Positive Listing Generic Medicaid-McLaren Health Plan-HMO

MedicaidFormulary GenericSort January2013
Key
* F M MDCH OTC PA QL SP ST Generic Available Females Only Males Only Michigan Department of Community Health Over the Counter Prior Authorization Quantity Limit Specialty Pharmacy Step Therapy
tel (888) 327 0671 fax (877) 502 1567 MclarenHealthPlan.org MHP42721015G
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) ZIAGEN EPZICOM TRIZIVIR CAMPRAL PRECOSE SECTRAL TYLENOL TYLENOL TYLENOL TYLENOL FEVERALL TYLENOL TYLENOL ES DIAMOX SEQUELS DIAMOX ACID JELLY ACETASOL VOSOL DOMEBORO OTIC VOSOL HC ACETASOL HC LITHOSTAT MUCOMYST TUDORZO PRESSAIR ZOVIRAX ZOVIRAX ZOVIRAX ZOVIRAX HUMIRA DIFFERIN 0.1% DIFFERIN 0.1% FABRAZYME ACCUNEB PROAIR HFA PROVENTIL HFA VENTOLIN HFA PROVENTIL
McLaren Health Plan-Medicaid Drug Formulary

GENERIC NAME ABACAVIR SULFATE ABACAVIR SULFATE/LAMUVIDINE ABACAVIR/LAMIVUDINE/ ZIDOVUDINE ACAMPROSATE CALCIUM ACARBOSE ACEBUTOLOL HCL ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAZOLAMIDE ACETAZOLAMIDE ACETIC AC/RICINOLEIC/OXYQUINOL ACETIC ACID ACETIC ACID ACETIC ACID/ALUMINUM ACETATE ACETIC ACID/HC ACETIC ACID/HYDROCORTISONE ACETOHYDROXAMIC ACID ACETYLCYSTEINE ACLIDINIUM BROMIDE ACYCLOVIR ACYCLOVIR ACYCLOVIR ACYCLOVIR ADALIMUMAB ADAPALENE ADAPALENE AGALSIDASE BETA ALBUTEROL ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE OTC DOSAGE FORM ALL FORMS ALL FORMS ALL FORMS ALL FORMS TABLET CAPSULE CHEW TAB DROPS ORAL SUSP RECT SUPP SUPPOSITORY TABLET TABLET CAPSULE ER TABLET JELLY/APP EAR DROP EAR DROP EAR DROP EAR DROP EAR DROP ALL FORMS VIAL-NEB AER INHALER CAPSULE OINTMENT ORAL SUSP TABLET KIT CREAM GEL ALL FORMS NEB SOLN HFA INHALER HFA INHALER HFA INHALER NEB SOLN RESTRICTIONS MDCH MDCH MDCH MDCH
Information is Subject to Change
COMMENTS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* * * * * *
OTC OTC OTC OTC OTC OTC OTC
AG
COVERED FOR THOSE MEMBERS 10 YEARS OF AGE AND YOUNGER.
* * * *
* * * * * * * * * * * * *
MDCH QL
BILLED TO STRAIGHT MEDICAID MAX ONE INHALER PER MONTH
PA., SP PA PA MDCH QL QL QL
CRITERIA MUST BE MET FAILURE OF RETIN-A FAILURE OF RETIN-A BILLED TO STRAIGHT MEDICAID MAX TWO INHALERS PER MONTH MAX TWO INHALERS PER MONTH MAX TWO INHALERS PER MONTH
* If GEQ is indicated, generic form must be used.
Page 1 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * PROVENTIL * PROVENTIL LASTACAFT * * * * * * ACLOVATE ACLOVATE ALCOHOL SWABS FOSAMAX FOSAMAX 35MG+70MG UROXATRAL CEREDASE LUMIZYME MYOZYME GENERIC NAME ALBUTEROL SULFATE ALBUTEROL SULFATE ALCAFTADINE

OTC DOSAGE FORM SYRUP TABLET EYE DROP CREAM OINTMENT MED PAD TABLET TABLET TAB ER 24HR ALL FORMS ALL FORMS ALL FORMS RESTRICTIONS
COMMENTS
PA
ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR
ALCLOMETASONE DIPROPIONATE ALCLOMETASONE DIPROPIONATE ALCOHOL ANTISEPTIC PADS ALENDRONATE SODIUM ALENDRONATE SODIUM ALFUZOSIN HCL ALGLUCERASE ALGLUCOSIDASE ALFA ALGLUCOSIDASE ALFA
OTC
QL QL QL PA MDCH MDCH MDCH
TEKTURNA
ALISKIREN HEMIFUMARATE
TABLET
PA, QL
TEKAMLO
ALISKIREN/AMLODIPINE
TABLET
PA
AMTURNIDE
ALISKIREN/AMLODIPINE/HCTZ
TABLET
PA
MAX 200 SWABS PER MONTH MAX ONE TABLET PER DAY MAX ONE TABLET PER WEEK ALT: FLOMAX BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID FAILURE OF TWO FORMULARY ACE INHIBITORS AND FAILURE OF COZAAR. MAX ONE TABLET PER DAY. ALT: ACCUPRIL, CAPOTEN, COZAAR, LOTENSIN, MONOPRIL, VASOTEC OR ZESTRIL PLUS NORVASC. FAILURE OF TWO FORMULARY ACE INHIBITORS PLUS HCTZ AND FAILURE OF HYZAAR. FAILURE OF TWO FORMULARY ACE INHIBITORS PLUS HCTZ AND FAILURE OF HYZAAR. MAX ONE TABLET PER DAY. ALT: ACCUPRIL, CAPOTEN, COZAAR, LOTENSIN, MONOPRIL, VASOTEC AND ZESTRIL. FAILURE OF AMERGE AND IMITREX. MAX NINE TABLETS PER MONTH. BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
TEKTURNA HCT
ALISKIREN/HCTZ
TABLET
PA, QL
VALTURNA ZYLOPRIM AXERT NIRAVAM XANAX XANAX XR DRYSOL XERAC AC ALTERNAGEL SYMMETREL
ALISKIREN/VALSARTAN ALLOPURINOL ALMOTRIPTAN MALATE ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALUMINUM CHLORIDE ALUMINUM CHLORIDE ALUMINUM HYDROXIDE AMANTADINE HCL
TABLET TABLET TABLET ALL FORMS ALL FORMS ALL FORMS SOLUTION SOLUTION ORAL SUSP CAPSULE
PA
* * * * * *
PA, QL MDCH MDCH MDCH
OTC
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January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * SYMMETREL MYTELASE LETAIRIS * MIDAMOR * MODURETIC * AMICAR 500MG * AMINOPYHLLINE * AMINOPYHLLINE * CORDARONE * ELAVIL * * * * * LIMBITROL LIMBITROL DS ETRAFON NORVASC CADUET LOTREL

GENERIC NAME AMANTADINE HCL AMBENONIUM CHLORIDE AMBRISENTAN AMILORIDE HCL AMILORIDE/HCTZ AMINOCAPROIC ACID AMINOPHYLLINE AMINOPHYLLINE AMIODARONE HCL AMITRIPTYLINE AMITRIPTYLINE/ CHLORDIAZEPOXIDE AMITRIPTYLINE/ CHLORDIAZEPOXIDE AMITRIPTYLINE/PERPHENAZINE AMLODIPINE BESYLATE AMLODIPINE/ATORVASTATIN AMLODIPINE/BENAZEPRIL OTC DOSAGE FORM SYRUP TABLET TABLET TABLET TABLET ALL FORMS SUPPOSITORY TABLET TABLET ALL FORMS ALL FORMS ALL FORMS ALL FORMS TABLET TABLET CAPSULE RESTRICTIONS
COMMENTS
PA
QUALIFYING DIAGNOSIS REQUIRED.
MDCH
BILLED TO STRAIGHT MEDICAID
MDCH MDCH MDCH MDCH QL PA QL
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX ONE TABLET PER DAY ALT: NORVASC PLUS LIPITOR MAX ONE CAPSULE PER DAY FAILURE OF ACE INHIBITORS PLUS NORVASC AND FAILURE OF COZAAR PLUS NORVASC. FAILURE OF FORMULARY ACE INHIBITORS PLUS NORVASC AND FAILURE OF COZAAR PLUS NORVASC FAILURE OF FORMULARY ACE INHIBITORS/HCTZ PLUS NORVASC AND FAILURE OF HYZAAR PLUS NORVASC.
AZOR
AMLODIPINE/OLMESARTAN
TABLET
PA
EXFORGE
AMLODIPINE/VALSARTAN
TABLET
PA
* *
* * * * * * * * *
EXFORGE HCT LAC-HYDRIN LAC-HYDRIN ASENDIN MOXATAG AMOXIL AMOXIL AMOXIL AUGMENTIN AUGMENTIN AUGMENTIN ES AUGMENTIN AUGMENTIN XR ADDERALL XR
AMLODIPINE/VALSARTAN/HCTZ AMMONIUM LACTATE AMMONIUM LACTATE AMOXAPINE AMOXICILLIN AMOXICILLIN TRIHYDRATE AMOXICILLIN TRIHYDRATE AMOXICILLIN TRIHYDRATE AMOXICILLIN/CLAVULANATE AMOXICILLIN/CLAVULANATE AMOXICILLIN/CLAVULANATE AMOXICILLIN/CLAVULANATE AMOXICILLIN/CLAVULANATE AMPHETAMINE SALTS
TABLET CREAM LOTION ALL FORMS TBMP 24HR CAPSULE CHEW TAB RECON SUSP CHEW TAB RECON SUSP RECON SUSP TABLET TABLET CAPSULE
PA
MDCH PA
BILLED TO STRAIGHT MEDICAID FAILURE OF AMOXIL
PA MDCH
ALT: GENERIC AUGMENTIN (NOT XR) BILLED TO STRAIGHT MEDICAID
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January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * ADDERALL * OMNIPEN * OMNIPEN CREON * AGRYLIN KINERET * ARIMIDEX ADVATE ALPHANATE HUMATE WILATE XYNTHIA KOGENATE RECOMBINATE HEMOFIL KOATE MONOCLATE FEIBA * AURALGAN ATRYN THROMBATE III TYLENOL W/ CODEINE TYLENOL W/ CODEINE ABILIFY IOPIDINE EMEND BROVANA NUVIGIL ASCRIPTIN SAPHRIS ASPIRIN BAYER ASPIRIN ASPIRIN

GENERIC NAME AMPHETAMINE SALTS AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE AMYLASE/LIPASE/PROTEASE ANAGRELIDE HCL ANAKINRA ANASTROZOLE ANTIHEMOPHELIA FACTOR ANTIHEMOPHILIC FACTOR ANTIHEMOPHILIC FACTOR ANTIHEMOPHILIC FACTOR ANTIHEMOPHILIC FACTOR ANTIHEMOPHILIC FACTOR HUMAN, RECOMBINATE ANTIHEMOPHILIC FACTOR HUMAN, RECOMBINATE ANTIHEMOPHILIC FACTOR, HUMAN ANTIHEMOPHILIC FACTOR, HUMAN ANTIHEMOPHILIC FACTOR, HUMAN ANTI-INHIBITOR COAGULANT ANTIPYRINE/BENZOCAINE/GLYCERI N ANTITHROMBIN III ANTITHROMBIN III APAP/CODEINE APAP/CODEINE APIPRAZOLE APRACLONIDINE HCL APREPITANT ARFORMOTEROL TARTRATE ARMODAFINIL ASA/CA CARB/MAG/AL HYDROX ASENAPINE ASPIRIN ASPIRIN ASPIRIN OTC DOSAGE FORM TABLET CAPSULE SUSP RECON CAPSULE CAPSULE ALL FORMS TABLET ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS EAR DROP ALL FORMS ALL FORMS ELIXER TABLET ALL FORMS EYE DROP CAPSULE NEB SOLN ALL FORMS TABLET ALL FORMS TABLET TABLET TABLET EC RESTRICTIONS MDCH
COMMENTS BILLED TO STRAIGHT MEDICAID
MDCH F, QL MDCH MDCH MDCH MDCH MDCH MDCH MDCH MDCH MDCH MDCH MDCH
BILLED TO STRAIGHT MEDICAID FEMALES ONLY. MAX ONE TABLET PER DAY BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID COVERED IN ORIGINAL GENERIC FORM ONLY BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
MDCH MDCH
* * *
MDCH
BILLED TO STRAIGHT MEDICAID CANCER DIAGNOSIS WITH FAILURE OF ZOFRAN ALT: FORADIL AND SEREVENT BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
PA PA MDCH MDCH
* * * *
OTC OTC OTC OTC
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January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * BUFFERIN AGGRENOX REYATAZ * TENORMIN STRATTERA * LIPITOR MEPRON * MALARONE * ISOPTO ATROPINE INLYTA AZASAN * IMURAN * OPTIVAR * ASTELIN

GENERIC NAME ASPIRIN/CALCIUM CARB/MAG ASPIRIN/DIPYRIDAMOLE ATAZANAVIR SULFATE ATENOLOL ATOMOXETINE ATORVASTATIN CALCIUM ATOVAQUONE ATOVAQUONE/PROGUANIL HCL ATROPINR SULFATE AXITINIB AZATHIOPRINE AZATHIOPRINE AZELASTINE HCL AZELASTINE HCL DOSAGE FORM OTC OTC TABLET CPMP 12HR ALL FORMS TABLET ALL FORMS TABLET ORAL SUSP TABLET EYE DROP ALL FORMS TABLET TABLET EYE DROP NASAL SPRAY RESTRICTIONS PA MDCH MDCH QL PA MDCH PA
COMMENTS ALT: ASPIRIN PLUS PERSANTINE BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX 1&1/2 TABLETS PER DAY ALT: LARIAM BILLED TO STRAIGHT MEDICAID ALT: IMURAN
PA
ASTEPRO
AZELASTINE HCL
NASAL SPRAY
PA
EDARBI EDARBYCLOR AZASITE ZITHROMAX 100MG/ML ZITHROMAX 200MG/ML ZITHROMAX 250MG ZITHROMAX 500MG CAYSTON BACITRACIN LIORESAL COLAZAL QVAR QNASL BECONASE AQ LOTENSIN LOTENSIN HCT OTICAINE
AZILSARTAN MEDOXOMIL AZILSARTAN/CHLORTHALIDONE AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZTREONAM LYSINE BACITRACIN BACLOFEN BALSALAZIDE DISODIUM BECLOMETHASONE DIPROPIONATE BECLOMETHASONE DIPROPIONATE BECLOMETHASONE DIPROPRIONATE BENAZEPRIL HCL BENAZEPRIL/HCTZ BENZOCAINE
TABLET TABLET EYE DROP SUSP RECON SUSP RECON TABLET TABLET NEB SOLN OINTMENT TABLET CAPSULE INHALER NASAL SPRAY NASAL SPRAY TABLET TABLET EAR DROP
PA, QL PA PA QL QL QL QL PA
FAILURE OF CLARITIN AND ZYRTEC FAILURE OF CLARITIN AND ZYRTEC FIRST-LINE AND FAILURE OF ASTELIN SECOND-LINE BY PRIOR AUTHORIZATION FAILURE OF TWO FORMULARY ACE INHIBITORS AND FAILURE OF COZAAR. MAX ONE TABLET PER DAY. ALT: COZAAR PLUS CHLORTHALIDONE FAILURE OF ERYTHROMYCIN MAX 15MLS PER FILL MAX 30MLS PER FILL MAX SIX TABLETS PER FILL MAX THREE TABLETS PER FILL CRITERIA MUST BE MET
* * * * * * *
OTC
QL PA PA QL QL
MAX ONE INHALER PER MONTH ALT: FLONASE AND NASACORT AQ ALT: FLONASE AND NASACORT AQ MAX TWO TABLETS PER DAY MAX TWO TABLETS PER DAY
* * *
Page 5 of 54
January 2013
GEQ ONLY * * * * * * * * BRAND NAME (REFERENCE ONLY) TESSALON PERLES PERSAGEL BENZAGEL PERSAGEL BENZOYL PEROXIDE DESQUAM-X DIDREX COGENTIN BEPREVE BESIVANCE CYSTADANE CELESTONE * * * * * * * * * * * * * * * * DIPROLENE AF DIPROSONE DIPROSONE DIPROLENE DIPROSONE DIPROLENE AF DIPROSONE VALISONE VALISONE VALISONE BETOPTIC BETOPTIC S KERLONE URECHOLINE CASODEX LUMIGAN DULCOLAX DULCOLAX HALFLYTELY GENERIC NAME BENZONATATE BENZOYL PEROXIDE BENZOYL PEROXIDE BENZOYL PEROXIDE BENZOYL PEROXIDE BENZOYL PEROXIDE BENZPHETAMINE HCL BENZTROPINE BEPOTASTINE BESILATE BESIFLOXACIN HCL BETAINE BETAMETHASONE

OTC DOSAGE FORM CAPSULE GEL GEL LOTION WASH WASH TABLET ALL FORMS EYE DROP EYE DROP ALL FORMS SYRUP CREAM CREAM GEL LOTION LOTION OINTMENT OINTMENT CREAM LOTION OINTMENT EYE DROP EYE DROP TABLET TABLET TABLET EYE DROP SUPPOSITORY TABLET KIT RESTRICTIONS QL
COMMENTS MAX 600MG PER DAY
PA MDCH PA PA MDCH
DIET AID CRITERIA MUST BE MET BILLED TO STRAIGHT MEDICAID ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR ALT: CILOXAN, OCUFLOX AND QUIXIN BILLED TO STRAIGHT MEDICAID
BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE BETAXOLOL HCL BETAXOLOL HCL BETAXOLOL HCL BETHANECOL CHLORIDE BICALUTAMIDE BIMATOPROST BISACODYL OTC BISACODYL OTC BISACODYL/NACL/NAHCO3/KCL/PE G
PA
FAILURE OF GENERIC BETOPTIC
M, QL PA
MALES ONLY. MAX ONE TABLET PER DAY ALT: XALATAN
PA
ALT: COLYTE, GOLYTELY, NULYTELY AND TRILYTE
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January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) HELIDAC KAOPECTATE PEPTO-BISMOL PYLERA ZEBETA ZIAC VICTRELIS TRACLEER TEST STRIPS ALPHAGAN ALPHAGAN-P 0.1% ALPHAGAN-P 0.15% COMBIGAN AZOPT BROMDAY PARLODEL ENTOCORT EC PULMICORT FLEXHALER RHINOCORT AQ PULMICORT * * PULMICORT SYMBICORT BUMEX BUTRANS SUBOXONE WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL FORFIVO XL ZYBAN APLENZIN BUSPAR VANSPAR MYLERAN GENERIC NAME BISMUTH SAL/METRONID/TETRACYC BISMUTH SUBSALICYCLATE BISMUTH SUBSALICYLATE BISMUTH/METRONIDAZOLE/ TETRACYCLINE BISOPROLOL FUMARATE BISOPROLOL/HCTZ BOCEPREVIR BOSENTAN BREEZE 2 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE BRIMONIDINE/TIMOLOL BRINZOLAMIDE BROMFENAC SODIUM BROMOCRIPTINE MESYLATE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE

OTC DOSAGE FORM COMBO PK ORAL SUSP ORAL SUSP CAPSULE TABLET TABLET CAPSULE TABLET OTC EYE DROP EYE DROP EYE DROP EYE DROP EYE DROP EYE DROP CAPSULE CAPSULE DR INHALER NASAL SPRAY NEB SOLN NEB SOLN INHALER TABLET PATCH TDWK ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS TABLET SA TABLET ALL FORMS ALL FORMS TABLET PA RESTRICTIONS PA
COMMENTS ALT: PEPTO-BISMOL, FLAGYL AND TETRACYCLINE BILLED SEPARATELY
* *
OTC OTC
PA
ALT: PEPTO BISMOL, FLAGYL AND TETRACYCLINE BILLED SEPARATELY
* *
PA, SP PA, SP QL
CRITERIA MUST BE MET CRITERIA MUST BE MET MAX 150 STRIPS PER MONTH
ALT: ALPHAGAN-P 0.15% OR ALPHAGAN ALT: ALPHAGAN AND TIMOPTIC BILLED SEPARATELY ALT: ACULAR AND VOLTAREN CRITERIA MUST BE MET MAX ONE INHALER PER MONTH ALT: FLONASE AND NASACORT AQ COVERED FOR THOSE MEMBERS UNDER THE AGE OF 10 COVERED FOR THOSE MEMBERS UNDER THE AGE OF 10 MAX ONE INHALER PER MONTH ALT: DURAGESIC AND MS CONTIN BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID SMOKING CESSATION-MAX 90 DAYS PER CALENDAR YEAR BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
PA PA PA QL
* *
AG AG QL PA MDCH MDCH MDCH MDCH MDCH QL MDCH MDCH MDCH
* * *
BUDESONIDE BUDESONIDE/FORMOTEROL BUMETANIDE BUPRENORPHINE BUPRENORPHINE/NALOXONE BUPROPION BUPROPION BUPROPION BUPROPION HCL BUPROPION HCL BUPROPRION BUSPIRONE BUSPIRONE BUSULFAN
* * *
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January 2013
GEQ ONLY * * * * * * * * BRAND NAME (REFERENCE ONLY) BUTISOL SODIUM PHRENILIN ESGIC ESGIC PLUS FIORICET FIORICET/CODEINE FIORINAL FIORINAL/CODEINE GYNAZOLE-1 RID BERINERT CINRYZE DOSTINEX CAFCIT CAFCIT DOVONEX DOVONEX MIACALCIN ROCALTROL PHOSLO PHOSLO CALTRATE-D CALTRATE PLUS CALCIUM CARBONATE CALCIUM CARBONATE TUMS CALCIUM CARBONATE CALTRATE OSCAL OSCAL-D CITRACAL PLUS CALCIUM CITRATE CITRACAL-D CALCIUM GLUCONATE

GENERIC NAME BUTABARBITAL BUTABITAL/APAP BUTABITAL/APAP/CAFFEINE BUTABITAL/APAP/CAFFEINE BUTABITAL/APAP/CAFFEINE BUTABITAL/APAP/CAFFEINE/ AND CODEINE BUTABITAL/ASP/CAFFEINE BUTABITAL/ASP/CAFFEINE/ AND CODEINE BUTACONAZOLE NITRATE BUTOXIDE/PYRETHRINS C1 ESTERASE INHIBITOR C1 ESTERASE INHIBITOR CABERGOLINE CAFFEINE CITRATED CAFFEINE CITRATED CALCIPOTRIENE CALCIPOTRIENE CALCITONIN SALMON CALCITRIOL CALCIUM ACETATE CALCIUM ACETATE CALCIUM CARB/VITAMIN D CALCIUM CARB/VITAMIN D/MIN CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CIT/MAGOX/VIT D/MINERALS CALCIUM CITRATE CALCIUM CITRATE/VITAMIN D CALCIUM GLUCONATE OTC DOSAGE FORM ALL FORMS TABLET CASULE TABLET TABLET TABLET CAPSULE CAPSULE CREAM SHAMPOO ALL FORMS ALL FORMS TABLET SOLUTION VIAL OINTMENT SOLUTION NASAL SPRAY CAPSULE CAPSULE TABLET TABLET TABLET CHEW TAB ORAL SUSP TAB CHEW TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET RESTRICTIONS MDCH QL QL QL PA QL QL PA MDCH MDCH QL AG AG QL QL QL
COMMENTS BILLED TO STRAIGHT MEDICAID MAX SIX CAPSULES PER DAY MAX SIX TABLETS PER DAY MAX SIX TABLETS PER DAY ALT: NORCO, TYLENOL #3 AND VICODIN MAX SIX CAPSULES PER DAY MAX SIX CAPSULES PER DAY ALT: MONISTAT AND TERAZOL BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX FOUR TABLETS PER WEEK MAX AGE OF ONE YEAR OLD MAX AGE OF ONE YEAR OLD MAX 60GMS PER MONTH MAX 60MLS PER MONTH MAX 3.7MLS PER MONTH
OTC
* * * * * * * * * * * * * * * * * * * * * *
OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC
ATACAND
CANDESARTAN
TABLET
PA, QL
FAILURE OF TWO FORMULARY ACE INHIBITORS AND COZAAR. MAX ONE TABLET PER DAY.
Page 8 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) GENERIC NAME

OTC DOSAGE FORM RESTRICTIONS
COMMENTS FAILURE OF TWO FORMULARY ACE INHIBITORS PLUS HCTZ AND FAILURE OF HYZAAR. MAX ONE TABLET PER DAY. QUALIFYING DIAGNOSIS REQUIRED.
* * *
* * * * *
ATACAND HCT XELODA CAPOTEN CAPOZIDE ISOPTO CARBACHOL CARBATROL EQUETRO ONFI TEGRETOL TEGRETOL XR PARCOPA SINEMET SINEMET CR RYNATUSS CARBAGLU
CANDESARTAN/HCTZ CAPECITABINE CAPTOPRIL CAPTOPRIL/HCTZ CARBACHOL CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CAR-B-PEN TA/EPHED TAN/PE/CP CARGLUMIC ACID
TABLET TABLET TABLET TABLET EYE DROP ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS TAB RAPID TABLET TABLET SR ORAL SUSP ALL FORMS
PA, QL PA, SP
MDCH MDCH MDCH MDCH MDCH PA
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: SINEMET
MDCH
* *
SOMA 350MG OCUPRESS COREG CR COREG CECLOR CECLOR DURICEF DURICEF DURICEF OMNICEF OMNICEF SUPRAX VANTIN VANTIN CEFZIL CEFZIL CEDAX CEFTIN CEFTIN
CARISOPRODOL CARTEOLOL HCL CARVEDILOL CARVEDILOL CEFACLOR CEFACLOR CEFADROXIL HYDRATE CEFADROXIL HYDRATE CEFADROXIL HYDRATE CEFDINIR CEFDINIR CEFIXIME CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL CEFPROZIL CEFPROZIL CEFTIBUTEN DIHYDRATE CEFUROXIME AXETIL CEFUROXIME AXETIL
TABLET EYE DROP CPMP 24HR TABLET CAPSULE RECON SUSP CAPSULE RECON SUSP TABLET CAPSULE SUSP RECON TABLET SUSP RECON TABLET RECON SUSP TABLET CAPSULE RECON SUSP TABLET
PA
BILLED TO STRAIGHT MEDICAID ALT: BACLOFEN, FLEXERIL, NORFLEX, PARAFON, ROBAXIN AND ZANAFLEX TABLETS. FAILURE OF AN EQUAL DOSAGE TRIAL OF COREG
PA
* * * * * * * * * * * * * *
PA QL QL
ALT: OMNICEF MAX 10MLS PER DAY MAX TWO TABLETS PER DAY
PA
Page 9 of 54
January 2013

* * * * * * *
CELEBREX KEFLEX KEFLEX 750MG KEFLEX VELOSEF CIMZIA ZYRTEC ZYRTEC ZYRTEC ZYRTEC-D
CELECOXIB CEPHALEXIN MONOHYDRATE CEPHALEXIN MONOHYDRATE CEPHALEXIN MONOHYDRATE CEPHRADINE CERTOLIZUMAB PEGOL CETIRIZINE HCL CETIRIZINE HCL CETIRIZINE HCL CETIRIZINE/PSE
OTC OTC OTC OTC
CAPSULE CAPSULE CAPSULE SUSP RECON CAPSULE KIT CHEW TAB SYRUP TABLET TABLET
PA PA
COMMENTS ALT: CATAFLAM, DAYPRO, FELDENE, LODINE, MOBIC, MOTRIN, NAPROSYN, RELAFEN AND VOLTAREN. FAILURE OF KEFLEX 500MG
PA, SP
CRITERIA MUST BE MET
* * *
* * * * * * * * * * * * * *
* * * *
EVOXAC THORAZINE SOMNOTE LEUKERAN LIBRITABS LIBRIUM PERIDEX CHLOROQUINE DIURIL DIURIL TELDRIN CHLOR-TRIMETON DIABINESE HYGROTON TENORETIC PARAFON FORTE VITAMIN D QUESTRAN LIGHT QUESTRAN ALVESCO ZETONNA OMNARIS LOPROX PLETAL TAGAMET TAGAMET SENSIPAR
CEVIMELINE HCL CHLOPROMAZINE CHLORAL HYDRATE CHLORAMBUCIL CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE CHLORHEXIDINE GLUCONATE CHLOROQUINE PHOSPHATE CHLOROTHIAZIDE CHLOROTHIAZIDE CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE CHLORPROPAMIDE CHLORTHALIDONE CHLORTHALIDONE/ATENOLOL CHLORZOXAZONE CHOLECALCIFEROL CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE/SUCROSE CICLESONIDE CICLESONIDE CICLESONIDE CICLOPIROX CILOSTAZOL CIMETIDINE CIMETIDINE CINACALCET
OTC
OTC
CAPSULE ALL FORMS ALL FORMS TABLET ALL FORMS ALL FORMS LIQUID TABLET ORAL SUSP TABLET CAPSULE SA TABLET TABLET TABLET TABLET TABLET DROPS POWDER POWDER INHALER NASAL SPRAY SPRAY/PUMP GEL TABLET ORAL LIQUID TABLET TABLET
PA, QL MDCH MDCH MDCH MDCH
DIAGNOSIS OF SJOGREN'S SYNDROME. FAILURE OF SALAGEN AND SALIVART BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
QL PA PA
MAX ONE INHALER PER MONTH ALT: FLONASE AND NASACORT AQ ALT: FLONASE AND NASACORT AQ
PA
CRITERIA MUST BE MET
Page 10 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * CILOXAN CILOXAN CIPRO * CIPRO * CIPRO XR CIPRODEX CIPRO HC CELEXA BICITRA BIAXIN BIAXIN XL BIAXIN TAVIST TAVIST TAVIST CLEOCIN CLEOCIN CLEOCIN CLEOCIN CLEOCIN CLEOCIN BENZACLIN LIBRAX TEMOVATE TEMOVATE TEMOVATE TEMOVATE ANAFRANIL KLONOPIN KAPVAY CATAPRES TTS NEXICLON XR CATAPRES CLORPRES PLAVIX TRANXENE GYNE-LOTRIMIN LOTRIMIN

GENERIC NAME CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN/ DEXAMETHASONE CIPROFLOXACIN/ HYDROCORTISONE CITALOPRAM HYDROBROMIDE CITRIC ACID/SODIUM CITRATE CLARITHROMYCIN CLARITHROMYCIN CLARITHROMYCIN CLEMASTINE FUMARATE CLEMASTINE FUMARATE CLEMASTINE FUMARATE CLINDAMYCIN HCL CLINDAMYCIN PALMITATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE OTC DOSAGE FORM RESTRICTIONS EYE DROP EYE OINTMENT RECON SUSP AG TABLET AG TBMP 24HR PA EAR DROP EAR DROP ALL FORMS SOLUTION RECON SUSP TAB DR 24HR TABLET SYRUP TABLET TABLET CAPSULE RECON SUSP GEL LOTION SOLUTION VAG CREAM GEL CAPSULE CREAM GEL OINTMENT SOLUTION CAPSULE ALL FORMS ALL FORMS PATCH TDWK TAB ER 24HR TABLET TABLET TABLET ALL FORMS CREAM CREAM QL PA MDCH
COMMENTS
MIN AGE OF 18 MIN AGE OF 18 ALT: CIPRO, FLOXIN AND LEVAQUIN MAX ONE BOTTLE PER FILL ALT: CIPRODEX BILLED TO STRAIGHT MEDICAID
* * * * * * * * * * * * * * * * * * * * * * * * * * *
QL
MAX ONE TABLET PER DAY
OTC
CLINDAMYCIN/BENZOYL PEROXIDE CLINDINIUM/CL-DIAZEPOXIDE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOMIPRAMINE CLONAZEPAM CLONIDINE HCL CLONIDINE HCL CLONIDINE HCL CLONIDINE HCL CLONIDINE/CHLORTHALIDONE CLOPIDOGREL BISULFATE CLORAZEPATE CLOTRIMAZOLE OTC CLOTRIMAZOLE OTC
PA
ALT: BENZOYL PEROXIDE PLUS CLINDAMYCIN OR BENZAMYCIN
MDCH MDCH MDCH QL PA
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX ONE PATCH PER WEEK ALT: CATAPRES
QL MDCH
MAX ONE TABLET PER DAY BILLED TO STRAIGHT MEDICAID
Page 11 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * LOTRIMIN * MYCELEX TROCHE * LOTRISONE CLOZAPINE CLOZARIL FAZACLO NOVOSEVEN EMPIRIN/CODEINE CODEINE COLCRYS COLCHICINE COL-BENEMID WELCHOL COLESTID COLESTID SANTYL CONDOMS CENESTIN TEST STRIPS TEST STRIPS ACTHAR CORTONE CORTROSYN XALKORI CROLOM INTAL INTAL EURAX GENERIC NAME CLOTRIMAZOLE CLOTRIMAZOLE

DOSAGE FORM OTC OTC SOLUTION TROCHE CREAM ALL FORMS ALL FORMS ALL FORMS ALL FORMS TABLET TABLET TABLET TABLET TABLET TABLET GRANULES TABLET OINTMENT OTC TABLET OTC OTC ALL FORMS TABLET ALL FORMS ALL FORMS EYE DROP NASAL SPRAY NEB SOLN CREAM RESTRICTIONS
COMMENTS
* * * *
CLOTRIMAZOLE/BETAMETHASONE CLOZAPINE CLOZAPINE CLOZAPINE COAGULATION FACTOR VIIA RECOMBINANT CODEINE PHOSPHATE/ASPIRIN CODEINE SULFATE COLCHICINE COLCHICINE COLCHICINE/PROBENECID COLESEVELAM HCL COLESTIPOL HCL COLESTIPOL HCL COLLAGENASE CONDOMS CONJ ESTROGENS SYN CONTOUR CONTOUR NEXT EZ CORTICOTROPIN CORTISONE ACETATE COSYNTROPIN CRIZOTINIB CROMOLYN SODIUM CROMOLYN SODIUM CROMOLYN SODIUM CROTAMITON
MDCH MDCH MDCH MDCH
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
QL
MAX TWO TABLETS PER DAY
PA
ALT: COLESTID AND QUESTRAN
QL QL QL QL MDCH MDCH MDCH
MAX 12 CONDOMS PER FILL AND 36 CONDOMS PER MONTH MAX ONE TABLET PER DAY MAX 150 STRIPS PER MONTH MAX 150 STRIPS PER MONTH BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* * *
AMRIX
CYCLOBENZAPRINE HCL
CAP ER 24HR
PA
* * *
FEXMID FLEXERIL CYCLOGEL CYTOXAN SEROMYCIN
CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL CYCLOPENTOLATE HCL CYCLOPHOSPHAMIDE CYCLOSERINE
TABLET TABLET EYE DROP TABLET CAPSULE
PA
ALT: BACLOFEN, FLEXERIL, NORFLEX, PARAFON, ROBAXIN AND ZANAFLEX TABLETS. ALT: BACLOFEN, FLEXERIL, NORFLEX, PARAFON, ROBAXIN AND ZANAFLEX TABLETS.
Page 12 of 54
January 2013
GEQ ONLY * * * * BRAND NAME (REFERENCE ONLY) GENGRAF NEORAL PERIACTIN PERIACTIN PRADAXA AMPYRA FRAGMIN PROCENTRA DANOCRINE DANTRIUM DAPSONE ARANESP ENABLEX PREZISTA TARCEVA SPRYCEL FERRIPROX DECHOLIN RESCRIPTOR HUMORSOL DECLOMYCIN NORPRAMIN CLARINEX CLARINEX-D DDAVP DDAVP CYCLESSA DESOGEN ORTHO-CEPT DESOWEN TRIDESILON DESOWEN DESOWEN

GENERIC NAME CYCLOSPORIN, MODIFIED CYCLOSPORIN, MODIFIED CYPROHEPTADINE HCL CYPROHEPTADINE HCL DABIGATRAN ETEXILATE MESYLATE DALFAMPRIDINE DALTEPARIN SODIUM, PORCINE D-AMPHETAMINE SULFATE DANAZOL DANTROLENE DAPSONE DARBEPOETIN ALFA IN POLYSORBATE DARIFENACIN HBR DARUNAVIR ETHANOLATE DASATINIB DASATINIB DEFERIPRONE DEHYDROCHOLIC ACID DELAVIRDINE MESYLATE DEMECARIUM BROMIDE DEMECLOCYCLINE HCL DESIPRAMINE HCL DESLORATADINE DESLORATADINE/PSE DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHNIYL ESTRADIOL DESONIDE DESONIDE DESONIDE DESONIDE OTC DOSAGE FORM CAPSULE CAPSULE SYRUP TABLET CAPSULE TAB ER 12HR DISP SYRINGE ALL FORMS CAPSULE CAPSULE TABLET DISP SYRIN TAB ER 24HR ALL FORMS ALL FORMS TABLET TABLET TABLET ALL FORMS EYE DROP TABLET ALL FORMS TABLET TABLET NASAL SPRAY TABLET TABLET TABLET TABLET CREAM CREAM LOTION OINTMENT RESTRICTIONS
COMMENTS
PA PA, SP PA, SP MDCH
FAILURE/INTOLERANCE TO COUMADIN CRITERIA MUST BE MET CRITERIA MUST BE MET BILLED TO STRAIGHT MEDICAID 25MG AND 50MG MAX THREE PER DAY. 100MG MAX FOUR PER DAY MAX THREE TABLETS PER DAY CRITERIA MUST BE MET ALT: DITROPAN/DITROPAN XL BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* *
QL QL PA, SP PA MDCH MDCH MDCH
MDCH
* * *
MDCH PA PA
BILLED TO STRAIGHT MEDICAID ALT: ALLEGRA (ST), CLARITIN, XYZAL AND ZYRTEC ALT: ALLEGRA-D (PA), CLARITIN-D AND ZYRTEC-D
* * * * * * * * *
F, QL F, QL F, QL
FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS
Page 13 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * TRIDESILON * * * * * * * TOPICORT PRISTIQ DECADRON DECADRON DECADRON DECADRON POLARAMINE POLARAMINE DEXILANT FOCALIN FOCALIN XR TEARS NATURALE ARTIFICIAL TEARS DEXEDRINE DEXTROSTAT DIASTAT VALIUM GENERIC NAME DESONIDE

OTC DOSAGE FORM OINTMENT CREAM ALL FORMS ELIXER EYE DROP EYE OINT TABLET SYRUP TABLET SA CAP DR MP ALL FORMS ALL FORMS EYE DROP EYE DROP ALL FORMS ALL FORMS ALL FORMS ALL FORMS PA MDCH MDCH RESTRICTIONS
COMMENTS ALT: CUTIVATE, HYTONE, LIDEX AND TEMOVATE BILLED TO STRAIGHT MEDICAID
DESOXIMETASONE DESVENLAFAXINE SUCCINATE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE DEXLANSOPRAZOLE DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE DEXTRAN 70/HP-M/CELL DEXTRAN 70/HP-M-CELL DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DIAZEPAM DIAZEPAM
PA MDCH
* * * * * *
FAILURE OF PREVACID OTC, PRILOSEC AND PROTONIX. BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
OTC OTC
MDCH MDCH MDCH MDCH
FLECTOR
DICLOFENAC EPOLAMINE
PATCH
PA
* * * * * * * * * *
CAMBIA CATAFLAM VOLTAREN VOLTAREN VOLTAREN XR ARTHROTEC DYNAPEN DICLOXACILLIN BENTYL BENTYL BENTYL VIDEX
DICLOFENAC POTASSIUM DICLOFENAC POTASSIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM/MISOPROSTOL DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM DICYCLOMINE HCL DICYCLOMINE HCL DICYCLOMINE HCL DIDANOSINE
POWD PACK TABLET EYE DROP TABLET TABLET TABLET DR CAPSULE CAPSULE CAPSULE SYRUP TABLET ALL FORMS
PA
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: CATAFLAM, DAYPRO, FELDENE, LODINE, MOBIC, MOTRIN, NAPROSYN, RELAFEN AND VOLTAREN. FAILURE OF DAYPRO, FELDENE, LODINE, MOBIC, MOTRIN, NAPROSYN, RELAFEN, VOLTAREN TABLETS AND VOLTAREN GEL (PA).
PA
ALT: CYTOTEC PLUS VOLTAREN
MDCH
Page 14 of 54
January 2013
GEQ ONLY * * BRAND NAME (REFERENCE ONLY) VIDEX EC TENUATE TENUATE SR MOTOFEN APEXICON FLORONE PSORCON APEXICON FLORONE PSORCON DOLOBID DUREZOL DIGOXIN DIGOXIN LANOXIN DILACOR XR CARDIZEM SR CARDIZEM CD CARDIZEM CD 180MG CARDIZEM CD 360MG TIAZAC CARDIZEM CARDIZEM LA DRAMAMINE BIDIL SOMINEX UNISOM BENADRYL BENADRYL 50MG BENADRYL BENADRYL BENADRYL LOMOTIL LOMOTIL PROPINE PERSANTINE NORPACE GENERIC NAME DIDANOSINE DIETHYLPROPION DIETHYLPROPION DIFENOXIN HCL/ATROPINE SULFATE DIFLORASONE DIACETATE DIFLORASONE DIACETATE DIFLORASONE DIACETATE DIFLORASONE DIACETATE DIFLORASONE DIACETATE DIFLORASONE DIACETATE DIFLUNISAL DIFLUPREDNATE DIGOXIN DIGOXIN DIGOXIN DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DIMENHYDRINATE DINITRATE/HYDRALAZINE DIPHENHYDRAMINE DIPHENHYDRAMINE DIPHENHYDRAMINE DIPHENHYDRAMINE DIPHENHYDRAMINE DIPHENHYDRAMINE DIPHENHYDRAMINE DIPHENOXYLATE/ATROPINE DIPHENOXYLATE/ATROPINE DIPIVEFRIN DIPYRIDAMOLE DISOPYRAMIDE PHOSPHATE

OTC DOSAGE FORM ALL FORMS TABLET TABLET SR TABLET CREAM CREAM CREAM OINTMENT OINTMENT OINTMENT TABLET EYE DROPS ORAL SOLN TABLET TABLET CAP ER DEG CAP SR 12HR CAPSULE ER CAPSULE ER CAPSULE ER CAPSULE SA TABLET TABLET TABLET TABLET ALL FORMS ALL FORMS CAPSULE CAPSULE ELIXER SYRUP TABLET ORAL LIQUID TABLET EYE DROP TABLET CAPSULE RESTRICTIONS MDCH PA PA PA
COMMENTS BILLED TO STRAIGHT MEDICAID DIET AID CRITERIA MUST BE MET DIET AID CRITERIA MUST BE MET FAILURE OF IMODIUM AND LOMOTIL
* * * * * * *
PA PA
FAILURE/INTOLERANCE TO FORMULARY NSAID MEDICATIONS ALT: DECADRON, FML AND PRED FORTE
* * * * * * * * * *
QL QL QL PA QL PA
MAX ONE CAPSULE PER DAY MAX ONE CAPSULE PER DAY MAX TWO CAPSULES PER DAY ALT: CARDIZEM CD 180MG 2/DAY MAX ONE CAPSULE PER DAY ALT: CARDIZEM CD AND PLENDIL
OTC
* * * * * * * * * *
OTC OTC OTC OTC OTC OTC
PA MDCH MDCH
FAILURE OF APRESOLINE PLUS ISORDIL BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
Page 15 of 54
January 2013
GEQ ONLY * * * * * * * * * BRAND NAME (REFERENCE ONLY) NORPACE CR ANTABUSE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE COLACE DOK COLACE COLACE TIKOSYN ANZEMET * ARICEPT ARICEPT 23MG ARICEPT ODT TRUSOPT COSOPT CARDURA XL CARDURA ADAPIN SILENOR SINEQUAN HECTORAL VIBRAMYCIN VIBRAMYCIN VIBRATABS MONODOX MONODOX 75MG ADOXA MARINOL MULTAQ INAPSINE CYMBALTA AVODART JALYN LUFYLLIN KALBITOR GENERIC NAME DISOPYRAMIDE PHOSPHATE DISULFIRAM DIVALPROEX SODIUM DIVALPROEX SODIUM DIVALPROEX SODIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM DOFETILIDE DOLASETRON MESYLATE DONEPEZIL DONEPEZIL DONEPEZIL DORZOLAMIDE HCL DORZOLAMIDE/TIMOLOL

OTC DOSAGE FORM CAPSULE SA TABLET ALL FORMS ALL FORMS ALL FORMS CAPSULE CAPSULE LIQUID SYRUP CAPSULE TABLET TABLET TABLET TABLET EYE DROP EYE DROP TAB DR 24HR TABLET ALL FORMS ALL FORMS ALL FORMS CAPSULE SYRUP CAPSULE TABLET CAPSULE CAPSULE TABLET CAPSULE TABLET ALL FORMS ALL FORMS CAPSULE CPMP 24HR TABLET ALL FORMS RESTRICTIONS MDCH MDCH MDCH MDCH
COMMENTS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
OTC OTC OTC OTC
PA PA PA PA PA QL PA MDCH MDCH MDCH
CRITERIA MUST BE MET CANCER DIAGNOSIS WITH FAILURE OF ZOFRAN. DIAGNOSIS OF ALZHEIMER'S DISEASE REQUIRED ALT: ARICEPT 10MG (2/DAY) BY PRIOR AUTHORIZATION INABILITY TO USE GENERIC ARICEPT TABLETS MAX 10MLS PER MONTH ALT: CARDURA, HYTRIN AND MINIPRES BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* *
* * * *
* * * * *
DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE DOXEPIN DOXEPIN DOXEPIN DOXERCALCIFEROL DOXYCYCLINE CALCIUM DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DRONABINOL DRONEDARONE HCL DROPERIDOL DULOXETINE DUTASTERIDE DUTASTERIDE/TAMSULOSIN HCL DYPHYLLINE ECALLANTIDE
PA PA PA QL MDCH MDCH PA PA MDCH
ALT: VIBRATABS OR MONODOX 50MG ALT: MINOCIN AND VIBRATABS CANCER DIAGNOSIS REQUIRED. MAX TWO TABLETS PER DAY BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: FLOMAX ALT: FOSAMAX BILLED TO STRAIGHT MEDICAID
Page 16 of 54
January 2013
GEQ ONLY * BRAND NAME (REFERENCE ONLY) PHOSPHOLINE IODIDE SPECTAZOLE SOLIRIS SUSTIVA ATRIPLA PEDIALYTE COLYTE RELPAX STRIBILD TRUVADA EMADINE COMPLERA EMTRIVA VASOTEC VASERETIC FUZEON LOVENOX COMTAN BARACLUDE ECOTRIN ELESTAT EPIPEN EPIPEN JR EPINAL INSPRA EPOGEN PROCRIT GENERIC NAME ECHOTHIOPHATE IODIDE ECONAZOLE NITRATE ECULIZUMAB EFAVIRENZ EFAVIRENZ/EMTRICITAB/ TENOFOVIR ELECTROLYTE SOLN, ORAL ELECTROLYTE SOLN/PEG

OTC DOSAGE FORM EYE DROP CREAM ALL FORMS ALL FORMS ALL FORMS ORAL SOLN SOLUTION TABLET ALL FORMS ALL FORMS EYE DROP ALL FORMS ALL FORMS TABLET TABLET ALL FORMS DISP SYRINGE TABLET TABLET TABLET DR EYE DROP DISP SYRINGE DISP SYRINGE EYE DROP TABLET VIAL VIAL RESTRICTIONS
COMMENTS
MDCH MDCH MDCH
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* *
OTC
ELETRIPTAN HBR ELVITEGR/COBICIST/EMTRIC/ TENOF EMCITRICTABINE/TENOFOVIR EMEDASTINE DIFUMARATE EMTRICITAB/RILPIVIRINE/ TENOFOVIR EMTRICITABINE ENALAPRIL MALEATE ENALAPRIL/HCTZ ENFUVIRTIDE ENOXAPARIN SODIUM ENTACAPONE ENTECAVIR ENTERIC COATED ASPIRIN EPINASTINE HCL EPINEPHRINE EPINEPHRINE EPINEPHRYL BORATE EPLERENONE EPOETIN ALFA EPOETIN ALFA
PA, QL MDCH MDCH PA MDCH MDCH
ALT: AMERGE AND IMITREX. MAX NINE TABLETS PER MONTH BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* *
MDCH PA PA, SP QL QL QL QL PA, SP PA, SP
* * * *
BILLED TO STRAIGHT MEDICAID PRIOR AUTHORIZATION REQUIRED IF QTY GREATER THAN 28 SYRINGES QUALIFYING DIAGNOSIS REQUIRED. MAX 5MLS PER MONTH MAX FOUR PENS PER FILL MAX FOUR PENS PER FILL MAX TWO TABLETS PER DAY CRITERIA MUST BE MET CRITERIA MUST BE MET FAILURE OF TWO FORMULARY ACE INHIBITORS AND FAILURE OF COZAAR. MAX ONE TABLET PER DAY. FAILURE OF TWO FORMULARY ACE INHIBITORS PLUS HCTZ AND FAILURE OF HYZAAR. MAX ONE TABLET PER DAY.
OTC
TEVETEN
EPROSARTAN MESYLATE
TABLET
PA, QL
TEVETEN HCT DRISDOL
EPROSARTAN/HCTZ ERGOCALCIFEROL
TABLET CAPSULE
PA, QL
Page 17 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * HYDERGINE * HYDERGINE ERGOMAR * CAFERGOT * CAFERGOT * ERY-GEL * ILOTYCIN * A/T/S * ERY-TAB * ERYC * T-STAT * ILSONE * * * * * PEDIAZOLE ERYPED EES ERYTHROMYCIN BENZAMYCIN LEXAPRO

GENERIC NAME ERGOLOID MESYLATES ERGOLOID MESYLATES ERGOTAMINE TARTRATE ERGOTAMINE/CAFFEINE ERGOTAMINE/CAFFEINE ERYTHROMYCIN ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE/ETHANOL ERYTHROMYCIN ESOLATE ERYTHROMYCIN ETHY SUCC/SULFISOXAZOLE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYSUCCINATE ERYTHROMYCIN STEARATE ERYTHROMYCIN/BENZOYL PEROXIDE ESCITALOPRAM OTC DOSAGE FORM TABLET TABLET SL TAB SL SUPPOSITORY TABLET GEL EYE OINT SOLUTION TABLET DR TABLET EC SOLUTION ORAL SUSP SUSP RECON RECON SUSP TABLET TABLET GEL ALL FORMS RESTRICTIONS
COMMENTS
MDCH
* * *
NEXIUM PROSOM ESTRATEST ESTRATEST HS ESTRACE ALORA CLIMARA ESTRACE OVRAL FEMTRACE ACTIVELLA
* * *
ESOMEPRAZOLE MAGNESIUM ESTAZOLAM ESTERIFIED ESTROGENS AND METHYLTESTOSTERONE ESTERIFIED ESTROGENS AND METHYLTESTOSTERONE ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ACETATE ESTRADIOL/ NORETHINDRONE ACETATE
CAPSULE DR ALL FORMS TABLET TABLET CREAM/APPL PATCH TDWK PATCH TDWK TABLET TABLET TABLET TABLET
PA MDCH
BILLED TO STRAIGHT MEDICAID FAILURE OF PREVACID OTC, PRILOSEC, PROTONIX AND ZEGERID OTC FIRSTLINE FOLLOWED BY A FAILURE OF DEXILANT SECOND-LINE BY PRIOR AUTHORIZATION, BILLED TO STRAIGHT MEDICAID
QL QL
MAX 8 PATCHES EVERY 28 DAYS MAX ONE PATCH PER WEEK FEMALES ONLY. MAX ONE PACK PER FILL ALT: ESTRACE, OGEN AND PREMARIN MAX ONE TABLET PER DAY
F, QL PA F, QL
Page 18 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) PREMPHASE PREMPRO PREMPRO LO MENEST ENJUVIA PREMARIN OGEN ORTHO-EST LUNESTA ENBREL MYAMBUTOL ETHAQUIN YASMIN TRECATOR ZARONTIN PEGANONE ETHYL CHLORIDE DEMULEN DIDRONEL LODINE XL LODINE NUVARING INTELENCE * AROMASIN

GENERIC NAME ESTROGEN, CON/M-PROGEST ACET ESTROGEN, CON/M-PROGEST ACET ESTROGEN, CON/M-PROGEST ACET ESTROGENS, ESTERIFIED ESTROGENS,CONJ,SYNTHETIC B ESTROGENS/ CONJUGATED ESTROPIPATE ESTROPIPATE ESZOPICLONE ETANERCEPT ETHAMBUTOL HCL ETHAVERINE HCL ETHINYL ESTRADIOL/DROSPIRENONE ETHIONAMIDE ETHOSUXIMIDE ETHOTOIN ETHYL CHLORIDE ETHYNODIOL D-ETHINYL ESTRADIOL ETIDRONATE DISODIUM ETODOLAC ETODOLAC ETONOGESTREL-ETHINYL ESTRADIOL ETRAVINE EXEMESTANE OTC DOSAGE FORM TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET ALL FORMS KIT TABLET TABLET TABLET TABLET ALL FORMS ALL FORMS SPRAY TABLET TABLET TAB ER 24HR TABLET VAG RING ALL FORMS TABLET RESTRICTIONS F, QL F, QL F, QL QL PA F, QL F F MDCH PA, SP
COMMENTS MAX ONE TABLET PER DAY MAX ONE TABLET PER DAY MAX ONE TABLET PER DAY MAX ONE TABLET PER DAY ALT: ESTRACE, OGEN AND PREMARIN MAX ONE TABLET PER DAY
* *
BILLED TO STRAIGHT MEDICAID CRITERIA MUST BE MET
* *
F, QL MDCH MDCH
FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS.
* * * *
F, QL
F, QL MDCH F, QL
BYETTA
EXENATIDE
PEN INJ
PA
BYDUREON ZETIA
EXENATIDE MICROSPHERES EZETIMIBE
INJECTION TABLET
PA PA
MAX ONE RING EVERY 28 DAYS BILLED TO STRAIGHT MEDICAID FEMALES ONLY. MAX ONE TABLET PER DAY TYPE II DIABETIC WHO HAS FAILED TO MEET DIABETIC A1C GOALS AFTER THE COMPLIANT USE OF TWO ORAL FORMULARY ALTERNATIVES. TYPE II DIABETIC WHO HAS FAILED TO MEET DIABETIC A1C GOALS AFTER THE COMPLIANT USE OF TWO ORAL FORMULARY ALTERNATIVES. ALT: LIPITOR, MEVACOR, PRAVACHOL AND ZOCOR
Page 19 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) VYTORIN POTIGA MONONINE BEBULIN BENEFIX PROFILNINE CORIFACT * * * FAMVIR PEPCID VITAFOL NIFEREX ULORIC FELBATOL PLENDIL LIPOFEN FENOGLIDE TRICOR TRIGLIDE LOFIBRA LOFIBRA ANTARA FIBRICOR TRILIPIX DURAGESIC SUBSYS GENERIC NAME

OTC DOSAGE FORM TABLET ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS TABLET TABLET TABLET CAPSULE TABLET ALL FORMS TAB ER 24HR CAPSULE TABLET TABLET TABLET CAPSULE TABLET CAPSULE TABLET CAPSULE DR RESTRICTIONS PA MDCH MDCH MDCH MDCH MDCH MDCH ST, QL
EZETIMIBE/SIMVASTATIN EZOGABINE FACTOR IX FACTOR IX COMPLEX, HUMAN FACTOR IX HUMAN, RECOMBINANT FACTOR IX HUMAN, RECOMBINANT FACTOR XIII FAMCICLOVIR FAMOTIDINE FE FUMARATE/CAL/FA/MIN FE P-SAC CMPLX/VIT B12/FA FEBUXOSTAT FELBAMATE FELODIPINE FENOFIBRATE FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE, MICRO FENOFIBRATE, MICRO FENOFIBRATE/ MICRONIZED FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) FENTANYL FENTANYL
COMMENTS ALT: LIPITOR, MEVACOR, PRAVACHOL AND ZOCOR BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID FAILURE OR ACYCLOVIR. MAX THREE TABLETS PER DAY
* *
PA, QL MDCH QL PA PA PA PA
FAILURE OF ALLOPURINOL. MAX ONE TABLET PER DAY. BILLED TO STRAIGHT MEDICAID MAX ONE TABLET PER DAY ALT: FIBRICOR, LOFIBRA AND LOPID ALT: FIBRICOR, LOFIBRA AND LOPID ALT: FIBRICOR, LOFIBRA AND LOPID ALT: FIBRICOR, LOFIBRA AND LOPID
* * *
PA PA
ALT: FIBRICOR, LOFIBRA AND LOPID ALT: FIBRICOR, LOFIBRA AND LOPID MAX ONE PATCH EVERY THREE DAYS CANCER DIAGNOSIS AND INABILITY TO USE ACTIQ LOZENGES CANCER DIAGNOSIS REQUIRED. FAILURE/INTOLERANCE TO DEMEROL, DILAUDID, MSIR AND OXYIR.
PATCH TD72HR QL SL SPRAY PA
ABSTRAL
FENTANYL
TABLET SL
PA
Page 20 of 54
January 2013

COMMENTS CANCER DIAGNOSIS REQUIRED. FAILURE/INTOLERANCE TO DEMEROL, DILAUDID, MSIR AND OXYIR. CANCER DIAGNOSIS. FAILURE/INTOLERANCE TO FORMULARY ALTERNATIVES CANCER DIAGNOSIS. FAILURE/INTOLERANCE TO FORMULARY ALTERNATIVES
ACTIQ
FENTANYL CITRATE
LOZENGE HD
PA
LAZANDA
FENTANYL CITRATE
NASAL SPRAY
PA
* * * * * * * * *
FENTORA FEOSOL FER-IN-SOL FEOSOL FEOSOL FERGON SLOW FE TOVIAZ ALLEGRA OTC ALLEGRA-D 12HR OTC ALLEGRA-D 24HR OTC DIFICID NEUPOGEN PROSCAR
FENTANYL CITRATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FESOTERODINE FUMARATE FEXOFENADINE FEXOFENADINE/ PSEUDOEPHEDRINE FEXOFENADINE/ PSEUDOEPHEDRINE FIDAXOMICIN FILGASTIM FINASTERIDE
OTC OTC OTC OTC OTC OTC OTC OTC OTC
TABLET EFF DROPS DROPS ELIXER TABLET TABLET TABLET SA TAB ER 24HR TABLET TABLET TABLET TABLET VIAL TABLET
PA
PA QL, ST PA, QL PA, QL PA PA
ALT: DITROPAN/DITROPAN XL FAILURE OF CLARITIN AND ZYRTEC FAILURE OF CLARITIN-D AND ZYRTEC-D. MAX TWO TABLETS PER DAY FAILURE OF CLARITIN-D AND ZYRTEC-D. MAX ONE TABLET PER DAY. QUALIFYING DIAGNOSIS. FAILURE OF FLAGYL WHEN APPROPRIATE. CRITERIA MUST BE MET DIAGNOSIS OF MULTIPLE SCLEROSIS AND FAILURE OF TWO FORMULARY ALTERNATIVES SUCH AS AVONEX, BETASERON, COPAXONE AND REBIF.
* * * * * * * * * * *
GILENYA URISPAS TAMBOCOR DIFLUCAN DIFLUCAN DIFLUCAN 150MG FLORINEF NASALIDE SYNALAR DERMOTIC DERMA-SMOOTH DERMA-SMOOTHE FS
FINGOLIMOD HCL FLAVOXATE HCL FLECAINIDE ACETATE FLUCONAZOLE FLUCONAZOLE FLUCONAZOLE FLUDROCORTISONE ACETATE FLUNISOLIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE
CAPSULE TABLET TABLET RECON SUSP TABLET TABLET TABLET NASAL SPRAY CREAM EAR DROP OIL OIL
PA, SP
QL QL QL
MAX EIGHT TABLETS PER MONTH MAX ONE CANNISTER EVERY 20 DAYS MAX 20MLS PER FILL
Page 21 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * SYNALAR CAPEX * LIDEX * LIDEX * LIDEX * LIDEX * LIDEX E * FML FML FORTE FML SOP * EFUDEX * ADRUCIL * EFUDEX * PROZAC * PROZAC WEEKLY * SARAFEM * HALOTESTIN * PROLIXIN * DALMANE * ANSAID * OCUFEN * EULEXIN VERAMYST * CUTIVATE FLOVENT HFA FLOVENT DISKUS * FLONASE * CUTIVATE ADVAIR DISKUS ADVAIR HFA * LESCOL LESCOL XL LUVOX LUVOX CR NEPHROCAPS B-PLEX NEPHROVITE RX ARIXTRA FORADIL GENERIC NAME FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE/EMOLLIENT FLUOROMETHOLONE FLUOROMETHOLONE FLUOROMETHOLONE FLUOROURACIL FLUOROURACIL FLUOROURACIL FLUOXETINE FLUOXETINE FLUOXETINE FLUOXYMESTERONE FLUPHENAZINE FLURAZEPAM FLURBIPROFEN FLURBIPROFEN SODIUM FLUTAMIDE FLUTICASONE FUROATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE/SALMETEROL FLUTICASONE/SALMETEROL FLUVASTATIN SODIUM

OTC DOSAGE FORM OINTMENT SHAMPOO CREAM GEL OINTMENT SOLUTION CREAM EYE DROP EYE DROP EYE OINT CREAM SOLUTION SOLUTION ALL FORMS ALL FORMS ALL FORMS TABLET ALL FORMS ALL FORMS TABLET EYE DROP TABLET NASAL SPRAY CREAM HFA INHALER INHALER NASAL SPRAY OINTMENT INHALER INHALER CAPSULE TAB ER 24HR ALL FORMS ALL FORMS CAPSULE TABLET TABLET DISP SYRIN CAP W/DEV RESTRICTIONS
COMMENTS
MDCH MDCH MDCH MDCH MDCH
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
PA QL QL QL QL QL PA PA MDCH MDCH
ALT: FLONASE AND NASACORT AQ MAX ONE INHALER PER MONTH MAX ONE INHALER PER MONTH MAX 16GMS PER MONTH MAX ONE INHALER PER MONTH MAX ONE INHALER PER MONTH ALT: LIPITOR, MEVACOR, PRAVACHOL AND ZOCOR ALT: LIPITOR, MEVACOR, PRAVACHOL AND ZOCOR BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* * * *
FLUVASTATIN SODIUM FLUVOXAMINE FLUVOXAMINE FOLIC ACID/VITAMIN B COMPLEX FOLIC ACID/VITAMIN B COMPLEX FOLIC ACID/VITAMIN B COMPLEX FONDAPARINAX SODIUM FORMOTEROL FUMARATE
PA, SP QL
ALT: COUMADIN WHEN APPROPRIATE MAX 60 DOSES PER MONTH
Page 22 of 54
January 2013
GEQ ONLY * * BRAND NAME (REFERENCE ONLY) LEXIVA MONOPRIL MONOPRIL HCT CEREBYX FROVA GOLYTELY LASIX LASIX NEURONTIN GRALISE HORIZANT RAZADYNE ER RAZADYNE NAGLAZYME CYTOVENE LOPID FACTIVE GARAMYCIN GARAMYCIN GARAMYCIN GARAMYCIN PRED-G PRED-G COPAXONE AMARYL GLUCOTROL XL GLUCOTROL GLUCAGON DIABETA MICRONASE GLYNASE ROBINUL ROBINUL FORTE SIMPONI SANCUSO GENERIC NAME FOSAMPRENAVIR CALCIUM FOSINOPRIL SODIUM FOSINOPRIL/HCTZ FOSPHENYTOIN FROVATRIPTAN SUCCINATE FULF/SOD/NA/KCL/PEGS FUROSEMIDE FUROSEMIDE GABAPENTIN GABAPENTIN GABAPENTIN ENACARBIL GALANTAMINE HBR

OTC DOSAGE FORM ALL FORMS TABLET TABLET ALL FORMS TABLET POWDER ORAL SOLN TABLET ALL FORMS TABLET ER TABLET ER CAP24HR PEL TABLET ALL FORMS CAPSULE TABLET TABLET CREAM EYE DROP EYE OINT OINTMENT EYE DROP EYE OINT KIT TABLET TAB ER 24HR TABLET KIT TABLET TABLET TABLET TABLET TABLET PEN INJ PATCH TDWK RESTRICTIONS MDCH QL QL MDCH PA, QL
COMMENTS BILLED TO STRAIGHT MEDICAID MAX TWO TABLETS PER DAY MAX TWO TABLETS PER DAY BILLED TO STRAIGHT MEDICAID FAILURE OF AMERGE AND IMITREX. MAX NINE TABLETS PER MONTH.
* * * *
MDCH PA PA PA PA MDCH PA PA
* *
* * * * *
* * *
* * * * *
GALANTAMINE HBR GALSULFASE GANCICLOVIR GEMFIBROZIL GEMIFLOXACIN MESYLATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN/PREDNISOLONE GENTAMICIN/PREDNISOLONE GLATIRAMER ACETATE GLIMEPIRIDE GLIPIZIDE GLIPIZIDE GLUCAGON, HUMAN RECOMBINANT GLYBURIDE GLYBURIDE GLYBURIDE MICRONIZED GLYCOPYRROLATE GLYCOPYRROLATE GOLIMUMAB GRANISETRON
BILLED TO STRAIGHT MEDICAID ALT: NEURONTIN ALT: NEURONTIN DIAGNOSIS OF ALZHEIMER'S DISEASE REQUIRED DIAGNOSIS OF ALZHEIMER'S DISEASE REQUIRED BILLED TO STRAIGHT MEDICAID CRITERIA MUST BE MET ALT: CIPRO, FLOXIN AND LEVAQUIN
PA, SP
DIAGNOSIS OF MULTIPLE SCLEROSIS
PA, SP PA
QUALIFYING DIAGNOSIS REQUIRED. CANCER DIAGNOSIS REQUIRED WITH FAILURE OF ZOFRAN
Page 23 of 54
January 2013
GEQ ONLY * * BRAND NAME (REFERENCE ONLY) KYTRIL GRIFULVIN V GRIFULVIN GRIS PEG ROBITUSSIN DM QUIBRON QUIBRON ORGANIDIN NR WYTENSIN INTUNIV TENEX ROBITUSSIN ROBITUSSIN AC ROBITUSSIN DAC ULTRAVATE ULTRAVATE HALDOL RONDEC DM RONDEC DM PANHEMATIN HEPARIN PHISOHEX ISOPTO HOMATROPINE HUMULIN 70/30 HUMULIN 70/30 NOVOLIN 70/30 APRESOLINE APRESAZIDE MARPRES HYDRODIURIL MICROZIDE ESIDREX LORCET LORTAB GENERIC NAME GRANISETRON HCL GRISEOFULVIN, MICROSIZE GRISEOFULVIN, MICROSIZE

OTC DOSAGE FORM CAPSULE ORAL SUSP TABLET TABLET SYRUP CAPSULE LIQUID TABLET TABLET ALL FORMS TABLET SYRUP SYRUP SYRUP CREAM OINTMENT ALL FORMS DROPS SYRUP ALL FORMS DISP SYRINGE LIQUID EYE DROP PEN VIAL VIAL TABLET CAPSULE TABLET CAPSULE CAPSULE TABLET TABLET TABLET QL QL RESTRICTIONS PA
COMMENTS CANCER DIAGNOSIS. FAILURE OF ZOFRAN.
* * * * * * * * * * * * * * *
GRISEOFULVIN, ULTRAMICROSIZE GUAIFENESIN/D-METHORPHAN OTC GUAIFENESIN/THEOPHYLLINE GUAIFENESIN/THEOPHYLLINE GUAIFENISIN GUANABENZ ACETATE GUANFACINE GUANFACINE HCL GUIAFENESIN OTC GUIAFENESIN/CODEINE GUIAFENESIN/PSE/CODEINE HALOBETASOL PROPIONATE HALOBETASOL PROPIONATE HALOPERIDOL HB/PE/CHLORPHEN HB/PE/CHLORPHEN HEMIN HEPARIN SODIUM, PORCINE HEXACHLOROPHENE HOMATROPINE HBR HUM INSULIN NPH/REG INSULIN HM HUM INSULIN NPH/REG INSULIN HM HUMAN INSULIN NPH/REG INSULIN HYDRALAZINE HYDRALAZINE/HCTZ HYDRALAZINE/RESERPINE/HCTZ HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCODONE/APAP HYDROCODONE/APAP
MDCH
MDCH
MDCH
AG
NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18
* * * * * * *
MAX 4000MGS OF APAP PER DAY (CUMMULATIVE) MAX 4000MGS OF APAP PER DAY (CUMMULATIVE)
Page 24 of 54
January 2013
GEQ ONLY * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * BRAND NAME (REFERENCE ONLY) NORCO VICODIN VICODIN ES VICODIN HP HYCODAN HYCODAN CORTAID HYTONE PROCTOCORT PROCTOZONE HC CORTENEMA HYTONE CORTAID HYTONE HYTONE CORTEF CORTIFOAM ANUSOL HC LOCOID LOCOID ANALPRAM HC PLAQUENIL DIUCARDIN DILAUDID DILAUDID DILAUDID HYDREA ATARAX VISTARIL LEVSINEX LEVSIN LEVSIN LEVBID LEVSIN LEVSIN SL BONIVA ADVIL MOTRIN IB MOTRIN

GENERIC NAME HYDROCODONE/APAP HYDROCODONE/APAP HYDROCODONE/APAP HYDROCODONE/APAP HYDROCODONE/HOMATROPINE HYDROCODONE/HOMATROPINE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE HYDROCORTISONE/PRAMOXINE HYDROCXYCHLOROQUINE SULFATE HYDROFLUMETHIAZIDE HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROXYUREA HYDROXYZINE HCL HYDROXYZINE PAMOATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE IBANDRONATE SODIUM IBUPROFEN IBUPROFEN IBUPROFEN OTC DOSAGE FORM TABLET TABLET TABLET TABLET SYRUP TABLET CREAM CREAM CREAM CREAM ENEMA LOTION OINTMENT OINTMENT SOLUTION TABLET FOAM SUPPOSITORY CREAM OINTMENT CREAM/APP TABLET TABLET LIQUID SUPPOSITORY TABLET CAPSULE TABLET CAPSULE CAPSULE SR DROPS ELIXER TAB ER 12HR TABLET TABLET SL TABLET TABLET CHEW TAB ORAL SUSP RESTRICTIONS QL QL QL QL QL QL
COMMENTS MAX 4000MGS OF APAP PER DAY MAX EIGHT TABLETS PER DAY MAX FIVE TABLETS PER DAY MAX SIX TABLETS PER DAY MAX 30MLS PER DAY MAX SIX TABLETS PER DAY
OTC
OTC
OTC
PA
ALT: ANUSOL HC AND PROCTOZONE HC
PA
ALT: FOSAMAX
OTC OTC OTC
Page 25 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * MOTRIN ELAPRASE FANAPT GLEEVEC CEREZYME * TOFRANIL * TOFRANIL PM * ALDARA ARCAPTA NEOHALER * LOZOL CRIXIVAN * INDOCIN * INDOCIN SR NOVOLOG MIX NOVOLOG MIX NOVOLOG NOVOLOG LEVEMIR LEVEMIR LANTUS LANTUS SOLASTAR LANTUS APIDRA APIDRA SOLASTAR APIDRA HUMALOG HUMALOG NOVOLIN-N HUMALOG MIX HUMALOG MIX GENERIC NAME IBUPROFEN IDURSULFASE ILOPERIDONE IMATINIB MESYLATE IMIGLUCERASE IMIPRAMINE IMIPRAMINE IMIQUIMOD INDACATEROL INDAPAMIDE INDINAVIR SULFATE INDOMETHACIN INDOMETHACIN

OTC DOSAGE FORM TABLET ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS PACKET INHALER TABLET ALL FORMS CAPSULE CAPSULE SR PEN VIAL PEN VIAL PEN VIAL CARTRIDGE PEN VIAL CARTRIDGE PEN VIAL PEN VIAL VIAL PEN VIAL AG AG AG RESTRICTIONS MDCH MDCH MDCH MDCH MDCH MDCH QL QL MDCH PA AG
COMMENTS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX 12 PACKETS PER FILL MAX ONE INHALER PER MONTH BILLED TO STRAIGHT MEDICAID ALT: INDOCIN (NOT SR) NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18
INSULIN ASP PRT/INSULIN ASPART INSULIN ASP PRT/INSULIN ASPART INSULIN ASPART INSULIN ASPART INSULIN DETEMIR INSULIN DETEMIR INSULIN GLARGINE INSULIN GLARGINE INSULIN GLARGINE INSULIN GLULISINE INSULIN GLULISINE INSULIN GLULISINE INSULIN LISPRO INSULIN LISPRO INSULIN NPH, HUMAN RECOM INSULIN NPL/INSULIN LISPRO INSULIN NPL/INSULIN LISPRO
NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18 NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18 NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18 NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18 NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18 NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18 NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18
AG AG
AG
AG
NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18
Page 26 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) HUMULIN R HUMULIN R NOVOLIN-R INTRON A AVONEX REBIF BETASERON YODOXIN COMBIVENT COMBIVENT RESPIMAT DUONEB ATROVENT HFA ATROVENT ATROVENT GENERIC NAME INSULIN REGULAR, HUMAN INSULIN REGULAR, HUMAN

OTC DOSAGE FORM PEN VIAL VIAL VIAL KIT DISP SYRINGE KIT TABLET INHALER INHALER NEB SOLN INHALER NASAL SPRAY NEB SOLN RESTRICTIONS AG
COMMENTS NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18
* * *
INSULIN REGULAR, HUMAN RECOM INTERFERON ALFA-2B, RECOM INTERFERON BETA-1A INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1B IODOQUINOL IPATROPIUM/ALBUTEROL IPATROPIUM/ALBUTEROL IPATROPIUM/ALBUTEROL IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE
PA, SP PA, SP PA, SP PA, SP QL QL QL QL
CRITERIA MUST BE MET DIAGNOSIS OF MULTIPLE SCLEROSIS DIAGNOSIS OF MULTIPLE SCLEROSIS DIAGNOSIS OF MULTIPLE SCLEROSIS MAX TWO INHALERS PER MONTH MAX TWO INHALERS PER MONTH MAX TWO INHALERS PER MONTH MAX ONE CANNISTER PER MONTH FAILURE OF TWO FORMULARY ACE INHIBITORS AND COZAAR. MAX ONE TABLET PER DAY. FAILURE OF TWO FORMULARY ACE INHIBITORS PLUS HCTZ AND FAILURE OF HYZAAR. MAX ONE TABLET PER DAY. BILLED TO STRAIGHT MEDICAID
AVAPRO
IRBESARTAN
TABLET
PA
AVALIDE MARPLAN BRONKOSOL MIDRIN INH INH ISONIAZID ISORDIL DILATRATE-SR ISORDIL SR ISORDIL IMDUR ISMO MONOKET ACCUTANE VASODILAN DYNACIRC CR
* * * * * * * * * * * *
IRBESARTAN/HCTZ ISOCARBOXAZIDE ISOETHARINE HCL ISOMETHEPTENE/APAP/ DICHLORPHEN ISONIAZID ISONIAZID ISONIAZID ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOTRETINOIN ISOXSUPRINE HCL ISRADIPINE
TABLET ALL FORMS SOLUTION CAPSULE SYRUP TABLET TABLET TABLET TABLET ER TABLET SA TABLET SL TAB ER 24HR TABLET TABLET CAPSULE TABLET TAB ER 24HR
PA, QL MDCH
QL
MAX SIX CAPSULES PER DAY
PA
ALT: ISORDIL (NOT SR)
PA, QL PA
ALT: BENZACLIN, BENZAMYCIN, CLEOCIN, RETIN-A AND TRIAZ. ALT: CARDIZEM AND PLENDIL
Page 27 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * DYNACIRC * SPORANOX SKLICE STROMECTOL * NIZORAL * NIZORAL * NIZORAL * ORUDIS * ACULAR * ACULAR LS ACUVAIL * TORADOL * ZADITOR * NORMODYNE VIMPAT CEPHULAC * LACTULOSE * CEPHULAC * CHRONULAC COMBIVIR * LAMICTAL LAMICTAL XR * EPIVIR PREVACID OTC * PREVACID RX FIRST-LANSOPRAZOLE GENERIC NAME

OTC DOSAGE FORM TABLET CAPSULE LOTION TABLET CREAM SHAMPOO TABLET CAPSULE EYE DROP EYE DROP EYE DROP TABLET EYE DROP TABLET ALL FORMS ALL FORMS ORAL SOLN SYRUP SYRUP ALL FORMS ALL FORMS ALL FORMS ALL FORMS CAPSULE CAPSULE SUSP RECON RESTRICTIONS PA PA PA
ISRADIPINE ITRACONAZOLE IVERMECTIN IVERMECTIN KETOCONAZOLE KETOCONAZOLE KETOCONAZOLE KETOPROFEN KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOTIFEN FUMERATE LABETALOL HCL LACOSAMIDE LACTULOSE LACTULOSE LACTULOSE LACTULOSE LAMIVUDINE/ZIDOVUDINE LAMOTRIGINE LAMOTRIGINE LAMUVIDINE LANSOPRAZOLE LANSOPRAZOLE LANSOPRAZOLE
COMMENTS ALT: CARDIZEM AND PLENDIL ALT: DIFLUCAN AND NYSTATIN ALT: RID
PA
ALT: ACULAR
OTC
MDCH MDCH
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
OTC
MDCH MDCH MDCH MDCH MDCH QL PA AG
PREVACID SOLUTAB PREVPAC FOSRENOL TYKERB ALDURAZYME XALATAN ARAVA FEMARA WELLCOVORIN
* * * *
LANSOPRAZOLE LANSOPRAZOLE/AMOXICILLIN AND CLARITHROMYCIN LANTHANUM CARBONATE LAPATINIB DITOSYLATE LARONIDASE LATANOPROST LEFLUNOMIDE LETROZOLE LEUCOVORIN CALCIUM
TAB RAPID PACK CHEW TAB ALL FORMS ALL FORMS EYE DROP TABLET TABLET TABLET
AG, QL PA PA MDCH MDCH QL
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX FOUR CAPSULES PER DAY ALT: PREVACID OTC, PRILOSEC, PROTONIX AND ZEGERID OTC COVERED FOR THOSE MEMBERS 10 YEARS OF AGE AND YOUNGER. COVERED FOR THOSE MEMBERS 10 YEARS OF AGE AND YOUNGER. MAX ONE TABLET PER DAY. ALT: PREVACID OTC, AMOXICILLIN AND BIAXIN BILLED SEPARATELY ALT: PHOSLO BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX 2.5MLS EVERY 28 DAYS FEMALES ONLY. MAX ONE TABLET PER DAY
F, QL
Page 28 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * LEUCOVORIN * LUPRON LUPRON DEPOT XOPENEX HFA * * * * XOPENEX KEPPRA KEPPRA XR BETAGAN CARNITOR XYZAL IQUIX LEVAQUIN NEXT CHOICE NEXT CHOICE PLUS PLAN B PLAN B ONE STEP ALESSE LEVLEN * * NORDETTE TRIPHASIL TIROSINT SYNTHROID LIDODERM XYLOCAINE XYLOCAINE XYLOCAINE EMLA TRADJENTA ZYVOX GENERIC NAME LEUCOVORIN CITRATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEVALBUTEROL HCL LEVALBUTEROL HCL LEVETRIACETAM LEVETRIACETAM LEVOBUNOLOL HCL LEVOCARNITINE LEVOCETIRIZINE DIHYDROCHLORIDE LEVOFLOXACIN LEVOFLOXACIN LEVONORGESTREL LEVONORGESTREL LEVONORGESTREL LEVONORGESTREL LEVONORGESTREL-ETHINYL ESTRADIOL LEVONORGESTREL-ETHINYL ESTRADIOL LEVONORGESTREL-ETHINYL ESTRADIOL LEVONORGESTREL-ETHINYL ESTRADIOL LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LIDOCAINE LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE/PRILOCAINE LINAGLIPTIN LINEZOLID

OTC DOSAGE FORM TABLET KIT KIT HFA INHALER NEB SOLN ALL FORMS ALL FORMS EYE DROP ALL FORMS TABLET EYE DROP TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE TABLET PATCH GEL OINTMENT SOLUTION CREAM TABLET TABLET RESTRICTIONS PA, SP PA, SP PA PA MDCH MDCH MDCH QL PA QL F, QL F, QL F, QL F,QL F, QL F, QL F, QL F, QL PA PA
COMMENTS CRITERIA MUST BE MET CRITERIA MUST BE MET FAILURE/INTOLERANCE TO ALBUTEROL FAILURE/INTOLERANCE TO ALBUTEROL BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX ONE TABLET PER DAY ALT: CILOXAN, OCUFLOX AND VIGAMOX MAX ONE TABLET PER DAY MAX TWO TABLETS PER MONTH MAX ONE TABLET PER MONTH MAX ONE TABLET PER MONTH MAX TWO TABLETS PER MONTH FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS ALT: LEVOTHROID, LEVOXYL AND SYNTHROID ALT: LIDOCAINE OINTMENT
* * *
OTC OTC OTC OTC
* * * * *
PA PA
FAILURE OF METFORMIN AND SULFONYLUREAS CRITERIA MUST BE MET
Page 29 of 54
January 2013

CYTOMEL THYROLAR PANCREASE PANCREAZE PERTZYE ZENPEP VIOKACE
LIOTHYRONINE SODIUM LIOTRIX LIPASE/AMYLASE/PROTEASE LIPASE/AMYLASE/PROTEASE LIPASE/AMYLASE/PROTEASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE
TABLET TABLET CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR TABLET
QL PA
COMMENTS MAX 4 TABLETS PER DAY ON 5MCG, MAX 2 TABLETS PER DAY ON 25MCG AND 50MCG ALT: ARMOUR THYROID AND SYNTHROID
* * * * * * *
VICTOZA VYVANSE PRINIVIL ZESTRIL PRINZIDE ZESTORETIC ESKALITH ESKALITH CR LITHOBID CIBALITH-S ALOMIDE CEENU IMODIUM KALETRA CLARITIN CLARITIN CLARITIN CLARITIN-D OTC 12HR CLARITIN-D OTC 24HR ATIVAN COZAAR HYZAAR ALREX
LIRAGLUTUDE LISDEXAMFETAMINE DIMESYLATE LISINOPRIL LISINOPRIL LISINOPRIL/HCTZ LISINOPRIL/HCTZ LITHIUM CARBONATE LITHIUM CARBONATE LITHIUM CARBONATE LITHIUM CITRATE LODOXAMIDE TROMETHAMINE LOMUSTINE LOPERAMIDE HCL LOPINAVIR/RITONAVIR LORATADINE LORATADINE LORATADINE
PEN INJ ALL FORMS TABLET TABLET TABLET TABLET ALL FORMS ALL FORMS ALL FORMS ALL FORMS EYE DROP CAPSULE CAPSULE ALL FORMS RAPDIS TAB SYRUP TABLET TABLET DR 12HR TABLET DR 24HR ALL FORMS TABLET TABLET EYE DROP
PA MDCH QL QL QL QL MDCH MDCH MDCH MDCH PA PA MDCH
TYPE II DIABETIC WHO HAS FAILED TO MEET DIABETIC A1C GOALS AFTER THE COMPLIANT USE OF TWO ORAL FORMULARY ALTERNATIVES. BILLED TO STRAIGHT MEDICAID MAX TWO TABLETS PER DAY MAX TWO TABLETS PER DAY MAX TWO TABLETS PER DAY MAX TWO TABLETS PER DAY BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR QUALIFYING DIAGNOSIS REQUIRED. BILLED TO STRAIGHT MEDICAID
* * * * * * * * *
OTC OTC OTC
LORATADINE/ PSEUDOEPHEDRINE OTC LORATADINE/ PSEUDOEPHEDRINE OTC LORAZEPAM LOSARTAN POTASSIUM LOSARTAN/HCTZ LOTEPREDNOL ETABONATE
QL QL MDCH QL QL PA
MAX TWO TABLETS PER DAY MAX ONE TABLET PER DAY BILLED TO STRAIGHT MEDICAID MAX ONE TABLET PER DAY MAX ONE TABLET PER DAY ALT: DECADRON, FML AND PRED FORTE
Page 30 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) LOTEMAX GENERIC NAME LOTEPREDNOL ETABONATE

OTC DOSAGE FORM EYE DROP RESTRICTIONS PA
COMMENTS ALT: DECADRON, FML AND PRED FORTE FAILURE OF LIPITOR, MEVACOR, PRAVACHOL AND ZOCOR. MAX ONE TABLET PER DAY. MAX ONE TABLET PER DAY MAX TWO TABLETS PER DAY BILLED TO STRAIGHT MEDICAID FAILURE OF COLACE, LACTULOSE, MIRALAX AND SENNA BILLED TO STRAIGHT MEDICAID
* * *
ALTOPREV MEVACOR MEVACOR 40MG LOXITANE AMITIZA LATUDA SULFAMYLON
LOVASTATIN LOVASTATIN LOVASTATIN LOXAPINE
TAB DR 24HR TABLET TABLET ALL FORMS CAPSULE ALL FORMS CREAM OTC OTC OTC ORAL SUSP ORAL SUSP ORAL SUSP TABLET LOTION ALL FORMS ALL FORMS CHEW TAB TABLET TABLET TABLET TABLET CAPSULE DISP SYRINGE TABLET TABLET ORAL SUSP ORAL SUSP TABLET TABLET TABLET TABLET TABLET SYRUP TABLET
PA QL QL MDCH PA MDCH
* * * *
* * * * * * * *
LUBIPROSTONE LURASIDONE HCL MAFENIDE ACETATE MAG CARB/AL HYDROX/ALGINIC ACID GAVISCON MAG HYDROXIDE/SIMETHICONE MAALOX MAGNESIUM HYDROXIDE MYLANTA MAGNESIUM SALICYLATE MAGAN MALATHION OVIDE MAPROTILINE LUDIOMIL MARAVIROC SELZENTRY MEBENDAZOLE VERMOX MECLIZINE DRAMAMINE MECLIZINE HCL ANTIVERT MECLIZINE HCL ANTIVERT 50MG MECLIZINE HCL BONINE MECLOFENAMATE SODIUM MECLOMEN MEDROXYPROGESTERONE DEPO-PROVERA 150MG ACETATE MEDROXYPROGESTERONE ACETATE PROVERA MEFLOQUINE HCL LARIAM MEGESTEROL ACETATE MEGACE MEGACE ES MEGACE MOBIC ALKERAN NAMENDA CANTIL DEMEROL DEMEROL MEGESTEROL ACETATE MEGESTEROL ACETATE MELOXICAM MELPHALAN MEMANTINE HCL MEPENZOLATE BROMIDE MEPERIDINE HCL MEPERIDINE HCL
QL MDCH MDCH
MAX 118MLS PER FILL BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
OTC
PA
ALT: ANTIVERT 25MG
OTC
F, QL
MAX ONE DOSE EVERY 75 DAYS
QL
MAX ONE TABLET PER WEEK ALT: MEGACE (NOT ES) TABLETS OR ORAL SUSPENSION MAX 15MG PER DAY CRITERIA MUST BE MET
PA QL PA
* *
* *
Page 31 of 54
January 2013
GEQ ONLY * * * * BRAND NAME (REFERENCE ONLY) MEBARAL EQUANIL MILTOWN PURINETHOL APRISO PENTASA ROWASA CANASA ASACOL ASACOL HD LIALDA ALUPENT ALUPENT ALUPENT ALUPENT

GENERIC NAME MEPHOBARBITAL MEPROBAMATE MEPROBAMATE MERCAPTOPURINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE METAPROTERENOL SULFATE METAPROTERENOL SULFATE METAPROTERENOL SULFATE METAPROTERENOL SULFATE OTC DOSAGE FORM ALL FORMS ALL FORMS ALL FORMS TABLET CAP ER 24HR CAPSULE SA ENEMA SUPPOSITORY TABLET DR TABLET DR TABLET DR INHALER SOLUTION SYRUP TABLET RESTRICTIONS MDCH MDCH MDCH PA
COMMENTS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: ASACOL AND PENTASA
PA
ALT: ASACOL AND PENTASA
PA
ALT: ASACOL AND PENTASA
* * *
* * * * * * * * * * * * * * * * * * * * * *
SKELAXIN FORTAMET GLUCOPHAGE XR GLUMETZA GLUCOPHAGE METAGLIP GLUCOVANCE DOLOPHINE DOLOPHINE METHADONE DESOXYN NEPTAZINE HIPREX UREX MANDELAMINE TAPAZOLE 10MG TAPAZOLE 5MG ROBAXIN METHOTREXATE RHEUMATREX METHOTREXATE CELONTIN ENDURON ALDOMET
METAXALONE METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN/GLIPIZIDE METFORMIN/GLYBURIDE METHADONE METHADONE METHADONE METHAMPHETAMINE METHAZOLAMIDE METHENAMINE HIPPURATE METHENAMINE HIPPURATE METHENAMINE MANDELATE METHIMAZOLE METHIMAZOLE METHOCARBAMOL METHOTREXATE METHOTREXATE METHOTREXATE METHSUXIMIDE METHYCLOTHIAZIDE METHYLDOPA
TABLET TAB ER 24HR TAB ER 24HR TABERGR24HR TABLET TABLET TABLET ORAL SOLN TABLET TABLET ALL FORMS ALL FORMS TABLET TABLET TABLET EC TABLET TABLET TABLET TABLET TABLET VIAL ALL FORMS TABLET TABLET
PA PA PA
ALT: BACLOFEN, FLEXERIL, NORFLEX, PARAFON, ROBAXIN AND ZANAFLEX TABLETS. ALT: GLUCOPHAGE XR ALT: GLUCOPHAGE XR
MDCH MDCH
QL QL
MAX SIX TABLETS PER DAY MAX THREE TABLETS PER DAY
MDCH
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January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * ALDORIL * METHERGINE * CONCERTA DAYTRANA * METADATE METADATE CD METADATE ER * METHYLIN * RITALIN RITALIN LA * RITALIN SR * MEDROL * MEDROL DOSEPACK

GENERIC NAME METHYLDOPA/HCTZ METHYLERGONOVINE MALEATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPREDNISOLONE METHYLPREDNISOLONE OTC DOSAGE FORM TABLET TABLET ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS TABLET TABLET RESTRICTIONS
COMMENTS
MDCH MDCH MDCH MDCH MDCH MDCH MDCH MDCH MDCH
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
ANDROID
METHYLTESTOSTERONE
TABLET
PA
* * * * * * * * * * * * *
METHITEST OPTIPRANOLOL REGLAN REGLAN ZAROXOLYN TOPROL XL LOPRESSOR LOPRESSOR HCT FLAGYL 375MG METROCREAM METROGEL METROGEL VAGINAL METROLOTION FLAGYL FLAGYL ER DEMSER MEXITIL MONISTAT MONISTAT-1 MONISTAT-3 MONISTAT-7 FUNGOID TINTURE
METHYLTESTOSTERONE METIPROPRANOLOL HCL METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL METOLAZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METOPROLOL/HCTZ METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METYROSINE MEXILETINE HCL MICONAZOLE NITRATE MICONAZOLE NITRATE MICONAZOLE NITRATE MICONAZOLE NITRATE MICONAZOLE NITRATE
TABLET EYE DROP ORAL SOLN TABLET TABLET TAB ER 24HR TABLET TABLET CAPSULE CREAM GEL GEL W/ APP LOTION TABLET TABLET ER CAPSULE CAPSULE CREAM CREAM W/APP CREAM W/APP CREAM W/APP TINCTURE
PA
PRESCRIBER MUST SUBMIT LAB WORK TO CONFIRM AN ABNORMALLY LOW TESTOSTERONE LEVEL. PRESCRIBER TO SUBMIT LAB WORK TO CONFIRM AN ABNORMALLY LOW TESTOSTERONE LEVEL.
PA
ALT: INDERAL, LOPRESSOR AND TENORMIN
PA
ALT: FLAGYL 250MG OR 500MG
QL PA
MAX 118MLS PER MONTH ALT: FLAGYL 250MG OR 500MG
* * * * *
OTC OTC OTC OTC OTC
Page 33 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * VERSED * PROAMTINE GLYSET ZAVESCA * * * * * * LACRI-LUBE SOP MINOCIN DYNACIN LONITEN REMERON CYTOTEC LYSODREN PROVIGIL UNIVASC GENERIC NAME MIDAZOLAM MIDODRINE MIGLITOL MIGLUSTAT

OTC DOSAGE FORM ALL FORMS TABLET TABLET ALL FORMS EYE OINT CAPSULE TABLET TABLET ALL FORMS TABLET TABLET ALL FORMS TABLET RESTRICTIONS MDCH QL PA MDCH
COMMENTS BILLED TO STRAIGHT MEDICAID MAX THREE TABLETS PER DAY FAILURE OF METFORMIN AND SULFONYLUREAS BILLED TO STRAIGHT MEDICAID
MINERAL OIL/PETROLATUM, WHITE MINOCYCLINE HCL MINOCYCLINE HCL MINOXIDIL MIRTAZIPINE MISOPROSTOL MITOTANE MODAFINIL MOEXIPRIL HCL
PA MDCH PA MDCH PA
ALT: MINOCIN AND VIBRATABS BILLED TO STRAIGHT MEDICAID QUALIFYING DIAGNOSIS REQUIRED. BILLED TO STRAIGHT MEDICAID ALT: ACCUPRIL, CAPOTEN, LOTENSIN, MONOPRIL, VASOTEC AND ZESTRIL. ALT: ACCURETIC, CAPOZIDE, MONOPRILHCT, VASERETIC OR ZESTORETIC. BILLED TO STRAIGHT MEDICAID MAX ONE INHALER PER MONTH ALT: FLONASE AND NASACORT AQ
* *
* * * * * *
UNIRETIC MOBAN ELOCON ASMANEX NASONEX ELOCON ELOCON DULERA SINGULAIR SINGULAIR SINGULAIR KADIAN AVINZA MSIR ROXANOL MSIR MS CONTIN ORAMORPH SR MOXEZA VIGAMOX
MOEXIPRIL/HCTZ MOLINDONE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE/FORMOTEROL MONTELUKAST SODIUM MONTELUKAST SODIUM MONTELUKAST SODIUM MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MOXIFLOXACIN HCL MOXIFLOXACIN HCL
TABLET ALL FORMS CREAM INHALER NASAL SPRAY OINTMENT SOLUTION HFA INHALER CHEW TAB GRANULES TABLET CAP ER PEL CPMP 24HR ORAL SOLN SUPPOSITORY TABLET TABLET SA TABLET SA EYE DROP EYE DROP
PA MDCH QL PA
QL QL PA QL PA PA
MAX ONE INHALER PER MONTH MAX ONE TABLET PER DAY ALT: SINGULAIR 4MG CHEWABLE TABLET MAX ONE TABLET PER DAY CANCER DIAGNOSIS. FAILURE OF MS CONTIN. CANCER DIAGNOSIS REQUIRED. FAILURE OF MS CONTIN
* * * * *
PA
ALT: CILOXAN, OCUFLOX AND QUIXIN
Page 34 of 54
January 2013
GEQ ONLY * * * * * * BRAND NAME (REFERENCE ONLY) AVELOX POLY VI SOL THERAGRAN M VICON FORTE POLY VI FLOR POLY VI FLOR POLY VI FLOR W/ IRON BACTROBAN BACTROBAN BACTROBAN POLY VI SOL W/ IRON CELLCEPT CELLCEPT BLEPHAMIDE SOP OPTIMYD VASOCIDIN RELAFEN NULYTELY CORGARD CORZIDE REVIA VASOCON NAPHCON-A OPCON-A OSMOPREP NAPROSYN NAPROSYN NAPROXEN EC ALEVE ANAPROX ANAPROX DS AMERGE STARLIX BYSTOLIC ALOCRIL SERZONE

GENERIC NAME MOXIFLOXACIN HCL MULTIVITAMIN MULTIVITAMIN/IRON/MIN/FA MULTIVITAMIN/MIN/FA MULTIVITAMINS/FLUORIDE MULTIVITAMINS/FLUORIDE MULTIVITAMINS/FLUORIDE/IRON MUPIROCIN MUPIROCIN MUPIROCIN MUTIVITAMIN W/ IRON MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL NA SULFACETAMIDE/ PREDNISOLONE NA SULFACETAMIDE/PRED NA SULFACETAMIDE/PRED NABUMETONE NACL/NAHCO3/KCL/PEG NADOLOL OTC OTC OTC DOSAGE FORM TABLET DROPS TABLET CAPSULE CHEW TAB DROPS DROPS CREAM NASAL OINTMENT DROPS CAPSULE TABLET EYE OINTMENT EYE DROP EYE DROP TABLET POWDER TABLET TABLET ALL FORMS EYE DROP EYE DROP EYE DROP TABLET ORAL SUSP TABLET TABLET DR TABLET TABLET TABLET TABLET TABLET TABLET EYE DROP ALL FORMS RESTRICTIONS PA
COMMENTS ALT: CIPRO, FLOXIN AND LEVAQUIN
PA PA
ALT: BACTROBAN OINTMENT ALT: BACTROBAN OINTMENT
* * * *
OTC
* * * * * * * * *
NADOLOL/ BENDROFLUMETHAZIDE NALTREXONE NAPHAZOLINE HCL NAPHAZOLINE HCL/PHENIR MAL OTC NAPHAZOLINE HCL/PHENIR MAL OTC NAPHOS M-B M-H/NAPHOS, DS-BA NAPROXEN NAPROXEN NAPROXEN NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN SODIUM NARATRIPTAN HCL NATEGLINIDE NEBIVOLOL HCL NEDOCROMIL SODIUM NEFAZODONE
MDCH
PA
ALT: COLYTE, GOLYTELY, NULYTELY AND TRILYTE
* * * * * * * *
OTC
QL
MAX NINE TABLETS PER MONTH ALT: INDERAL, LOPRESSOR AND TENORMIN ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR BILLED TO STRAIGHT MEDICAID
PA PA MDCH
Page 35 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) VIRACEPT MAXITROL MAXITROL NEGRAM NEOMYCIN CORTISPORIN MYCITRACIN NEOSPORIN PEDIOTIC POLY-PRED CORTISPORIN CORTISPORIN NEOSPORIN NEOSPORIN PROSTIGMIN NEVANAC VIRAMUNE VIRAMUNE XR SLO-NIACIN NIASPAN NIACIN NIACIN SLO-NIACIN ADVICOR SIMCOR CARDENE NICOTROL NS

GENERIC NAME NELFINAVIR MESYLATE NEO/POLY B SULF/DEXAMETHASONE NEO/POLY B SULF/DEXAMETHASONE NEOMYCIN SULFATE NEOMYCIN SULFATE NEOMYCIN/BACITRACIN/ POLYMIXIN/HC NEOMYCIN/BACITRACIN/ POLYMYXIN NEOMYCIN/POLY B/BACITRACIN NEOMYCIN/POLY B/BUFFERS/HC NEOMYCIN/POLY B/PRED NEOMYCIN/POLYMIXIN B/HC NEOMYCIN/POLYMIXIN/HC NEOMYCIN-POLYMYXIN-GRAMIC NEOMYCIN-POLYMYXIN-GRAMIC NEOSTIGMINE BROMIDE NEPAFENAC NEVIRAPINE NEVIRAPINE NIACIN NIACIN NIACIN NIACIN NIACIN NIACIN/LOVASTATIN NIACIN/SIMVASTATIN NICARDIPINE HCL NICOTINE OTC DOSAGE FORM ALL FORMS EYE DROP EYE OINT TABLET TABLET OINTMENT OTC OTC OINTMENT OINTMENT EAR DROP EYE DROP EYE DROP SOLUTION EYE DROP EYE OINT TABLET EYE DROP ALL FORMS ALL FORMS CAPSULE SA TAB ER 24HR TABLET TABLET SA TABLET SA TBMP 24HR TBMP 24HR CAPSULE NASAL SPRAY RESTRICTIONS MDCH
COMMENTS BILLED TO STRAIGHT MEDICAID
* * * * * * * * * * * *
* * * * * *
PA MDCH MDCH PA
ALT: ACULAR AND VOLTAREN BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: SLO-NIACIN
OTC OTC OTC OTC
PA PA PA
ALT: NIACIN PLUS MEVACOR ALT: NIACIN PLUS ZOCOR ALT: NICODERM, NICORETTE, ZYBAN MAX 90 DAYS OF SMOKING CESSATION THERAPY PER CALENDAR YEAR MAX 90 DAYS OF SMOKING CESSATION THERAPY PER CALENDAR YEAR MAX 90 DAYS OF SMOKING CESSATION THERAPY PER CALENDAR YEAR
NICODERM
NICOTINE
OTC
PATCH TD 24HR QL
NICOTINE PATCH
NICOTINE
OTC
PATCH TD 24HR QL
NICORETTE
NICOTINE POLACRILEX
OTC
GUM
QL
Page 36 of 54
January 2013

COMMENTS MAX 90 DAYS OF SMOKING CESSATION THERAPY PER CALENDAR YEAR MAX ONE TABLET PER DAY MAX ONE TABLET PER DAY ALT: PLENDIL AND PROCARDIA BILLED TO STRAIGHT MEDICAID
* * * * * * * * *
NICOTINE GUM PROCARDIA ADALAT CC PROCARDIA XL NIMOTOP SULAR ORFADIN FURADANTIN MACROBID MACRODANTIN MACRODANTIN 25MG FURACIN FURACIN NITROMIST NITRO-BID NITRO-BID NITRO-DUR NITRO-DUR NITROLINGUAL NITROGARD NITROGLYCERIN NITROSTAT AXID AR VCF
NICOTINE POLACRILEX NIFEDIPINE NIFEDIPINE NIFEDIPINE NIMODOPINE NISOLDIPINE NITISINONE NITROFURANTOIN NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL NITROFURAZONE NITROFURAZONE NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NIZATIDINE NONOXYNOL 9 NORELGESTROMIN/ETHINYL ESTRADIOL NORETHINDRONE NORETHINDRONE NORETHINDRONE NORETHINDRONE ACETATE
OTC
GUM CAPSULE TAB DR 24HR TABLET SA CAPSULE TABLET ALL FORMS ORAL SUSP CAPSULE CAPSULE CAPSULE CREAM OINTMENT AEROSOL CAPSULE SA OINTMENT PATCH TD 24HR
QL QL QL PA MDCH
PA
ALT: MACRODANTIN 50MG OR MACROBID
PA
ALT: NITROSTAT
* * * *
OTC OTC
PATCH TD 24HR SL SPRAY ST TAB BUC SA TAB SL TAB SL TABLET VAG FOAM
FAILURE OF NITROSTAT SL TABLETS
ORTHO EVRA * * * * MICRONOR NOR-QD ORTHO-MICRONOR AYGESTIN
PATCH TDWK TABLET TABLET TABLET TABLET
F, PA F, QL F, QL F, QL
ALT: FORMULARY BIRTH CONTROL TABLETS, DEPO-PROVERA AND NUVARING FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS
Page 37 of 54
January 2013
GEQ ONLY * * * * * * * * * BRAND NAME (REFERENCE ONLY) FEMHRT LOESTRIN LOESTRIN FE BREVICON MODICON NECON NORINYL ORTHO-NOVUM TRI-NORINYL NOROXIN ORTHO TRI-CYCLEN ORTHO-CYCLEN LO/OVRAL AVENTYL PAMELOR HUMULIN N HUMULIN N MYCOSTATIN MYCOSTATIN MYCOSTATIN MYCOSTATIN NYSTOP NYSTATIN MYCOLOG MYCOLOG FLOXIN OCUFLOX FLOXIN

GENERIC NAME NORETHINDRONE ACETATE/ ETHINYL ESTRADIOL NORETHINDRONE A-ETHINYL ESTRADIOL NORETHINDRONE A-ETHINYL ESTRADIOL/FE FUMARATE NORETHINDRONE ETHINYL ESTRADIOL NORETHINDRONE-ETHINYL ESTRADIOL NORETHINDRONE-ETHINYL ESTRADIOL NORETHINDRONE-ETHINYL ESTRADIOL NORETHINDRONE-ETHINYL ESTRADIOL NORETHINDRONE-ETHINYL ESTRADIOL NORFLOXACIN NORGESTIMATE-ETHINYL ESTRADIOL NORGESTIMATE-ETHINYL ESTRADIOL NORGESTREL-ETHINYL ESTRADIOL NORTRIPTYLINE NORTRIPTYLINE NPH, HUMAN INSULIN ISOPHANE NPH, HUMAN INSULIN ISOPHANE NYSTATIN NYSTATIN NYSTATIN NYSTATIN NYSTATIN NYSTATIN NYSTATIN/TRIAMCINOLONE NYSTATIN/TRIAMCINOLONE OFLOXACIN OFLOXACIN OFLOXACIN OTC DOSAGE FORM TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET ALL FORMS ALL FORMS PEN VIAL CREAM OINTMENT ORAL SUSP POWDER POWDER TABLET CREAM OINTMENT EAR DROPS EYE DROP TABLET RESTRICTIONS F, QL F, QL F, QL F, QL F, QL F, QL F, QL F, QL F, QL PA F, QL F, QL F, QL MDCH MDCH AG
COMMENTS MAX ONE TABLET PER DAY FEMALES ONLY. MAX ONE TABLET PER DAY FEMALES ONLY. MAX ONE TABLET PER DAY FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS. FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS ALT: CIPRO, FLOXIN AND LEVAQUIN FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS FEMALES ONLY. MAX ONE PACK EVERY 28 DAYS FEMALES ONLY. MAX ONE TABLET PER DAY BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID NO PRIOR AUTHORIZATION REQUIRED IF UNDER THE AGE OF 18
* * * * *
* * * * * * * * * *
Page 38 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * ZYPREXA * SYMBYAX GENERIC NAME OLANZAPINE OLANZAPINE/FLUOXETINE

OTC DOSAGE FORM ALL FORMS ALL FORMS RESTRICTIONS MDCH MDCH
BENICAR
OLMESARTAN MEDOXOMIL
TABLET
PA, QL
TRIBENZOR
OLMESARTAN/AMLODIPINE/HCTZ
TABLET
PA
COMMENTS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID FAILURE OF TWO FORMULARY ACE INHIBITORS AND COZAAR. MAX ONE TABLET PER DAY. ALT: ACCURETIC, CAPOZIDE, HYZAAR, MONOPRIL-HCT, VASERETIC OR ZESTORETIC PLUS NORVASC. FAILURE OF TWO FORMULARY ACE INHIBITORS PLUS HCTZ AND FAILURE OF HYZAAR. MAX ONE TABLET PER DAY. ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR CRITERIA MUST BE MET MAX FOUR CAPSULES PER DAY MAX TWO CAPSULES PER DAY COVERED FOR THOSE MEMBERS 10 YEARS OF AGE AND YOUNGER. MAX TWO CAPSULES PER DAY MAX FOUR TABLETS PER DAY MAX FOUR TABLETS PER DAY ALT: ZOFRAN TABLETS MAX 30 TABLETS PER MONTH
BENICAR HCT PATADAY PATANOL DIPENTUM LOVAZA PRILOSEC 20MG PRILOSEC 40MG FIRST-OMEPRAZOLE PRILOSEC 10MG PRILOSEC OTC ZEGERID OTC ZOFRAN ODT ZOFRAN OPIUM B&O SUPPRETTES NEUMEGA ALLI XENICAL NORFLEX TAMIFLU TAMIFLU BACTOCILL DAYPRO SERAX TRILEPTAL
OLMESARTAN/HCTZ OLOPATADINE HCL OLOPATADINE HCL OLSALAZINE SODIUM OMEGA-3 ACID ETHYL ESTERS OMEPRAZOLE OMEPRAZOLE OMEPRAZOLE OMEPRAZOLE OMEPRAZOLE MAGNESIUM OMEPRAZOLE/SODIUM BICARBONATE ONDANSETRON HCL ONDANSETRON HCL OPIUM OPIUM/BELLADONNA ALKALOIDS OPRELVEKIN ORLISTAT ORLISTAT ORPHENADRINE CITRATE OSELTAMIVIR OSELTAMIVIR OXACILLIN SODIUM OXAPROZIN OXAZEPAM OXCARBAMAZEPINE
TABLET EYE DROP EYE DROP CAPSULE CAPSULE CAPSULE CAPSULE SUSP RECON CAPSULE TABLET TABLET TAB RAPID TABLET TINCTURE SUPPOSITORY VIAL CAPSULE CAPSULE TABLET CAPSULE SUSP RECON CAPSULE TABLET ALL FORMS ALL FORMS
PA, QL PA PA PA QL QL AG QL QL QL PA QL
* *
OTC OTC
* * *
OTC
PA, SP PA PA
CRITERIA MUST BE MET DIET AID CRITERIA MUST BE MET DIET AID CRITERIA MUST BE MET
* * *
MDCH MDCH
Page 39 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) OXYTROL DITROPAN DITROPAN XL DITROPAN XL 5MG DITROPAN ROXICODONE OXYCONTIN OXYIR TYLOX PERCOCET 5/325 ROXICET PERCODAN OPANA ER * OPANA INVEGA PROTONIX ACCUZYME PAVABID PAVABID PAREGORIC HUMATIN PAXIL PAXIL CR PEXEVA VOTRIENT MOVIPREP ADAGEN NEULASTA PEGASYS PEGINTRON ALAMAST LEVATOL GENERIC NAME OXYBUTYNIN OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE/APAP OXYCODONE/APAP OXYCODONE/APAP OXYCODONE/ASPIRIN OXYMORPHONE HCL OXYMORPHONE HCL PALIPERIDONE PANTOPRAZOLE SOD SESQUIHYDRATE PAPAIN AND UREA PAPAVERINE HCL PAPAVERINE HCL PAREGORIC PAROMOMYCIN SULFATE PAROXETINE PAROXETINE PAROXETINE MESYLATE PAZOPANIB HCL PEG 3350/SOD SUL/NACL/ASB/C/KCL PEGADEMASE BOVINE PEGFILGASTRIM PEGINTERFERON ALFA-2A PEGINTERFERON ALFA-2B PEMIROLAST POTASSIUM PENBUTOLOL SULFATE

OTC DOSAGE FORM PATCH TDSW SYRUP TAB ER 24HR TAB ER 24HR TABLET ORAL SOLN TAB ER 12HR TABLET CAPSULE TABLET TABLET TABLET TAB ER 12HR TABLET ALL FORMS TABLET DR OINTMENT CAPSULE SA TABLET LIQUID CAPSULE ALL FORMS ALL FORMS ALL FORMS ALL FORMS POWDER PACK ALL FORMS DISP SYRINGE DISP SYRINGE KIT EYE DROP TABLET PA PA MDCH QL RESTRICTIONS PA QL QL
COMMENTS ALT: DITROPAN TABLETS AND DITROPAN SYRUP MAX TWO TABLETS PER DAY MAX ONE TABLET PER DAY
* * * * *
PA
ALT: DURAGESIC, METHADONE AND MS CONTIN
* * * * *
QL
MAX 4000MGS OF APAP PER DAY MAX 4000MGS OF ACETAMINOPHEN PER DAY FAILURE OF DURAGESIC, METHADONE AND MS CONTIN FAILURE OF DILAUDID, MSIR, OXYIR AND PERCOCET BILLED TO STRAIGHT MEDICAID MAX TWO TABLETS PER DAY
* * * * * * *
MDCH MDCH MDCH MDCH PA MDCH PA, SP PA, SP PA, SP PA PA
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: COLYTE, GOLYTELY, NULYTELY AND TRILYTE BILLED TO STRAIGHT MEDICAID CRITERIA MUST BE MET CRITERIA MUST BE MET CRITERIA MUST BE MET ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR ALT: INDERAL, LOPRESSOR AND TENORMIN
Page 40 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) CUPRIMINE CUPRIMINE DEPEN PENICILLIN VK PENICILLIN VK NEBUPENT GENERIC NAME PENICILLAMINE PENICILLAMINE PENICILLAMINE PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PENTAMIDINE ISETHIONATE

OTC DOSAGE FORM CAPSULE TABLET TABLET SUSP RECON TABLET VIAL NEB RESTRICTIONS
COMMENTS
* *
PA DIAGNOSIS OF INTERSTITIAL CYSTITIS. MAX THREE CAPSULES PER DAY. FAILURE OF ACCUPRIL, CAPOTEN, LOTENSIN, MONOPRIL, VASOTEC AND ZESTRIL MAX THREE TUBES PER WEEK BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
ELMIRON TRENTAL
PENTOSAN POLYSULFATE SODIUM PENTOXIFYLLINE
CAPSULE TABLET
PA, QL
* * * * * * * * * *
ACEON ELIMITE NIX PERPHENAZINE TRILAFON TRIAVIL PYRIDIUM NARDIL DONNATAL DONNATAL LUMINAL NEMBUTAL PHENOBARBITAL ADIPEX-P IONAMIN SUDAFED PE TYMPAGESIC RONDEC CYCLOMYDRIL RYNATAN RYNATAN DILANTIN PHENYTEK MEPHYTON PILOCAR PILOPINE HS
* *
PERINDOPRIL ERBUMINE PERMETHRIN PERMETHRIN OTC PERPHENAZINE PERPHENAZINE PERPHENAZINE/AMITRIPTYLINE PHENAZOPYRIDINE HCL PHENELZINE SULFATE PHENOBARB/HYOSCY/ATROPINE/S COP PHENOBARB/HYOSCY/ATROPINE/S COP PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENTERMINE PHENTERMINE RESIN PHENYLEPHRINE OTC PHENYLEPHRINE/ANTIPY/B-CAINE PHENYLEPHRINE/CHLORMAL PHENYLEPHRINE/CYCLOPENT PHENYLEPHRINE/PYRIL/CP PHENYLEPHRINE/PYRIL/CP PHENYTOIN PHENYTOIN SODIUM PHYTONADIONE PILOCARPINE PILOCARPINE
TABLET CREAM LIQUID ALL FORMS ALL FORMS ALL FORMS TABLET ALL FORMS ELIXER TABLET ALL FORMS ALL FORMS ALL FORMS TABLET CAPSULE SA TABLET EAR DROP SYRUP EYE DROP ORAL SUSP TABLET ALL FORMS ALL FORMS TABLET EYE DROP EYE GEL
PA QL MDCH MDCH MDCH MDCH
MDCH MDCH MDCH PA PA
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID DIET AID CRITERIA MUST BE MET DIET AID CRITERIA MUST BE MET
* * * * *
MDCH MDCH
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January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * ISOPTO CARPINE * SALAGEN ELIDEL ORAP * VISKEN * ACTOS DUETACT * * ACTOPLUS MET MAXAIR AUTOHALER FELDENE GENERIC NAME PILOCARPINE HCL PILOCARPINE HCL PIMECROLIMUS PIMOZIDE PINDOLOL PIOGLITAZONE PIOGLITAZONE/GLIMEPIRIDE PIOGLITAZONE/METFORMIN PIRBUTEROL ACETATE PIROXICAM

OTC DOSAGE FORM EYE DROP TABLET CREAM ALL FORMS TABLET TABLET TABLET TABLET AER BR ACT CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CHEW TAB TABLET SOLUTION POWDER EYE DROP POWDER CAPSULE SA ORAL LIQUID TAB PRT SR TABLET TABLET SA TABLET SA ELIXER TABLET SOLUTION TABLET OINTMENT SOLUTION RESTRICTIONS
COMMENTS
PA MDCH
CRITERIA MUST BE MET BILLED TO STRAIGHT MEDICAID FAILURE OF METFORMIN PLUS SULFONYLUREA FAILURE OF METFORMIN AND SULFONYLUREAS FAILURE OF METFORMIN PLUS SULFONYLUREA ALT: PROAIR HFA AND XOPENEX HFA ALT: LIPITOR, MEVACOR, PRAVACHOL AND ZOCOR
PA PA PA PA
* * * * * * * * * * * * * * * * * * * * * * * * * *
PITAVASTATIN CALCIUM LIVALO PNV/ FE FUMARATE/FA PRENATAL PLUS PNV/CA CARB/FE PREMESIS RX PNV/CA/FE/FA NATALINS PNV/CALCIUM/FE/FA PRENATAL RX PNV/FE FUMARATE/FA O-CAL FA PNV/FE FUMARATE/FA STRONGSTART PNV/FE FUMARATE/FA STUARTNATAL PNV/FE FUMARATE/FA/SE PRENATAL MTR PNV/FERROUS FUM/FOLIC ACID NATACHEW PNV/IRON CARB/FA NATAFORT PODOFILOX CONDYLOX POLUETHYLENE GLYCOL GLYCOLAX POLY B SULFATE/TMP POLYTRIM POLYETHYLENE GLYCOL 3350 MIRALAX POTASSIUM CHLORIDE MICRO-K POTASSIUM CHLORIDE KAYCIEL POTASSIUM CHLORIDE K-DUR POTASSIUM CHLORIDE K-LOR POTASSIUM CHLORIDE KLOR-CON POTASSIUM CHLORIDE K-TAB POTASSIUM GLUCONATE KAON POTASSIUM GLUCONATE POTASSIUM GLUCONATE POTASSIUM IODIDE SSKI POTASSIUM PHOSPHATE K-PHOS POVIDONE-IODINE BETADINE POVIDONE-IODINE BETADINE
PA F F F F F F F F F F
OTC
OTC OTC
Page 42 of 54
January 2013
GEQ ONLY * BRAND NAME (REFERENCE ONLY) MIRAPEX ER MIRAPEX GENERIC NAME PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL

OTC DOSAGE FORM TAB ER 24HR TABLET RESTRICTIONS PA QL
* * * * * * * * * * * * * * * * * * * * * * * * * * * *
SYMLIN EFFIENT PRAVACHOL MINIPRESS DERMATOP PRELONE PRED FORTE PRED MILD ORAPRED PEDIPRED ORAPRED ODT PREDNISONE DELTASONE PREDNISONE INFLAMASE INFLAMASE FORTE LYRICA MISSION PRENATAL MATERNA PRIMAQUIINE MYSOLINE BENEMID PRONESTYL PROCAN COMPAZINE COMPAZINE COMPAZINE PROMETRIUM 100MG PROMETRIUM 200MG PHENERGAN PHENERGAN PHENERGAN PHENERGAN VC W/COD PHENERGAN W/ COD PHENERGAN DM PHENERGAN VC
PRAMLINTIDE ACETATE PRASUGREL HCL PRAVASTATIN SODIUM PRAZOSIN HCL PREDNICARBATE PREDNISOLONE PREDNISOLONE ACETATE PREDNISOLONE ACETATE PREDNISOLONE PHOSPHATE PREDNISOLONE PHOSPHATE PREDNISOLONE PHOSPHATE PREDNISONE PREDNISONE PREDNISONE PREDNISONE PHOSPHATE PREDNISONE PHOSPHATE PREGABALIN PRENATAL VIT PRENATAL VIT/FE FUMARATE PRIMAQUINE PHOSPHATE PRIMIDONE PROBENECID PROCAINAMIDE HCL PROCAINAMIDE HCL PROCHLORPERAZINE MALEATE PROCHLORPERAZINE MALEATE PROCHLORPERAZINE MALEATE PROGESTERONE, MICRONIZED PROGESTERONE, MICRONIZED PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE/COD/PE PROMETHAZINE/CODEINE PROMETHAZINE/DEXTROMETH PROMETHAZINE/PHENYEPHRINE
VIAL TABLET TABLET CAPSULE CREAM SYRUP EYE DROP EYE DROP ORAL SOLN ORAL SOLN TAB RAPID ORAL SOLN TABLET TABLET EYE DROP EYE DROP ALL FORMS TABLET TABLET TABLET ALL FORMS TABLET CAPSULE TABLET SA SUPPOSITORY SYRUP TABLET CAPSULE CAPSULE SUPPOSITORY SYRUP TABLET SYRUP SYRUP SYRUP SYRUP
PA PA QL
COMMENTS ALT: REQUIP AND MIRAPEX (NOT ER) MAX THREE TABLETS PER DAY TYPE I DIABETIC WHO HAS FAILED TO REACH A1C GOALS AFTER COMPLIANT DAILY USE OF INSULIN. ALT: PLAVIX MAX ONE TABLET PER DAY
PA
ALT: CUTIVATE, HYTONE AND KENALOG
PA
ALT: ORAPRED LIQUID
MDCH F F MDCH
QL QL
MAX ONE CAPSULE PER DAY MAX TWO CAPSULES PER DAY
Page 43 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * RYTHMOL SR * RYTHMOL PRO-BANTHINE PROPANTHELINE * OPTHANE * INDERAL LA INNOPRAN XL * INDERAL * INDERAL * INDERIDE * PROPYLTHIOURACIL * PTU CEPROTIN VIVACTIL ACTIFED SINUS ACTIFED ALLERGY SUDAFED METAMUCIL ANTIMINTH PYRAZINAMIDE MESTINON MESTINON MESTINON VITAMIN B-6 DARAPRIM DORAL SEROQUEL SEROQUEL XR ACCUPRIL ACCURETIC QUINAGLUTE QUINAMM QUINIDINE QUINIDINE

GENERIC NAME PROPAFENONE HCL PROPAFENONE HCL PROPANTHELINE BROMIDE PROPANTHELINE BROMIDE PROPARACAINE HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL/HCTZ PROPYLTHIOURACIL PROPYLTHIOURACIL PROTEIN C CONCENTRATE, HUMAN PROTRIPTYLINE PSE/APAP/DIPHENHYDRAMINE PSE/DIPHENHYDRAMINE PSEUDOEPHEDRINE PSYLLIUM POWDER PYRANTEL PAMOATE PYRAZINAMIDE PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE PYRIDOXINE HCL PYRIMETHAMINE QUAZEPAM QUETIAPINE QUETIAPINE QUINAPRIL QUINAPRIL/HCTZ QUINIDINE GLUCONATE QUININE SULFATE QUININE SULFATE QUININE SULFATE OTC DOSAGE FORM CAP ER 12HR TABLET TABLET TABLET EYE DROP CAP ER 24HR CAPSULE ORAL SOLN TABLET TABLET TABLET TABLET ALL FORMS ALL FORMS TABLET TABLET TABLET ORAL SUSP TABLET SYRUP TABLET TABLET SA TABLET TABLET ALL FORMS ALL FORMS ALL FORMS TABLET TABLET TABLET SA TABLET TABLET TABLET SA RESTRICTIONS PA
COMMENTS ALT: RYTHMOL TABLETS
PA
ALT: INDERAL AND INDERAL LA
* * * * * * * *
MDCH MDCH
OTC OTC OTC OTC
OTC
* * * * * *
MDCH MDCH MDCH QL QL
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX ONE TABLET PER DAY MAX ONE TABLET PER DAY
ACIPHEX EVISTA
RABEPRAZOLE SODIUM RALOXIFENE
TABLET TABLET
PA
FAILURE OF PRILOSEC, PREVACID OTC AND PROTONIX FIRST-LINE FOLLOWED BY A FAILURE OF DEXILANT SECONDLINE BY PRIOR AUTHORIZATION.
Page 44 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) ISENTRESS ROZEREM ALTACE ALTACE 10MG ALTACE ZANTAC ZANTAC RANEXA RAUDIXIN TASIGNA PRANDIN PRANDIMET SERPASIL HYDROPRES ALTABAX COPEGUS RIBASPHERE RIBATAB MYCOBUTIN RIFADIN RIFAMATE XIFAXAN 200MG GENERIC NAME RALTEGRAVIR POTASSIUM RAMELTEON RAMIPRIL RAMIPRIL RAMIPRIL RANITIDINE HCL RANITIDINE HCL RANOLAZINE RAUWOLFIA SERPENTINA REGORAFENIB REPAGLINIDE REPAGLINIDE/METFORMIN RESERPINE RESERPINE/HCTZ RETAPAMULIN RIBAVIRIN RIBAVIRN RIBAVIRN RIFABUTIN RIFAMPIN RIFAMPIN/ISONIAZID RIFAXIMIN

OTC DOSAGE FORM ALL FORMS ALL FORMS CAPSULE CAPSULE TABLET SYRUP TABLET TAB SR 12HR TABLET ALL FORMS TABLET TABLET TABLET TABLET OINTMENT TABLET CAPSULE TABLET CAPSULE CAPSULE CAPSULE TABLET RESTRICTIONS MDCH MDCH QL QL PA
* * * *
COMMENTS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID MAX ONE CAPSULE PER DAY MAX TWO CAPSULES PER DAY ALT: ALTACE CAPSULES
ST, QL MDCH PA PA
FAILURE OF IMDUR 60MG. MAX TWO TABLETS PER DAY BILLED TO STRAIGHT MEDICAID FAILURE OF METFORMIN AND SULFONYLUREAS FAILURE OF METFORMIN AND SULFONYLUREAS
* * * * * * *
PA PA, SP PA PA
ALT: BACTROBAN OINTMENT CRITERIA MUST BE MET CRITERIA MUST BE MET CRITERIA MUST BE MET
QL
MAX 10 TABLETS PER FILL FAILURE OF LACTULOSE IN THE PAST 60 DAYS. MAX OF TWO TABLETS PER DAY. BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
XIFAXAN 550MG ARCALYST EDURANT FLUMADINE VEXOL ACTONEL ACTONEL WEEKLY ATELVIA ACTONEL/CALCIUM RISPERDAL NORVIR XARELTO
RIFAXIMIN RILONACEPT RILPIVIRINE HYDROCHLORIDE RIMANTADINE HCL RIMEXOLONE RISEDRONATE SODIUM RISEDRONATE SODIUM RISEDRONATE SODIUM RISEDRONATE SODIUM/CALCIUM RISPERIDONE RITONAVIR RIVAROXABAN
TABLET ALL FORMS ALL FORMS TABLET EYE DROP TABLET TABLET TABLET TABLET ALL FORMS ALL FORMS TABLET
PA, QL MDCH MDCH
PA PA PA PA PA MDCH MDCH PA
ALT: DECADRON, FML AND PRED FORTE ALT: FOSAMAX ALT: FOSAMAX ALT: FOSAMAX ALT: FOSAMAX PLUS CALCIUM BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID FAILURE/INTOLERANCE TO COUMADIN
Page 45 of 54
January 2013
GEQ ONLY * BRAND NAME (REFERENCE ONLY) EXELON GENERIC NAME RIVASTIGMINE TARTRATE

OTC DOSAGE FORM CAPSULE RESTRICTIONS PA
EXELON MAXALT MLT MAXALT DALIRESP REQUIP XL REQUIP AVANDIA
RIVASTIGMINE TARTRATE RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE ROFLUMILAST ROPINIROLE HCL ROPINIROLE HCL ROSIGLITAZONE MALEATE
PATCH TAB RAPDIS TABLET TABLET TAB ER 24HR TABLET TABLET
PA PA PA PA PA
COMMENTS DIAGNOSIS OF ALZHEIMER'S DISEASE REQUIRED DIAGNOSIS OF ALZHEIMER'S DISEASE REQUIRED AND INABILITY TO USE EXELON CAPSULES. ALT: AMERGE AND IMITREX. MAX NINE TABLETS PER MONTH ALT: AMERGE AND IMITREX. MAX NINE TABLETS PER MONTH FAILURE OF FORMULARY BRONCHODILATORS ALT: MIRAPEX AND REQUIP FAILURE OF METFORMIN, SULFONYLUREAS AND ACTOS (PA) FAILURE OF LIPITOR, MEVACOR, PRAVACHOL AND ZOCOR. MAX ONE TABLET PER DAY. BILLED TO STRAIGHT MEDICAID DIAGNOSIS OF INTERMEDIATE OR HIGH RISK MYELOFIBROSIS BILLED TO STRAIGHT MEDICAID
PA
CRESTOR BANZEL JAKAFI SUCRAID TRILISATE TRILISATE WART REMOVER SEREVENT DISKUS DISALCID KUVAN INVIRASE LEUKINE ONGLYZA KOMBIGLIYZE XR PAMINE SECONAL EMSAM ELDEPRYL SELSUN RX SENNA
ROSUVASTATIN CALCIUM RUFINAMIDE RUXOLITINIB PHOSPHATE SACROSIDASE SALICYLATE SALICYLATE SALICYLIC ACID/COLLODION SALMETEROL XINAFOATE SALSALATE SAPROPTERIN DIHYDROCHLORIDE SAQUANAVIR MESYLATE SARGARMOSTIM SAXAGLIPTIN HCL SAXAGLIPTIN HCL/METFORMIN SCOPOLAMINE HBR SECOBARBITAL SELEGILINE HCL SELEGILINE HCL SELENIUM SULFIDE SENNOSIDES
TABLET ALL FORMS TABLET ALL FORMS ORAL LIQUID TABLET LIQUID INHALER TABLET ALL FORMS ALL FORMS VIAL TABLET TBMP 24HR TABLET ALL FORMS ALL FORMS CAPSULE LOTION TABLET
PA, QL MDCH PA, SP MDCH
* *
OTC
QL
MAX ONE INHALER PER MONTH
MDCH MDCH PA, SP PA PA MDCH MDCH
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID CRITERIA MUST BE MET FAILURE OF METFORMIN AND SULFONYLUREAS FAILURE OF METFORMIN AND SULFONYLUREAS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* * * * *
OTC
Page 46 of 54
January 2013
GEQ ONLY * * * BRAND NAME (REFERENCE ONLY) PERICOLACE SENOKOT ZOLOFT RENAGEL RENVELA RAPAFLO SILVADENE ZOCOR RAPAMUNE JANUMET JANUVIA POLYCITRA POLYCITRA K SODIUM BICARBONATE SODIUM CHLORIDE LURIDE PREVIDENT LURIDE PREVIDENT PREVIDENT BUPHENYL SPS * * SPS KAYEXALATE VESICARE NUTROPIN AQ OMNITROPE GENOTROPIN NORDITROPIN GENERIC NAME

OTC OTC OTC DOSAGE FORM CAPSULE TABLET ALL FORMS TABLET TABLET CAPSULE CREAM TABLET TABLET TABLET TABLET ORAL SOLN ORAL SOLN TABLET VIAL CHEW TAB CREAM DROPS GEL SOLUTION ALL FORMS ENEMA ORAL SUSP POWDER TABLET CARTRIDGE CARTRIDGE DISP SYRINGE PEN INJ RESTRICTIONS
COMMENTS
SENNOSIDES/DOCUSATE SODIUM SENNOSIDES/DOCUSATE SODIUM SERTRALINE SEVELAMER HCL SEVELAMER HCL SILODOSIN SILVER SULFADIAZINE SIMVASTATIN SIROLIMUS SITAGLIPTIN PHOS/METFORMIN SITAGLIPTIN PHOS/METFORMIN SOD/K CIT/MA CIT/CA SOD/K CIT/MA CIT/CA SODIUM BICARBONATE SODIUM CHLORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM PHENYLBUTYRATE SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE SOLIFENACIN SUCCINATE SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN
MDCH ST ST PA QL PA PA PA
BILLED TO STRAIGHT MEDICAID ALT: PHOSLO ALT: PHOSLO ALT: FLOMAX MAX ONE TABLET PER DAY ALT: PROGRAF FAILURE OF METFORMIN AND SULFONYLUREAS FAILURE OF METFORMIN AND SULFONYLUREAS
* *
* * * * * * * * *
OTC
MDCH
PA PA, SP PA, SP PA, SP PA, SP
ALT: DITROPAN/DITROPAN XL GROWTH HORMONE CRITERIA MUST BE MET GROWTH HORMONE CRITERIA MUST BE MET GROWTH HORMONE CRITERIA MUST BE MET GROWTH HORMONE CRITERIA MUST BE MET
Page 47 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) HUMATROPE NUTROPIN SEROSTIM TEV-TROPIN NEXAVAR SORBITOL BETAPACE BETAPACE AF SPACERS ALDACTONE ALDACTAZIDE 25/25 ALDACTAZIDE 50/50 GEL-KAM ZERIT CHEMET CARAFATE CARAFATE EXELDERM BLEPH-10 KLARON SODIUM SULAMYD PLEXION SULFACET-R PLEXION BLEPHAMIDE BACTRIM BACTRIM BACTRIM DS SEPTRA SEPTRA DS AVC GENERIC NAME SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SORAFENIB TOSYLATE SORBITOL SOTALOL HCL SOTALOL HCL SPACERS SPIRONOLACTONE SPIRONOLACTONE/HCTZ SPIRONOLACTONE/HCTZ STANNOUS FLUORIDE STAVUDINE SUCCIMER SUCRALFATE SUCRALFATE SULCONAZOLE NITRATE SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM

OTC DOSAGE FORM VIAL VIAL VIAL VIAL ALL FORMS SOLUTION TABLET TABLET RESTRICTIONS PA, SP PA, SP PA, SP PA, SP MDCH
COMMENTS GROWTH HORMONE CRITERIA MUST BE MET GROWTH HORMONE CRITERIA MUST BE MET GROWTH HORMONE CRITERIA MUST BE MET GROWTH HORMONE CRITERIA MUST BE MET BILLED TO STRAIGHT MEDICAID
* *
QL TABLET TABLET TABLET GEL ALL FORMS CAPSULE ORAL SUSP TABLET CREAM EYE DROP TOP SUSP EYE OINT CLEANSER LOTION MED PAD EYE DROP ORAL SUSP TABLET TABLET TABLET TABLET CREAM W/APP
MAX TWO SPACERS EVERY SIX MONTHS
* * *
PA MDCH PA
ALT: ALDACTAZIDE 25/25 BILLED TO STRAIGHT MEDICAID ALT: CARAFATE TABLETS ALT: LAMISIL, NIZORAL AND SPECTAZOLE MAX 236MLS PER MONTH
OTC
PA QL
* * * * * *
SULFACETAMIDE SODIUM-SULFUR SULFACETAMIDE SODIUM-SULFUR SULFACETAMIDE SODIUM-SULFUR SULFACETAMIDE/ PREDNISOLONE SULFAMETHOXAZOLE/TMP SULFAMETHOXAZOLE/TMP SULFAMETHOXAZOLE/TMP SULFAMETHOXAZOLE/TMP SULFAMETHOXAZOLE/TMP SULFANILAMIDE
* * * * *
Page 48 of 54
January 2013
GEQ ONLY * * * * * * * * * * BRAND NAME (REFERENCE ONLY) AZULFIDINE AZULFIDINE ENTABS SULTRIN ANTURANE ANTURANE CLINORIL ALSUMA IMITREX IMITREX IMITREX TREXIMET PROGRAF

GENERIC NAME SULFASALAZINE SULFASALAZINE SULFATHIAZ/SULFACET/SULF SULFINPYRAZONE SULFINPYRAZONE SULINDAC SUMATRIPTAN SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN/NAPROXEN TACROLIMUS ANHYDROUS OTC DOSAGE FORM TABLET TABLET DR VAG CREAM CAPSULE TABLET TABLET PEN INJ KIT NASAL SPRAY TABLET TABLET CAPSULE RESTRICTIONS
COMMENTS
QL QL QL QL PA
MAX 2MLS PER MONTH MAX 2MLS PER MONTH MAX ONE BOX PER MONTH MAX NINE TABLETS PER MONTH ALT: AMERGE OR IMITREX PLUS NAPROXEN. DIAGNOSIS OF RA. FAILURE OF METHOTREXATE, IMURAN AND PLAQUENIL. MAX TWO TABLETS PER DAY. QUALIFYING DIAGNOSIS REQUIRED. ALT: XALATAN BILLED TO STRAIGHT MEDICAID MAX TWO CAPSULES PER DAY CRITERIA MUST BE MET CRITERIA MUST BE MET ALT: BIAXIN, ERYTHROMYCIN AND ZITHROMAX FAILURE OF TWO ACE INHIBITORS AND FAILURE OF COZAAR. MAX ONE TABLET PER DAY. ALT: ACCUPRIL, CAPOTEN/ COZAAR, LOTENSIN, MONOPRIL, VASOTEC OR ZESTRIL PLUS NORVASC FAILURE OF TWO ACE INHIBITORS PLUS HCTZ AND FAILURE OR HYZAAR. MAX ONE TABLET PER DAY. BILLED TO STRAIGHT MEDICAID QUALIFYING DIAGNOSIS REQUIRED. BILLED TO STRAIGHT MEDICAID MAX ONE TABLET PER DAY
* *
XELJANZ ADCIRCA ZIOPTAN ELELYSO NOLVADEX FLOMAX NUCYNTA ER NUCYNTA KETEK
TAFACITINIB CITRATE TAFALAFIL TAFLUPROST PF TALIGLUCERASE ALFA TAMOXIFEN CITRATE TAMSULOSIN HCL TAPENTADOL HCL TAPENTADOL HCL TELITHROMYCIN
TABLET TABLET EYE DROP ALL FORMS TABLET CAPSULE TAB ER 12HR TABLET TABLET
PA, QL, SP PA, SP PA MDCH QL PA PA PA
MICARDIS
TELMISARTAN
TABLET
PA, QL
TWYNSTA
TELMISARTAN/AMLODIPINE
TABLET
PA
MICARDIS HCT RESTORIL TEMODAR VIREAD HYTRIN LAMISIL
TELMISARTAN/HCTZ TEMAZEPAM TEMOZOLOMIDE TENOVIR DISOPROXIL FUMARATE TERAZOSIN HCL TERBINAFINE HCL
TABLET ALL FORMS CAPSULE ALL FORMS CAPSULE TABLET
PA, QL MDCH PA, SP MDCH QL
* *
Page 49 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * BRETHINE * TERAZOL * TERAZOL GENERIC NAME TERBUTALINE SULFATE TERCONAZOLE TERCONAZOLE

OTC DOSAGE FORM TABLET VAG CREAM VAG SUPP RESTRICTIONS
COMMENTS
AUBAGIO
TERIFLUNOMIDE
TABLET
PA, QL, SP
FORTEO
TERIPARATIDE
PEN INJ
PA, SP
TESTIM
TESTOSTERONE
GEL
PA
FORTESTA
TESTOSTERONE
GEL MD PMP
PA
ANDROGEL
TESTOSTERONE
GEL PACKET
PA
AXIRON
TESTOSTERONE
GEL PUMP
PA
ANDRODERM
TESTOSTERONE
PATCH TD24HR PA
* *
* * * * * * *
DEPO-TESTOSTERONE PONTOCAINE PONTOCAINE PONTOCAINE SUMYCIN TETRACYCLINE THALOMID SLO-BID THEO-DUR VITAMIN B-1 THIOGUANINE MELLARIL NAVANE
TESTOSTERONE TETRACAINE HCL TETRACAINE HCL TETRACAINE HCL TETRACYCLINE TETRACYCLINE THALIDOMIDE THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THIAMINE HCL THIOGUANINE THIORIDAZINE THIOTHIXENE
OTC
VIAL EYE DROP OINTMENT SOLUTION CAPSULE CAPSULE CAPSULE CAPSULE SA TAB SR 12HR TABLET TABLET ALL FORMS ALL FORMS
PA
DIAGNOSIS OF MULTIPLE SCLEROSIS. FAILURE OF TWO OF THE FOLLOWING: AVONEX, BETASERON, COPAXONE AND REBIF. MAX ONE TABLET PER DAY. DIAGNOSIS OF OSTEOPOROSIS WITH FAILURE/INTOLERANCE TO FOSAMAX AND BONIVA. PRESCRIBER MUST SUBMIT LAB WORK TO CONFIRM AN ABNORMALLY LOW TESTOSTERONE LEVEL. PRESCRIBER MUST SUBMIT LAB WORK TO CONFIRM AN ABNORMALLY LOW TESTOSTERONE LEVEL. PRESCRIBER MUST SUBMIT LAB WORK TO CONFIRM AN ABNORMALLY LOW TESTOSTERONE LEVEL. PROVIDER MUST SUBMIT LAB WORK CONFIRMING AN ABNORMALLY LOW TESTOSTERONE LEVEL. PRESCRIBER MUST SUBMIT LAB WORK TO CONFIRM AN ABNORMALLY LOW TESTOSTERONE LEVEL. PRESCRIBER MUST SUBMIT LAB WORK TO CONFIRM AN ABNORMALLY LOW TESTOSTERONE LEVEL.
PA, SP
QUALIFYING DIAGNOSIS REQUIRED.
PA MDCH MDCH
QUALIFYING DIAGNOSIS REQUIRED. BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
Page 50 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) ARMOUR THYROID GABITRIL BRILINTA TICLID BETIMOL ISTALOL TIMOPTIC TIMOPTIC XE BLOCADREN SPIRIVA APTIVUS ZANAFLEX TOBI TOBREX TOBREX TOBRADEX TOBRADEX TOLINASE ORINASE TINACTIN TINACTIN TOLECTIN TOLECTIN DS DETROL LA * * * * * * DETROL TOPAMAX FARESTON DEMADEX ULTRAM ULTRACET MAVIK GENERIC NAME THYROID TIAGABINE

OTC DOSAGE FORM TABLET ALL FORMS TABLET TABLET EYE DROP EYE DROP EYE DROP EYE DROP TABLET INHALER ALL FORMS TABLET AMP NEB EYE DROP EYE OINT EYE DROP EYE OINT TABLET TABLET CREAM SPRAY CAPSULE TABLET CAP DR 24HR TABLET ALL FORMS TABLET TABLET TABLET TABLET TABLET RESTRICTIONS MDCH PA, QL PA PA
COMMENTS BILLED TO STRAIGHT MEDICAID ALT: PLAVIX. MAX ONE TABLET PER DAY ALT: TIMOPTIC ALT: TIMOPTIC
* * *
* * * * * * * * * *
TICAGRELOR TICLOPIDINE HCL TIMOLOL TIMOLOL MALEATE TIMOLOL MALEATE TIMOLOL MALEATE TIMOLOL MALEATE TIOTROPIUM BROMIDE TIPRANIVIR TIZANIDINE HCL TOBRAMYCIN IN 0.225% NACL TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN/DEXAMETHASONE TOLAZAMIDE TOLBUTAMIDE TOLFANATE TOLFANATE TOLMETIN SODIUM TOLMETIN SODIUM TOLTERODINE TARTRATE TOLTERODINE TARTRATE TOPIRAMATE TOREMIFENE CITRATE TORSEMIDE TRAMADOL HCL TRAMADOL/APAP TRANDOLAPRIL
QL MDCH PA, SP
MAX ONE INHALER PER MONTH BILLED TO STRAIGHT MEDICAID CRITERIA MUST BE MET
OTC OTC
PA PA MDCH
FAILURE OF DITROPAN. MAX ONE CAPSULE PER DAY. FAILURE OF DITROPAN. MAX TWO TABLETS PER DAY. BILLED TO STRAIGHT MEDICAID
QL PA PA
TARKA CYKLOKAPRON LYSTEDA TRANEXAMIC ACID
TRANDOLAPRIL/VERAPAMIL TRANEXAMIC ACID TRANEXAMIC ACID TRANEXAMIC ACID
TBMP 24HR ALL FORMS ALL FORMS ALL FORMS
PA MDCH MDCH MDCH
MAX EIGHT TABLETS PER DAY ALT: ULTRAM PLUS TYLENOL ALT: ACCUPRIL, CAPOTEN, LOTENSIN, MONOPRIL, VASOTEC AND ZESTRIL. ALT: ACCUPRIL, CAPOTEN, LOTENSIN, MONOPRIL, VASOTEC OR ZESTRIL PLUS VERAPAMIL BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
Page 51 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) PARNATE TRAVATAN TRAVATAN Z OLEPTRO DESYREL GENERIC NAME TRANYLCYPROMINE TRAVOPROST TRAVOPROST TRAZADONE HCL TRAZODONE

OTC DOSAGE FORM ALL FORMS EYE DROP EYE DROP ALL FORMS ALL FORMS RESTRICTIONS MDCH QL QL MDCH MDCH
RETIN-A
TRETINOIN
CREAM
AG
* * * * * * * * * * * * * * * * * * * * * * * * * * *
RETIN-A ARISTOCORT ARISTOCORT TRIAMCINOLONE ARISTOCORT TRIAMCINOLONE KENALOG KENALOG NASACORT AQ KENALOG KENALOG ORALONE DYRENIUM DYAZIDE MAXZIDE HALCION SYPRINE STELAZINE VIROPTIC ARTANE TIGAN TIGAN TRIMPEX SURMONTIL MYDRIACYL ELLA CARMOL CARMOL CARMOL ACTIGALL URSO
TRETINOIN TRIAMCINOLONE TRIAMCINOLONE TRIAMCINOLONE TRIAMCINOLONE TRIAMCINOLONE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMTERENE TRIAMTERENE/HCTZ TRIAMTERENE/HCTZ TRIAZOLAM TRIENTINE HCL TRIFLUOPERAZINE TRIFLURIDINE TRIHEXYPHENIDYL TRIMETHOBENZAMIDE TRIMETHOBENZAMIDE TRIMETHOPRIM TRIMIPRAMINE MALEATE TROPICAMIDE ULIPRISTAL ACETATE UREA UREA UREA URSODIOL URSODIOL
GEL CREAM OINTMENT OINTMENT TABLET CREAM CREAM LOTION NASAL SPRAY OINTMENT PASTE PASTE CAPSULE CAPSULE TABLET ALL FORMS CAPSULE ALL FORMS EYE DROP ALL FORMS CAPSULE RECT SUPP TABLET ALL FORMS EYE DROP TABLET CREAM GEL LOTION CAPSULE TABLET
AG
COMMENTS BILLED TO STRAIGHT MEDICAID ALT: XALATAN ALT: XALATAN BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID COVERED FOR THOSE MEMBERS UNDER THE AGE OF 30 WITHOUT PRIOR AUTHORIZATION COVERED FOR THOSE MEMBERS UNDER THE AGE OF 30 WITHOUT PRIOR AUTHORIZATION
QL
MAX ONE CANNISTER PER MONTH
QL
MAX TWO TUBES PER MONTH
MDCH MDCH MDCH
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
MDCH QL
BILLED TO STRAIGHT MEDICAID MAX ONE TABLET PER MONTH
PA
ALT: ACTIGAL
Page 52 of 54
January 2013
GEQ BRAND NAME ONLY (REFERENCE ONLY) * URSO FORTE * VALTREX DEPACON * DEPAKENE STAVZOR GENERIC NAME URSODIOL VALACYCLOVIR HCL VALPROATE SODIUM VALPROATE SODIUM VALPROIC ACID

OTC DOSAGE FORM TABLET TABLET ALL FORMS ALL FORMS ALL FORMS RESTRICTIONS PA PA MDCH MDCH MDCH
DIOVAN
VALSARTAN
TABLET
PA, QL
COMMENTS ALT: ACTIGAL ALT: ZOVIRAX BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID FAILURE OF TWO FORMULARY ACE INHIBITORS AND FAILURE OF COZAAR. MAX ONE TABLET PER DAY. FAILURE OF TWO FORMULARY ACE INHIBITORS PLUS HCTZ AND FAILURE OF HYZAAR. MAX ONE TABLET PER DAY. BILLED TO STRAIGHT MEDICAID FAILURE OF NICODERM AND ZYBAN BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* * * *
DIOVAN HCT VANCOCIN CAPRELSA CHANTIX VPRIV ZELBORAF EFFEXOR EFFEXOR XR VENLAFAXINE ER ISOPTIN ISOPTIN SR SABRIL VIIBRYD ERIVEDGE AQUASOL A BEROCCA PLUS BEROCCA COUMADIN ACCOLATE SONATA RELENZA RETROVIR GEODON ZOMIG AMBIEN AMBIEN CR ZOLPIMIST
VALSARTAN/HCTZ VANCOMYCIN HCL VANDETANIB VARENICLINE TARTRATE VELAGLUCERASE ALFA VEMURAFENIB VENLAFAXINE VENLAFAXINE VENLAFAXINE HCL VERAPAMIL HCL VERAPAMIL HCL VIGABATRIN VILAZODONE HCL VISMODEGIB VITAMIN A VITAMIN B CMPD/FE/HEMATIN VITAMIN B COMPOUND PLUS WARFARIN SODIUM ZAFIRLUKAST ZALEPLON ZANAMAVIR ZIDOVUDINE ZIPRADISONE ZOLMITRIPTAN ZOLPIDEM ZOLPIDEM ZOLPIDEM
TABLET CAPSULE ALL FORMS TABLET ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS TABLET TABLET SA ALL FORMS ALL FORMS CAPSULE CAPSULE TABLET TABLET TABLET TABLET ALL FORMS INHALER ALL FORMS ALL FORMS TABLET ALL FORMS ALL FORMS ALL FORMS
PA, QL MDCH PA MDCH MDCH MDCH MDCH MDCH
MDCH MDCH PA, SP
BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID DIAGNOSIS OF ADVANCED BASAL CELL CARCINOMA
* * * * *
PA, QL MDCH MDCH MDCH PA MDCH MDCH MDCH
ASTHMA DIAGNOSIS REQUIRED. MAX TWO TABLETS PER DAY. BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID ALT: AMERGE AND IMITREX. MAX NINE TABLETS PER MONTH BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
* *
Page 53 of 54
January 2013
GEQ ONLY BRAND NAME (REFERENCE ONLY) EDLUAR INTERMEZZO ZONEGRAN IRESSA REFACTO LANCETS GENERIC NAME ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZONISAMIDE

OTC DOSAGE FORM ALL FORMS ALL FORMS ALL FORMS ALL FORMS ALL FORMS RESTRICTIONS MDCH MDCH MDCH MDCH MDCH
COMMENTS BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID BILLED TO STRAIGHT MEDICAID
OTC
Page 54 of 54

Positive Listing Generic Medicaid-McLaren Health Plan-HMO

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Positive Listing Generic Medicaid-McLaren Health Plan-HMO

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MedicaidFormulary GenericSort January2013

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

OTC OTC OTC OTC OTC OTC OTC

COVERED FOR THOSE MEMBERS 10 YEARS OF AGE AND YOUNGER.

BILLED TO STRAIGHT MEDICAID MAX ONE INHALER PER MONTH

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

ALT: CROLOM, ELESTAT, OPTIVAR AND ZADITOR

QL QL QL PA MDCH MDCH MDCH

PA, QL MDCH MDCH MDCH

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

QUALIFYING DIAGNOSIS REQUIRED.

BILLED TO STRAIGHT MEDICAID

MDCH MDCH MDCH MDCH QL PA QL

BILLED TO STRAIGHT MEDICAID FAILURE OF AMOXIL

ALT: GENERIC AUGMENTIN (NOT XR) BILLED TO STRAIGHT MEDICAID

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

COMMENTS BILLED TO STRAIGHT MEDICAID

OTC OTC OTC OTC

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

COMMENTS MAX 600MG PER DAY

FAILURE OF GENERIC BETOPTIC

MALES ONLY. MAX ONE TABLET PER DAY ALT: XALATAN

ALT: COLYTE, GOLYTELY, NULYTELY AND TRILYTE

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

COMMENTS ALT: PEPTO-BISMOL, FLAGYL AND TETRACYCLINE BILLED SEPARATELY

ALT: PEPTO BISMOL, FLAGYL AND TETRACYCLINE BILLED SEPARATELY

AG AG QL PA MDCH MDCH MDCH MDCH MDCH QL MDCH MDCH MDCH

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

MDCH MDCH MDCH MDCH MDCH PA

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

OTC OTC OTC OTC

CRITERIA MUST BE MET

PA, QL MDCH MDCH MDCH MDCH

CRITERIA MUST BE MET

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary

Information is Subject to Change

MAX ONE TABLET PER DAY

ALT: BENZOYL PEROXIDE PLUS CLINDAMYCIN OR BENZAMYCIN

MDCH MDCH MDCH QL PA

MAX ONE TABLET PER DAY BILLED TO STRAIGHT MEDICAID

* If GEQ is indicated, generic form must be used.

McLaren Health Plan-Medicaid Drug Formulary