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Abh Ky - Aetna Better Health

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AETNA BETTER HEALTH® Formulary Guide Aetna Better Health of Kentucky Formulary Guide November 2016 http://www.aetnabetterhealth.com/kentucky AETNA BETTER HEALTH® Formulary Guide What is the Aetna Better Health of Kentucky Formulary? This is a drug list created by Aetna Better Health (“plan”). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy. Can the Plan’s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website. How do I use the Plan’s Formulary?  Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug).  Column #2: shows brand drug for the generic; brand drugs are not covered if generic equivalent is available.  Column #3: tells you if drug has a need for prior authorization or other restrictions Drugs are also grouped by drug class. If you know what class your drug is in, please look for that class name in the table of contents. Then look under that page for your drug. What are generic drugs? The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. Are there Medication Copays? Refer to member handbook for copay information. Updated: November 2016 Page | 2 AETNA BETTER HEALTH® Formulary Guide What are some types of coverage rules?  Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.  Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.  Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan’s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then:   Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. Updated: November 2016 Page | 3 Aetna Better Health Kentucky Table of Contents ableofC ntsT *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* ..................................................................................................................................... 3 *AMINOGLYCOSIDES* ................................................................................................................................................................................................................................................................................. 4 *ANALGESICS - ANTI-INFLAMMATORY* .............................................................................................................................................................................................................. 4 *ANALGESICS - NONNARCOTIC* ........................................................................................................................................................................................................................................... 5 *ANALGESICS - OPIOID* .......................................................................................................................................................................................................................................................................... 6 *ANDROGENS-ANABOLIC* ................................................................................................................................................................................................................................................................. 8 *ANORECTAL AGENTS* ............................................................................................................................................................................................................................................................................ 9 *ANTHELMINTICS* ............................................................................................................................................................................................................................................................................................. 9 *ANTIANGINAL AGENTS* ..................................................................................................................................................................................................................................................................... 9 *ANTIANXIETY AGENTS* ...................................................................................................................................................................................................................................................................... 9 *ANTIARRHYTHMICS* ............................................................................................................................................................................................................................................................................. 10 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* ....................................................................................................................................................... 10 *ANTICOAGULANTS* ................................................................................................................................................................................................................................................................................. 12 *ANTICONVULSANTS* ............................................................................................................................................................................................................................................................................ 12 *ANTIDEPRESSANTS* ................................................................................................................................................................................................................................................................................ 14 *ANTIDIABETICS* ............................................................................................................................................................................................................................................................................................. 15 *ANTIDIARRHEALS* .................................................................................................................................................................................................................................................................................... 17 *ANTIDOTES* ............................................................................................................................................................................................................................................................................................................. 17 *ANTIEMETICS* ..................................................................................................................................................................................................................................................................................................... 17 *ANTIFUNGALS* .................................................................................................................................................................................................................................................................................................. 17 *ANTIHISTAMINES* ...................................................................................................................................................................................................................................................................................... 18 *ANTIHYPERLIPIDEMICS* ................................................................................................................................................................................................................................................................ 18 *ANTIHYPERTENSIVES* ....................................................................................................................................................................................................................................................................... 19 *ANTI-INFECTIVE AGENTS - MISC.* ............................................................................................................................................................................................................................. 21 *ANTIMALARIALS* ........................................................................................................................................................................................................................................................................................ 21 *ANTIMYASTHENIC AGENTS* ................................................................................................................................................................................................................................................. 22 *ANTIMYCOBACTERIAL AGENTS* ................................................................................................................................................................................................................................ 22 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* ............................................................................................................................................................. 22 *ANTIPARKINSON AGENTS* ....................................................................................................................................................................................................................................................... 24 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* .................................................................................................................................................................................................... 25 *ANTIRETROVIRALS ADJUVANTS*** ....................................................................................................................................................................................................................... 26 *ANTISEPTICS & DISINFECTANTS* ................................................................................................................................................................................................................................ 26 *ANTIVIRALS* .......................................................................................................................................................................................................................................................................................................... 26 *ASSORTED CLASSES* ............................................................................................................................................................................................................................................................................ 29 *BETA BLOCKERS* ......................................................................................................................................................................................................................................................................................... 30 *CALCIUM CHANNEL BLOCKERS* ................................................................................................................................................................................................................................. 31 *CARDIOTONICS* .............................................................................................................................................................................................................................................................................................. 32 *CARDIOVASCULAR AGENTS - MISC.* .................................................................................................................................................................................................................. 32 *CEPHALOSPORINS* .................................................................................................................................................................................................................................................................................... 32 *CHEMICALS* ............................................................................................................................................................................................................................................................................................................ 33 *CONTRACEPTIVES* .................................................................................................................................................................................................................................................................................... 33 *CORTICOSTEROIDS* ................................................................................................................................................................................................................................................................................ 38 *COUGH/COLD/ALLERGY* .............................................................................................................................................................................................................................................................. 39 *DERMATOLOGICALS* ........................................................................................................................................................................................................................................................................... 40 *DIAGNOSTIC PRODUCTS* ............................................................................................................................................................................................................................................................. 45 *DIGESTIVE AIDS* ........................................................................................................................................................................................................................................................................................... 45 1 ableofC ntsT *DIURETICS* ................................................................................................................................................................................................................................................................................................................ 46 *ENDOCRINE AND METABOLIC AGENTS - MISC.* .......................................................................................................................................................................... 46 *ESTROGENS* ............................................................................................................................................................................................................................................................................................................ 47 *FLUOROQUINOLONES* ...................................................................................................................................................................................................................................................................... 48 *GASTROINTESTINAL AGENTS - MISC.* ............................................................................................................................................................................................................. 48 *GENITOURINARY AGENTS - MISCELLANEOUS* ............................................................................................................................................................................. 49 *GOUT AGENTS* .................................................................................................................................................................................................................................................................................................. 50 *HEMATOLOGICAL AGENTS - MISC.* ....................................................................................................................................................................................................................... 50 *HEMATOPOIETIC AGENTS* ....................................................................................................................................................................................................................................................... 51 *HEPATITIS C AGENT - COMBINATIONS*** ................................................................................................................................................................................................. 52 *HYPNOTICS* ............................................................................................................................................................................................................................................................................................................. 52 *LAXATIVES* ............................................................................................................................................................................................................................................................................................................. 52 *MACROLIDES* ...................................................................................................................................................................................................................................................................................................... 53 *MEDICAL DEVICES* .................................................................................................................................................................................................................................................................................. 53 *MIGRAINE PRODUCTS* ...................................................................................................................................................................................................................................................................... 59 *MINERALS & ELECTROLYTES* .......................................................................................................................................................................................................................................... 59 *MOUTH/THROAT/DENTAL AGENTS* ...................................................................................................................................................................................................................... 60 *MULTIVITAMINS* ......................................................................................................................................................................................................................................................................................... 61 *MUSCULOSKELETAL THERAPY AGENTS* .................................................................................................................................................................................................. 65 *NASAL AGENTS - SYSTEMIC AND TOPICAL* ........................................................................................................................................................................................ 66 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** ......................................................................................... 66 *NEUROMUSCULAR AGENTS* ................................................................................................................................................................................................................................................ 66 *OPHTHALMIC AGENTS* .................................................................................................................................................................................................................................................................... 67 *OTIC AGENTS* ...................................................................................................................................................................................................................................................................................................... 69 *OXYTOCICS* ............................................................................................................................................................................................................................................................................................................ 69 *PASSIVE IMMUNIZING AGENTS* .................................................................................................................................................................................................................................... 70 *PENICILLINS* ......................................................................................................................................................................................................................................................................................................... 70 *PHARMACEUTICAL ADJUVANTS* ............................................................................................................................................................................................................................... 70 *POTASSIUM REMOVING AGENTS*** ...................................................................................................................................................................................................................... 74 *PROGESTINS* ......................................................................................................................................................................................................................................................................................................... 74 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* .................................................................................................................. 75 *SULFONAMIDES* ............................................................................................................................................................................................................................................................................................ 76 *TETRACYCLINES* ......................................................................................................................................................................................................................................................................................... 76 *THYROID AGENTS* .................................................................................................................................................................................................................................................................................... 77 *ULCER DRUGS* .................................................................................................................................................................................................................................................................................................. 77 *URINARY ANTI-INFECTIVES* ................................................................................................................................................................................................................................................ 79 *URINARY ANTISPASMODICS* .............................................................................................................................................................................................................................................. 79 *VACCINES* .................................................................................................................................................................................................................................................................................................................. 79 *VAGINAL PRODUCTS* .......................................................................................................................................................................................................................................................................... 79 *VASOPRESSORS* ............................................................................................................................................................................................................................................................................................. 80 *VITAMINS* ................................................................................................................................................................................................................................................................................................................... 80 2 Aetna Better Health Kentucky CURRENT AS OF 11/1/2016 Drug Name Reference *ADHD/ANTI-NARCOLEPSY/ANT I-OBESITY/ANOREXIANTS* *Amphetamine Mixtures*** Restrictions Adderall XR QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) Adderall QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) dextroamphetamine sulfate er Dexedrine AL (Min 6 Years and Max 18 Years) dextroamphetamine sulfate oral tablet Zenzedi AL (Min 6 Years and Max 18 Years) DEXEDRINE ORAL TABLET Dextroamphetamine Sulfate AL (Min 6 Years and Max 18 Years) ZENZEDI ORAL TABLET 10 MG, 5 MG Dextroamphetamine Sulfate AL (Min 6 Years and Max 18 Years) dexmethylphenidate hcl Focalin QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) methylphenidate hcl er (cd) Metadate CD QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) methylphenidate hcl er (la) Ritalin LA AL (Min 6 Years and Max 18 Years) amphetamine-dextroamphet er amphetamine-dextroamphetamine *Amphetamines*** *Stimulants - Misc.*** methylphenidate hcl er oral tablet extended release 24 hr* QLL (30 EA per 30 days) methylphenidate hcl er oral tablet extendedrelease* 10 mg AL (Min 6 Years and Max 18 Years) methylphenidate hcl er oral tablet Concerta extendedrelease* 18 mg, 27 mg, 36 mg, 54 mg QLL (30 EA per 30 days); AL (Min 5 Years and Max 18 Years) 3 Drug Name Reference Restrictions methylphenidate hcl er oral tablet extendedrelease* 20 mg Metadate ER AL (Min 6 Years and Max 18 Years) methylphenidate hcl oral solution 10 mg/5ml Methylin QLL (600 ML per 30 days); AL (Min 6 Years and Max 18 Years) methylphenidate hcl oral solution 5 mg/5ml Methylin QLL (300 ML per 30 days); AL (Min 6 Years and Max 18 Years) methylphenidate hcl oral tablet Ritalin QLL (120 EA per 30 days); AL (Min 6 Years and Max 18 Years) methylphenidate hcl oral tablet chewable Methylin QLL (120 EA per 30 days); AL (Min 5 Years and Max 18 Years) METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG Methylphenidate HCl ER AL (Min 6 Years and Max 18 Years) *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral paromomycin sulfate oral tobramycin inhalation Tobi *ANALGESICS ANTI-INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML PA HUMIRA PEN SUBCUTANEOUS* PA HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* PA HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* PA HUMIRA SUBCUTANEOUS* 20 MG/0.4ML, 40 MG/0.8ML PA *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral *Gold Compounds*** RIDAURA 4 CeleBREX ST; AL (Min 65 Years) Drug Name *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** Reference diclofenac potassium Cataflam diclofenac sodium er Voltaren-XR Restrictions diclofenac sodium oral etodolac er etodolac oral fenoprofen calcium oral tablet flurbiprofen oral ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er indomethacin oral ketoprofen oral ketorolac tromethamine oral QLL (2 Claims per 180 days) meclofenamate sodium oral meloxicam oral tablet Mobic nabumetone oral naproxen dr EC-Naprosyn naproxen kit Naprosyn naproxen oral Naprosyn naproxen sodium oral tablet 275 mg Anaprox naproxen sodium oral tablet 550 mg Anaprox DS oxaprozin Daypro piroxicam oral Feldene sulindac oral tolmetin sodium *Pyrimidine Synthesis Inhibitors*** leflunomide oral Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS* PA ENBREL SURECLICK SUBCUTANEOUS* PA *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen Tencon butalbital-apap-caffeine oral capsule 50-300-40 mg Orbivan 5 Drug Name Reference Restrictions butalbital-apap-caffeine oral capsule 50-325-40 mg Esgic QLL (180 EA per 30 days) butalbital-apap-caffeine oral tablet 50-325-40 Fioricet mg QLL (180 EA per 30 days) butalbital-aspirin-caffeine oral capsule Fiorinal QLL (180 EA per 30 days) margesic Esgic QLL (180 EA per 30 days) marten-tab Tencon CAPACET Margesic QLL (180 EA per 30 days) ESGIC ORAL CAPSULE Margesic QLL (180 EA per 30 days) TENCON ORAL TABLET 50-325 MG Marten-Tab ZEBUTAL ORAL CAPSULE 50-325-40 MG Margesic QLL (180 EA per 30 days) *Salicylate Combinations*** choline & mag trisalicylate oral tablet 1000 mg choline-mag trisalicylate *Salicylates*** diflunisal oral salsalate oral Disalcid *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine acetaminophen-codeine #2 acetaminophen-codeine #3 Tylenol with Codeine #3 acetaminophen-codeine #4 Tylenol with Codeine #4 butalbital-apap-caff-cod oral capsule 50-300-40-30 mg Fioricet/Codeine butalbital-apap-caff-cod oral capsule 50-325-40-30 mg Fioricet/Codeine QLL (30 EA per 30 days) butalbital-asa-caff-codeine Ascomp-Codeine QLL (180 EA per 30 days) ASCOMP-CODEINE Butalbital Compound/Codeine QLL (180 EA per 30 days) *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml Hycet hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg Norco hydrocodone-acetaminophen oral tablet 2.5-325 mg Verdrocet hydrocodone-ibuprofen oral tablet 7.5-200 mg Vicoprofen 6 Drug Name Reference LORCET Hydrocodone-Acetaminophen LORCET HD Hydrocodone-Acetaminophen LORCET PLUS ORAL TABLET 7.5-325 MG Hydrocodone-Acetaminophen LORTAB ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG Hydrocodone-Acetaminophen ZAMICET Hydrocodone-Acetaminophen Restrictions *Opioid Agonists*** codeine sulfate oral tablet QLL (120 EA per 30 days) fentanyl citrate buccal Actiq ST; QLL (90 EA per 30 days) fentanyl transdermal patch 72 hr 100 mcg/hr Duragesic-100 PA; QLL (10 Patches per 30 days) fentanyl transdermal patch 72 hr 12 mcg/hr Duragesic-12 PA; QLL (10 Patches per 30 days) fentanyl transdermal patch 72 hr 25 mcg/hr Duragesic-25 PA; QLL (10 Patches per 30 days) fentanyl transdermal patch 72 hr 50 mcg/hr Duragesic-50 PA; QLL (10 Patches per 30 days) fentanyl transdermal patch 72 hr 75 mcg/hr Duragesic-75 PA; QLL (10 Patches per 30 days) hydromorphone hcl oral tablet 2 mg Dilaudid hydromorphone hcl oral tablet 4 mg, 8 mg Dilaudid QLL (180 EA per 30 days) Methadose PA hydromorphone hcl suppository methadone hcl oral concentrate PA methadone hcl oral solution methadone hcl oral tablet Dolophine PA; QLL (240 EA per 30 days) methadone hcl oral tablet soluble Methadose PA; QLL (240 EA per 30 days) morphine sulfate er oral capsule extended release 24 hour Kadian PA; QLL (60 EA per 30 days) morphine sulfate er oral tablet extendedrelease* MS Contin PA; QLL (60 EA per 30 days) morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate oral solution morphine sulfate oral tablet QLL (180 EA per 30 days) morphine sulfate suppository oxycodone hcl oral capsule QLL (180 EA per 30 days) oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet 10 mg QLL (180 EA per 30 days) 7 Drug Name Reference Restrictions oxycodone hcl oral tablet 15 mg, 5 mg Roxicodone QLL (180 EA per 30 days) oxycodone hcl oral tablet 20 mg QLL (240 EA per 30 days) oxycodone hcl oral tablet 30 mg Roxicodone oxymorphone hcl Opana oxymorphone hcl er QLL (240 EA per 30 days) PA; QLL (60 EA per 30 days) tramadol hcl oral Ultram PA; QLL (240 EA per 30 days) METHADONE HCL INTENSOL Methadone HCl PA METHADOSE ORAL TABLET SOLUBLE Methadone HCl PA; QLL (240 EA per 30 days) *Opioid Combinations*** oxycodone-acetaminophen oral tablet 10-325 Endocet mg oxycodone-acetaminophen oral tablet 2.5-325 Percocet mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg Percodan ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG Oxycodone-Acetaminophen ROXICET ORAL TABLET 5-325 MG Oxycodone-Acetaminophen QLL (240 EA per 30 days) *Opioid Partial Agonists*** buprenorphine hcl sublingual buprenorphine hcl-naloxone hcl PA Suboxone butorphanol tartrate nasal PA QLL (1 Bottle per 30 days) pentazocine-naloxone hcl *Tramadol Combinations*** tramadol-acetaminophen Ultracet PA; QLL (240 EA per 30 days) *ANDROGENS-ANABOLIC* *Androgens*** danazol oral methyltestosterone oral Android testosterone cypionate intramuscular* solution 200 mg/ml Depo-Testosterone testosterone transdermal gel 12.5 mg/act (1%) AndroGel Pump testosterone transdermal gel 25 mg/2.5gm (1%) AndroGel testosterone transdermal gel 50 mg/5gm (1%) Testim ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%) 8 PA Drug Name *ANORECTAL AGENTS* *Intrarectal Steroids*** Reference hydrocortisone enema Cortenema COLOCORT Hydrocortisone Restrictions CORTIFOAM *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace cream LidaZone HC lidocaine-hydrocortisone ace kit 3-0.5 %, 3-1 % LIDAZONE HC CREAM Lidocaine-Hydrocortisone Ace PROCTOFOAM HC *Rectal Steroids*** PROCTO-PAK Hydrocortisone PROCTOSOL HC Hemorrhoidal-HC PROCTOZONE-HC Hemorrhoidal-HC *ANTHELMINTICS* *Anthelmintics*** ivermectin oral Stromectol ALBENZA *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er isosorbide dinitrate oral Isordil Titradose isosorbide mononitrate isosorbide mononitrate er Imdur nitroglycerin er Nitro-Time nitroglycerin transdermal patch 24 hr Nitro-Dur nitroglycerin translingual solution Nitrolingual MINITRAN Nitroglycerin NITRO-BID NITROSTAT Nitroglycerin NITRO-TIME Nitroglycerin ER *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg QLL (90 EA per 30 days) buspirone hcl oral tablet 30 mg QLL (60 EA per 30 days) 9 Drug Name Reference Restrictions hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral Vistaril meprobamate *Benzodiazepines*** alprazolam er Xanax XR alprazolam oral Xanax alprazolam xr Xanax XR chlordiazepoxide hcl clorazepate dipotassium Tranxene-T diazepam oral concentrate Diazepam Intensol diazepam oral solution 1 mg/ml diazepam oral tablet Valium lorazepam oral Ativan oxazepam ALPRAZOLAM INTENSOL DIAZEPAM INTENSOL Diazepam LORAZEPAM INTENSOL LORazepam *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral Norpace quinidine gluconate er quinidine sulfate oral *Antiarrhythmics Type I-B*** mexiletine hcl oral *Antiarrhythmics Type I-C*** flecainide acetate Tambocor propafenone hcl Rythmol *Antiarrhythmics Type Iii*** amiodarone hcl oral Pacerone MULTAQ PACERONE ORAL TABLET 100 MG, 200 Amiodarone HCl MG, 400 MG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol ADVAIR DISKUS 10 DuoNeb AL (Max 12 Years) Drug Name Reference ANORO ELLIPTA Restrictions QLL (1 EA per 30 Days) COMBIVENT RESPIMAT DULERA ST; QLL (1 canister per 30 Days) STIOLTO RESPIMAT SYMBICORT *Anti-Inflammatory Agents*** cromolyn sodium inhalation *Beta Adrenergics*** albuterol sulfate er VoSpire ER albuterol sulfate inhalation QLL (130 vials per 30 days) albuterol sulfate oral metaproterenol sulfate oral terbutaline sulfate oral VENTOLIN HFA QLL (2 Inhalers per 30 days) *Bronchodilators Anticholinergics*** ipratropium bromide inhalation ATROVENT HFA INCRUSE ELLIPTA SPIRIVA HANDIHALER ST; QLL (30 EA per 30 days) SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 2.5 MCG/ACT ST TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet Singulair QLL (1 packet per 1 day) montelukast sodium oral tablet Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet chewable Singulair QLL (30 EA per 30 days) zafirlukast Accolate QLL (527 EA per 30 days) Pulmicort QLL (527 ML per 30 days); AL (Max 5 Years) *Steroid Inhalants*** budesonide inhalation FLOVENT DISKUS PULMICORT FLEXHALER QLL (1 Inhaler per 30 days) QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT, 80 MCG/ACT 11 Drug Name *Xanthines*** Reference theophylline er Theochron Restrictions theophylline oral solution THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 200 MG, 300 MG Theophylline ER *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral Coumadin JANTOVEN Warfarin Sodium *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf *Low Molecular Weight Heparins*** enoxaparin sodium injection Lovenox enoxaparin sodium subcutaneous* Lovenox FRAGMIN SUBCUTANEOUS* SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML QLL (20 Syringes per 10 days) QLL (10 Syringes per 10 days) *Synthetic Heparinoid-Like Agents*** fondaparinux sodium Arixtra *ANTICONVULSANTS* *Anticonvulsants Benzodiazepines*** clonazepam oral KlonoPIN diazepam gel Diastat Pediatric QLL (2 EA per 30 days) Carbatrol QLL (400 EA per 100 days); AL (Min 6 Years) *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release TEGretol XR 12 hr* 100 mg QLL 6 - 15 yrs old QL = 1000 mg/day > 15 and adults QL = 1200 mg/day; QLL (12 EA per 1 Day) carbamazepine er oral tablet extended release TEGretol XR 12 hr* 200 mg, 400 mg QLL (400 EA per 100 days); AL (Min 6 Years) 12 Drug Name Reference Restrictions carbamazepine oral TEGretol gabapentin oral capsule 100 mg Neurontin QLL (36 EA per 1 day) gabapentin oral capsule 300 mg Neurontin QLL (12 EA per 1 day) gabapentin oral capsule 400 mg Neurontin QLL (9 EA per 1 day) gabapentin oral solution 250 mg/5ml Neurontin gabapentin oral tablet 600 mg Neurontin QLL (6 EA per 1 day) gabapentin oral tablet 800 mg Neurontin QLL (4 EA per 1 day) lamotrigine oral tablet LaMICtal lamotrigine oral tablet chewable LaMICtal levetiracetam er Keppra XR levetiracetam oral Keppra oxcarbazepine Trileptal primidone oral Mysoline topiramate oral Topiragen QLL (120 EA per 30 days) zonisamide oral Zonegran QLL (180 EA per 30 days) EPITOL CarBAMazepine TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG CarBAMazepine ER *Carbamates*** felbamate Felbatol *Gaba Modulators*** tiagabine hcl Gabitril GABITRIL ORAL TABLET 12 MG, 16 MG QLL (60 EA per 30 days) QLL (60 EA per 30 days) *Hydantoins*** phenytoin oral suspension 125 mg/5ml Dilantin phenytoin oral tablet chewable Dilantin Infatabs phenytoin sodium extended Dilantin DILANTIN ORAL CAPSULE 30 MG PHENYTEK Phenytoin Sodium Extended PHENYTOIN INFATABS Phenytoin *Succinimides*** ethosuximide oral Zarontin CELONTIN *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hr* Depakote ER divalproex sodium oral tablet delayed release Depakote 13 Drug Name Reference valproic acid oral capsule Depakene valproic acid oral solution Depakene Restrictions *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral QLL (30 EA per 30 days) *Antidepressants - Misc.*** bupropion hcl er (sr) Budeprion SR QLL (60 EA per 30 days) bupropion hcl er (xl) Wellbutrin XL QLL (30 EA per 30 days) bupropion hcl oral Wellbutrin QLL (90 EA per 30 days) maprotiline hcl *Modified Cyclics*** trazodone hcl oral *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral Nardil tranylcypromine sulfate Parnate MARPLAN *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution QLL (300 ML per 30 days) citalopram hydrobromide oral tablet CeleXA QLL (30 EA per 30 days) escitalopram oxalate oral solution Lexapro QLL (300 ML per 30 days) escitalopram oxalate oral tablet Lexapro QLL (30 EA per 30 days) fluoxetine hcl oral capsule 10 mg PROzac QLL (30 EA per 30 days) fluoxetine hcl oral capsule 20 mg, 40 mg PROzac QLL (60 EA per 30 days) fluoxetine hcl oral solution QLL (150 ML per 30 days) fluoxetine hcl oral tablet 10 mg QLL (30 EA per 30 days) fluoxetine hcl oral tablet 20 mg QLL (60 EA per 30 days) fluoxetine hcl oral tablet 60 mg fluvoxamine maleate oral tablet 100 mg QLL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 mg QLL (30 EA per 30 days) fluvoxamine maleate oral tablet 50 mg QLL (60 EA per 30 days) paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg Paxil QLL (30 EA per 30 days) paroxetine hcl oral tablet 30 mg Paxil QLL (60 EA per 30 days) sertraline hcl oral concentrate Zoloft QLL (75 ML per 30 days) sertraline hcl oral tablet 100 mg, 50 mg Zoloft QLL (60 EA per 30 days) 14 Drug Name Reference Restrictions sertraline hcl oral tablet 25 mg Zoloft QLL (30 EA per 30 days) Cymbalta QLL (60 EA per 30 days) Effexor XR QLL (30 EA per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg venlafaxine hcl venlafaxine hcl er oral capsule extended release 24 hour venlafaxine hcl er oral tablet extended release 24 hr* *Tricyclic Agents*** amitriptyline hcl oral amoxapine clomipramine hcl oral Anafranil desipramine hcl oral Norpramin doxepin hcl oral imipramine hcl oral Tofranil imipramine pamoate Tofranil-PM nortriptyline hcl oral Pamelor protriptyline hcl Vivactil *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose Precose *Biguanides*** metformin hcl er Glucophage XR metformin hcl oral Glucophage *Diabetic Other*** GLUCAGEN HYPOKIT GLUCAGON EMERGENCY *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate Nesina QLL (30 EA per 30 Days) Kazano QLL (60 EA per 30 Days) *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** alogliptin-metformin hcl 15 Drug Name *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** Reference Restrictions alogliptin-pioglitazone Oseni QLL (30 EA per 30 Days) *Human Insulin*** HUMALOG HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML, 200 UNIT/ML PA; AL (Max 18 Years) HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* PA; AL (Max 18 Years) HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* PA; AL (Max 18 Years) HUMULIN R U-500 (CONCENTRATED) LANTUS LEVEMIR LEVEMIR FLEXTOUCH NOVOLOG NOVOLOG MIX 70/30 NOVOLOG PENFILL SUBCUTANEOUS* *Meglitinide Analogues*** nateglinide Starlix repaglinide Prandin *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl PrandiMet *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl Metaglip glyburide-metformin Glucovance *Sulfonylureas*** chlorpropamide glimepiride Amaryl glipizide er GlipiZIDE XL glipizide oral Glucotrol glipizide xl GlipiZIDE XL glyburide micronized Glynase glyburide oral Diabeta 16 Drug Name Reference Restrictions Duetact QLL (30 EA per 30 days) Actoplus Met QLL (90 EA per 30 days) Actos QLL (30 EA per 30 days) tolazamide tolbutamide *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl *Thiazolidinediones*** pioglitazone hcl AVANDIA ORAL TABLET 2 MG, 4 MG ST; QLL (30 EA per 30 days) *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine Lonox lofene Lonox loperamide hcl oral capsule Imodium A-D *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET *Opioid Antagonists*** naltrexone hcl oral Depade *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral ondansetron Zofran ODT ondansetron hcl oral Zofran *Antiemetics - Anticholinergic*** meclizine hcl oral tablet Antivert trimethobenzamide hcl oral Tigan OTC *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE *ANTIFUNGALS* *Antifungals*** bio-statin oral powder griseofulvin microsize oral Grifulvin V griseofulvin ultramicrosize Gris-PEG 17 Drug Name Reference Restrictions LamISIL QLL (84 EA per 365 days) nystatin oral terbinafine hcl oral *Imidazoles*** ketoconazole oral *Triazoles*** fluconazole oral Diflucan itraconazole oral Sporanox Pulsepak SPORANOX ORAL SOLUTION *ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet Arbinoxa clemastine fumarate oral tablet 2.68 mg ARBINOXA ORAL TABLET Carbinoxamine Maleate *Antihistamines - Non-Sedating*** cetirizine hcl oral solution Wal-Zyr Childrens QLL (150 ML per 30 days) cetirizine hcl oral syrup 1 mg/ml Wal-Zyr Childrens OTC; QLL (150 ML per 30 days) *Antihistamines - Phenothiazines*** promethazine hcl oral promethazine hcl suppository Phenadoz PHENADOZ Promethazine HCl PHENERGAN Promethazine HCl PROMETHEGAN Promethazine HCl *Antihistamines - Piperidines*** cyproheptadine hcl oral *ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light Questran Light cholestyramine oral Questran colestipol hcl Colestid PREVALITE Cholestyramine Light *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg Lofibra fenofibrate oral tablet 145 mg, 48 mg Tricor 18 Drug Name Reference Restrictions fenofibrate oral tablet 160 mg, 54 mg Lofibra fenofibric acid oral capsule delayed release Trilipix gemfibrozil oral Lopid QLL (60 EA per 30 days) atorvastatin calcium oral Lipitor QLL (30 EA per 30 days) fluvastatin sodium Lescol QLL (30 EA per 30 days) fluvastatin sodium er Lescol XL QLL (30 EA per 30 days) *Hmg Coa Reductase Inhibitors*** lovastatin oral tablet 10 mg QLL (30 EA per 30 days) lovastatin oral tablet 20 mg Mevacor QLL (30 EA per 30 days) lovastatin oral tablet 40 mg Mevacor QLL (60 EA per 30 days) pravastatin sodium QLL (30 EA per 30 days) rosuvastatin calcium Crestor PA; QLL (1 EA per 1 Day) simvastatin oral Zocor QLL (30 EA per 30 days) *Intestinal Cholesterol Absorption Inhibitors*** ZETIA ST *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) Niaspan *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl Lotrel *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide captopril-hydrochlorothiazide enalapril-hydrochlorothiazide fosinopril sodium-hctz lisinopril-hydrochlorothiazide Zestoretic moexipril-hydrochlorothiazide Uniretic quinapril-hydrochlorothiazide Accuretic *Ace Inhibitors*** benazepril hcl oral captopril oral enalapril maleate oral Vasotec fosinopril sodium lisinopril oral tablet 10 mg, 2.5 mg, 30 mg, 5 mg Zestril QLL (30 EA per 30 days) 19 Drug Name Reference Restrictions lisinopril oral tablet 20 mg Prinivil QLL (30 EA per 30 days) lisinopril oral tablet 40 mg Zestril QLL (60 EA per 30 days) moexipril hcl Univasc perindopril erbumine quinapril hcl Accupril ramipril Altace trandolapril Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz Atacand HCT irbesartan-hydrochlorothiazide Avalide losartan potassium-hctz Hyzaar valsartan-hydrochlorothiazide Diovan HCT QLL (30 EA per 30 days) *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil Atacand irbesartan Avapro losartan potassium Cozaar valsartan Diovan QLL (60 EA per 30 days) Exforge HCT QLL (30 EA per 30 days) *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz *Antiadrenergics - Centrally Acting*** clonidine hcl oral Catapres clonidine hcl transdermal Catapres-TTS-1 guanfacine hcl oral Tenex methyldopa oral *Antiadrenergics - Peripherally Acting*** doxazosin mesylate Cardura prazosin hcl oral Minipress terazosin hcl oral 20 QLL (30 EA per 30 days) QLL (30 EA per 30 days) Drug Name *Beta Blocker & Diuretic Combinations*** Reference atenolol-chlorthalidone Tenoretic 50 bisoprolol-hydrochlorothiazide Ziac metoprolol-hydrochlorothiazide Lopressor HCT nadolol-bendroflumethiazide Corzide Restrictions propranolol-hctz *Vasodilators*** hydralazine hcl oral minoxidil oral *ANTI-INFECTIVE AGENTS MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral Flagyl trimethoprim oral vancomycin hcl intravenous* solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg vancomycin hcl oral Vancocin HCl FIRST-VANCOMYCIN 25 FIRST-VANCOMYCIN 50 *Anti-Infective Misc. Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml Sulfatrim Pediatric sulfamethoxazole-trimethoprim oral tablet Bactrim SULFATRIM PEDIATRIC Sulfamethoxazole-Trimethopri m *Leprostatics*** dapsone oral *Lincosamides*** clindamycin hcl oral Cleocin clindamycin palmitate hcl Cleocin *ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral hydroxychloroquine sulfate oral Plaquenil mefloquine hcl 21 Drug Name Reference Restrictions DARAPRIM *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral Mestinon *ANTIMYCOBACTERIAL AGENTS* *Anti Tb Combinations*** RIFAMATE *Antimycobacterial Agents*** ethambutol hcl oral Myambutol isoniazid oral pyrazinamide oral rifabutin Mycobutin rifampin oral Rifadin PRIFTIN *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** HEXALEN MYLERAN *Antiadrenals*** LYSODREN *Antiandrogens*** bicalutamide Casodex flutamide NILANDRON Nilutamide *Antiestrogens*** tamoxifen citrate oral FARESTON SOLTAMOX *Antimetabolites*** capecitabine oral tablet 150 mg Xeloda PA; QLL (140 EA per 21 days) capecitabine oral tablet 500 mg Xeloda PA; QLL (154 EA per 21 days) mercaptopurine oral Purinethol methotrexate oral TABLOID 22 Drug Name Reference *Antineoplastic - Histone Deacetylase Inhibitors*** Restrictions ZOLINZA PA *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR PA *Antineoplastic - Multikinase Inhibitors*** NEXAVAR PA; QLL (120 EA per 30 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG PA SUTENT ORAL CAPSULE 37.5 MG PA; QLL (30 EA per 30 days) SUTENT ORAL CAPSULE 50 MG PA; QLL (28 EA per 42 days) *Antineoplastic - Tyrosine Kinase Inhibitors*** CABOMETYX GLEEVEC ORAL TABLET 400 MG PA; QLL (30 EA per 30 Days) Imatinib Mesylate PA SPRYCEL PA TARCEVA ORAL TABLET 100 MG, 150 MG PA TARCEVA ORAL TABLET 25 MG TASIGNA PA TYKERB PA; QLL (180 EA per 30 days) VOTRIENT PA *Antineoplastics Misc.*** hydroxyurea oral Hydrea MATULANE PA *Aromatase Inhibitors*** anastrozole oral Arimidex exemestane Aromasin letrozole oral Femara *Estrogens-Antineoplastic*** EMCYT *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral *Imidazotetrazines*** temozolomide Temodar 23 Drug Name *Lhrh Analogs*** Reference Restrictions ELIGARD PA TRELSTAR PA TRELSTAR MIXJECT PA VANTAS PA ZOLADEX PA *Mitotic Inhibitors*** etoposide oral *Nitrogen Mustards*** ALKERAN ORAL LEUKERAN *Nitrosoureas*** GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Lomustine *Progestins-Antineoplastic*** megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml Megace Oral megestrol acetate oral tablet *Retinoids*** tretinoin oral PA *Urinary Tract Protective Agents*** MESNEX ORAL *ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate oral trihexyphenidyl hcl *Antiparkinson Dopaminergics*** amantadine hcl oral bromocriptine mesylate oral Parlodel *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral Eldepryl *Levodopa Combinations*** carbidopa-levodopa Sinemet carbidopa-levodopa er oral tablet extendedrelease* 25-100 mg, 50-200 mg Sinemet CR carbidopa-levodopa-entacapone Stalevo 50 24 QLL (270 EA per 30 days) Drug Name *Nonergoline Dopamine Receptor Agonists*** Reference pramipexole dihydrochloride Mirapex ropinirole hcl Requip ropinirole hcl er Requip XL Restrictions QLL (90 EA per 30 days) *Peripheral Comt Inhibitors*** entacapone Comtan QLL (120 EA per 30 days) *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium lithium carbonate er Lithobid lithium carbonate oral *Antipsychotics - Misc.*** ziprasidone hcl Geodon QLL (60 EA per 30 days) risperidone oral solution RisperDAL QLL (240 ML per 30 days); AL (Min 5 Years) risperidone oral tablet RisperDAL QLL (60 EA per 30 days); AL (Min 5 Years) *Benzisoxazoles*** QLL (60 EA per 30 days); AL (Min 5 Years) risperidone oral tablet dispersible RISPERIDONE M-TAB RisperiDONE QLL (60 EA per 30 days); AL (Min 5 Years) Haldol Decanoate AL (Min 3 Years) *Butyrophenones*** haloperidol decanoate intramuscular* haloperidol lactate AL (Min 3 Years) haloperidol oral AL (Min 3 Years) *Dibenzodiazepines*** clozapine oral tablet Clozaril AL (Min 9 Years) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg SEROquel QLL (90 EA per 30 days); AL (Min 10 Years) quetiapine fumarate oral tablet 300 mg, 400 mg SEROquel QLL (60 EA per 30 days); AL (Min 10 Years) Loxitane AL (Min 5 Years) *Dibenzothiazepines*** *Dibenzoxazepines*** loxapine succinate oral 25 Drug Name *Phenothiazines*** Reference Restrictions chlorpromazine hcl oral AL (Min 5 Years) fluphenazine decanoate injection AL (Min 12 Years) fluphenazine hcl injection AL (Min 12 Years) fluphenazine hcl oral AL (Min 12 Years) perphenazine oral AL (Min 5 Years) prochlorperazine Compro prochlorperazine maleate oral Compazine thioridazine hcl oral AL (Min 2 Years) trifluoperazine hcl oral COMPRO Prochlorperazine *Thienbenzodiazepines*** olanzapine oral ZyPREXA QLL (30 EA per 30 days) *Thioxanthenes*** thiothixene oral AL (Min 13 Years) *ANTIRETROVIRALS ADJUVANTS*** *Antiretrovirals Adjuvants*** TYBOST *ANTISEPTICS & DISINFECTANTS* *Chlorine Antiseptics*** chlorhexidine gluconate solution 20 % *ANTIVIRALS* *Antiretroviral Combinations*** abacavir-lamivudine-zidovudine Trizivir lamivudine-zidovudine Combivir ATRIPLA COMPLERA DESCOVY EPZICOM QLL (30 EA per 30 Days) Abacavir Sulfate-Lamivudine EVOTAZ GENVOYA QLL (30 EA per 30 Days) KALETRA ORAL SOLUTION KALETRA ORAL TABLET STRIBILD TRIUMEQ 26 QLL (30 EA per 30 days) Drug Name Reference TRUVADA ORAL TABLET 200-300 MG Restrictions QLL (30 EA per 30 days) *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY *Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL PACKET ISENTRESS ORAL TABLET QLL (120 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE QLL (180 EA per 30 days) TIVICAY ORAL TABLET 50 MG QLL (60 EA per 30 days) VITEKTA *Antiretrovirals - Protease Inhibitors*** APTIVUS CRIXIVAN ORAL CAPSULE 200 MG, 400 MG INVIRASE LEXIVA NORVIR PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL PACKET VIRACEPT ORAL TABLET *Antiretrovirals Rti-Non-Nucleoside Analogues*** nevirapine Viramune nevirapine er Viramune XR EDURANT INTELENCE RESCRIPTOR SUSTIVA 27 Drug Name *Antiretrovirals - Rti-Nucleoside Analogues-Purines*** Reference abacavir sulfate Ziagen didanosine Videx EC Restrictions VIDEX ZIAGEN ORAL SOLUTION *Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** lamivudine oral solution Epivir lamivudine oral tablet 150 mg, 300 mg Epivir EMTRIVA *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** stavudine Zerit zidovudine Retrovir RETROVIR INTRAVENOUS* *Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL POWDER VIREAD ORAL TABLET QLL (30 EA per 30 days) *Hepatitis B Agents*** entecavir Baraclude QLL (30 EA per 30 days) ribavirin oral capsule Rebetol PA; ST ribavirin oral tablet 200 mg Copegus PA; ST MODERIBA Ribavirin PA; ST BARACLUDE ORAL SOLUTION TYZEKA *Hepatitis C Agents*** PEGASYS PROCLICK PA PEGASYS SUBCUTANEOUS* SOLUTION PA PEGINTRON PA PEG-INTRON REDIPEN PA PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS* KIT 120 MCG/0.5ML PA REBETOL ORAL SOLUTION PA; ST RIBASPHERE RIBASPHERE RIBAPAK ORAL TABLET 200 & 400 MG, 400 & 600 MG 28 Ribavirin PA; ST PA; ST Drug Name *Herpes Agents - Purine Analogues*** Reference Restrictions acyclovir oral capsule Zovirax QLL (60 EA per 30 days) acyclovir oral suspension Zovirax acyclovir oral tablet Zovirax QLL (60 EA per 30 days) valacyclovir hcl oral tablet 1 gm Valtrex QLL (30 EA per 30 days) valacyclovir hcl oral tablet 500 mg Valtrex QLL (60 EA per 30 days) *Herpes Agents - Thymidine Analogues*** famciclovir oral Famvir *Influenza Agents*** rimantadine hcl Flumadine QLL (14 Tablets Max Qty Per Fill Retail) *Neuraminidase Inhibitors*** RELENZA DISKHALER QLL (20 Inhalations Max Qty Per Fill Retail) TAMIFLU ORAL CAPSULE 30 MG QLL (20 Capsules Max Qty Per Fill Retail) TAMIFLU ORAL CAPSULE 45 MG, 75 MG QLL (10 Capsules Max Qty Per Fill Retail) TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML QLL (3 Bottles Max Qty Per Fill Retail) *ASSORTED CLASSES* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 50 MG PA; QLL (30 EA per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG PA; QLL (60 EA per 30 days) *Chelating Agents*** CUPRIMINE ORAL CAPSULE 250 MG *Cyclosporine Analogs*** cyclosporine modified Gengraf cyclosporine oral capsule SandIMMUNE GENGRAF ORAL CAPSULE 100 MG, 25 CycloSPORINE Modified MG GENGRAF ORAL SOLUTION CycloSPORINE Modified *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG PA; QLL (31 EA per 31 days) 29 Drug Name Reference Restrictions PA; ST; QLL (31 EA per 31 days) REVLIMID ORAL CAPSULE 5 MG *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil CellCept *Irrigation Solutions*** sterile water for irrigation Argyle Sterile Water ARGYLE STERILE WATER Sterile Water for Irrigation *Macrolide Immunosuppressants*** sirolimus oral Rapamune tacrolimus oral Hecoria RAPAMUNE ORAL SOLUTION *Potassium Removing Resins*** sodium polystyrene sulfonate oral SPS sodium polystyrene sulfonate suspension KIONEX Sodium Polystyrene Sulfonate SPS Sodium Polystyrene Sulfonate *Purine Analogs*** azathioprine oral Imuran *BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol Coreg labetalol hcl oral Trandate QLL (60 EA per 30 days) *Beta Blockers Cardio-Selective*** acebutolol hcl oral Sectral atenolol oral Tenormin betaxolol hcl oral Kerlone bisoprolol fumarate Zebeta metoprolol succinate er Toprol XL metoprolol tartrate oral tablet 100 mg, 50 mg Lopressor metoprolol tartrate oral tablet 25 mg *Beta Blockers Non-Selective*** nadolol oral tablet 20 mg, 40 mg, 80 mg Corgard pindolol propranolol hcl er Inderal LA propranolol hcl oral sotalol hcl (af) 30 Betapace AF QLL (60 EA per 30 days) Drug Name Reference sotalol hcl oral Sorine Restrictions timolol maleate oral SORINE Sotalol HCl *CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers*** amlodipine besylate oral Norvasc QLL (30 EA per 30 days) diltiazem cd oral capsule extended release 24 Cardizem CD hour 120 mg, 180 mg, 240 mg QLL (60 EA per 30 days) diltiazem hcl er beads Tiazac QLL (60 EA per 30 days) diltiazem hcl er coated beads Cardizem CD QLL (60 EA per 30 days) diltiazem hcl er oral capsule extended release 12 hour QLL (60 EA per 30 days) diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg QLL (60 EA per 30 days) diltiazem hcl er oral capsule extended release Dilacor XR 24 hour 240 mg QLL (60 EA per 30 days) diltiazem hcl oral QLL (120 EA per 30 days) Cardizem QLL (60 EA per 30 days) dilt-xr felodipine er isradipine nicardipine hcl oral nifedipine er Nifediac CC QLL (30 EA per 30 days) nifedipine er osmotic release Procardia XL QLL (30 EA per 30 days) nifedipine oral Procardia nimodipine oral Nimotop nisoldipine er oral tablet extended release 24 hr* 17 mg, 34 mg, 8.5 mg Sular nisoldipine er oral tablet extended release 24 hr* 20 mg, 30 mg, 40 mg QLL (30 EA per 30 days) nisoldipine er oral tablet extended release 24 hr* 25.5 mg verapamil hcl er oral capsule extended release Verelan PM 24 hour QLL (30 EA per 30 days) verapamil hcl er oral tablet extendedrelease* Calan SR 120 mg, 180 mg, 240 mg QLL (60 EA per 30 days) verapamil hcl oral QLL (120 EA per 30 days) AFEDITAB CR NIFEdipine ER QLL (30 EA per 30 days) CARTIA XT Diltiazem HCl ER Coated Beads QLL (60 EA per 30 days) 31 Drug Name Reference Restrictions MATZIM LA Diltiazem HCl ER Coated Beads QLL (60 EA per 30 days) NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG NIFEdipine ER QLL (30 EA per 30 days) NIFEDICAL XL NIFEdipine ER Osmotic QLL (30 EA per 30 days) TAZTIA XT Diltzac QLL (60 EA per 30 days) *CARDIOTONICS* *Cardiac Glycosides*** digoxin oral Lanoxin DIGITEK Digoxin DIGOX Digoxin LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG LANOXIN ORAL TABLET 250 MCG Digoxin *CARDIOVASCULAR AGENTS MISC.* *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** amlodipine-atorvastatin Caduet *Pulmonary Hypertension Phosphodiesterase Inhibitors*** sildenafil citrate oral Revatio ADCIRCA PA; QLL (60 EA per 30 days) *CEPHALOSPORINS* *Cephalosporins - 1St Generation*** cefadroxil cephalexin oral capsule 250 mg, 500 mg Keflex cephalexin oral suspension reconstituted cephalexin oral tablet *Cephalosporins - 2Nd Generation*** cefaclor cefprozil cefuroxime axetil oral tablet Ceftin CEFTIN ORAL SUSPENSION RECONSTITUTED Cefuroxime Axetil *Cephalosporins - 3Rd Generation*** cefdinir 32 PA; QLL (90 EA per 30 days) Drug Name Reference cefixime Suprax Restrictions cefpodoxime proxetil ceftriaxone sodium injection solution reconstituted 1 gm, 500 mg Rocephin QLL (2 Grams Max Qty Per Fill Retail) ceftriaxone sodium injection solution reconstituted 2 gm, 250 mg QLL (2 Grams Max Qty Per Fill Retail) SUPRAX ORAL TABLET CHEWABLE QLL (1 Tablet Max Qty Per Fill Retail) *CHEMICALS* *Bulk Chemicals - Hy's*** hydroxyprogesterone caproate *Bulk Chemicals - St's*** stevia extract powder steviol glycosides stevioside *Liquids*** benzyl benzoate OTC glycerine *CONTRACEPTIVES* *Biphasic Contraceptives - Oral*** desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5) Kariva viorele Kariva AZURETTE Viorele BEKYREE Viorele KARIVA Viorele KIMIDESS Viorele NECON 10/11 (28) PIMTREA Viorele *Combination Contraceptives Oral*** alyacen 1/35 Necon 1/35 (28) briellyn Philith desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg Reclipsen drospirenone-ethinyl estradiol Loryna levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg Lessina-28 33 Drug Name Reference levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg Kurvelo marlissa Kurvelo norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg Microgestin FE 1/20 norethindrone acet-ethinyl est Gildess 1/20 norgestimate-eth estradiol oral tablet 0.25-35 Mono-Linyah mg-mcg ALTAVERA Marlissa APRI Desogestrel-Ethinyl Estradiol AUBRA Levonorgestrel-Ethinyl Estrad AVIANE Levonorgestrel-Ethinyl Estrad BALZIVA Briellyn BLISOVI FE 1/20 Norethin Ace-Eth Estrad-FE CHATEAL Marlissa CRYSELLE-28 CYCLAFEM 1/35 Alyacen 1/35 CYRED Desogestrel-Ethinyl Estradiol DASETTA 1/35 Alyacen 1/35 DELYLA Levonorgestrel-Ethinyl Estrad ELINEST EMOQUETTE Desogestrel-Ethinyl Estradiol ENSKYCE Desogestrel-Ethinyl Estradiol ESTARYLLA Norgestimate-Eth Estradiol FALMINA Levonorgestrel-Ethinyl Estrad GIANVI Drospirenone-Ethinyl Estradiol GILDAGIA Briellyn GILDESS FE 1.5/30 GILDESS FE 1/20 Norethin Ace-Eth Estrad-FE JULEBER Desogestrel-Ethinyl Estradiol JUNEL 1.5/30 JUNEL 1/20 Norethindrone Acet-Ethinyl Est JUNEL FE 1.5/30 JUNEL FE 1/20 Norethin Ace-Eth Estrad-FE KELNOR 1/35 KURVELO LARIN 1.5/30 34 Marlissa Restrictions Drug Name Reference LARIN 1/20 Norethindrone Acet-Ethinyl Est Restrictions LARIN FE 1.5/30 LARIN FE 1/20 Norethin Ace-Eth Estrad-FE LESSINA Levonorgestrel-Ethinyl Estrad LEVORA 0.15/30 (28) Marlissa LORYNA Drospirenone-Ethinyl Estradiol LOW-OGESTREL LUTERA Levonorgestrel-Ethinyl Estrad MICROGESTIN 1.5/30 MICROGESTIN 1/20 Norethindrone Acet-Ethinyl Est MICROGESTIN FE 1.5/30 MICROGESTIN FE 1/20 Norethin Ace-Eth Estrad-FE MONO-LINYAH Norgestimate-Eth Estradiol MONONESSA Norgestimate-Eth Estradiol NECON 0.5/35 (28) NECON 1/35 (28) Alyacen 1/35 NECON 1/50 (28) NIKKI Drospirenone-Ethinyl Estradiol NORTREL 0.5/35 (28) NORTREL 1/35 (21) Alyacen 1/35 NORTREL 1/35 (28) Alyacen 1/35 OCELLA Drospirenone-Ethinyl Estradiol OGESTREL ORSYTHIA Levonorgestrel-Ethinyl Estrad PHILITH Briellyn PIRMELLA 1/35 Alyacen 1/35 PORTIA-28 Marlissa PREVIFEM Norgestimate-Eth Estradiol RECLIPSEN Desogestrel-Ethinyl Estradiol SOLIA Desogestrel-Ethinyl Estradiol SPRINTEC 28 Norgestimate-Eth Estradiol SRONYX Levonorgestrel-Ethinyl Estrad SYEDA Drospirenone-Ethinyl Estradiol TARINA FE 1/20 Norethin Ace-Eth Estrad-FE VESTURA Drospirenone-Ethinyl Estradiol VYFEMLA Briellyn WERA 35 Drug Name Reference ZARAH Drospirenone-Ethinyl Estradiol ZENCHENT Briellyn Restrictions ZOVIA 1/35E (28) ZOVIA 1/50E (28) *Combination Contraceptives Transdermal*** XULANE QLL (3 Patches per 30 days) *Combination Contraceptives Vaginal*** NUVARING QLL (1 EA per 30 days) *Continuous Contraceptives Oral*** levonorgestrel-ethinyl estrad oral tablet 90-20 Amethyst mcg AMETHYST Levonorgestrel-Ethinyl Estrad *Emergency Contraceptives*** levonorgestrel oral tablet 1.5 mg Next Choice One Dose OTC; QLL (3 Packs per 365 days) Levonorgestrel OTC; QLL (3 Packs per 365 days) ELLA MY WAY *Extended-Cycle Contraceptives Oral*** levonorgest-eth estrad 91-day Camrese Lo AMETHIA Levonorgest-Eth Estrad 91-Day AMETHIA LO Levonorgest-Eth Estrad 91-Day ASHLYNA Levonorgest-Eth Estrad 91-Day CAMRESE Levonorgest-Eth Estrad 91-Day CAMRESE LO Levonorgest-Eth Estrad 91-Day DAYSEE Levonorgest-Eth Estrad 91-Day INTROVALE Levonorgest-Eth Estrad 91-Day JOLESSA Levonorgest-Eth Estrad 91-Day 36 Drug Name Reference QUASENSE Levonorgest-Eth Estrad 91-Day SETLAKIN Levonorgest-Eth Estrad 91-Day Restrictions *Progestin Contraceptives Implants*** NEXPLANON QLL (1 EA per 3 Yearss) *Progestin Contraceptives Injectable*** medroxyprogesterone acetate intramuscular* Depo-Provera suspension QLL (1 Injection per 90 days) *Progestin Contraceptives - Iud*** MIRENA (52 MG) QLL (1 EA per 5 Yearss) SKYLA QLL (1 EA per 3 Yearss) *Progestin Contraceptives - Oral*** norethindrone oral Jolivette QLL (28 EA per 30 days) CAMILA Norethindrone QLL (28 EA per 30 days) DEBLITANE Norethindrone QLL (28 EA per 30 days) ERRIN Norethindrone QLL (28 EA per 30 days) HEATHER Norethindrone QLL (28 EA per 30 days) JENCYCLA Norethindrone QLL (28 EA per 30 days) JOLIVETTE Norethindrone QLL (28 EA per 30 days) LYZA Norethindrone QLL (28 EA per 30 days) NORA-BE Norethindrone QLL (28 EA per 30 days) NORLYROC Norethindrone QLL (28 EA per 30 days) SHAROBEL Norethindrone QLL (28 EA per 30 days) *Triphasic Contraceptives - Oral*** alyacen 7/7/7 Nortrel 7/7/7 levonorg-eth estrad triphasic Myzilra norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg Tri-Linyah ARANELLE CAZIANT CESIA CYCLAFEM 7/7/7 Alyacen 7/7/7 DASETTA 7/7/7 Alyacen 7/7/7 ENPRESSE-28 Levonorg-Eth Estrad Triphasic LEENA LEVONEST Levonorg-Eth Estrad Triphasic 37 Drug Name Reference MYZILRA Levonorg-Eth Estrad Triphasic NECON 7/7/7 Alyacen 7/7/7 NORTREL 7/7/7 Alyacen 7/7/7 PIRMELLA 7/7/7 Alyacen 7/7/7 TILIA FE TRI-ESTARYLLA Norgestim-Eth Estrad Triphasic TRI-LEGEST FE TRI-LINYAH Norgestim-Eth Estrad Triphasic TRINESSA (28) Norgestim-Eth Estrad Triphasic TRI-PREVIFEM Norgestim-Eth Estrad Triphasic TRI-SPRINTEC Norgestim-Eth Estrad Triphasic TRIVORA (28) Levonorg-Eth Estrad Triphasic VELIVET *CORTICOSTEROIDS* *Glucocorticosteroids*** cortisone acetate oral dexamethasone oral hydrocortisone oral Cortef methylprednisolone oral tablet Medrol prednisolone oral solution Prelone prednisolone oral syrup 15 mg/5ml Prelone prednisolone sodium phosphate oral solution 15 mg/5ml Orapred prednisolone sodium phosphate oral solution 25 mg/5ml prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml Pediapred prednisone oral solution prednisone oral tablet DELTASONE PredniSONE PEDIAPRED PrednisoLONE Sodium Phosphate *Mineralocorticoids*** fludrocortisone acetate oral 38 Restrictions Drug Name *COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** Reference benzonatate oral capsule 100 mg Tessalon Perles benzonatate oral capsule 200 mg Tessalon Restrictions *Antitussive - Opioid*** hydrocodone-homatropine Tussigon hydromet TUSSIGON Hydrocodone-Homatropine *Antitussive-Expectorants-Decongest ant*** biotuss *Decongestant & Antihistamine*** promethazine vc plain promethazine-phenylephrine *Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % Nebusal sodium chloride inhalation nebulization solution 7 % HyperSal HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 % NEBUSAL Sodium Chloride PULMOSAL Sodium Chloride *Mucolytics*** acetylcysteine inhalation *Non-Narc Antitussive-Antihistamine*** promethazine-dm *Non-Narc Antitussive-Decongestant-Antihistam ine*** tgq 50pse/3brm/30dm Neo DM BROMFED DM Pseudoeph-Bromphen-DM *Opioid Antitussive-Antihistamine*** promethazine-codeine 39 Drug Name Reference *Opioid Antitussive-Decongestant-Antihistam ine*** phenyleph-promethazine-cod promethazine vc/codeine *DERMATOLOGICALS* *Acne Antibiotics*** clindamycin phosphate external Cleocin-T ery erythromycin external sulfacetamide sodium (acne) Klaron sulfacetamide sodium external suspension Klaron CLINDACIN ETZ EXTERNAL SWAB Clindamycin Phosphate CLINDACIN-P Clindamycin Phosphate CLINDAMAX EXTERNAL GEL Clindamycin Phosphate *Acne Combinations*** benzoyl peroxide-erythromycin Benzamycin bp 10-1 Cerisa Wash bp cleansing wash Claris Clarifying Wash clindamycin phos-benzoyl perox BenzaClin sulfacetamide sodium-sulfur external emulsion Prascion sulfacetamide sodium-sulfur external liquid† 9-4.5 % Sumadan Wash sulfacetamide sodium-sulfur external lotion 10-5 % sulfacetamide sodium-sulfur external pad 10-4 Sumaxin % sulfacetamide sodium-sulfur external suspension 10-5 % AVAR CLEANSER Sulfacetamide Sodium-Sulfur CERISA WASH BP 10-1 NEUAC EXTERNAL GEL Clindamycin Phos-Benzoyl Perox PRASCION Sulfacetamide Sodium-Sulfur ROSANIL CLEANSER Sulfacetamide Sodium-Sulfur ROSULA EXTERNAL PAD Sulfacetamide Sodium-Sulfur *Acne Products*** adapalene external cream Differin adapalene external gel 0.1 % Differin 40 Restrictions Drug Name Reference Restrictions bp foaming wash PanOxyl Wash bp wash external liquid† 2.5 % PanOxyl bp wash external liquid† 7 % PR Benzoyl Peroxide Wash tretinoin external cream Retin-A QLL (20 GM per 30 days) tretinoin external gel 0.01 %, 0.025 % Retin-A QLL (20 GM per 30 days) AVITA Tretinoin QLL (20 GM per 30 days) BENZEPRO CREAMY WASH SE BPO Wash BENZIQ WASH BP Wash CLARAVIS CLEARPLEX X Benzoyl Peroxide MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG OSCION CLEANSER EXTERNAL LOTION 6 % Benzoyl Peroxide Cleanser PR BENZOYL PEROXIDE WASH SE BPO Wash ZENATANE *Antibiotics - Topical*** gentamicin sulfate gentamicin sulfate external mupirocin calcium Bactroban mupirocin external Bactroban *Antifungals - Topical Combinations*** clotrimazole-betamethasone Lotrisone nystatin-triamcinolone *Antifungals - Topical*** ciclopirox Ciclodan ciclopirox olamine external nystatin external Nyamyc CICLODAN Ciclopirox NYAMYC Nystatin NYSTOP Nystatin *Anti-Inflammatory Agents Topical*** diclofenac sodium transdermal gel 1 % Voltaren ST *Antineoplastic Antimetabolites Topical*** fluorouracil external 41 Drug Name Reference Restrictions Solaraze ST FLUOROPLEX *Antineoplastic Or Premalignant Lesions - Topical Nsaid's*** diclofenac sodium transdermal gel 3 % *Antipsoriatics - Systemic*** methoxsalen rapid Oxsoralen Ultra *Antipsoriatics*** calcipotriene external ointment Calcitrene calcipotriene external solution CALCITRENE Calcipotriene *Antiseborrheic Combinations*** selenium sulfide external shampoo selenium sulf-pyrithione-urea *Antiseborrheic Products*** selenium sulfide external lotion Selsun sulfacetamide sodium external liquid† Seb-Prev Wash SEB-PREV WASH Sulfacetamide Sodium *Antivirals - Topical*** acyclovir external Zovirax ABREVA OTC *Burn Products*** silver sulfadiazine external Thermazene SSD Silver Sulfadiazine *Cauterizing Agent Combinations*** grafco silver nit applicator Arzol Silver Nit Applicators ARZOL SILVER NIT APPLICATORS Grafco Silver Nit Applicator *Corticosteroids - Topical*** ala cort KeriCort 10 alclometasone dipropionate Aclovate alphatrex amcinonide betamethasone dipropionate aug Diprolene AF betamethasone dipropionate external betamethasone valerate external cream betamethasone valerate external lotion betamethasone valerate external ointment clobetasol propionate e 42 ST Temovate E Drug Name Reference clobetasol propionate external cream Temovate clobetasol propionate external foam Olux clobetasol propionate external gel Temovate clobetasol propionate external lotion Clobex clobetasol propionate external ointment Temovate clobetasol propionate external shampoo Clobex clobetasol propionate external solution Cormax Scalp Application desonide external DesOwen desoximetasone external Topicort Restrictions diflorasone diacetate external fluocinolone acetonide fluocinolone acetonide external Synalar fluocinonide external fluocinonide-e fluticasone propionate external cream Cutivate fluticasone propionate external ointment Cutivate halobetasol propionate Ultravate hydrocortisone acetate powder hydrocortisone butyr lipo base Locoid Lipocream hydrocortisone butyrate external Locoid hydrocortisone external cream 2.5 % Proctozone-HC hydrocortisone external lotion 2.5 % hydrocortisone external ointment 2.5 % hydrocortisone micronized hydrocortisone powder hydrocortisone valerate mometasone furoate external Elocon prednicarbate Dermatop scalacort Ala Scalp triamcinolone acetonide triamcinolone acetonide external cream triamcinolone acetonide external lotion triamcinolone acetonide external ointment CLODAN EXTERNAL SHAMPOO Clobetasol Propionate CORMAX SCALP APPLICATION Clobetasol Propionate LOKARA Desonide TRIDERM EXTERNAL CREAM Triamcinolone Acetonide 43 Drug Name *Emollients*** Reference NEOSALUS EXTERNAL LOTION Complete Moisture TROPAZONE EXTERNAL LOTION Complete Moisture Restrictions *Enzymes - Topical*** SANTYL *Imidazole-Related Antifungals Topical*** clotrimazole external FungiCure Intensive/NailGuard OTC econazole nitrate external ketoconazole external cream ketoconazole external shampoo Nizoral kp clotrimazole Desenex OTC *Immunomodulators Imidazoquinolinamines - Topical*** imiquimod external Aldara *Keratolytic/Antimitotic Agents*** podofilox external Condylox salicylic acid external cream Salacyn salicylic acid external gel Keralyt salicylic acid external lotion Salacyn salicylic acid external shampoo Aliclen CONDYLOX EXTERNAL GEL SALACYN Salicylic Acid *Local Anesthetics - Topical*** lidocaine external ointment lidocaine external patch 5 % Lidoderm lidocaine hcl external cream Lidopin lidocaine hcl external gel 2 % Regenecare HA QLL (90 EA per 30 days) lidocaine hcl external lotion lidocaine hcl external solution Xylocaine lidopin external cream 3 % Lidopin premium lidocaine CIDALEAZE Lidocaine HCl GLYDO Lidocaine HCl *Macrolide Immunosuppressants Topical*** ELIDEL 44 ST; QLL (30 GM per 30 days) Drug Name *Rosacea Agents*** Reference metronidazole external Rosadan ROSADAN EXTERNAL CREAM MetroNIDAZOLE ROSADAN EXTERNAL GEL MetroNIDAZOLE Restrictions *Scabicides & Pediculicides*** lindane external shampoo malathion external Ovide QLL (1 Bottle per 180 days) permethrin external cream Elimite QLL (1 Bottle per 180 days) ULESFIA QLL (454 GM per 180 days) *Skin Cleansers*** essentra wipes 9x9" Pharmacist Choice Alcohol *Topical Anesthetic Combinations*** lidocaine-prilocaine EMLA LIVIXIL PAK Lidocaine-Prilocaine LP LITE PAK Lidocaine-Prilocaine RELADOR PAK EXTERNAL KIT Lidocaine-Prilocaine RELADOR PAK PLUS Lidocaine-Prilocaine *Topical Selective Retinoid X Receptor Agonists*** TARGRETIN EXTERNAL *DIAGNOSTIC PRODUCTS* *Diagnostic Tests*** ONETOUCH ULTRA BLUE ONETOUCH VERIO IN VITRO STRIP Blood Glucose Test Quantity limit applies to members older than 12 years old; OTC; QLL (150 EA per 30 days) Blood Glucose Test Quantity limit applies to members older than 12 years old; OTC; QLL (150 EA per 30 days) *DIGESTIVE AIDS* *Digestive Enzymes*** CREON PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-25000 UNIT, 16800-40000 UNIT, 21000-37000 UNIT, 4200-10000 UNIT 45 Drug Name Reference Restrictions ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT *DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er Diamox Sequels acetazolamide oral methazolamide oral Neptazane *Diuretic Combinations*** amiloride-hydrochlorothiazide spironolactone-hctz Aldactazide triamterene-hctz Dyazide *Loop Diuretics*** bumetanide oral Bumex furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet Lasix torsemide oral Demadex *Potassium Sparing Diuretics*** amiloride hcl oral spironolactone oral Aldactone *Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral Microzide indapamide oral methyclothiazide oral metolazone Zaroxolyn *ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral solution alendronate sodium oral tablet 10 mg, 40 mg, Fosamax 5 mg QLL (30 EA per 30 days) alendronate sodium oral tablet 35 mg, 70 mg QLL (4 EA per 30 days) Fosamax etidronate disodium ibandronate sodium intravenous* solution 3 mg/3ml 46 Boniva Drug Name Reference ibandronate sodium oral Boniva Restrictions pamidronate disodium intravenous* solution *Calcitonins*** calcitonin (salmon) Fortical *Carnitine Replenisher - Agents*** levocarnitine oral solution Carnitor SF OTC levocarnitine oral tablet Carnitor OTC *Dopamine Receptor Agonists*** cabergoline *Growth Hormones*** OMNITROPE SUBCUTANEOUS* SOLUTION RECONSTITUTED PA *Hyperparathyroid Treatment Vitamin D Analogs*** calcitriol oral Rocaltrol paricalcitol oral Zemplar ST Evista QLL (30 EA per 30 days) *Selective Estrogen Receptor Modulators (Serms)*** raloxifene hcl *Somatostatic Agents*** SOMATULINE DEPOT PA *Vasopressin*** desmopressin ace rhinal tube DDAVP Rhinal Tube QLL (1 Bottle per 30 days) desmopressin ace spray refrig Minirin QLL (1 Bottle per 30 days) desmopressin acetate oral DDAVP QLL (90 EA per 30 days) desmopressin acetate spray DDAVP QLL (1 Bottle per 30 days) *ESTROGENS* *Estrogen & Progestin*** estradiol-norethindrone acet Activella jevantique lo Femhrt Low Dose norethindrone-eth estradiol Femhrt Low Dose CLIMARA PRO COMBIPATCH JINTELI Norethindrone-Eth Estradiol MIMVEY Estradiol-Norethindrone Acet MIMVEY LO Estradiol-Norethindrone Acet PREFEST 47 Drug Name Reference Restrictions PREMPHASE PREMPRO *Estrogens*** estradiol oral Estrace estradiol transdermal patch biweekly Alora estradiol transdermal patch weekly Climara estropipate oral Ortho-Est 0.625 QLL (4 Patches per 30 days) MENEST PREMARIN ORAL *FLUOROQUINOLONES* *Fluoroquinolones*** ciprofloxacin hcl oral QLL (28 EA per 30 days) ciprofloxacin-ciproflox hcl er Cipro XR levofloxacin oral Levaquin QLL (3 Tablets Max Qty Per Fill Retail) ofloxacin oral tablet 400 mg *GASTROINTESTINAL AGENTS MISC.* *Gallstone Solubilizing Agents*** ursodiol oral Actigall *Gastrointestinal Chloride Channel Activators*** AMITIZA ST; QLL (60 EA per 30 days) *Gastrointestinal Stimulants*** metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet Reglan *Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** LINZESS ST; QLL (30 EA per 30 Days) *Inflammatory Bowel Agents*** balsalazide disodium Colazal mesalamine enema mesalamine oral Asacol HD sulfasalazine oral Azulfidine CANASA DELZICOL DIPENTUM 48 QLL (42 EA per 30 days) Drug Name Reference Restrictions PENTASA SULFAZINE SulfaSALAzine *Intestinal Acidifiers*** enulose generlac lactulose encephalopathy *Peripheral Opioid Receptor Antagonists*** MOVANTIK PA; QLL (30 EA per 30 Days) *Phosphate Binder Agents*** calcium acetate (phos binder) oral capsule PhosLo RENVELA Sevelamer Carbonate *Tumor Necrosis Factor Alpha Blockers*** REMICADE PA *GENITOURINARY AGENTS MISCELLANEOUS* *5-Alpha Reductase Inhibitors*** finasteride oral tablet 5 mg Proscar *Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er Uroxatral tamsulosin hcl Flomax M; QLL (60 EA per 30 days) *Citrates*** citric acid-sodium citrate Shohls Modified cytra k crystals Polycitra-K cytra-2 Shohls Modified cytra-k pot & sod cit-cit ac potassium citrate er Urocit-K 5 potassium citrate-citric acid sod citrate-citric acid Shohls Modified tricitrates virtrate-2 Shohls Modified virtrate-3 virtrate-k CYTRA-3 TARON-CRYSTALS Cytra K Crystals 49 Drug Name *Genitourinary Irrigants*** Reference sodium chloride irrigation solution 0.9 % Curity Sterile Saline ARGYLE STERILE SALINE Sodium Chloride CURITY STERILE SALINE Sodium Chloride Restrictions *Interstitial Cystitis Agents*** ELMIRON *Phosphates*** K-PHOS NO 2 *Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 200 mg Pyridium PHENAZO ORAL TABLET 200 MG Phenazopyridine HCl *GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid *Gout Agents*** allopurinol oral Zyloprim ULORIC ST *Uricosurics*** probenecid oral *HEMATOLOGICAL AGENTS MISC.* *Complement Inhibitors*** SOLIRIS *Hematorheologic Agents*** pentoxifylline er TRENtal *Phosphodiesterase Iii Inhibitors*** cilostazol Pletal *Platelet Aggregation Inhibitors*** dipyridamole oral Persantine *Quinazoline Agents*** anagrelide hcl Agrylin *Thienopyridine Derivatives*** clopidogrel bisulfate 50 Plavix QLL (30 EA per 30 days) Drug Name *HEMATOPOIETIC AGENTS* *Cobalamins*** Reference Restrictions cyanocobalamin injection *Cxcr4 Receptor Antagonist*** MOZOBIL *Cytotoxic Agents*** DROXIA *Erythropoietins*** ARANESP (ALBUMIN FREE) INJECTION PA ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML PA EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PA PROCRIT PA *Folic Acid/Folate Combinations*** fa-vitamin b-6-vitamin b-12 Folcaps folplex 2.2 Folcaps *Folic Acid/Folates*** folic acid oral tablet 1 mg OTC *Granulocyte Colony-Stimulating Factors (G-Csf)*** NEULASTA ONPRO PA NEULASTA SUBCUTANEOUS* PA NEUPOGEN INJECTION PA NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML PA *Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** LEUKINE INTRAVENOUS* PA *Iron Combinations*** ICAR-C PLUS Iron 100 Plus *Thrombopoietin (Tpo) Receptor Agonists*** PROMACTA PA 51 Drug Name *HEPATITIS C AGENT COMBINATIONS*** *Hepatitis C Agent Combinations*** Reference ZEPATIER Restrictions PA *HYPNOTICS* *Barbiturate Hypnotics*** phenobarbital oral *Benzodiazepine Hypnotics*** estazolam QLL (30 EA per 30 days) flurazepam hcl QLL (30 EA per 30 days) temazepam oral capsule 15 mg, 30 mg Restoril QLL (30 EA per 30 days) zaleplon Sonata QLL (30 EA per 30 days) zolpidem tartrate oral Ambien QLL (30 EA per 30 days) triazolam *Non-Benzodiazepine Gaba-Receptor Modulators*** *Selective Melatonin Receptor Agonists*** ROZEREM ST; QLL (30 EA per 30 days) *LAXATIVES* *Bowel Evacuant Combinations*** peg 3350/electrolytes Colyte with Flavor Packs peg 3350-kcl-na bicarb-nacl Nulytely with Flavor Packs peg-3350/electrolytes Golytely GAVILYTE-C PEG 3350/Electrolytes GAVILYTE-G PEG-3350/Electrolytes GAVILYTE-N WITH FLAVOR PACK PEG 3350-KCl-Na Bicarb-NaCl TRILYTE PEG 3350-KCl-Na Bicarb-NaCl *Laxatives - Miscellaneous*** constulose lactulose oral polyethylene glycol 3350 oral packet CVS Purelax OTC; QLL (30 EA per 30 days) polyethylene glycol 3350 oral powder MiraLax OTC; QLL (527 grams per 30 days) PEGYLAX Polyethylene Glycol 3350 QLL (527 grams per 30 days) 52 Drug Name *MACROLIDES* *Azithromycin*** Reference Restrictions azithromycin oral packet Zithromax azithromycin oral suspension reconstituted Zithromax azithromycin oral tablet 250 mg Zithromax Z-Pak azithromycin oral tablet 500 mg Zithromax Tri-Pak azithromycin oral tablet 600 mg Zithromax QLL (8 EA per 30 days) Biaxin XL Pac QLL (14 EA per 30 days) Biaxin QLL (28 EA per 30 days) QLL (12 EA per 30 days) *Clarithromycin*** clarithromycin er clarithromycin oral suspension reconstituted clarithromycin oral tablet *Erythromycins*** erythromycin base oral capsule delayed release particles erythromycin base oral tablet erythromycin ethylsuccinate oral tablet E.E.S. 400 E.E.S. 400 ORAL TABLET Erythromycin Ethylsuccinate E.E.S. GRANULES Erythromycin Ethylsuccinate ERYPED 200 Erythromycin Ethylsuccinate ERYPED 400 ERYTHROCIN STEARATE ORAL TABLET 250 MG Erythromycin Stearate *MEDICAL DEVICES* *Applicators,Cotton Balls,Etc*** alcohol wipes pad Curity Alcohol Swabs ALCOH-GLOVE CONTOURED WIPE QC Alcohol Swabs *Cervical Caps*** FEMCAP PRENTIF CAVITY-RIM CERV CAP PRENTIF FITTING SET *Diaphragms*** OMNIFLEX DIAPHRAGM ORTHO DIAPHRAGM COIL ORTHO DIAPHRAGM FLAT WIDE-SEAL DIAPHRAGM 60 WIDE-SEAL DIAPHRAGM 65 WIDE-SEAL DIAPHRAGM 70 WIDE-SEAL DIAPHRAGM 75 53 Drug Name Reference Restrictions WIDE-SEAL DIAPHRAGM 80 WIDE-SEAL DIAPHRAGM 85 WIDE-SEAL DIAPHRAGM 90 WIDE-SEAL DIAPHRAGM 95 *Glucose Monitoring Test Supplies*** PARADIGM LINK GLUCOSE MONITOR Blood Glucose Monitor System *Nebulizers*** compressor nebulizer Proneb Ultra II Deluxe/LCD nebulizer compressor Proneb Ultra II Deluxe/LCD nebulizer updraft-style Proneb Ultra II Deluxe/LCD soothe neb mesh nebulizer Proneb Ultra II Deluxe/LCD AEROECLIPSE II NEBULIZER Nebulizer Updraft-Style AERONEB GO COMPLETE SYSTEM Nebulizer Updraft-Style AERONEB GO CONVENIENCE UNIT Nebulizer Updraft-Style AERONEB GO HANDSET/CABLE Nebulizer Updraft-Style AERONEB GO NEBULIZER HANDSET Nebulizer Updraft-Style AIRIAL COMPACT COMPRESSOR NEB Nebulizer Updraft-Style AIRIAL COMPACT MINI NEBULIZER Nebulizer Updraft-Style AIRIAL COMPRESS PED NEBULIZER Nebulizer Updraft-Style AIRIAL PEDIATRIC NEBULIZER Nebulizer Updraft-Style AIRIAL VOYAGER NEBULIZER Nebulizer Updraft-Style BESTMED COMPRESSOR NEBULIZER Nebulizer Updraft-Style BESTMED ULTRASONIC NEBULIZER Nebulizer Updraft-Style COMP AIR COMPRESSOR NEBULIZER Nebulizer Updraft-Style COMP AIR ELITE COMPACT NEB Nebulizer Updraft-Style COMP-AIR ELITE COMPACT NEB Nebulizer Updraft-Style COMPAIR NEBULIZER Nebulizer Updraft-Style COMPAIR XL NEBULIZER Nebulizer Updraft-Style COMPAIR XLT NEBULIZER Nebulizer Updraft-Style DEVILBISS PULMO-AIDE Nebulizer Updraft-Style DEVILBISS TRAVELER NEBULIZER Nebulizer Updraft-Style EFLOW SCF ELECTRONIC NEBULIZER Nebulizer Updraft-Style EFLOW SCF NEBULIZER HANDSET Nebulizer Updraft-Style ELITE NEBULIZER SYSTEM Nebulizer Updraft-Style HEALTHY LIVING COMPRESSOR/NEB Nebulizer Updraft-Style INNOSPIRE ELEGANCE NEBULIZER 54 Nebulizer Updraft-Style OTC Drug Name Reference INNOSPIRE ESSENCE NEBULIZER Nebulizer Updraft-Style INNOSPIRE MINI COMPRESSOR NEB Nebulizer Updraft-Style INSPIRATION ELITE COMPRESS/NEB Nebulizer Updraft-Style INSPIRATION ELITE NEBULIZER Nebulizer Updraft-Style INSPIRATION NEBULIZER SYSTEM Nebulizer Updraft-Style LEXAN POCKET NEBULIZER Nebulizer Updraft-Style LUMINEB II PISTON NEBULIZER Nebulizer Updraft-Style MICRO AIR NEBULIZER Nebulizer Updraft-Style MICRO PLUS NEBULIZER Nebulizer Updraft-Style MICROELITE COMPRESSOR NEB SYS Nebulizer Updraft-Style MINI COMPRESSOR Nebulizer Updraft-Style MINI PLUS NEBULIZER Nebulizer Updraft-Style MINIELITE COMPRESSOR NEB SYS Nebulizer Updraft-Style MISTERNEB COMPRESSOR NEBULIZER Nebulizer Updraft-Style OPTIONHOME NEBULIZER SYSTEM Nebulizer Updraft-Style PARI ALTERA NEBULIZER SYSTEM Nebulizer Updraft-Style PARI BABY Nebulizer Updraft-Style PARI BABY SIZE 1/PARI LC PLUS Nebulizer Updraft-Style PARI ERAPID NEBULIZER SYSTEM Nebulizer Updraft-Style PARI LC D NEBULIZER Nebulizer Updraft-Style PARI LC PLUS Nebulizer Updraft-Style PARI LC PLUS NEB SET PED MASK Nebulizer Updraft-Style PARI LC PLUS NEBULIZER Nebulizer Updraft-Style PARI LC SPRINT NEBULIZER SET Nebulizer Updraft-Style PARI LC STAR Nebulizer Updraft-Style PARI LC STAR NEBULIZER Nebulizer Updraft-Style PARI PRONEB ULTRA II Nebulizer Updraft-Style PARI SINUS AEROSOL SYSTEM Nebulizer Updraft-Style PARI TREK S W/12V DC ADAPTOR Nebulizer Updraft-Style PARI VIOS PRO LC PLUS SYSTEM Nebulizer Updraft-Style PARI VIOS PRO LC SPRINT SYSTEM Nebulizer Updraft-Style PRONEB ULTRA II DELUXE/LC STAR Nebulizer Updraft-Style PRONEB ULTRA II DELUXE/LCD Nebulizer Updraft-Style PRONEB ULTRA II DELX/LC SPRINT Nebulizer Updraft-Style PRONEB ULTRA II PEDIATRIC Nebulizer Updraft-Style PRONEB ULTRA II/LC PLUS Nebulizer Updraft-Style PRONEB ULTRA II/LC SPRINT Nebulizer Updraft-Style Restrictions OTC 55 Drug Name Reference PULMOMATE COMP/MICRO-MIST NEB Nebulizer Updraft-Style SIDESTREAM NEBULIZER-DISP Nebulizer Updraft-Style Restrictions SIDESTREAM NEBULIZER-REUSABLE Nebulizer Updraft-Style SIDESTREAM PLUS NEBULIZER Nebulizer Updraft-Style VIOS AEROSOL DELIVERY SYSTEM Nebulizer Updraft-Style VIOS LC PLUS Nebulizer Updraft-Style VIOS LC PLUS DELUXE Nebulizer Updraft-Style VIOS LC PLUS PEDIATRIC Nebulizer Updraft-Style VIOS LC SPRINT Nebulizer Updraft-Style VIOS LC SPRINT DELUXE Nebulizer Updraft-Style VIOS LC SPRINT PEDIATRIC Nebulizer Updraft-Style VIXONE DISPOSABLE NEBULIZER Nebulizer Updraft-Style *Needles & Syringes*** ASSURE ID INSULIN SAFETY SYR 29G Kroger Insulin Syringe X 1/2" 1 ML QLL (100 Syringes per 30 days) MAGELLAN INSULIN SAFETY SYR Kroger Insulin Syringe QLL (100 Syringes per 30 days) MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC; QLL (100 Syringes per 30 days) MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC; QLL (100 Syringes per 30 days) MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe QLL (100 Syringes per 30 days) MONOJECT INSULIN SYRINGE 29G X 1/2" 0.5 ML Hy-Vee Insulin Syringe QLL (100 Syringes per 30 days) MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr QLL (100 Syringes per 30 days) MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML Drug Mart Ultra Comfort Syr OTC; QLL (100 Syringes per 30 days) MONOJECT INSULIN SYRINGE U-100 1 Kmart Valu Insulin Syringe ML 30G QLL (100 Syringes per 30 days) MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC; QLL (100 Syringes per 30 days) MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC; QLL (100 Syringes per 30 days) MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5 ML Drug Mart Ultra Comfort Syr OTC; QLL (100 Syringes per 30 days) MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 1 ML Drug Mart Ultra Comfort Syr QLL (100 Syringes per 30 days) ULTICARE INSULIN SAFETY SYR Hy-Vee Insulin Syringe QLL (100 Syringes per 30 days) 56 Drug Name *Peak Flow Meters*** Reference Restrictions TRUZONE PEAK FLOW METER Peak Flow Meter Universal Rang QLL (2 EA per 365 days) BREATHERITE VALVED MDI CHAMBER Spiro PD QLL (2 EA per 365 Days) VORTEX HOLDING CHAMBER/MASK Spiro PD QLL (2 EA per 365 Days) valved holding chamber Pocket Chamber QLL (2 EA per 365 days) AEROCHAMBER MINI CHAMBER Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER MV Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS Valved Holding Chamber QLL (2 EA per 365 Days) AEROCHAMBER PLUS FLO-VU Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU MEDIUM Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLOW VU Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS W/MASK SMALL Valved Holding Chamber QLL (2 EA per 365 Days) AEROCHAMBER W/FLOWSIGNAL Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS/LARGE Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS/MEDIUM Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS/SMALL Valved Holding Chamber QLL (2 EA per 365 days) AEROVENT PLUS Valved Holding Chamber QLL (2 EA per 365 days) ARIAL CHAMBER Valved Holding Chamber OTC; QLL (2 EA per 365 days) BREATHERITE Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE COLL SPACER ADULT Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE COLL SPACER CHILD Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE COLL SPACER INFANT Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE RIGID SPACER/MASK Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE SPACER NEONATE Valved Holding Chamber QLL (2 EA per 365 days) *Respiratory Therapy Supplies*** *Spacer/Aerosol-Holding Chambers & Supplies*** 57 Drug Name Reference Restrictions BREATHERITE SPACER SMALL CHILD Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE/LARGE MASK Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE/MEDIUM MASK Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE/SMALL MASK Valved Holding Chamber QLL (2 EA per 365 days) EASIVENT Valved Holding Chamber QLL (2 EA per 365 days) EASIVENT MASK LARGE Valved Holding Chamber QLL (2 EA per 365 days) EASIVENT MASK MEDIUM Valved Holding Chamber QLL (2 EA per 365 days) EASIVENT MASK SMALL Valved Holding Chamber QLL (2 EA per 365 days) E-Z SPACER Valved Holding Chamber QLL (2 EA per 365 days) E-Z SPACER THE BODY GUARDS PK Valved Holding Chamber QLL (2 EA per 365 days) FLEXICHAMBER Valved Holding Chamber QLL (2 EA per 365 days) FLEXICHAMBER ADULT MASK/SMALL QLL (2 EA per 365 Days) FLEXICHAMBER CHILD MASK/LARGE QLL (2 EA per 365 Days) FLEXICHAMBER CHILD MASK/SMALL QLL (2 EA per 365 Days) INSPIRACHAMBER/LARGE Valved Holding Chamber QLL (2 EA per 365 Days) INSPIRACHAMBER/MEDIUM Valved Holding Chamber QLL (2 EA per 365 days) INSPIRACHAMBER/MOUTHPIECE Valved Holding Chamber QLL (2 EA per 365 days) INSPIRACHAMBER/SMALL Valved Holding Chamber QLL (2 EA per 365 days) INSPIREASE Valved Holding Chamber QLL (2 EA per 365 days) LITEAIRE Valved Holding Chamber QLL (2 EA per 365 days) MICROCHAMBER Valved Holding Chamber QLL (2 EA per 365 days) MICROSPACER Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER ADVANTAGE Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER ADVANTAGE-LG MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER ADVANTAGE-MED MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER ADVANTAGE-SM MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER DIAMOND Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER DIAMOND-LG MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER DIAMOND-MD MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER DIAMOND-SM MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER FACE MASK-LARGE Valved Holding Chamber OTC; QLL (2 EA per 365 days) OPTICHAMBER FACE MASK-MEDIUM Valved Holding Chamber OTC; QLL (2 EA per 365 days) OPTICHAMBER FACE MASK-SMALL OTC; QLL (2 EA per 365 days) 58 Valved Holding Chamber Drug Name Reference Restrictions OPTIHALER Valved Holding Chamber QLL (2 EA per 365 days) POCKET CHAMBER Valved Holding Chamber QLL (2 EA per 365 days) POCKET SPACER Valved Holding Chamber QLL (2 EA per 365 days) RITEFLO Valved Holding Chamber QLL (2 EA per 365 days) VORTEX VALVED HOLDING CHAMBER Valved Holding Chamber QLL (2 EA per 365 days) WATCHHALER Valved Holding Chamber QLL (2 EA per 365 days) Migranal QLL (8 Units per 30 days) *MIGRAINE PRODUCTS* *Ergot Combinations*** CAFERGOT MIGERGOT *Migraine Products*** dihydroergotamine mesylate nasal ERGOMAR *Selective Serotonin Agonists 5-Ht(1)*** naratriptan hcl Amerge rizatriptan benzoate Maxalt QLL (18 EA per 30 days) sumatriptan nasal Imitrex QLL (6 Tablets per 30 days) sumatriptan succinate oral Imitrex QLL (9 EA per 30 days) sumatriptan succinate refill subcutaneous* Imitrex STATdose Refill QLL (2 ML per 30 days) sumatriptan succinate subcutaneous* 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose System QLL (4 Vials per 30 days) sumatriptan succinate subcutaneous* 6 mg/0.5ml QLL (2 ML per 30 days) sumatriptan succinate subcutaneous* solution Alsuma 6 mg/0.5ml QLL (4 Vials per 30 days) *MINERALS & ELECTROLYTES* *Bicarbonates*** sodium bicarbonate intravenous* solution 8.4 % *Fluoride Combinations*** FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 1 (F)-236.79 MG *Fluoride*** fluoritab Luride sodium fluoride oral FLUORABON 59 Drug Name Reference FLUOR-A-DAY ORAL SOLUTION Fluoritab FLURA-DROPS Fluoritab KARIDIUM Fluoritab LUDENT Fluoritab NAFRINSE Fluoritab NAFRINSE DROPS Fluoritab *Phosphate*** av-phos 250 neutral Phospha 250 Neutral virt-phos 250 neutral Phospha 250 Neutral K-PHOS PHOSPHA 250 NEUTRAL Virt-Phos 250 Neutral *Potassium Combinations*** effervescent pot chloride pot bicarb-pot chloride *Potassium*** k-effervescent Klor-Con/EF k-vescent oral tablet effervescent Klor-Con/EF potassium bicarbonate oral Klor-Con/EF potassium chloride crys er Klor-Con M10 potassium chloride er Micro-K potassium chloride oral packet Klor-Con potassium chloride oral solution 20 meq/15ml K-Sol (10%), 40 meq/15ml (20%) EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ K-Vescent KLOR-CON Potassium Chloride ER KLOR-CON 10 Potassium Chloride ER KLOR-CON M10 Potassium Chloride Crys ER KLOR-CON M15 KLOR-CON M20 Potassium Chloride Crys ER KLOR-CON SPRINKLE Potassium Chloride ER KLOR-CON/EF K-Vescent K-PRIME K-Vescent K-SOL Potassium Chloride *MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine hcl mouth/throat 60 LTA 360 Kit Restrictions Drug Name Reference Restrictions lidocaine viscous *Anti-Infectives - Throat*** clotrimazole mouth/throat nystatin mouth/throat *Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat Periogard PAROEX Chlorhexidine Gluconate PERIOGARD Chlorhexidine Gluconate *Dental Products - Combinations*** FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE *Fluoride Dental Products*** neutral sodium fluoride CaviRinse sf NeutraGard Advanced sf 5000 plus Denta 5000 Plus CAVAREST SF CAVIRINSE Neutral Sodium Fluoride CONTROLRX DENTAL CREAM Dentall 1100 Plus DENTA 5000 PLUS Dentall 1100 Plus DENTAGEL SF FLUORIDEX DAILY DEFENSE SF OTC FLUORIDEX ENHANCED WHITENING SF KARIGEL SF KARIGEL-N SF NEUTRAGARD ADVANCED SF PHOS-FLUR SF *Saliva Stimulants*** pilocarpine hcl oral Salagen *Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat Oralone ORALONE Triamcinolone Acetonide *MULTIVITAMINS* *Multiple Vitamins W/ Minerals*** biocel Orthovite b-plex plus Orthovite v-c forte Ocuvite Eye Health Formula vit b3-azelac-turm-fa-b6-zn-cu Orthovite 61 Drug Name Reference CORVITE FREE One Daily Calcium/Iron/Zinc LYSIPLEX PLUS ORAL TABLET One Daily Calcium/Iron/Zinc NUTRIFAC ZX One Daily Calcium/Iron/Zinc VIC-FORTE Antioxidant Formula VITA S FORTE One Daily Calcium/Iron/Zinc VITACEL One Daily Calcium/Iron/Zinc Restrictions *Ped Multi Vitamins W/Fl & Fe*** multi-vit/fluoride/iron Escavite LQ multi-vitamin/fluoride/iron Escavite LQ *Ped Mv W/ Fluoride*** multi vitamin/fluoride MVC-Fluoride multi-vit/fluoride oral solution Quflora Pediatric multi-vitamin/fluoride oral solution Quflora Pediatric multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride multi-vitamin/fluoride oral tablet chewable 0.5 MVC-Fluoride mg multivitamins/fluoride MVC-Fluoride multi-vitamins/fluoride oral solution 0.5 mg/ml Quflora Pediatric MVC-FLUORIDE Multi Vita-Bets/Fluoride QUFLORA PEDIATRIC ORAL SOLUTION Multi-Vitamins/Fluoride *Ped Vitamins Acd Fluoride & Iron*** tri-vit/fluoride/iron *Ped Vitamins Acd W/ Fluoride*** triple-vitamin/fluoride tri-vit/fluoride tri-vitamin/fluoride vitamins acd-fluoride *Prenatal Mv & Min W/Fe-Fa*** bp multinatal plus Vinate C QLL (100 EA per 90 days) completenate Prenatal 19 QLL (100 EA per 90 days) dothelle dha Taron-C DHA QLL (100 EA per 90 days) hemenatal ob + dha Prefera OB + DHA mynatal plus Vitafol-OB QLL (100 EA per 90 days) mynatal-z Vitafol-OB QLL (100 EA per 90 days) mynate 90 plus 62 Drug Name Reference Restrictions pnv fe fum/docusate/folic acid Prenatal 19 pnv folic acid + iron TriCare QLL (100 EA per 90 days) pnv prenatal plus multivitamin TriCare OTC; QLL (100 EA per 90 days) pnv tabs 29-1 Prenatabs Rx pnv-select Zatean-Pn QLL (100 EA per 90 days) pnv-vp-u Prenatal-U QLL (100 EA per 90 days) prenatabs fa Co-Natal FA QLL (100 EA per 90 days) prenatal 19 oral tablet Prenatal 19 QLL (100 EA per 90 days) prenatal 19 oral tablet 29-1 mg Prenatal 19 prenatal 19 oral tablet chewable Prenatal 19 QLL (100 EA per 90 days) prenatal low iron oral tablet 27-1 mg TriCare QLL (100 EA per 90 days) prenatal oral tablet 27-1 mg TriCare QLL (100 EA per 90 days) prenatal plus TriCare QLL (100 EA per 90 days) prenatal plus iron Prenatabs Rx preplus TriCare pretab Co-Natal FA purefe ob plus Tandem OB se-natal 19 oral tablet Prenatal 19 se-natal 19 oral tablet chewable Prenatal 19 thrivite 19 Prenatal 19 thrivite rx Prenatabs Rx QLL (100 EA per 90 days) QLL (100 EA per 90 days) tl folate tl-care dha TriCare Prenatal DHA ONE triadvance Ultra NatalCare trinatal gt Ultra NatalCare trinatal rx 1 Vinate One ultimatecare one Folcaps Omega 3 ultimatecare one nf OB-Natal One vena-bal dha Bal-Care DHA virt nate Trinate virt-advance Ultra NatalCare virt-c dha Taron-C DHA virt-care one Folcaps Omega 3 virt-vite gt Ultra NatalCare vol-nate Trinate vol-plus TriCare vol-tab rx Prenatabs Rx QLL (100 EA per 90 days) QLL (100 EA per 90 days) QLL (100 EA per 90 days) QLL (100 EA per 90 days) 63 Drug Name Reference vp-heme ob + dha Prefera OB + DHA Restrictions ATABEX EC BAL-CARE DHA Vena-Bal DHA CITRANATAL B-CALM CO-NATAL FA Prenatabs FA CONCEPT DHA Virt-C DHA QLL (100 EA per 90 days) CONCEPT OB FOLCAPS OMEGA 3 ORAL CAPSULE 27-1 MG UltimateCare ONE FOLIVANE-OB INATAL ADVANCE Trinatal GT QLL (100 EA per 90 days) INATAL GT Trinatal GT QLL (100 EA per 90 days) INATAL ULTRA ORAL TABLET Trinatal GT QLL (100 EA per 90 days) M-VIT Prenatal Plus/Iron QLL (100 EA per 90 days) MYNATAL MYNATAL ADVANCE Trinatal GT NIVA-PLUS Prenatal Plus/Iron QLL (100 EA per 90 days) Prenatal Plus/Iron QLL (100 EA per 90 days) PRENATABS RX Prenatal Plus Iron QLL (100 EA per 90 days) PRENATAL-U PNV-VP-U QLL (100 EA per 90 days) OBSTETRIX DHA OBSTETRIX EC O-CAL FA O-CAL PRENATAL SELECT-OB ORAL TABLET CHEWABLE 29-1 MG QLL (100 EA per 90 days) TARON-BC TARON-C DHA Virt-C DHA QLL (100 EA per 90 days) TRICARE Prenatal Plus/Iron QLL (100 EA per 90 days) TRICARE PRENATAL COMPLEAT TRICARE PRENATAL DHA ONE TL-Care DHA TRINATE Vol-Nate QLL (100 EA per 90 days) VINACAL B VINATE AZ EXTRA VINATE C QLL (100 EA per 90 days) BP MultiNatal Plus VINATE CALCIUM VINATE IC QLL (100 EA per 90 days) PureFe OB Plus VINATE II QLL (100 EA per 90 days) VINATE M QLL (100 EA per 90 days) VINATE ONE 64 Se-Natal ONE QLL (100 EA per 90 days) Drug Name Reference Restrictions VITAFOL-OB Mynatal-Z QLL (100 EA per 90 days) VITA-PREN *Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** complete natal dha NESTABS ABC PR NATAL 400 EC PR NATAL 430 SetonET PR NATAL 430 EC SetonET-EC *Prenatal Mv & Min W/Fe-Fa-Dha*** folcal dha oral capsule 27-1.25-300 mg VemaVite-PRx 2 QLL (100 EA per 90 days) pnv ob+dha CitraNatal DHA pnv-dha Zatean-Pn DHA QLL (100 EA per 90 days) pnv-dha+docusate VemaVite-PRx 2 QLL (100 EA per 90 days) CITRANATAL DHA Prenatal+DHA PREQUE 10 ORAL TABLET 15-25-0.5-50 MG SELECT-OB+DHA Choice-OB+DHA QLL (100 EA per 90 days) Folcal DHA QLL (100 EA per 90 days) Folbecal QLL (100 EA per 90 days) TARON-PREX VEMAVITE-PRX 2 ZATEAN-CH *Prenatal Vitamins*** bp folinatal plus b *Specialty Vitamins Products*** urosex Green Source *MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen oral carisoprodol oral Soma QLL (120 EA per 30 days) chlorzoxazone oral tablet 500 mg Parafon Forte DSC cyclobenzaprine hcl oral tablet 10 mg, 5 mg Flexeril QLL (120 EA per 30 days) metaxalone oral tablet 800 mg Skelaxin QLL (120 EA per 30 days) methocarbamol oral Robaxin QLL (120 EA per 30 days) Metaxalone QLL (120 EA per 30 days) tizanidine hcl oral tablet METAXALL 65 Drug Name *Direct Muscle Relaxants*** Reference dantrolene sodium oral Dantrium Restrictions *Muscle Relaxant Combinations*** carisoprodol-aspirin carisoprodol-aspirin-codeine *NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Anticholinergics*** ipratropium bromide nasal Atrovent *Nasal Antihistamines*** azelastine hcl nasal solution 0.1 % Astelin azelastine hcl nasal solution 0.15 % Astepro QLL (60 ML per 30 days) *Nasal Steroids*** flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal Flonase OTC mometasone furoate nasal Nasonex ST; QLL (1 canister per 30 days) triamcinolone acetonide nasal aerosol† Nasacort Allergy 24HR OTC FLONASE ALLERGY RELIEF SUSPENSION 50 MCG/ACT NASAL Fluticasone Propionate Children's Flonase is covered; OTC; QLL (1 canister per 30 Days) NASACORT ALLERGY 24HR Triamcinolone Acetonide OTC; QLL (1 bottle per 30 days) NASACORT ALLERGY 24HR CHILDREN Triamcinolone Acetonide OTC; QLL (1 bottle per 30 days) RHINOCORT ALLERGY Budesonide OTC; QLL (1 bottle per 30 Days) *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** ENTRESTO PA; QLL (60 EA per 30 Days) *NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole 66 Rilutek Drug Name *OPHTHALMIC AGENTS* *Beta-Blockers - Ophthalmic Combinations*** Reference dorzolamide hcl-timolol mal Cosopt Restrictions COMBIGAN *Beta-Blockers - Ophthalmic*** betaxolol hcl ophthalmic carteolol hcl levobunolol hcl ophthalmic solution 0.5 % Betagan metipranolol Optipranolol timolol maleate ophthalmic Timoptic BETOPTIC-S *Cycloplegic Mydriatics*** atropine sulfate ophthalmic Isopto Atropine cyclopentolate hcl ophthalmic solution 1 %, 2 Cyclogyl % homatropine hbr ophthalmic Isopto Homatropine tropicamide ophthalmic HOMATROPAIRE Homatropine HBr *Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 1 %, 2 %, Isopto Carpine 4% *Ophthalmic Antiallergic*** azelastine hcl ophthalmic Optivar ST cromolyn sodium ophthalmic epinastine hcl Elestat *Ophthalmic Antibiotics*** bacitracin ophthalmic ciprofloxacin hcl ophthalmic Ciloxan erythromycin ophthalmic Ilotycin gatifloxacin ophthalmic Zymaxid gentamicin sulfate ophthalmic Gentak levofloxacin ophthalmic ofloxacin ophthalmic Ocuflox tobramycin ophthalmic Tobrex CILOXAN OPHTHALMIC OINTMENT GENTAK OPHTHALMIC OINTMENT Gentamicin Sulfate ILOTYCIN Romycin 67 Drug Name Reference Restrictions TOBREX OPHTHALMIC OINTMENT VIGAMOX *Ophthalmic Anti-Infective Combinations*** ak-poly-bac Polycin bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm Polycin neomycin-bacitracin zn-polymyx Neo-Polycin neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 Neosporin polymyxin b-trimethoprim Polytrim NEO-POLYCIN Triple Antibiotic POLYCIN AK-Poly-Bac *Ophthalmic Antivirals*** trifluridine ophthalmic Viroptic *Ophthalmic Carbonic Anhydrase Inhibitors*** dorzolamide hcl Trusopt AZOPT ST; QLL (1 bottle per 30 days) *Ophthalmic Decongestants*** phenylephrine hcl ophthalmic solution 10 % Altafrin phenylephrine hcl ophthalmic solution 2.5 % Mydfrin ALTAFRIN OPHTHALMIC SOLUTION 10 %, 2.5 % Phenylephrine HCl *Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** diclofenac sodium ophthalmic Voltaren flurbiprofen sodium Ocufen ketorolac tromethamine ophthalmic Acular LS *Ophthalmic Selective Alpha Adrenergic Agonists*** brimonidine tartrate ophthalmic Alphagan P *Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc Neo-Polycin HC neomycin-polymyxin-dexameth ophthalmic ointment Maxitrol neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 Maxitrol 68 Drug Name Reference Restrictions neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 sulfacetamide-prednisolone ophthalmic solution tobramycin-dexamethasone TobraDex NEO-POLYCIN HC Bacitra-Neomycin-PolymyxinHC TOBRADEX OPHTHALMIC OINTMENT *Ophthalmic Steroids*** dexamethasone sodium phosphate ophthalmic fluorometholone ophthalmic FML Liquifilm prednisolone acetate ophthalmic Pred Forte prednisolone sodium phosphate ophthalmic FML FORTE PRED MILD *Ophthalmic Sulfonamides*** sulfacetamide sodium ophthalmic Bleph-10 *Prostaglandins - Ophthalmic*** latanoprost ophthalmic Xalatan *OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic VoSol acetic acid-aluminum acetate *Otic Anti-Infectives*** ciprofloxacin hcl solution 0.2 % otic Cetraxal ofloxacin otic Floxin Otic *Otic Steroid-Anti-Infective Combinations*** neomycin-polymyxin-hc otic CIPRO HC CIPRODEX *Otic Steroids*** hydrocortisone-acetic acid VoSoL HC ACETASOL HC Hydrocortisone-Acetic Acid *OXYTOCICS* *Oxytocics*** methylergonovine maleate oral Methergine 69 Drug Name Reference *PASSIVE IMMUNIZING AGENTS* *Antiviral Monoclonal Antibodies*** Restrictions SYNAGIS PA *Immune Serums*** HEPAGAM B HYPERHEP B S/D HYPERRHO S/D INTRAMUSCULAR* MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR* NABI-HB RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR* RHOPHYLAC INJECTION *PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule amoxicillin oral suspension reconstituted amoxicillin oral tablet amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin *Natural Penicillins*** penicillin v potassium *Penicillin Combinations*** amoxicillin-pot clavulanate er Augmentin XR QLL (28 EA per 30 days) amoxicillin-pot clavulanate oral suspension reconstituted amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet chewable QLL (28 EA per 30 days) Augmentin QLL (28 EA per 30 days) *Penicillinase-Resistant Penicillins*** dicloxacillin sodium *PHARMACEUTICAL ADJUVANTS* *Antimicrobial Agents*** benzyl alcohol 70 OTC Drug Name *Flavoring Agents*** Reference almond oil bitter flavor Flavorx anise extract Flavorx Restrictions anise flavor apricot flavor liquid† Flavorx bitter stop flavor Flavorx blackberry flavor Flavorx butter flavor Flavorx butter rum flavor Flavorx chicken flavor oil soluble Flavorx chicken flavor water miscible Flavorx chocolate hazelnut flavor Flavorx cinnamon flavor coconut flavor Flavorx cran-raspberry flavor Flavorx english toffee flavor Flavorx eucalyptus flavor eugenol flavor Flavorx fish flavor Flavorx ham flavor Flavorx kahlua flavor Flavorx lemon extract Flavorx lemon flavor oil lemonade flavor licorice flavor Flavorx lime flavor maple flavor Flavorx orange cream flavor Flavorx orange oil flavor Flavorx peppermint flavor pralines and cream flavor Flavorx pumpkin flavor Flavorx shrimp flavor Flavorx spearmint flavor tangerine flavor oil teaberry flavor tutti-frutti flavor Flavorx vanilla flavor Flavorx 71 Drug Name Reference wild cherry flavor Flavorx PCCA SWEETNESS ENHANCER Banana Flavor *Gelatin Capsules (Empty)*** capsule coni-snap #1 pink DRcaps Size 1 capsule #1-drcaps DRcaps Size 1 capsule coni-snap #0 blu/white DRcaps Size 1 capsule coni-snap #0 clear DRcaps Size 1 capsule coni-snap #0 dark blue DRcaps Size 1 capsule coni-snap #0 green/clr DRcaps Size 1 capsule coni-snap #0 pink DRcaps Size 1 capsule coni-snap #0 red/white DRcaps Size 1 capsule coni-snap #0 white DRcaps Size 1 capsule coni-snap #00 clear DRcaps Size 1 capsule coni-snap #00 white DRcaps Size 1 capsule coni-snap #000 clear DRcaps Size 1 capsule coni-snap #1 aqua blue DRcaps Size 1 capsule coni-snap #1 blue DRcaps Size 1 capsule coni-snap #1 blue/pink DRcaps Size 1 capsule coni-snap #1 blue/wht DRcaps Size 1 capsule coni-snap #1 brown DRcaps Size 1 capsule coni-snap #1 brwn/ivry DRcaps Size 1 capsule coni-snap #1 clear DRcaps Size 1 capsule coni-snap #1 dk grn/or DRcaps Size 1 capsule coni-snap #1 drk green DRcaps Size 1 capsule coni-snap #1 grey/pink DRcaps Size 1 capsule coni-snap #1 grn/ylw DRcaps Size 1 capsule coni-snap #1 orange DRcaps Size 1 capsule coni-snap #1 pink/blue DRcaps Size 1 capsule coni-snap #1 pink/clr DRcaps Size 1 capsule coni-snap #1 pink/whit DRcaps Size 1 capsule coni-snap #1 pink/yllw DRcaps Size 1 capsule coni-snap #1 purple DRcaps Size 1 capsule coni-snap #1 red/blue DRcaps Size 1 capsule coni-snap #1 red/white DRcaps Size 1 capsule coni-snap #1 white DRcaps Size 1 capsule coni-snap #1 white/grn DRcaps Size 1 capsule coni-snap #1 wht/clr DRcaps Size 1 capsule coni-snap #1 yellow DRcaps Size 1 72 Restrictions Drug Name Reference capsule coni-snap #1 yellow/gr DRcaps Size 1 capsule coni-snap #2 clear DRcaps Size 1 capsule coni-snap #2 white DRcaps Size 1 capsule coni-snap #3 blu/clear DRcaps Size 1 capsule coni-snap #3 brn/blue DRcaps Size 1 capsule coni-snap #3 gray/ylw DRcaps Size 1 capsule coni-snap #3 green/blu DRcaps Size 1 capsule coni-snap #3 grey/pink DRcaps Size 1 capsule coni-snap #3 maron/blu DRcaps Size 1 capsule coni-snap #3 mint grn DRcaps Size 1 capsule coni-snap #3 olive/clr DRcaps Size 1 capsule coni-snap #3 orange DRcaps Size 1 capsule coni-snap #3 pink/pink DRcaps Size 1 capsule coni-snap #3 pnk/clear DRcaps Size 1 capsule coni-snap #3 red/clear DRcaps Size 1 capsule coni-snap #3 red/red DRcaps Size 1 capsule coni-snap #3 white DRcaps Size 1 capsule coni-snap #3 wht/clr DRcaps Size 1 capsule coni-snap #3 yellow DRcaps Size 1 capsule coni-snap #4 black/grn DRcaps Size 1 capsule coni-snap #4 clear DRcaps Size 1 capsule coni-snap #4 white DRcaps Size 1 capsule locking #0 clear DRcaps Size 1 capsule locking #00 clear DRcaps Size 1 capsule locking #1 clear DRcaps Size 1 capsule locking #3 clear DRcaps Size 1 empty capsule size 0 purp/wht DRcaps Size 1 empty capsule size 00 blue opq DRcaps Size 1 empty capsule size 1 drk green DRcaps Size 1 empty capsule size 1 grn/ornge DRcaps Size 1 empty capsule size 1 grn/white DRcaps Size 1 empty capsule size 1 ivory DRcaps Size 1 empty capsule size 1 maroon/cl DRcaps Size 1 empty capsule size 1 mint grn DRcaps Size 1 empty capsule size 1 orge/clr DRcaps Size 1 empty capsule size 1 pink/clr DRcaps Size 1 empty capsule size 1 pink/yllw DRcaps Size 1 empty capsule size 1 red/blue DRcaps Size 1 Restrictions 73 Drug Name Reference empty capsule size 3 black/grn DRcaps Size 1 empty capsule size 3 blue opq DRcaps Size 1 empty capsule size 3 blue/clr DRcaps Size 1 empty capsule size 3 blue/wht DRcaps Size 1 empty capsule size 3 dark grn DRcaps Size 1 empty capsule size 3 grey/pink DRcaps Size 1 empty capsule size 3 grey/yllw DRcaps Size 1 empty capsule size 3 marn/blue DRcaps Size 1 empty capsule size 3 marn/clr DRcaps Size 1 empty capsule size 3 olive/clr DRcaps Size 1 empty capsule size 3 orange/wh DRcaps Size 1 empty capsule size 3 pink/blue DRcaps Size 1 empty capsule size 3 pink/wh DRcaps Size 1 empty capsule size 3 pink/yllw DRcaps Size 1 empty capsule size 3 prple/clr DRcaps Size 1 empty capsule size 3 red/white DRcaps Size 1 DRCAPS SIZE 0 Empty Capsule Size 0 Blue DRCAPS SIZE 00 Empty Capsule Size 0 Blue DRCAPS SIZE 1 Empty Capsule Size 0 Blue *Non Gelatin Capsules (Empty)*** capsule coni-snap #3 clear AR Caps #1 Acid Resistant *Oral Vehicles*** sorbitol solution syrpalta oral syrup 85 % SYRSPEND SF PH4 *Parenteral Vehicles*** sterile water for injection *POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral Kayexalate sodium polystyrene sulfonate suspension KIONEX Kalexate SPS Sodium Polystyrene Sulfonate *PROGESTINS* *Progestins*** medroxyprogesterone acetate oral 74 Provera Restrictions Drug Name Reference Restrictions megestrol acetate oral suspension 625 mg/5ml Megace ES norethindrone acetate oral Aygestin progesterone micronized oral Prometrium *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC.* *Alcohol Deterrents*** disulfiram oral Antabuse *Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline *Cholinomimetics - Ache Inhibitors*** donepezil hcl oral tablet 10 mg, 5 mg Aricept QLL (30 EA per 30 days) donepezil hcl oral tablet dispersible Aricept ODT QLL (30 EA per 30 days) galantamine hydrobromide Razadyne QLL (60 EA per 30 days) galantamine hydrobromide er Razadyne ER QLL (30 EA per 30 days) rivastigmine Exelon rivastigmine tartrate Exelon QLL (60 EA per 30 days) *Fibromyalgia Agent - Snris*** SAVELLA ST SAVELLA TITRATION PACK ST *Multiple Sclerosis Agents Interferons*** EXTAVIA SUBCUTANEOUS* KIT PA REBIF REBIDOSE SUBCUTANEOUS* PA REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* PA REBIF SUBCUTANEOUS* PA REBIF TITRATION PACK SUBCUTANEOUS* PA *Multiple Sclerosis Agents*** COPAXONE SUBCUTANEOUS* PA *N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral Namenda 75 Drug Name *Phenothiazines & Tricyclic Agents*** Reference Restrictions Buproban QLL (6 Claims per 365 days); AL (Min 18 Years) perphenazine-amitriptyline *Smoking Deterrents*** bupropion hcl er (smoking det) CHANTIX PA; QLL (360 EA per 365 days); AL (Min 18 Years) CHANTIX CONTINUING MONTH PAK PA; QLL (360 EA per 365 days); AL (Min 18 Years) CHANTIX STARTING MONTH PAK PA; QLL (360 EA per 365 days); AL (Min 18 Years) NICOTROL PA; QLL (6 Claims per 365 days); AL (Min 18 Years) NICOTROL NS PA; QLL (6 Claims per 365 days); AL (Min 18 Years) *Thienbenzodiazepines & Ssris*** olanzapine-fluoxetine hcl Symbyax *SULFONAMIDES* *Sulfonamides*** sulfadiazine oral *TETRACYCLINES* *Tetracyclines*** avidoxy Adoxa demeclocycline hcl oral doxycycline hyclate oral capsule Morgidox doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet delayed release 100 mg doxycycline hyclate oral tablet delayed release Doryx 150 mg doxycycline monohydrate oral capsule 100 mg Monodox doxycycline monohydrate oral capsule 150 mg Adoxa doxycycline monohydrate oral capsule 50 mg Mondoxyne NL doxycycline monohydrate oral suspension reconstituted Vibramycin doxycycline monohydrate oral tablet Adoxa minocycline hcl oral tablet Dynacin tetracycline hcl oral 76 Drug Name Reference Restrictions MONDOXYNE NL ORAL CAPSULE 100 Doxycycline Monohydrate MG, 50 MG MORGIDOX ORAL CAPSULE 100 MG Doxycycline Hyclate *THYROID AGENTS* *Antithyroid Agents*** methimazole oral Tapazole propylthiouracil oral *Thyroid Hormones*** levothyroxine sodium oral Synthroid liothyronine sodium oral Cytomel np thyroid oral tablet 30 mg, 60 mg, 90 mg Armour Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 180 MG, 240 MG, 300 MG ARMOUR THYROID ORAL TABLET 15 NP Thyroid MG LEVO-T Levothyroxine Sodium LEVOXYL Levothyroxine Sodium NATURE-THROID ORAL TABLET 130 MG UNITHROID Levothyroxine Sodium UNITHROID DIRECT Levothyroxine Sodium WESTHROID ORAL TABLET 130 MG WP THYROID ORAL TABLET 130 MG *ULCER DRUGS* *Antispasmodics*** dicyclomine hcl oral Bentyl *Belladonna Alkaloids*** ed-spaz NuLev hyoscyamine sulfate er oral tablet extended release 12 hr* Levbid hyoscyamine sulfate oral Levsin hyoscyamine sulfate sublingual HyoMax-SL hyosyne oscimin Levsin oscimin sr Levbid NULEV Hyoscyamine Sulfate SYMAX-SL Oscimin SYMAX-SR Hyoscyamine Sulfate ER 77 Drug Name *H-2 Antagonists*** Reference Restrictions cimetidine hcl oral cimetidine oral tablet 300 mg, 400 mg, 800 mg famotidine oral suspension reconstituted Pepcid famotidine oral tablet 20 mg, 40 mg Pepcid nizatidine Axid ranitidine hcl oral capsule ranitidine hcl oral syrup Zantac ranitidine hcl oral tablet 150 mg Wal-Zan 150 Maximum Strength ranitidine hcl oral tablet 300 mg Zantac OTC *Misc. Anti-Ulcer*** sucralfate oral Carafate *Proton Pump Inhibitors*** lansoprazole oral capsule delayed release 15 mg Prevacid 24HR OTC; QLL (60 EA per 30 days) lansoprazole oral capsule delayed release 30 mg Prevacid QLL (30 EA per 30 Days) omeprazole capsule delayed release 20 mg oral PriLOSEC QLL (60 EA per 30 Days) omeprazole capsule delayed release 40 mg oral PriLOSEC QLL (30 EA per 30 Days) omeprazole oral capsule delayed release 10 mg PriLOSEC QLL (90 EA per 30 Days) omeprazole oral capsule delayed release 20 mg PriLOSEC QLL (60 EA per 30 days) omeprazole oral capsule delayed release 40 mg PriLOSEC QLL (30 EA per 30 days) pantoprazole sodium oral Protonix QLL (30 EA per 30 days) rabeprazole sodium Aciphex QLL (30 EA per 30 Days) FIRST-LANSOPRAZOLE QLL (60 EA per 30 days) FIRST-OMEPRAZOLE OMEPRAZOLE+SYRSPEND SF ALKA PREVACID SOLUTAB PA *Quaternary Anticholinergics*** glycopyrrolate oral Robinul propantheline bromide oral *Ulcer Drugs - Prostaglandins*** misoprostol oral 78 Cytotec Drug Name *URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** Reference methenamine hippurate Urex Restrictions methenamine mandelate oral nitrofurantoin macrocrystal oral Macrodantin nitrofurantoin monohyd macro Macrobid nitrofurantoin oral suspension Furadantin MACRODANTIN ORAL CAPSULE 25 MG Nitrofurantoin Macrocrystal *URINARY ANTISPASMODICS* *Urinary Antispasmodic Antimuscarinics (Antichol)***(New) oxybutynin chloride er Ditropan XL oxybutynin chloride oral tolterodine tartrate Detrol trospium chloride Sanctura trospium chloride er QLL (60 EA per 30 days) QLL (30 EA per 30 days) *Urinary Antispasmodics Cholinergic Agonists*** (New) bethanechol chloride oral Urecholine *Urinary Antispasmodics - Direct Muscle Relaxants*** (New) flavoxate hcl *VACCINES* *Bacterial Vaccines*** PNEUMOVAX 23 *VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** miconazole 3 vaginal suppository terconazole Terazol 7 ZAZOLE VAGINAL CREAM 0.8 % Terconazole ZAZOLE VAGINAL SUPPOSITORY Terconazole *Vaginal Anti-Infectives*** clindamycin phosphate vaginal Cleocin metronidazole vaginal Vandazole CLEOCIN VAGINAL SUPPOSITORY VANDAZOLE MetroNIDAZOLE 79 Drug Name *Vaginal Estrogens*** Reference Restrictions ESTRACE VAGINAL ESTRING FEMRING QLL (1 EA per 90 days) PREMARIN VAGINAL VAGIFEM VAGINAL TABLET 10 MCG *VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection 0.3 mg/0.3ml EpiPen 2-Pak EPIPEN 2-PAK INJECTION EPINEPHrine EPIPEN JR 2-PAK INJECTION *Vasopressors*** midodrine hcl *VITAMINS* *Vitamin D*** ergocalciferol oral capsule Drisdol vitamin d (ergocalciferol) Drisdol *Vitamin K*** MEPHYTON 80 QLL (4 pens per 1 Year)

Abh Ky - Aetna Better Health

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