA ST QL AL AL GR
max min max m/f
GA
PIROXICAM
F
FENOPROFEN CALCIUM
FENOPROFEN CALCIUM
F
IBUPROFEN
IBUPROFEN
F
INDOCIN
INDOMETHACIN
F
INDOMETHACIN
INDOMETHACIN
KETOPROFEN
Extended-release product not covered.
F
KETOPROFEN
F
MECLOFENAMATE SODIUM
MECLOFENAMATE SODIUM
MELOXICAM
Generic 90-days
F
Generic 90-days
GA
MELOXICAM
MOBIC
MELOXICAM
NAPROSYN
GA
NAPROXEN
F
NAPROXEN
NAPROXEN
F
NAPROXEN DR
NAPROXEN
F
NAPROXEN SODIUM
NAPROXEN SODIUM
F
OXAPROZIN
OXAPROZIN
F
PIROXICAM
PIROXICAM
►OXAZOLIDINONES
ZYVOX
PA Required 100MG/5ML
NF
Y
PA Required 600MG
NF
Y
LINEZOLID
ZYVOX
LINEZOLID
►OXYTOCICS
F
METHYLERGONOVINE MALEATE
METHYLERGONOVINE MALEATE
►PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
ARICEPT
Min Age 18
GA
18
Min Age 18
GA
18
DONEPEZIL HYDROCHLORIDE
ARICEPT ODT
DONEPEZIL HYDROCHLORIDE
F
BETHANECHOL CHLORIDE
BETHANECHOL CHLORIDE
DONEPEZIL HCL
F
18
Formulary Drug Min Age 18
GA
18
Formulary Drug Min Age 18
F
18
Min Age 18
DONEPEZIL HYDROCHLORIDE
EXELON
RIVASTIGMINE TARTRATE
EXELON
RIVASTIGMINE
F
MESTINON
PYRIDOSTIGMINE BROMIDE
F
MESTINON TIMESPAN
PYRIDOSTIGMINE BROMIDE
PROSTIGMIN
Min Age 18
F
18
NEOSTIGMINE BROMIDE
PYRIDOSTIGMINE BROMIDE
F
PYRIDOSTIGMINE BROMIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 55 of 73
Brand Name
Generic Name
RIVASTIGMINE TARTRATE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Min Age 18
F
18
RIVASTIGMINE TARTRATE
URECHOLINE
GA
BETHANECHOL CHLORIDE
►PARATHYROID
F
CALCITONIN-SALMON
CALCITONIN,SALMON
MIACALCIN
GA
CALCITONIN,SALMON
►PENICILLINASE-RESISTANT PENICILLINS
F
DICLOXACILLIN SODIUM
DICLOXACILLIN SODIUM
►PERIPHERAL ADRENERGIC INHIBITORS
F
RESERPINE
RESERPINE
►PHENOTHIAZINE DERIVATIVES
PHENERGAN
GA
PROMETHAZINE HYDROCHLORIDE
F
PROMETHAZINE HCL
PROMETHAZINE HYDROCHLORIDE
F
PROMETHAZINE VC PLAIN
PHENYLEPHRINE HYDROCHLORIDE; PROMETHAZINE HYDROCHLORIDE
►PHENOTHIAZINES
F
CHLORPROMAZINE HCL
CHLORPROMAZINE HYDROCHLORIDE
F
FLUPHENAZINE DECANOATE
FLUPHENAZINE DECANOATE
F
FLUPHENAZINE HCL
FLUPHENAZINE HYDROCHLORIDE
F
PERPHENAZINE
PERPHENAZINE
F
THIORIDAZINE HCL
THIORIDAZINE HYDROCHLORIDE
F
TRIFLUOPERAZINE HCL
TRIFLUOPERAZINE HYDROCHLORIDE
►PHOSPHATE-REMOVING AGENTS
F
CALCIUM ACETATE
CALCIUM ACETATE
F
FOSRENOL
LANTHANUM CARBONATE
PHOSLO
GA
CALCIUM ACETATE
F
RENAGEL
SEVELAMER HYDROCHLORIDE
F
RENVELA
SEVELAMER CARBONATE
►PHOSPHODIESTERASE TYPE 4 INHIBITORS
DALIRESP
Requires trial and failure or intolerance to COPD agent. (500MCG TABS)
F
Y
ROFLUMILAST
►PHOSPHODIESTERASE TYPE 5 INHIBITORS
REVATIO
PA Required 20MG
GA
Y
PA Required 20MG
F
Y
PA Required 0.01%
GA
Y
Tablets will pay at the point of sale for members 6 years old and older. PA GA
Required 0.1MG Min Age 6
Y
SILDENAFIL CITRATE
SILDENAFIL CITRATE
SILDENAFIL CITRATE
►PITUITARY
DDAVP
DESMOPRESSIN ACETATE
DDAVP
DESMOPRESSIN ACETATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
6
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Page 56 of 73
Brand Name
Generic Name
DDAVP
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
DESMOPRESSIN ACETATE
Tablets will pay at the point of sale for members 6 years old and older. PA GA
Required 0.2MG Min Age 6
DESMOPRESSIN ACETATE
PA Required 0.01%
Y
6
F
Y
Tablets will pay at the point of sale for members 6 years old and older. PA F
Required 0.1MG Min Age 6
Y
6
Tablets will pay at the point of sale for members 6 years old and older. PA F
Required 0.2MG Min Age 6
Y
6
DESMOPRESSIN ACETATE
DESMOPRESSIN ACETATE
DESMOPRESSIN ACETATE
DESMOPRESSIN ACETATE
DESMOPRESSIN ACETATE
►PLATELET-AGGREGATION INHIBITORS
F
CILOSTAZOL
CILOSTAZOL
F
CLOPIDOGREL
CLOPIDOGREL BISULFATE
F
EFFIENT
PRASUGREL HYDROCHLORIDE
PLAVIX
GA
CLOPIDOGREL BISULFATE
PLETAL
GA
CILOSTAZOL
F
TICLOPIDINE HCL
TICLOPIDINE HYDROCHLORIDE
►POLYENES
F
NYSTATIN
NYSTATIN
►POLYENES (SKIN & MUCOUS MEMBRANE)
F
NYSTATIN/TRIAMCINOLONE
NYSTATIN; TRIAMCINOLONE ACETONIDE
►POTASSIUM-REMOVING AGENTS
F
SPS
SODIUM POLYSTYRENE SULFONATE
►POTASSIUM-SPARING DIURETICS
F
AMILORIDE HCL
AMILORIDE HYDROCHLORIDE (ANHYDROUS)
F
AMILORIDE/HYDROCHLOROTHIAZIDE
AMILORIDE HYDROCHLORIDE (ANHYDROUS); HYDROCHLOROTHIAZIDE
DYAZIDE
GA
HYDROCHLOROTHIAZIDE; TRIAMTERENE
F
DYRENIUM
FD&C YELLOW #6 (SUNSET YELLOW); TRIAMTERENE
F
DYRENIUM
TRIAMTERENE
MAXZIDE
GA
HYDROCHLOROTHIAZIDE; TRIAMTERENE
MAXZIDE-25
GA
HYDROCHLOROTHIAZIDE; TRIAMTERENE
F
TRIAMTERENE/HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE; TRIAMTERENE
►PROGESTINS
AYGESTIN
(Gender F)
GA
F
(Gender F)
F
F
(Gender F)
GA
F
(Gender F)
F
F
(Gender F)
F
F
NORETHINDRONE ACETATE
DEPO-PROVERA
MEDROXYPROGESTERONE ACETATE
DEPO-PROVERA CONTRACEPTIVE
MEDROXYPROGESTERONE ACETATE
MEDROXYPROGESTERONE ACETATE
MEDROXYPROGESTERONE ACETATE
NORETHINDRONE ACETATE
NORETHINDRONE ACETATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 57 of 73
Brand Name
Generic Name
PROVERA
Notes and Restrictions
(Gender F)
Status PA ST QL AL AL GR
max min max m/f
GA
F
MEDROXYPROGESTERONE ACETATE
►PROKINETIC AGENTS
F
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HYDROCHLORIDE
REGLAN
GA
METOCLOPRAMIDE HYDROCHLORIDE
►PROPYLAMINE DERIVATIVES
ALLER-CHLOR
OTC 2MG/5ML SYRP
F
OTC 4MG TABS
F
OTC 4MG; 60MG TABS
F
CHLORPHENIRAMINE MALEATE
ALLERGY
CHLORPHENIRAMINE MALEATE
DECONGESTANT PLUS
CHLORPHENIRAMINE MALEATE; PSEUDOEPHEDRINE HYDROCHLORIDE
►PROSTAGLANDIN ANALOGS
F
LATANOPROST
LATANOPROST
TRAVOPROST
Requires a trial of generic latanoprost. (0.00% SOLN)
F
Y
TRAVOPROST
XALATAN
GA
LATANOPROST
►PROSTAGLANDINS
CYTOTEC
GA
MISOPROSTOL
F
MISOPROSTOL
MISOPROSTOL
►PROTECTANTS
CARAFATE
GA
SUCRALFATE
F
SUCRALFATE
SUCRALFATE
►PROTON-PUMP INHIBITORS
ACIPHEX
PA Required 20MG
NF
(Max Age 7)
GA
PA Required 15MG
NF
Y
PA Required 30MG
NF
Y
PA Required 10MG
NF
Y
PA Required 20MG
NF
Y
PA Required 20MG
NF
Y
PA Required 40MG
NF
Y
PA Required 40MG
NF
Y
Y
RABEPRAZOLE SODIUM
FIRST-OMEPRAZOLE
7
OMEPRAZOLE
LANSOPRAZOLE
LANSOPRAZOLE
LANSOPRAZOLE
LANSOPRAZOLE
NEXIUM
ESOMEPRAZOLE MAGNESIUM TRIHYDRATE
NEXIUM
ESOMEPRAZOLE MAGNESIUM TRIHYDRATE
NEXIUM
ESOMEPRAZOLE MAGNESIUM
NEXIUM
ESOMEPRAZOLE MAGNESIUM TRIHYDRATE
NEXIUM
ESOMEPRAZOLE MAGNESIUM
OMEPRAZOLE
Generic 90-days
F
OMEPRAZOLE
OMEPRAZOLE
OTC 20MG TBEC Generic 90-days
F
(Max Age 7)
F
OTC 20.6MG CPDR
F
OMEPRAZOLE
OMEPRAZOLE + SYRSPEND SF ALKA
7
OMEPRAZOLE
OMEPRAZOLE MAGNESIUM
OMEPRAZOLE MAGNESIUM
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 58 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
PANTOPRAZOLE SODIUM
PANTOPRAZOLE SODIUM SESQUIHYDRATE
PREVACID
PA Required 15MG
NF
Y
PA Required 30MG
NF
Y
LANSOPRAZOLE
PREVACID
LANSOPRAZOLE
PREVACID 24HR
LANSOPRAZOLE
PREVACID SOLUTAB
LANSOPRAZOLE
PRILOSEC
Requires step therapy with omeprazole or pantoprazoleOTC 15MG CPDR
(15MG CPDR)
F
Will pay at point of sale for members < 8 years old only. Non-formulary
for members 8 years old and older. (Max Age 7)
F
Y
7
Generic 90-days
GA
PA Required 10MG Generic 90-days
NF
Y
PA Required 2.5MG Generic 90-days
NF
Y
PA Required 20MG OTC 20MG TBEC
NF
Y
Generic 90-days
GA
PA Required 40MG Generic 90-days
NF
Y
PA Required 20MG
NF
Y
PA Required 20MG; 1100MG
NF
Y
PA Required 20MG; 1680MG
NF
Y
PA Required 40MG; 1100MG
NF
Y
PA Required 40MG; 1680MG
NF
Y
OMEPRAZOLE
PRILOSEC
OMEPRAZOLE MAGNESIUM
PRILOSEC
OMEPRAZOLE MAGNESIUM
PRILOSEC OTC
OMEPRAZOLE MAGNESIUM
PROTONIX
PANTOPRAZOLE SODIUM SESQUIHYDRATE
PROTONIX
PANTOPRAZOLE SODIUM SESQUIHYDRATE
RABEPRAZOLE SODIUM
RABEPRAZOLE SODIUM
ZEGERID
OMEPRAZOLE; SODIUM BICARBONATE
ZEGERID
OMEPRAZOLE; SODIUM BICARBONATE
ZEGERID
OMEPRAZOLE; SODIUM BICARBONATE
ZEGERID
OMEPRAZOLE; SODIUM BICARBONATE
ZEGERID OTC
OMEPRAZOLE; SODIUM BICARBONATE
Requires step therapy with omeprazole or pantoprazoleOTC 20MG;
1100MG CAPS (20MG; 1100MG CAPS)
►QUINOLONES
AVELOX
F
Y
(400MG) QL 10 QY per 30 DY
GA
10
(400MG) QL 1 FL per 30 DY
GA
1
MOXIFLOXACIN HYDROCHLORIDE
AVELOX ABC PACK
MOXIFLOXACIN HYDROCHLORIDE
CIPRO
Formulary Drug
F
CIPROFLOXACIN
CIPRO
Formulary Drug (250MG) QL 68 QY per 34 DY
GA
68
Formulary Drug (500MG) QL 68 QY per 34 DY
GA
68
CIPROFLOXACIN HCL
CIPRO
CIPROFLOXACIN HCL
F
CIPROFLOXACIN ER
CIPROFLOXACIN; CIPROFLOXACIN HCL
F
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
(250MG) QL 68 QY per 34 DY
F
68
(500MG) QL 68 QY per 34 DY
F
68
(750MG) QL 28 QY per 30 DY
F
28
(250MG) QL 14 QY per 30 DY
GA
14
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
CIPROFLOXACIN HCL
LEVAQUIN
LEVOFLOXACIN HEMIHYDRATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 59 of 73
Brand Name
Generic Name
LEVAQUIN
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
(25MG/ML) QL 1 FL per 30 DY
GA
1
(500MG) QL 14 QY per 30 DY
GA
14
(750MG) QL 14 QY per 30 DY
GA
14
(250MG) QL 14 QY per 30 DY
F
14
(25MG/ML) QL 1 FL per 30 DY
F
1
(500MG) QL 14 QY per 30 DY
F
14
(750MG) QL 14 QY per 30 DY
F
14
(400MG) QL 10 QY per 30 DY
F
10
LEVOFLOXACIN HEMIHYDRATE
LEVAQUIN
LEVOFLOXACIN HEMIHYDRATE
LEVAQUIN
LEVOFLOXACIN HEMIHYDRATE
LEVOFLOXACIN
LEVOFLOXACIN HEMIHYDRATE
LEVOFLOXACIN
LEVOFLOXACIN HEMIHYDRATE
LEVOFLOXACIN
LEVOFLOXACIN HEMIHYDRATE
LEVOFLOXACIN
LEVOFLOXACIN HEMIHYDRATE
MOXIFLOXACIN HCL
MOXIFLOXACIN HYDROCHLORIDE
F
OFLOXACIN
OFLOXACIN
OFLOXACIN
(200MG) QL 28 QY per 30 DY (Gender F)
F
28
F
(300MG) QL 28 QY per 30 DY (Gender F)
F
28
F
(400MG) QL 28 QY per 30 DY (Gender F)
F
28
F
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (150MG; 5MG; 12.5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 10MG; 12.5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 10MG; 25MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 5MG; 12.5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 5MG; 25MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (150MG; 10MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (150MG; 5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 10MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (150MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (150MG; 12.5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (150MG; 25MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 12.5MG TABS)
F
Y
Requires ST with losartan, losartan/hydrochlorothiazide, or
valsartan/hydrochlorothiazide (300MG; 25MG TABS)
F
Y
OFLOXACIN
OFLOXACIN
OFLOXACIN
OFLOXACIN
OFLOXACIN
►RENIN INHIBITORS
AMTURNIDE
ALISKIREN FUMARATE; AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE
AMTURNIDE
ALISKIREN FUMARATE; AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE
AMTURNIDE
ALISKIREN FUMARATE; AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE
AMTURNIDE
ALISKIREN FUMARATE; AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE
AMTURNIDE
ALISKIREN FUMARATE; AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE
TEKAMLO
ALISKIREN FUMARATE; AMLODIPINE BESYLATE
TEKAMLO
ALISKIREN FUMARATE; AMLODIPINE BESYLATE
TEKAMLO
ALISKIREN FUMARATE; AMLODIPINE BESYLATE
TEKAMLO
ALISKIREN FUMARATE; AMLODIPINE BESYLATE
TEKTURNA
ALISKIREN FUMARATE
TEKTURNA
ALISKIREN FUMARATE
TEKTURNA HCT
ALISKIREN FUMARATE; HYDROCHLOROTHIAZIDE
TEKTURNA HCT
ALISKIREN FUMARATE; HYDROCHLOROTHIAZIDE
TEKTURNA HCT
ALISKIREN FUMARATE; HYDROCHLOROTHIAZIDE
TEKTURNA HCT
ALISKIREN FUMARATE; HYDROCHLOROTHIAZIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Brand Name
Generic Name
Notes and Restrictions
►REPLACEMENT PREPARATIONS
CALCARB 600/VITAMIN D
Status PA ST QL AL AL GR
max min max m/f
OTC 600MG; 400UNIT TABS
F
OTC 950MG TABS
F
OTC 600MG; 200UNIT TABS
F
OTC 1250MG TABS
F
OTC 600MG TABS
F
OTC 250MG TABS
F
OTC 200MG; 125UNIT TABS
F
OTC 315MG; 200UNIT TABS
F
OTC 500MG; 200UNIT TABS
F
OTC 250MG; 250UNIT; 115MG CHEW
F
OTC 315MG; 250UNIT TABS
F
OTC 200MG; 250UNIT TABS
F
CALCIUM CARBONATE; CHOLECALCIFEROL
CALCITRATE
CALCIUM CITRATE
CALCIUM + D3
CALCIUM CARBONATE; CHOLECALCIFEROL
CALCIUM CARBONATE
CALCIUM CARBONATE
CALCIUM CARBONATE
CALCIUM CARBONATE
CALCIUM CITRATE
CALCIUM CITRATE
CALCIUM CITRATE W/D
CALCIUM CITRATE; CHOLECALCIFEROL
CALCIUM CITRATE/VITAMIN D
CALCIUM CITRATE; CHOLECALCIFEROL
CALCIUM/VITAMIN D
CALCIUM; VITAMIN D
CITRACAL CALCIUM GUMMIES
CALCIUM; CHOLECALCIFEROL; PHOSPHORUS
CITRUS CALCIUM +D
CALCIUM CITRATE; CHOLECALCIFEROL
CITRUS CALCIUM/VITAMIN D
CALCIUM CITRATE; CHOLECALCIFEROL
F
KLOR-CON
POTASSIUM CHLORIDE
F
KLOR-CON M10
POTASSIUM CHLORIDE
F
KLOR-CON M20
POTASSIUM CHLORIDE
LIQUID CALCIUM/VITAMIN D
OTC 600MG; 200UNIT CAPS
F
OTC 64MG TBCR
F
OTC 500MG TABS
F
OTC 400UNIT; 500MG TABS
F
OTC 500MG; 125UNIT TABS
F
OTC 250MG; 125UNIT TABS
F
OTC 250MG; 125UNIT; 0 TABS
F
OTC 600MG; 125UNIT TABS
F
OTC 35MEQ/L; 20GM/L; 5GM/L; 20MEQ/L; 45MEQ/L SOLN
F
CALCIUM CARBONATE; CHOLECALCIFEROL
MAG-DELAY
MAGNESIUM CHLORIDE
OYSTER SHELL CALCIUM
OYSTER SHELL
OYSTER SHELL CALCIUM + D
CHOLECALCIFEROL; OYSTER SHELL
OYSTER SHELL CALCIUM 500 + D
CALCIUM; VITAMIN D
OYSTER SHELL CALCIUM/VITAMIN D
CALCIUM CARBONATE; VITAMIN D
OYSTER SHELL CALCIUM/VITAMIN D
CALCIUM CARBONATE; CHOLECALCIFEROL; OYSTER SHELL
OYSTER SHELL/VITAMIN D
CALCIUM CARBONATE; VITAMIN D
PEDIATRIC ELECTROLYTE
CHLORIDE ION; DEXTROSE (ANHYDROUS); FRUCTOSE; POTASSIUM (+1); SODIUM (+1)
F
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
F
POTASSIUM CHLORIDE ER
POTASSIUM CHLORIDE
TH CALCIUM/MAGNESIUM/ZINC
OTC 334MG; 134MG; 5MG TABS
F
CALCIUM CARBONATE; MAGNESIUM OXIDE; ZINC OXIDE
►RESPIRATORY AND CNS STIMULANTS
CAFCIT
GA
CITRATED CAFFEINE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
CAFFEINE CITRATE
CITRATED CAFFEINE
CONCERTA
METHYLPHENIDATE HYDROCHLORIDE
CONCERTA
METHYLPHENIDATE HYDROCHLORIDE
CONCERTA
METHYLPHENIDATE HYDROCHLORIDE
CONCERTA
METHYLPHENIDATE HYDROCHLORIDE
DEXMETHYLPHENIDATE HCL
DEXMETHYLPHENIDATE HYDROCHLORIDE
DEXMETHYLPHENIDATE HCL
DEXMETHYLPHENIDATE HYDROCHLORIDE
DEXMETHYLPHENIDATE HCL ER
DEXMETHYLPHENIDATE HYDROCHLORIDE
DEXMETHYLPHENIDATE HCL ER
DEXMETHYLPHENIDATE HYDROCHLORIDE
DEXMETHYLPHENIDATE HCL ER
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
FOCALIN XR
DEXMETHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL
METHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL
METHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL
METHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL ER
METHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL ER
METHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL ER
METHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL ER
METHYLPHENIDATE HYDROCHLORIDE
METHYLPHENIDATE HCL SR
METHYLPHENIDATE HYDROCHLORIDE
RITALIN
METHYLPHENIDATE HYDROCHLORIDE
RITALIN
METHYLPHENIDATE HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
Prior authorization required for members age 21 and older. PA Required GA
18MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required GA
27MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required GA
36MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required GA
54MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required
10MG
F
Y
Prior authorization required for members age 21 and older. PA Required
5MG
F
Y
Prior authorization required for members age 21 and older. PA Required
15MG
F
Y
Prior authorization required for members age 21 and older. PA Required
30MG
F
Y
Prior authorization required for members age 21 and older. PA Required
40MG
F
Y
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 10MG (Max Age 20)
GA
Y
20
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 15MG (Max Age 20)
GA
Y
20
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 20MG (Max Age 20)
F
Y
20
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 25MG (Max Age 20)
F
Y
20
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 30MG (Max Age 20)
GA
Y
20
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 35MG (Max Age 20)
F
Y
20
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 40MG (Max Age 20)
GA
Y
20
Formulary Drug Prior authorization required for members age 21 and
older. PA Required 5MG (Max Age 20)
GA
Y
20
Prior authorization required for members age 21 and older. PA Required
10MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
20MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
5MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
18MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
27MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
36MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
54MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required
20MG (Max Age 20)
F
Y
20
Prior authorization required for members age 21 and older. PA Required GA
10MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required GA
20MG (Max Age 20)
Y
20
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Brand Name
Generic Name
RITALIN
METHYLPHENIDATE HYDROCHLORIDE
RITALIN SR
METHYLPHENIDATE HYDROCHLORIDE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Prior authorization required for members age 21 and older. PA Required GA
5MG (Max Age 20)
Y
20
Prior authorization required for members age 21 and older. PA Required GA
20MG (Max Age 20)
Y
20
►RESPIRATORY SMOOTH MUSCLE RELAXANTS
THEO-24
F
THEOPHYLLINE
F
THEOPHYLLINE ER
THEOPHYLLINE
►SALICYLATES
ASPIRIN
OTC 325MG TABS Generic 90-days
F
OTC 325MG TBEC Generic 90-days
F
OTC 81MG TBEC Generic 90-days
F
ASPIRIN
ASPIRIN EC
ASPIRIN
ASPIRIN EC
ASPIRIN
F
BUTALBITAL/ASPIRIN/CAFFEINE
ASPIRIN; BUTALBITAL; CAFFEINE
F
SALSALATE
SALSALATE
►SCABICIDES AND PEDICULICIDES
EURAX
(10%) QL 60 QY per 30 DY
F
60
(4%; 0.33%) QL 120 QY per 30 DYOTC 4%; 0.33% SHAM
F
120
CROTAMITON
LICE KILLING MAXIMUM STRENGTH
PIPERONYL BUTOXIDE TECHNICAL; PYRETHRINS
NATROBA
GA
Y
SPINOSAD
Requires trial and failure of an OTC permethrin or pyrethrin/piperonyl
butoxide product. (0.90% SUSP)
PERMETHRIN
(1%) QL 118 QY per 30 DYOTC 1% LOTN
F
118
(5%) QL 60 QY per PD
F
60
Requires trial and failure of an OTC permethrin or pyrethrin/piperonyl
butoxide product. (0.90% SUSP)
F
PERMETHRIN
PERMETHRIN
PERMETHRIN
SPINOSAD
SPINOSAD
►SECOND GENERATION ANTIHISTAMINES
ALAVERT
OTC 10MG TABS Generic 90-days
GA
OTC 10MG TBDP Generic 90-days
GA
OTC 5MG; 120MG TB12
GA
Y
LORATADINE
ALAVERT
LORATADINE
ALAVERT ALLERGY/SINUS
LORATADINE; PSEUDOEPHEDRINE SULFATE
Requires trial and failure or intolerance to loratadine OTC and cetirizine
OTC.OTC 180MG TABS (180MG TABS)
F
Y
Requires trial and failure or intolerance to loratadine OTC and cetirizine
OTC.OTC 60MG TABS (60MG TABS)
F
Y
Requires trial and failure or intolerance to loratadine OTC and cetirizine
OTC.OTC 30MG TABS (30MG TABS)
F
Y
FEXOFENADINE HYDROCHLORIDE
ALLERGY RELIEF
OTC 10MG TBDP Generic 90-days
F
OTC 10MG; 240MG TB24
F
OTC 10MG TABS
F
OTC 5MG TABS
F
OTC 1MG/ML SYRP
F
OTC 5MG; 120MG TB12
F
ALLEGRA ALLERGY
FEXOFENADINE HYDROCHLORIDE
ALLEGRA ALLERGY
FEXOFENADINE HYDROCHLORIDE
ALLEGRA ALLERGY CHILDRENS
LORATADINE
ALLERGY RELIEF/NASAL DECONGESTANT
LORATADINE; PSEUDOEPHEDRINE SULFATE
CETIRIZINE HCL
CETIRIZINE HCL
CETIRIZINE HCL
CETIRIZINE HCL
CETIRIZINE HCL CHILDRENS ALLERGY
CETIRIZINE HCL
CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ER
CETIRIZINE HCL; PSEUDOEPHEDRINE HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 63 of 73
Brand Name
Generic Name
CHILDRENS LORATADINE
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
OTC 5MG/5ML SYRP Generic 90-days
F
LORATADINE
CLARINEX
PA Required 0.5MG/ML
NF
Y
PA Required 5MG
NF
Y
PA Required 2.5MG
NF
Y
PA Required 5MG
NF
Y
PA Required 2.5MG; 120MG
NF
Y
OTC 10MG TABS Generic 90-days
GA
OTC 5MG/5ML SYRP Generic 90-days
GA
Formulary Drug OTC 10MG TBDP Generic 90-days
GA
Formulary Drug OTC 5MG TBDP Generic 90-days
F
DESLORATADINE
CLARINEX
DESLORATADINE
CLARINEX REDITABS
DESLORATADINE
CLARINEX REDITABS
DESLORATADINE
CLARINEX-D 12 HOUR
DESLORATADINE; PSEUDOEPHEDRINE SULFATE
CLARITIN
LORATADINE
CLARITIN
LORATADINE
CLARITIN REDITABS
LORATADINE
CLARITIN REDITABS
LORATADINE
CLARITIN-D 12 HOUR
OTC 5MG; 120MG TB12
GA
OTC 10MG; 240MG TB24
GA
LORATADINE; PSEUDOEPHEDRINE SULFATE
CLARITIN-D 24 HOUR
LORATADINE; PSEUDOEPHEDRINE SULFATE
Requires trial and failure or intolerance to loratadine OTC and cetirizine
OTC.OTC 180MG TABS (180MG TABS)
F
Y
Requires trial and failure or intolerance to loratadine OTC and cetirizine
OTC.OTC 60MG TABS (60MG TABS)
F
Y
FEXOFENADINE HYDROCHLORIDE
LORATADINE
OTC 10MG TABS Generic 90-days
F
OTC 10MG; 240MG TB24
F
PA Required 2.5MG/5ML
NF
FEXOFENADINE HCL
FEXOFENADINE HYDROCHLORIDE
FEXOFENADINE HCL
LORATADINE
LORATADINE-D 24HR
LORATADINE; PSEUDOEPHEDRINE HYDROCHLORIDE
XYZAL
Y
LEVOCETIRIZINE DIHYDROCHLORIDE
F
LEVOCETIRIZINE DIHYDROCHLORIDE
Requires trial and failure or intolerance to loratadine OTC and cetirizine
OTC. (5MG TABS)
ZYRTEC CHILDRENS ALLERGY
OTC 1MG/ML SYRP Generic 90-days
GA
OTC 10MG TABS Generic 90-days
GA
OTC 5MG; 120MG TB12
GA
XYZAL
Y
CETIRIZINE HCL
ZYRTEC HIVES RELIEF
CETIRIZINE HCL
ZYRTEC-D ALLERGY/CONGESTION
CETIRIZINE HCL; PSEUDOEPHEDRINE HYDROCHLORIDE
►SECOND GENERATION CEPHALOSPORINS
F
CEFACLOR
CEFACLOR
CEFPROZIL
Tablets require prior authorization.
F
CEFPROZIL
CEFTIN
Formulary Drug
GA
CEFUROXIME AXETIL
CEFTIN
Formulary Drug (250MG/5ML) QL 100 QY per PD
F
100
CEFUROXIME AXETIL
F
CEFUROXIME AXETIL
CEFUROXIME AXETIL
CEFUROXIME AXETIL
(125MG/5ML) QL 100 QY per PD
F
100
CEFUROXIME AXETIL
►SEL. SEROTONIN & NOREPI REUPTAKE INHIBTR
CYMBALTA
Formulary Drug
GA
DULOXETINE HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Page 64 of 73
Brand Name
Generic Name
CYMBALTA
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
Formulary Drug
F
DULOXETINE HYDROCHLORIDE
F
DULOXETINE HCL
DULOXETINE HYDROCHLORIDE
EFFEXOR XR
GA
VENLAFAXINE HCL
F
VENLAFAXINE HCL
VENLAFAXINE HCL
F
VENLAFAXINE HCL ER
VENLAFAXINE HCL
►SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
FLOMAX
(Gender M)
GA
M
(Gender M)
F
M
TAMSULOSIN HYDROCHLORIDE
TAMSULOSIN HCL
TAMSULOSIN HYDROCHLORIDE
►SELECTIVE BETA-2-ADRENERGIC AGONISTS
F
ALBUTEROL SULFATE
ALBUTEROL SULFATE
F
SEREVENT DISKUS
SALMETEROL XINAFOATE
F
TERBUTALINE SULFATE
TERBUTALINE SULFATE
Proventil HFA & ProAir are non-formulary.(108MCG/ACT) QL 1 QY per 30
DY
F
ALBUTEROL SULFATE
XOPENEX HFA
Requires trial of albuterol sulfate inhalation. (45MCG/ACT AERO)
F
VENTOLIN HFA
1
Y
LEVALBUTEROL TARTRATE
►SELECTIVE SEROTONIN AGONISTS
AMERGE
(1MG) QL 12 QY per 30 DY PA Required 1MG
NF
(2.5MG) QL 12 QY per 30 DY
GA
(12.5MG) QL 12 QY per 30 DY PA Required 12.5MG
NF
Y
12
(6.25MG) QL 12 QY per 30 DY PA Required 6.25MG
NF
Y
12
(2.5MG) QL 12 QY per 30 DY PA Required 2.5MG
NF
Y
12
Formulary Drug (100MG) QL 12 QY per 30 DY
GA
12
Formulary Drug (25MG) QL 12 QY per 30 DY
GA
12
Formulary Drug (50MG) QL 12 QY per 30 DY
GA
12
Formulary Drug QL: 4 vials per 30 days.(6MG/0.5ML) QL 4 QY per 30 DY GA
4
Y
12
NARATRIPTAN HYDROCHLORIDE
AMERGE
12
NARATRIPTAN HYDROCHLORIDE
AXERT
ALMOTRIPTAN MALATE
AXERT
ALMOTRIPTAN MALATE
FROVA
FROVATRIPTAN SUCCINATE MONOHYDRATE
IMITREX
SUMATRIPTAN SUCCINATE
IMITREX
SUMATRIPTAN SUCCINATE
IMITREX
SUMATRIPTAN SUCCINATE
IMITREX
SUMATRIPTAN SUCCINATE
IMITREX
SUMATRIPTAN
IMITREX
Formulary Drug QL: 6 nasal sprays (1 box) per 30 days(20MG/ACT) QL 1
QY per 30 DY
F
1
Formulary Drug QL: 6 nasal sprays (1 box) per 30 days(5MG/ACT) QL 6 QY GA
per 30 DY
6
SUMATRIPTAN
IMITREX STATDOSE REFILL
QL: 2 kits (4 injections) per 30 days(4MG/0.5ML) QL 2 QY per 30 DY
GA
2
QL: 2 kits (4 injections) per 30 days(6MG/0.5ML) QL 2 QY per 30 DY
GA
2
QL: 2 kits (4 injections) per 30 days(4MG/0.5ML) QL 2 QY per 30 DY
GA
2
QL: 2 kits (4 injections) per 30 days(6MG/0.5ML) QL 2 QY per 30 DY
GA
2
SUMATRIPTAN SUCCINATE
IMITREX STATDOSE REFILL
SUMATRIPTAN SUCCINATE
IMITREX STATDOSE SYSTEM
SUMATRIPTAN SUCCINATE
IMITREX STATDOSE SYSTEM
SUMATRIPTAN SUCCINATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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Brand Name
Generic Name
MAXALT
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
(10MG) QL 12 QY per 30 DY
GA
12
(5MG) QL 12 QY per 30 DY
GA
12
(10MG) QL 12 QY per 30 DY
GA
12
(5MG) QL 12 QY per 30 DY
GA
12
F
12
RIZATRIPTAN BENZOATE
MAXALT
RIZATRIPTAN BENZOATE
MAXALT-MLT
RIZATRIPTAN BENZOATE
MAXALT-MLT
RIZATRIPTAN BENZOATE
NARATRIPTAN HCL
(2.5MG) QL 12 QY per 30 DY
NARATRIPTAN HYDROCHLORIDE
RELPAX
(20MG) QL 12 QY per 30 DY PA Required 20MG
NF
Y
12
(40MG) QL 12 QY per 30 DY PA Required 40MG
NF
Y
12
ELETRIPTAN HYDROBROMIDE
RELPAX
ELETRIPTAN HYDROBROMIDE
RIZATRIPTAN BENZOATE
(10MG) QL 12 QY per 30 DY
F
12
(5MG) QL 12 QY per 30 DY
F
12
(10MG) QL 12 QY per 30 DY
F
12
(5MG) QL 12 QY per 30 DY
F
12
QL: 6 nasal sprays (1 box) per 30 days(20MG/ACT) QL 6 QY per 30 DY
F
6
QL: 6 nasal sprays (1 box) per 30 days(5MG/ACT) QL 6 QY per 30 DY
F
6
(100MG) QL 12 QY per 30 DY
F
12
(25MG) QL 12 QY per 30 DY
F
12
(50MG) QL 12 QY per 30 DY
F
12
QL: 2 kits (4 injections) per 30 days(4MG/0.5ML) QL 2 QY per 30 DY
F
2
QL: 2 kits (4 injections) per 30 days(6MG/0.5ML) QL 2 QY per 30 DY
F
2
QL: 4 vials per 30 days.(4MG/0.5ML) QL 4 QY per 30 DY
F
4
QL: 4 vials per 30 days.(6MG/0.5ML) QL 4 QY per 30 DY
F
4
QL: 2 kits (4 injections) per 30 days(4MG/0.5ML) QL 2 QY per 30 DY
F
2
QL: 2 kits (4 injections) per 30 days(6MG/0.5ML) QL 2 QY per 30 DY
F
2
RIZATRIPTAN BENZOATE
RIZATRIPTAN BENZOATE
RIZATRIPTAN BENZOATE
RIZATRIPTAN BENZOATE ODT
RIZATRIPTAN BENZOATE
RIZATRIPTAN BENZOATE ODT
RIZATRIPTAN BENZOATE
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE REFILL
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE REFILL
SUMATRIPTAN SUCCINATE
ZOMIG
(2.5MG) QL 12 QY per 30 DY PA Required 2.5MG
NF
Y
12
(5MG) QL 12 QY per 30 DY PA Required 5MG
NF
Y
12
1 box (6 spray units) per 30 days.(5MG) QL 1 QY per 30 DY PA Required
5MG
NF
Y
1
ZOLMITRIPTAN
ZOMIG ZMT
(2.5MG) QL 12 QY per 30 DY PA Required 2.5MG
NF
Y
12
(5MG) QL 12 QY per 30 DY PA Required 5MG
NF
Y
12
ZOLMITRIPTAN
ZOMIG
ZOLMITRIPTAN
ZOMIG NASAL SPRAY
ZOLMITRIPTAN
ZOMIG ZMT
ZOLMITRIPTAN
►SELECTIVE-SEROTONIN REUPTAKE INHIBITORS
CELEXA
GA
CITALOPRAM HYDROBROMIDE
CITALOPRAM HYDROBROMIDE
F
CITALOPRAM HYDROBROMIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 66 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
ESCITALOPRAM OXALATE
ESCITALOPRAM OXALATE
F
FLUOXETINE HCL
FLUOXETINE HCL
FLUOXETINE HCL
Use two 20mg capsules PA Required 40MG
F
Y
FLUOXETINE HCL
F
FLUVOXAMINE MALEATE
FLUVOXAMINE MALEATE
LEXAPRO
GA
ESCITALOPRAM OXALATE
F
PAROXETINE HCL
PAROXETINE HYDROCHLORIDE
PAXIL
GA
PAROXETINE HYDROCHLORIDE
PROZAC
GA
FLUOXETINE HCL
PROZAC
Use two 20mg capsules PA Required 40MG
GA
Y
FLUOXETINE HCL
F
SERTRALINE HCL
SERTRALINE HYDROCHLORIDE
ZOLOFT
GA
SERTRALINE HYDROCHLORIDE
►SEROTONIN MODULATORS
F
NEFAZODONE HCL
NEFAZODONE HYDROCHLORIDE
F
TRAZODONE HCL
TRAZODONE HYDROCHLORIDE
►SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
ALDARA
(5%) QL 24 QY per 30 DY
GA
24
IMIQUIMOD
AMNESTEEM
PA Required 10MG
F
Y
PA Required 20MG
F
Y
PA Required 40MG
F
Y
OTC 0.03% CREA
F
PA Required 10MG
F
Y
PA Required 20MG
F
Y
PA Required 30MG
F
Y
PA Required 40MG
F
Y
Formulary Drug
F
Formulary Drug
GA
PA Required 1%
F
(5%) QL 24 QY per 30 DY
F
ISOTRETINOIN
AMNESTEEM
ISOTRETINOIN
AMNESTEEM
ISOTRETINOIN
CAPSAICIN
CAPSAICIN
CLARAVIS
ISOTRETINOIN
CLARAVIS
ISOTRETINOIN
CLARAVIS
ISOTRETINOIN
CLARAVIS
ISOTRETINOIN
CONDYLOX
PODOFILOX
CONDYLOX
PODOFILOX
ELIDEL
Y
PIMECROLIMUS
IMIQUIMOD
24
IMIQUIMOD
F
PODOFILOX
PODOFILOX
PROTOPIC
PA Required 0.03%
F
Y
TACROLIMUS
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 67 of 73
Brand Name
Generic Name
PROTOPIC
Notes and Restrictions
PA Required 0.10%
Status PA ST QL AL AL GR
max min max m/f
F
Y
TACROLIMUS
F
RECTIV
NITROGLYCERIN
F
SANTYL
COLLAGENASE
TRIXAICIN HP
OTC 0.08% CREA
F
OTC 0.08% CREA
GA
CAPSAICIN
ZOSTRIX HP
CAPSAICIN
►SUCCINIMIDES
F
ETHOSUXIMIDE
ETHOSUXIMIDE
ZARONTIN
GA
ETHOSUXIMIDE
►SULFONAMIDES (SYSTEMIC)
AZULFIDINE
GA
SULFASALAZINE
AZULFIDINE EN-TABS
GA
SULFASALAZINE
BACTRIM
GA
SULFAMETHOXAZOLE; TRIMETHOPRIM
BACTRIM DS
GA
SULFAMETHOXAZOLE; TRIMETHOPRIM
F
SULFADIAZINE
SULFADIAZINE
F
SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE; TRIMETHOPRIM
F
SULFAMETHOXAZOLE/TRIMETHOPRIM DS
SULFAMETHOXAZOLE; TRIMETHOPRIM
F
SULFASALAZINE
SULFASALAZINE
►SULFONYLUREAS
AMARYL
Generic 90-days
GA
Generic 90-days
GA
Generic 90-days
F
Generic 90-days
F
Generic 90-days
F
Generic 90-days
F
GLIMEPIRIDE
DIABETA
GLYBURIDE
GLIMEPIRIDE
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE
GLIPIZIDE ER
GLIPIZIDE
GLIPIZIDE XL
GLIPIZIDE
F
GLIPIZIDE/METFORMIN HCL
GLIPIZIDE; METFORMIN HYDROCHLORIDE
GLUCOTROL
Generic 90-days
GA
Generic 90-days
GA
GLIPIZIDE
GLUCOTROL XL
GLIPIZIDE
GLUCOVANCE
GA
GLYBURIDE; METFORMIN HYDROCHLORIDE
GLYBURIDE
Generic 90-days
F
GLYBURIDE
GLYBURIDE MICRONIZED
F
GLYBURIDE
GLYBURIDE/METFORMIN HCL
F
GLYBURIDE; METFORMIN HYDROCHLORIDE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 68 of 73
Brand Name
Generic Name
Notes and Restrictions
GLYNASE
Status PA ST QL AL AL GR
max min max m/f
GA
GLYBURIDE
METAGLIP
GA
GLIPIZIDE; METFORMIN HYDROCHLORIDE
►TETRACYCLINES
F
DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE
F
MINOCYCLINE HCL
MINOCYCLINE HYDROCHLORIDE
F
TETRACYCLINE HCL
TETRACYCLINE HYDROCHLORIDE
VIBRAMYCIN
GA
DOXYCYCLINE HYCLATE
►THIAZIDE DIURETICS
F
CHLOROTHIAZIDE
CHLOROTHIAZIDE
F
DIURIL
CHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
Generic 90-days
F
HYDROCHLOROTHIAZIDE
F
METHYCLOTHIAZIDE
METHYCLOTHIAZIDE
►THIAZIDE-LIKE DIURETICS
F
CHLORTHALIDONE
CHLORTHALIDONE
F
INDAPAMIDE
INDAPAMIDE
F
METOLAZONE
METOLAZONE
ZAROXOLYN
GA
METOLAZONE
►THIOCARBAMATES (SKIN & MUCOUS MEMBRANE)
TOLNAFTATE 1% ANTIFUNGAL
OTC 1% CREA
F
TOLNAFTATE
►THIOXANTHENES
THIOTHIXENE
Formulary Drug
GA
Formulary Drug
F
THIOTHIXENE
THIOTHIXENE
THIOTHIXENE
►THIRD GENERATION CEPHALOSPORINS
F
CEFDINIR
CEFDINIR
F
CEFPODOXIME PROXETIL
CEFPODOXIME PROXETIL
SUPRAX
(400MG) QL 10 QY per 30 DY
F
10
CEFIXIME
►THYROID AGENTS
ARMOUR THYROID
F
THYROID
CYTOMEL
GA
LIOTHYRONINE SODIUM
LEVOTHYROXINE SODIUM
F
LEVOTHYROXINE SODIUM
LIOTHYRONINE SODIUM
F
LIOTHYRONINE SODIUM
NATURE-THROID
F
THYROID
SYNTHROID
GA
LEVOTHYROXINE SODIUM
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 69 of 73
Brand Name
Generic Name
Notes and Restrictions
THYROLAR-1
Status PA ST QL AL AL GR
max min max m/f
F
LIOTRIX
THYROLAR-1/2
F
LIOTRIX
THYROLAR-1/4
F
LIOTRIX
THYROLAR-2
F
LIOTRIX
THYROLAR-3
F
LIOTRIX
UNITHROID
GA
LEVOTHYROXINE SODIUM
►TRYCYCLICS & OTHER NOREPINEPH.-RU INHIB
AMITRIPTYLINE HCL
F
AMITRIPTYLINE HYDROCHLORIDE
AMOXAPINE
F
AMOXAPINE
ANAFRANIL
GA
CLOMIPRAMINE HCL
CHLORDIAZEPOXIDE/AMITRIPTYLINE
F
AMITRIPTYLINE HYDROCHLORIDE; CHLORDIAZEPOXIDE
CLOMIPRAMINE HCL
F
CLOMIPRAMINE HCL
DESIPRAMINE HCL
F
DESIPRAMINE HYDROCHLORIDE
DOXEPIN HCL
F
DOXEPIN HYDROCHLORIDE
IMIPRAMINE HCL
F
IMIPRAMINE HYDROCHLORIDE
MAPROTILINE HCL
F
MAPROTILINE HYDROCHLORIDE
NORPRAMIN
GA
DESIPRAMINE HYDROCHLORIDE
NORTRIPTYLINE HCL
F
NORTRIPTYLINE HYDROCHLORIDE
PAMELOR
GA
NORTRIPTYLINE HYDROCHLORIDE
PERPHENAZINE/AMITRIPTYLINE
F
AMITRIPTYLINE HYDROCHLORIDE; PERPHENAZINE
TOFRANIL
GA
IMIPRAMINE HYDROCHLORIDE
►URICOSURIC AGENTS
PROBENECID
F
PROBENECID
PROBENECID/COLCHICINE
F
COLCHICINE; PROBENECID
►URINARY ANTI-INFECTIVES
FURADANTIN
F
NITROFURANTOIN
MACROBID
GA
NITROFURANTOIN MONOHYDRATE MACROCRYSTALS
MACRODANTIN
GA
NITROFURANTOIN MACROCRYSTALLINE
NITROFURANTOIN MACROCRYSTALS
F
NITROFURANTOIN MACROCRYSTALLINE
NITROFURANTOIN MONOHYDRATE
F
NITROFURANTOIN MONOHYDRATE MACROCRYSTALS
TRIMETHOPRIM
F
TRIMETHOPRIM
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 70 of 73
Brand Name
Generic Name
Notes and Restrictions
►VACCINES
FLUCELVAX 2014-2015
Status PA ST QL AL AL GR
max min max m/f
GA
INFLUENZA VAC TISSUE-CULT TRIVAL 2014-15
FLUMIST QUADRIVALENT
GA
INFLUENZA VAC LIVE QUADRIVALENT 2014-15
FLUVIRIN 2014-2015
GA
INFLUENZA VAC/TYPE A,B/TRIVAL 2014-2015
FLUVIRIN PF 2014-2015
GA
INFLUENZA VAC/TYPE A,B/TRIVAL 2014-2015
FLUZONE HIGH-DOSE PF 2014-2015
GA
INFLUENZA VAC/TYPE A,B/TRIVAL 2014-2015
FLUZONE INTRADERMAL
GA
INFLUENZA VAC/TYPE A,B/TRIVAL 2014-2015
FLUZONE QUADRIVALENT 2014-2015
GA
INFLUENZA VAC/TYPE A,B/QUAD 2014-2015
FLUZONE SPLIT 2014-2015
GA
INFLUENZA VAC/TYPE A,B/TRIVAL 2014-2015
ZOSTAVAX
(19400UNT/0.65ML) QL 1 QY per 365 DY
GA
1
ZOSTER VACCINE LIVE (OKA/MERCK)
►VASOCONSTRICTORS
F
ADRENALIN
EPINEPHRINE HYDROCHLORIDE
MYDFRIN
GA
PHENYLEPHRINE HYDROCHLORIDE
F
NAPHAZOLINE HCL
NAPHAZOLINE HYDROCHLORIDE
NEO-SYNEPHRINE
OTC 0.25% SOLN
GA
OTC 0.50% SOLN
GA
PHENYLEPHRINE HYDROCHLORIDE
NEO-SYNEPHRINE
PHENYLEPHRINE HYDROCHLORIDE
F
PHENYLEPHRINE HCL
PHENYLEPHRINE HYDROCHLORIDE
►VASODILATING AGENTS (RESPIRATORY TRACT)
LETAIRIS
PA Required 10MG
F
Y
PA Required 5MG
F
Y
AMBRISENTAN
LETAIRIS
AMBRISENTAN
►VASODILATING AGENTS, MISCELLANEOUS
AGGRENOX
F
ASPIRIN; DIPYRIDAMOLE
DIPYRIDAMOLE
F
DIPYRIDAMOLE
PERSANTINE
GA
DIPYRIDAMOLE
►VITAMIN A
BETA CAROTENE
F
BETA CAROTENE
VITAMIN A
F
VITAMIN A
►VITAMIN B COMPLEX
B COMPLEX
F
CALCIUM PANTOTHENATE; CYANOCOBALAMIN; LIVER EXTRACT; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; YEAST
DRIED
B2
F
RIBOFLAVIN
B-COMPLEX
F
CYANOCOBALAMIN; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE;
RIBOFLAVIN; THIAMINE MONONITRATE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 71 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
B-COMPLEX +C
ASCORBIC ACID; CALCIUM PANTOTHENATE; CYANOCOBALAMIN; NIACINAMIDE;
PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE
F
B-COMPLEX WITH B-12
CALCIUM PANTOTHENATE; CYANOCOBALAMIN; NIACINAMIDE; PYRIDOXINE
HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE
F
BIOTIN
BIOTIN
Generic 90-days
FOLIC ACID
F
FOLIC ACID
FOLIC ACID
1MG TABS Generic 90-days
F
FOLIC ACID
F
NIACINAMIDE
NIACINAMIDE
NICOMIDE
1.5MG; 500MCG; 750MG; 25MG TABS
F
CUPRIC OXIDE; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); NIACINAMIDE;
ZINC OXIDE
F
PANTOTHENIC ACID
CALCIUM PANTOTHENATE
PANTOTHENIC ACID
(Max Age 20)
F
20
PANTOTHENIC ACID
PYRI 500
F
PYRIDOXINE HYDROCHLORIDE
STRESS B-COMPLEX/VITAMIN C/ZINC
F
ASCORBIC ACID; BIOTIN; CALCIUM PANTOTHENATE; CUPRIC OXIDE;
CYANOCOBALAMIN; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE;
RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA; ZINC
SULFATE (ANHYDROUS)
SUPER BIOTIN
F
BIOTIN
VITAMIN B COMPLEX
F
BREWERS YEAST (SACCHAROMYCES CEREVISIAE); CHOLINE BITARTRATE;
CYANOCOBALAMIN; DESICCATED LIVER; INOSITOL; NIACINAMIDE; PANTOTHENIC
ACID; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE
VITAMIN B-1
F
THIAMINE HYDROCHLORIDE
VITAMIN B-1
F
THIAMINE HYDROCHLORIDE
VITAMIN B-12
F
CYANOCOBALAMIN
VITAMIN B-12 CR
F
CYANOCOBALAMIN
VITAMIN B-2
F
RIBOFLAVIN
VITAMIN B6
F
PYRIDOXINE HYDROCHLORIDE
VITAMIN B-6
F
PYRIDOXINE HYDROCHLORIDE
VITAMIN B-6
F
PYRIDOXINE HYDROCHLORIDE
►VITAMIN C
C-500
F
ASCORBIC ACID; SODIUM ASCORBATE
VITAMIN C
F
ASCORBIC ACID
VITAMIN C CR
F
ASCORBIC ACID
VITAMIN C TR
F
ASCORBIC ACID
►VITAMIN D
BIO-D-MULSION
F
CHOLECALCIFEROL
Coverage by AmeriHealth First
Last updated copy:11/20/2014
www.amerihealthcaritaspa.com
Page 72 of 73
Brand Name
Generic Name
Notes and Restrictions
Status PA ST QL AL AL GR
max min max m/f
F
BIO-D-MULSION FORTE
CHOLECALCIFEROL
CALCITRIOL
0.25MCG CAPS
F
0.5MCG CAPS
F
1MCG/ML SOLN
F
CALCITRIOL
CALCITRIOL
CALCITRIOL
CALCITRIOL
CALCITRIOL
F
D 1000
CHOLECALCIFEROL
F
D 400
CHOLECALCIFEROL
F
D3-50
CHOLECALCIFEROL
DRISDOL
50000UNIT CAPS
GA
ERGOCALCIFEROL
F
JUST D
CHOLECALCIFEROL
ROCALTROL
0.25MCG CAPS
GA
0.5MCG CAPS
GA
CALCITRIOL
ROCALTROL
CALCITRIOL
F
VITAMIN D
CHOLECALCIFEROL
VITAMIN D
50000UNIT CAPS
F
ERGOCALCIFEROL
F
VITAMIN D3
CHOLECALCIFEROL
F
VITAMIN D3 400
CHOLECALCIFEROL
►VITAMIN E
F
E-400
TOCOPHERYL ACET,DL-ALPHA
F
E-OIL
VITAMIN E
F
VITAMIN E
VITAMIN E
F
VITAMIN E
TOCOPHERYL ACET,DL-ALPHA
►VITAMIN K ACTIVITY
MEPHYTON
5MG TABS
F
PHYTONADIONE
Coverage by AmeriHealth First
Last updated copy:11/20/2014
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