Pharmacy Benefit Management (PBM) Program FORMULARY
advertisement
Workforce Safety & Insurance 1600 E Century Ave Ste 1 PO Box 5585 Bismarck, ND 58506-5585 701.328.3800 1.800.777.5033 www.WorkforceSafety.com Revised Document Date: 12/28/2012 Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS Key: B G Available as brand name only Available as a generic equivalent $ $$ $$$ $$$$ $$$$$ Average cost < $50 per prescription Average cost $50 to $99 per prescription Average cost $100 to $249 per prescription Average cost $250 to $499 per prescription Average cost > $499 per prescription F N/F Formulary: Indicates that the product is available without prior authorization. Non-Formulary: Indicates that the product is not available. An alternative F (Formulary) or PA (Prior Authorization) agent must be selected. Prior Authorization: Indicates that the product require prior approval by WSI before being dispensed to the injured worker. PA 88 Mouth/Throat/Dental Agents 8810 Anti-Infectives - Throat Description Brand Name Carbamide Peroxide Liquid 15% Carbamide Peroxide Soln 10% Clotrimazole Troches 10mg Hydrogen Peroxide Soln 1.5% Orajel Gly-Oxide, Oral Peroxide Peroxyl Dental Rinse, Orajel Antiseptic Mouth Sore Rinse B/G B G G B Cost Status PA PA PA PA G G Nystatin Susp 100,000 units/ml Nystatin Tab 500,000 units $ PA PA 8815 Antiseptics - Mouth/Throat Chlorhexidine Gluconate Chip 2.5mg Chlorhexidine Gluconate Oral Rinse 0.12% Hexylresorcinol Soln 0.1% 881599 Antiseptic Combinations - Mouth/Throat Sulfuric Acid-Sulfonated Phenolics Liquid 30%/50% 8820 Lozenges Benzocaine Lozenge 5mg Benzocaine Lozenge 10mg Benzocaine Lozenge 15mg Benzocaine Troches 10mg Benzocaine/Cetylpyridinium Cl Lozenge 15mg/5mg Benzocaine/Menthol Lozenge 6mg/10mg Cetylpyridinium Cl-Benzyl Alcohol Lozenge 0.7%/0.3% Dyclonine Lozenge 1.2mg Dyclonine Lozenge 2mg Dyclonine Lozenge 3mg Hexylresorcinol Lozenge 2.4mg Menthol Lozenge 5mg Menthol Lozenge 6mg Menthol Lozenge 6.5mg Menthol Lozenge 7.4mg Menthol Lozenge 8.4mg Menthol Lozenge 10mg Menthol Tab 5mg Menthol Tab 6mg 2 PerioChip Oro Clense, Peridex, Periogard, PerioRx, Perisol S.T. 37 B G B PA Debacterol B PA Vicks Children’s Chloraseptic Cepacol Maximum Strength, Spec-T Mycinettes Cepacol Sore Throat Cylex B B PA PA B B B PA PA PA Vicks Chloraseptic Sore Throat Cepacol Throat B B PA PA Sucrets Children’s Formula Sucrets Original Formula Sucrets Maximum Strength Sucrets Sore Throat N’ ice ‘n Clear, Robitussin Honey Cough Kof-Eze Menthol Cough Drops Hall’s Triple Cough Drops Extra Strength Vicks Cough Drops Extra Strength Vicks Cough, Maximum Strength Halls-Plus Hall’s Sugar Free Mentholyptus Hall’s Sugar Free Mentholyptus B B B B B PA PA PA PA PA B B B B B PA PA PA PA PA B B PA PA $ PA PA Phenol Lozenge 14.5mg Phenol Lozenge 29mg Cepastat Cherry Cepastat Extra Strength B B PA PA Orabase HCA Oralone B G PA PA Aphthasol B PA TiSol Cepacol Scope B B B PA PA PA Orasept Vicks Chloraseptic Listerine B G B PA PA PA Orajel P.M. Anbesol Baby Anbesol, Orajel Baby Anbesol Jr, Baby Orajel Nighttime, Orajel/d, Zilactin-B Medicated Hurricaine, Maximum Strength Anbesol, Orajel Maximum Strength, Orajel Brace-Aid, Orajel Mouth-Aid, SensoGARD Dent’s Extra Strength Anbesol, Orasol Anbesol Maximum Strength, DentO-Kain, Dent’s Maximum Strength, Maximum Strength Orajel, Orajel Mouth-Aid Kank-A Numzit Teething Babee Teething B B B B PA PA PA PA B PA B B G PA PA PA B B B PA PA PA 8825 Steroids - Mouth/Throat Hydrocortisone Acetate Paste 0.5% Triamcinolone Paste 0.1% 8827 Antiallergy Agents – Mouth/Throat Amlexanox Paste 5% 8830 Mouthwashes Benzyl Alcohol-Menthol Soln 1%/0.04% Cetylpyridinium Cl Rinse 0.05% Cetylpyridinium Cl-SD Alcohol 38-F Rinse 67.9% Methylbenzethonium Cl Liquid 1.53% Phenol Rinse 1.4% Thymol-Eucalyptol-Methyl Salicylate-Menthol Rinse 0.064%/0.092%/0.06%/0.042% 8835 Anesthetics - Mouth/Throat Benzocaine Crm 20% Benzocaine Gel 6.3% Benzocaine Gel 7.5% Benzocaine Gel 10% Benzocaine Gel 20% Benzocaine Gum 20% Benzocaine Liquid 6.3% Benzocaine Liquid 20% Benzocaine Liquid Film 20% Benzocaine Lotion 0.2% Benzocaine Lotion 2.5% 3 Benzocaine Oint 20% Benzocaine Paste 20% Lidocaine Soln 2% Pramoxine 1% Liquid Tannic Acid Gel 7% 883599 Anesthetics Topical Oral - Combinations Dyclonine-Allantoin Gel 1%/0.5% 8845 Periodontal Products 884520 Periodontal Anti-Infectives Minocycline Microspheres Sust Rel 1mg 8850 Throat Products – Miscellaneous Dyclonine Spray 0.1% Menthol-Glycerin Spray 0.12%/25% Phenol Spray 0.5% Phenol Spray 1.4% Anbesol, Benzodent Orabase-B Lidomar, Xylocaine Viscous Curasore Zilactin Medicated B B G B B Tanac B PA Arestin B PA Sucrets N’ ice Children’s Vicks Chloraseptic, Triaminic Sore Throat Cheracol Sore Throat, Green Throat Spray, Mycinette, Phenaseptic, Red Throat Spray, Sore Throat Spray, Throto-Ceptic B B B PA PA PA B PA Entertainer’s Secret, MouthKote, Moi-Stir, Salivart Moi-Stir G PA B PA Evoxac Salagen Salagen B G G Herpecin-L OraMagic Rx Chap Stick Medicated B B B PA PA PA Lip Medex Blistex B B PA PA $ PA PA PA PA PA 885010 Artificial Saliva Saliva Substitute Soln Saliva Substitute Swabs 885015 Saliva Stimulants Cevimeline Cap 30mg Pilocarpine Tab 5mg Pilocarpine Tab 7.5mg 885020 Protectants - Mouth/Throat Allantoin-Padimate O Lip Balm AloemannonPlus Powder Camphor-Menthol-Phenol Lip Balm 1%/1%/0.5% Camphor-Phenol Oint 1%/0.54% Camphor-Phenol-Allantoin Oint 0.5%/0.5%/1% 4 $$$$ $$ PA PA PA Probax Propolis Gel 2% 5 B PA
