Health Plus 2013-14 Drug Formulary

2013-2014 Drug Formulary
For Commercial, Medicaid, Point-of-Service, PPO,

Signature PPO Closed Formulary, TPA, MIChild
and HealthPlus Senior Program (non-Part D)
Updated 10/7/2013
The Drug Formulary for Commercial, Medicaid, Point-of-Service, PPO,

Signature PPO Closed Formulary, TPA, MIChild and HealthPlus Senior Program
(non-Part D)
2013-2014 DRUG FORMULARY
TABLE OF CONTENTS
PREFACE TO THE EIGHTEENTH EDITION ............................................................................................ ii
TABLE OF FORMULARY SECTIONS ..................................................................................................... iii
HOW TO USE THIS FORMULARY........................................................................................................ viii
DEFINITIONS ...........................................................................................................................................x
MEMBER PRESCRIPTION BENEFIT ...................................................................................................... xi
GENERIC SUBSTITUTION GUIDELINES ............................................................................................... xi
PRIOR AUTHORIZATION PROGRAM ................................................................................................... xii
PHARMACY AUDIT PROGRAM............................................................................................................ xiii
DRUG RECALL SURVEILLANCE PROGRAM ...................................................................................... xiii
DOSE OPTIMIZATION PROGRAM ....................................................................................................... xiii
DRUG UTILIZATION REVIEW (DUR) .................................................................................................... xiv
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP) ........................................................ xiv
ASK FOR 90 RX PROGRAM ................................................................................................................. xiv
SPECIALTY PHARMACY PROGRAM .................................................................................................... xv
HEALTHPLUS DENTAL FORMULARY .................................................................................................. xv
PHARMACY & THERAPEUTICS COMMITTEE .................................................................................... xvii
FORMULARY UPDATES AND REVISIONS ......................................................................................... xvii
SMOKING CESSATION PHARMACOTHERAPY ................................................................................ xviii
FORMULARY KEY ................................................................................................................................ xix
FORMULARY DRUG PRODUCT .......................................................................................................... 20
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY .................................................... 109
HEALTHPLUS PARTNERS (MEDICAID) OVER-THE-COUNTER (OTC) MEDICATIONS .................. 110
PHARMACY PRIOR AUTHORIZATION FORM ................................................................................... 111
COMMERCIAL/MEDICARE (NON PART-D)/PPO/TPA PRIOR AUTHORIZATION CRITERIA ............ 112
MEDICAID PRIOR AUTHORIZATION CRITERIA ................................................................................ 136
SPECIALTY INJECTABLE PRIOR AUTHORIZATION CRITERIA ....................................................... 158
A RESOURCE FOR PROMOTING QUALITY IN HEALTHCARE
Visit the HealthPlus website at www.healthplus.org
PREFACE TO THE EIGHTEENTH EDITION

Since the publication of the 2013 edition of the HealthPlus Drug Formulary, many new drugs
and treatment options have become available. Every section of the Formulary has been
reviewed and updated. Recommendations in the Formulary are intended to promote the most
cost-effective therapy while maintaining a high quality drug benefit. The Drug Formulary is not
meant to take the place of the product package insert, and users are encouraged to refer to the
full prescribing information provided with the product.
Input and suggestions for inclusion in the 2015 edition are encouraged. Please direct your
comments and suggestions to:
HealthPlus of Michigan
Pharmacy Department
2050 S Linden Road
P.O. Box 1700
Flint, MI 48501-1700
Or e-mail:
rx@healthplus.org
Formulary information is also available at www.healthplus.org.
You may also download formulary information to a PDA or view the formulary online with a PC
through www.epocrates.com. To learn more about the Epocrates formulary program, please go
to www.epocrates.com. Formulary information may also be available through various eprescribing applications (along with eligibility verification and prescription history).
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TABLE OF FORMULARY SECTIONS

GASTROINTESTINAL DRUGS ..................................................................................................... 20
ANTI-ULCER AGENTS .............................................................................................................. 20
INFLAMMATORY BOWEL DISEASE ......................................................................................... 21
DIGESTIVE ENZYMES .............................................................................................................. 21
HEMORRHOIDS AND OTHER GASTROINTESTINALS ............................................................ 22
ANTIEMETICS ........................................................................................................................... 22
PROMOTILITY AGENTS ........................................................................................................... 23
ANTIDIARRHEALS .................................................................................................................... 23
ANTISPASMODICS ................................................................................................................... 23
LAXATIVES/CATHARTICS ........................................................................................................... 24
CARDIOVASCULAR AGENTS ..................................................................................................... 25
NITRATES ................................................................................................................................. 25
ANTIARRHYTHMICS ................................................................................................................. 25
CARDIAC GLYCOSIDES ........................................................................................................... 26
DIURETICS ................................................................................................................................ 26
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs) ................................................ 26
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs) ............................................................ 27
VASODILATORS ....................................................................................................................... 28
CALCIUM CHANNEL BLOCKERS ............................................................................................. 28
BETA-BLOCKERS ..................................................................................................................... 29
ALPHA BLOCKERS ................................................................................................................... 30
PULMONARY ANTIHYPERTENSIVES ...................................................................................... 30
MISCELLANEOUS ANTIHYPERTENSIVES .............................................................................. 30
ANTIHYPERLIPIDEMICS .............................................................................................................. 31
ANTIMICROBIALS AND INFECTIOUS DISEASE ........................................................................ 32
PENICILLINS ............................................................................................................................. 32
CEPHALOSPORINS .................................................................................................................. 32
TETRACYCLINES ...................................................................................................................... 33
MACROLIDES............................................................................................................................ 33
SULFONAMIDES ....................................................................................................................... 34
QUINOLONES ........................................................................................................................... 34
MISCELLANEOUS ANTIBIOTICS .............................................................................................. 34
URINARY ANTI-INFECTIVES (UTI) ........................................................................................... 35
ORAL ANTIFUNGALS................................................................................................................ 35
ANTITUBERCULOSIS AGENTS ................................................................................................ 36
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ANTIVIRALS .............................................................................................................................. 36
ANTIMALARIALS/ANTIPROTOZOALS ...................................................................................... 37
ANTIHELMINTICS ..................................................................................................................... 37
AMEBICIDES ............................................................................................................................. 37
ANALGESICS ............................................................................................................................... 38
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) ................................................... 38
NARCOTIC ANALGESICS ......................................................................................................... 39
RESPIRATORY DRUGS ............................................................................................................... 41
ALLERGIES ............................................................................................................................... 41
NASAL SPRAYS ........................................................................................................................ 42
ANTIHISTAMINE/ANTITUSSIVES ............................................................................................. 42
DECONGESTANT/ANTIHISTAMINES ....................................................................................... 42
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT ............................................................ 43
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES ...................................................... 43
ORALLY INHALED DRUGS ....................................................................................................... 43
OTHER BRONCHODILATORS, ORAL ...................................................................................... 45
THEOPHYLLINES...................................................................................................................... 45
LEUKOTRIENE RECEPTOR ANTAGONISTS ........................................................................... 45
MUCOLYTICS ............................................................................................................................ 45
DERMATOLOGICS ....................................................................................................................... 46
TOPICAL STEROIDS ................................................................................................................. 46
TOPICAL EMOLLIENTS ............................................................................................................ 48
TOPICAL IMMUNOMODULATORS ........................................................................................... 49
PSORIASIS ................................................................................................................................ 49
ANTI-INFECTIVES (TOPICAL) .................................................................................................. 49
BURN PREPARATIONS ............................................................................................................ 49
ANTIFUNGALS (TOPICAL) ........................................................................................................ 49
ACNE ......................................................................................................................................... 51
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS ................................................................... 52
SCABICIDES & PEDICULOCIDES ............................................................................................ 53
TOPICAL ENZYMES .................................................................................................................. 53
OTHER AGENTS ....................................................................................................................... 53
BLOOD MODIFIERS ..................................................................................................................... 53
ANTICOAGULANTS................................................................................................................... 53
ANTI-PLATELET DRUGS .......................................................................................................... 54
HEMORRHEOLOGIC AGENTS ................................................................................................. 54
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COLONY STIMULATING FACTORS ......................................................................................... 54

ERYTHROCYTE STIMULATORS .............................................................................................. 54
HEMOSTATICS ......................................................................................................................... 54
EENT DRUGS ............................................................................................................................... 55
GLAUCOMA AGENTS ............................................................................................................... 55
TOPICAL OPHTHALMIC STEROIDS......................................................................................... 56
TOPICAL OPHTHALMIC ANTIBIOTICS..................................................................................... 57
TOPICAL OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY ......................................... 57
TOPICAL OPHTHALMIC VASOCONSTRICTORS/ANTIHISTAMINES ...................................... 58
TOPICAL OPHTHALMIC NSAIDS.............................................................................................. 58
OTIC AGENTS ........................................................................................................................... 59
BEHAVIORAL HEALTH ................................................................................................................ 59
DEPRESSION ............................................................................................................................ 59
ANXIETY .................................................................................................................................... 61
INSOMNIA ................................................................................................................................. 61
PSYCHOSIS/MANIC DEPRESSIVES ........................................................................................ 62
ATTENTION DEFICIT DISORDER/NARCOLEPSY ................................................................... 63
ANTICONVULSANTS ................................................................................................................... 64
MIGRAINE MEDICATIONS ........................................................................................................... 65
SKELETAL MUSCLE RELAXANTS ............................................................................................. 66
MISCELLANEOUS AUTONOMIC AGENTS ................................................................................. 66
PARKINSON'S DISEASE (PD) ..................................................................................................... 67
ALZHEIMER'S DISEASE .............................................................................................................. 67
HORMONES.................................................................................................................................. 68
ORAL ADRENAL CORTICOSTEROIDS .................................................................................... 68
ORAL CONTRACEPTIVES, GF ................................................................................................. 68
NON-ORAL CONTRACEPTIVES, GF ........................................................................................ 74
ESTROGENS, GF ...................................................................................................................... 74
PROGESTINS ............................................................................................................................ 75
COMBINATION ESTROGEN/ANDROGEN ................................................................................ 75
COMBINATION ESTROGEN/PROGESTINS ............................................................................. 75
DDAVP-DESMOPRESSIN ACETATE ........................................................................................ 76
ANDROGENS, GM .................................................................................................................... 76
INFERTILITY .............................................................................................................................. 76
ENDOMETRIOSIS ......................................................................................................................... 77
OSTEOPOROSIS .......................................................................................................................... 77
SELECTIVE ESTROGEN RECEPTOR MODULATOR............................................................... 77

BISPHOSPHONATES ................................................................................................................ 77
THYROID DISORDERS................................................................................................................. 78
DIABETES..................................................................................................................................... 78
INSULINS................................................................................................................................... 78
NEEDLES/SYRINGES ............................................................................................................... 79
SULFONYLUREAS .................................................................................................................... 79
ORAL ANTIHYPERGLYCEMICS ............................................................................................... 79
DPP-4 INHIBITORS ................................................................................................................... 79
THIAZOLIDINEDIONES ............................................................................................................. 80
MISCELLANEOUS ..................................................................................................................... 80
GLUCAGON............................................................................................................................... 81
ANTI-GOUT DRUGS ..................................................................................................................... 81
SUPPLEMENTS ............................................................................................................................ 81
ANTI-ANEMIA DRUGS .............................................................................................................. 81
PRENATAL VITAMINS............................................................................................................... 81
POTASSIUM .............................................................................................................................. 83
VITAMIN D ................................................................................................................................. 83
VITAMINS WITH FLUORIDE ..................................................................................................... 84
TOPICAL FLUORIDE ................................................................................................................. 84
VITAMIN K ................................................................................................................................. 84
MISCELLANEOUS AGENTS ........................................................................................................ 84
HEAVY METAL ANTAGONISTS ................................................................................................ 84
QUININE SULFATE ................................................................................................................... 84
ALKALINIZING AGENTS ........................................................................................................... 84
AMINO ACID DERIVATIVES...................................................................................................... 84
GALLSTONE SOLUBILIZERS ................................................................................................... 84
SMOKING CESSATION PRODUCTS ........................................................................................ 85
SUBSTANCE ABUSE DETERRENTS ....................................................................................... 85
ERECTILE DYSFUNCTION (ED) ............................................................................................... 85
IMMUNE SUPPRESSANTS ....................................................................................................... 86
RHEUMATOLOGIC MEDCATIONS ........................................................................................... 86
LOCAL ANESTHETICS.............................................................................................................. 87
POTASSIUM REMOVING RESINS ............................................................................................ 87
UROLOGY ................................................................................................................................. 87
OXYTOCICS .............................................................................................................................. 88
vi
HEPATITIS C PRODUCTS ........................................................................................................ 88

IRRITABLE BOWEL SYNDROME/CHRONIC CONSTIPATION ................................................. 89
FIBROMYALGIA ........................................................................................................................ 89
CYSTIC FIBROSIS .................................................................................................................... 89
MULTIPLE SCLEROSIS ............................................................................................................ 89
NEUROLOGICAL MISCELLANEOUS ........................................................................................ 89
ELECTROLYTES & MISCELLANEOUS NUTRIENTS................................................................ 90
ONCOLOGY-ONCOLOGY DRUGS ARE ON FORMULARY UNLESS LISTED OTHERWISE ... 90
GROWTH HORMONES ............................................................................................................. 90
HIV ALL HIV SELF-ADMINISTERED DRUGS ARE ON FORMULARY ................................... 90
MEDICAL PRIOR AUTHORIZATION DRUGS WITH A MEDICAL BENEFIT COPAY ................ 91
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM COVERED AT A ZERO COPAY
WITH PRESCRIPTION .......................................................................................................................... 91
Nicotinic Acid: .............................................................................................................................. 96
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HOW TO USE THIS FORMULARY

ORGANIZATION
The HealthPlus Drug Formulary contains information about medication coverage, generic and
preferred brand prescriptions, and information about HealthPlus Pharmacy policies and
procedures that reflect best practices in the pharmacy industry and current treatment standards.
The Formulary is organized into SECTIONS according to classes of drugs and/or disease state.
When searching for a particular drug, you may use the Find or Search function if you are
viewing the PDF document electronically. If you are viewing a paper copy, it is best to refer to
the index (see last section) under the brand or generic name. Similarly, when looking for the
drugs used to treat a particular disease state, you may use the Find or Search function or refer
to the TABLE OF FORMULARY SECTIONS starting on page iii.
CONTENT
Formulary recommendations are developed through the Pharmacy & Therapeutics Committee
and are based on a review of current drug information and medical literature. HealthPlus
recognizes that it is the sole responsibility of the physician to determine the best course of care
for a particular patient. The HealthPlus Drug Formulary is VOLUNTARY or OPEN, with some
restrictions for drugs included in special programs such as the Prior Authorization program
(including Step Therapy). Procedures for requesting consideration of non-Formulary drugs for
addition to the Formulary are discussed under the heading Formulary Revisions on page xvii.
This document also includes copay tier and status of drugs for a closed formulary (currently
administered only for Signature PPO products).
DRUG LISTING
For each Formulary Section, there is an alphabetic listing of medications that includes both the
commonly used brand name and the generic name. The list includes products that are
Formulary and Non-Formulary. There is also a column that indicates generic availability
(Y=yes, a generic is available). The copay level/tier is included for each medication, along with
any type of restrictions such as prior authorization, quantity limits, etc.
For Commercial/Medicaid/POS/TPA/HealthPlus Senior Program (non-Part D) products, the
following copay tiers apply:
Generic Drugs=Tier 1, lowest copay
Formulary/Preferred Brand Drugs=Tier 2, medium copay
Non-Formulary/Non-Preferred Brand Drugs=Tier 3, highest copay
NOTE: For members with a two tier copay (generic/brand), the standard brand copay applies
for all drugs in copay tiers 2 and 3. For some benefits, a fourth tier copay may apply.
In some cases, an employer group(s) may choose to place specific drugs in a different copay
tier from the standard formulary. Members have access to up-to-date information about
prescription drugs, the formulary and information specific to their benefit at the website at
www.healthplus.org.
viii
HealthPlus encourages the consideration of OTC products. In general, OTC products are not
covered for the Commercial/PPO/HealthPlus Senior Program (non-Part D) lines of business,
with the exception of insulin, insulin syringes, AEROCHAMBER, and sterile saline for
nebulization. There are some additional exceptions, including generic Claritin and Claritin-D
OTC products, Zaditor OTC and generic Nicotine Patches. These products are a covered
benefit, with a written prescription, unless specifically excluded from the members benefit. If an
OTC product is a covered product, it will be included in the category/drug listing. Specifically for
the HealthPlus Partners program, a small list of OTC products is included for coverage as
mandated by the State of Michigan. Please refer to the HealthPlus Partners (Medicaid) OTC
summary list (Appendix B) on page 110.
ix
DEFINITIONS
1. FORMULARY: A list of medications and medical devices recommended for use under
the HealthPlus prescription drug benefit.
2. OPEN FORMULARY: A Drug Formulary that is voluntary. The HealthPlus Drug
Formulary is currently an open or voluntary Formulary, with some restrictions for drugs
included in special programs, such as the Prior Authorization program. Prescriptions for
drugs not listed in the HealthPlus Drug Formulary are still a covered benefit to the patient
as stipulated in the individual group subscriber contract, with exceptions as noted.
3. CLOSED FORMULARY: A Drug Formulary that is mandatory. In a mandatory
Formulary, prescriptions for products not listed in the Formulary are not a covered benefit
for the patient. Patients are still at liberty to use out-of-pocket expenses for nonformulary drug products.
4. PHARMACY & THERAPEUTICS COMMITTEE: An interdisciplinary committee
comprised of HealthPlus staff and community physicians and pharmacists who are
primarily responsible for the maintenance of the HealthPlus Drug Formulary, including the
evaluation and selection of drug products. The Pharmacy & Therapeutics Committee
meets at least five times annually.
5. FORMULARY (Preferred) DRUGS: Drugs included in copay tier 1 or 2 in the HealthPlus
Drug Formulary or updates to the Formulary.
6. NON-FORMULARY (Non-Preferred) DRUGS: Drug products not recommended by the
Pharmacy & Therapeutics Committee and included in copay tier 3. Non-formulary drugs
are still a covered benefit, in an Open Formulary, with the exception of specific
limitations. See Prescription Benefit Limitations (Appendix E, page 197).
7. MAXIMUM ALLOWABLE COST (MAC): The maximum allowable cost that HealthPlus
reimburses to a pharmacy for generic medications.
8. EXCLUDED DRUGS: Drugs that are excluded from the drug benefit. Excluded drugs
that are not reimbursable to the pharmacy include (but are not limited to): products for
cosmetic use, experimental drugs and medical foods. Also, prescriptions written by a
dentist that are not included on the DENTAL FORMULARY (see page xv) are excluded.
Exclusions may also vary depending on the members benefit. See Prescription Benefit
Limitations (Appendix E, page 197) for specific limitations.
9. PRIOR AUTHORIZATION DRUGS: Drugs for which specific criteria must be met for
coverage. Criteria is usually based on appropriate selection of recommended first-line
alternatives prior to selection of the prior authorization drug. A sample prior authorization
request form is included as Appendix C, page 111.
10. STEP THERAPY: Drugs for which a first step medication is required before coverage of
the second step drug. Step therapy is a process that may be used for administering
established Prior Authorization criteria.
11. COPAYMENT: A fee charged to the member for each prescription filled. Copayments
vary depending on the members benefit level.
MEMBER PRESCRIPTION BENEFIT

For HMO Commercial/Medicaid/HealthPlus Senior Program, prescriptions must be written by a
participating physician, or a non-participating physician with the required referral (this does not
apply to PPO members). If the medication is a covered benefit, members may fill their
prescription at a participating HealthPlus pharmacy by presenting their identification card. A list
of participating pharmacies may be found in the Provider Directory, on-line at
www.healthplus.org or by contacting the Customer Service Department.
Based on the members benefit level, a copayment may be required. Copayments vary. If you
or the member has questions about copayments or deductibles (if applicable), please contact
the HealthPlus Customer Service Department at 1-800-332-9161. For specific information
about PPO members, please contact HealthPlus PPO Customer Service at 1-888-212-1512.
GENERIC SUBSTITUTION GUIDELINES
Specified drugs which have generic equivalents MUST BE DISPENSED GENERICALLY.
These drugs are identified by a Y for YES in the GEQ column in the Formulary. Maximum
Allowable Cost (MAC) limits have been established for the majority of these agents. Drug
products considered to be generically and therapeutically equivalent are pharmaceutical
equivalents that can be expected to have the same therapeutic effects when administered to
patients under the conditions specified in the labeling.
The FDA assigns a rating for all generic products. Products with a rating that begins with an A
are considered equivalent to the brand name product. Some products approved before 1962 do
not have a designated rating. Therefore, even though generic equivalents are available, no A
rating has been assigned. These products will be reviewed on a case-by-case basis for addition
to the MAC list.
In cases of medical necessity, generic substitution may be overridden by the use of the
Dispense as Written notation, with Prior Authorization required in these instances (please refer
to Appendix D, page 112, Prior Authorization Criteria). For Commercial/PPO/HealthPlus Senior
Program (non-Part D) and RDS lines of business, if DAW is not medically necessary on a
generically available brand name prescription or the member chooses the brand product in the
absence of a DAW, he or she may do so by paying the difference in cost and/or any applicable
copayment. In some cases based on the members benefit level, there may be a higher copay
for branded products. For HealthPlus Partners, if the member requests the brand name drug he
or she may be responsible for the entire cost of the prescription.
xi
Generic substitution is not required for some products that may have an A rating, due to a
narrow therapeutic index. These include:
Coumadin
Depakene
Depakote
Dilantin
Lanoxin
Premarin
Synthroid
Tegretol
Theo-Dur
Narrow therapeutic index drugs are reviewed on a case by case basis for addition to the MAC
list. If a HealthPlus pharmacy submits the claim for the brand name drug, the brand name drug
is covered, and reimbursement is based on the price of the brand name drug and applicable
discounts. If a HealthPlus pharmacy submits the claim for a generic product, and the drug is
included on the MAC list, reimbursement is based on the MAC price.
PRIOR AUTHORIZATION PROGRAM
HealthPlus requires prior authorization for selected drug products based on clinical, safety, or
cost reasons. A copy of the Pharmacy Prior Authorization Form and the Prior Authorization
Criteria for medications that require prior authorization at the time of publication are included as
Appendix C and D (pages 111 and 112). Please note that the criteria documents include criteria
for Commercial/PPO/HealthPlus Senior Program (non-Part D) lines of business, HealthPlus
Partners (Medicaid) criteria, and criteria for specialty/injectable medications. For PPO,
requirements for Prior Authorization may or may not apply based on the benefit purchased by
the employer.
HealthPlus uses automated Step Therapy for some medications that require prior authorization.
This means that there are established first step drugs that must be used before the second
step drug is covered. If the pharmacy submits a claim for a second step drug, and the member
has already tried and failed the first step drug (based on a system look-back for previous
claims), the claim for the second drug will automatically be approved and paid.
For the Signature PPO Closed Formulary, an Exceptions Process is available for review of
medical necessity for coverage of non-formulary medications.The Exceptions Process also
applies to drugs that are excluded as specified by the employer.
To prescribe a medication that requires prior authorization or to submit a request for the
Exceptions Process:
The physician or office staff may complete the Pharmacy Prior Authorization form.
Fax the form to the HealthPlus Pharmacy Department:
FAX (810) 720-2757 (FLINT)
FAX (989) 797-4181 (SAGINAW)
If the patient presents a prescription to the pharmacy and prior authorization or an
exception has not been obtained, the pharmacy should contact the prescribing physician
and suggest preferred alternatives or instruct the physician to complete the Pharmacy
xii
Prior Authorization Form. For medications included in the specialty injectable program,
the physician may initiate the request for medication through the specialty vendor. The
specialty vendor will then contact HealthPlus.
7-Day Starter Dose:
To ensure that members are never in a situation where they are unable to obtain their
medication, a 7-day starter dose may be dispensed by the pharmacy when an on-line edit is
received for a medication or quantity that requires prior authorization. This override is a onetime override and is subject to audit.
If the prescribing physician is unavailable for consult, the pharmacy may dispense up to a
7-day starter dose to initiate care for the member.
Place a 06 in the denial clarification field (field 420) and enter up to a 7 for the days
supply.
Emergency Override:
Pharmacies may also override non-participating physician edits that may apply when a
prescription is written for an emergency situation. Entering 03 in the level of service field (field
418) will allow an override for emergency prescriptions only. This override is intended to be a
one-time override and is subject to audit.
If you would like an updated list of medications that require prior authorization, or if you have
questions about this program, please call the Prior Authorization line at:
Flint local phone (810) 720-2758
Toll-free phone (877) 710-0993
Note: These overrides do not apply to the Signature PPO Closed Formulary Benefit.
PHARMACY AUDIT PROGRAM
HealthPlus (or its designee) performs pharmacy audits to help ensure consistent and accurate
electronic submission of prescription claims by the pharmacy network. Prescription claim audit
activities may include a review of utilization by pharmacies, physicians, and members. The
pharmacy audit program includes desk (paper) audits, on-site audits, and an appeals process.
DRUG RECALL SURVEILLANCE PROGRAM
When a particular drug product is recalled or withdrawn from the market due to safety reasons,
HealthPlus reviews prescription utilization to identify members receiving that drug. HealthPlus
notifies members and physicians affected by the recall, as appropriate.
DOSE OPTIMIZATION PROGRAM
HealthPlus administers a Dose Optimization Program to target medications that are
recommended for once daily dosing and/or support maximum dose recommendations through
quantity limits. By optimizing the dose and decreasing the frequency, patient compliance
increases and prescription costs decrease.
xiii
System edits apply for the targeted medications when prescribed more often than once daily or
above the quantity limits. Physicians may submit the standard HealthPlus Pharmacy Prior
Authorization form, with information that includes a current diagnosis and medical necessity for
the dosage regimen.
Some of the categories included in the Dose Optimization Program are: proton pump inhibitors,
HMG CoA reductase inhibitors, COX-II inhibitors, angiotensin II receptor antagonists, selected
narcotic analgesics, selected antipsychotics, selected urinary incontinence drugs and selected
sleeping medications. For more information regarding the Dose Optimization Program, please
contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877-710-0993.
DRUG UTILIZATION REVIEW (DUR)
HealthPlus administers a comprehensive DUR program to help ensure the quality and safety of
prescribing and dispensing medications to members. The program includes point-of-service
quality and safety edits to the pharmacist when a prescription is being filled, and retrospective
analysis of claims data (with integration of medical and pharmacy data) to identify opportunities
for educational intervention and improve quality and outcomes. For more information regarding
the DUR program, please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or
toll-free at 1-877-710-0993.
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP)
HealthPlus offers services through a Controlled Substances Pharmacy Program to support the
appropriate management of pain, ensure patient safety of narcotic use, and monitor for and
prevent potential fraud and abuse of narcotics. For more information about the CSPP program,
please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877710-0993.
ASK FOR 90 RX PROGRAM

Based on their benefit, the member may be eligible for the HealthPlus Ask for 90 Rx 90-day
medication program. With the Ask for 90 Rx program, there are two options for obtaining a 90day supply of medications:
1. LOCAL PHARMACIES-Members may receive up to a 90-day supply of medication from
participating local retail pharmacies.Copay savings may apply. For more information, go
to www.healthplus.org for a Frequently Asked Questions flyer and a list of retail
pharmacies that participate in the Ask for 90 Rx program. Or, you may contact the
HealthPlus Customer Service Department.
2. MAIL SERVICE PROGRAM-Members may receive up to a 90-day of medication by mail
order through Express Scripts and have prescriptions delivered to their home with no
shipping costs.Copay savings may apply. For more information about mail service, go to
www.healthplus.org, or contact the HealthPlus Customer Service Department.
For most benefits, copay savings from both of these programs are the same. Based on their
benefit, the member pays the same copay for a 90-day supply at an Ask for 90 Rx retail
pharmacy as they do at mail order.
xiv
Most chronic medications are covered through the 90-day programs. Compounded medications
and injectable medications, with the exception of injectable diabetes medications, glucagon, EpiPen and Imitrex, are NOT covered through the 90-day programs.
To receive a 90-day supply in the Ask for 90 Rx Program, HealthPlus requires that the member
has already received a 30-day supply of the same drug and same strength within the last year
(to help assure the member is stabilized on the drug and dose before receiving a 90-day
supply). The prescription claims processing system looks for previous pharmacy claims billed to
HealthPlus for the member.
NOTE: Based on their benefit, the member may be enrolled in the Mandatory 90-Day
Medication Program. For most chronic medications, members are required to receive a 90-day
supply each time they fill their prescription at a participating local retail pharmacy or through mail
order with Express Scripts.
SPECIALTY PHARMACY PROGRAM
HealthPlus administers a specialty pharmacy program for injectable medications; including
medications administered in the physicians office and self-administered medications. For more
information about the specialty pharmacy program, please contact the HealthPlus Customer
Service Department at 1-800-332-9161. For PPO, please contact HealthPlus PPO Customer
Service at 1-888-212-1512.
NOTE: Based on their benefit, the member may be enrolled in the Mandatory Specialty
Program. For specific self-injected medications, the member is required to receive the
medication from a HealthPlus-contracted specialty pharmacy (the specialty pharmacy will mail
the medication to the physicians office or the members home). This program applies to selfinjected medications for Rheumatoid Arthritis, Hepatitis C, Multiple Sclerosis, Infertility,
Endometriosis (for HealthPlus Partners), and other targeted categories.
HEALTHPLUS DENTAL FORMULARY
The HealthPlus Dental Formulary is a restricted list of pharmaceutical agents covered when
prescribed by dentists. This list was established by the Medical Affairs Committee and Board of
Directors with recommendations by the Pharmacy & Therapeutics Committee. In the opinion of
the Medical Affairs Committee, these medications are of established value in the treatment or
prophylaxis of dental conditions, and present a broad range of choices to meet the usual clinical
problems. These products are covered when written by a dental provider treating a patient with
a HealthPlus drug benefit. Products that are not listed on the Dental Formulary are not a
covered benefit when prescribed by a dentist. Medications listed in the Dental Formulary are
available as either oral solids or oral liquids, whichever fits the clinical situation as determined by
the prescriber. Products listed with Y for YES in the GEQ column in the Formulary, must be
filled with a generic equivalent; for these generic medications, a tier 1 copay applies. In cases
of medical necessity, generic substitution may be overridden by the use of the Dispense as
Written (DAW) notation, with prior authorization required for these instances. A copy of the
HEALTHPLUS DENTAL FORMULARY is printed on the next page.
xv
HEALTHPLUS DENTAL FORMULARY

Antifungals
nystatin
MYCOSTATIN*
Antivirals
acyclovir
valacyclovir
ZOVIRAX*
VALTREX*
Antibiotics
Cephalosporins
cephalexin HCL
cefadroxil
cefuroxime
KEFLEX* (NOT 750MG)

DURICEF*
CEFTIN*
Erythromycins
erythromycin
ERYTHROMYCIN*
Penicillins
amoxicillin
amoxicillin-clavulanate potassium
penicillin V potassium
AMOXIL*
AUGMENTIN*
PENVEEK*
Tetracyclines
doxycycline hyclate
tetracycline HCL
VIBRAMYCIN*, VIBRATABS*
(NOT DORYX, ORACEA)
Miscellaneous Antibiotics
clindamycin HCL
CLEOCIN 150mg*
Miscellaneous Anti-Infectives
metronidazole
FLAGYL*
Skeletal Muscle Relaxants
diazepam
ibuprofen
indomethacin
naproxen
VALIUM*
Nonsteroidal Anti-Inflammatory Agents
RX MOTRIN*
INDOCIN*
NAPROSYN*
Narcotic Analgesics
acetaminophen/codeine
acetaminophen 500/hydrocodone 5
acetaminophen 750/hydrocodone 7.5
acetaminophen 325/oxycodone 5
aspirin/caffeine/dihydrocodeine
aspirin/codeine
aspirin 325/oxycodone 5
butalbital/aspirin/caffeine/codeine
acetaminophen 325/hydrocodone 7.5
ibuprofen 200/hydrocodone 7.5
TYLENOL W/CODEINE*
VICODIN* 5/500
VICODIN ES* 7.5/750
PERCOCET*
SYNALGOS-DC*
EMPIRIN W/CODEINE*
PERCODAN*
FIORINAL W/CODEINE*
NORCO*
NORCO*
NORCO*
VICOPROFEN*
Systemic Corticosteroids
methylprednisolone
MEDROL DOSE PAK*

Miscellaneous Rinses
chlorhexidine gluconate
PERIDEX*
Miscellaneous
lidocaine viscous solution/ointment
LIDOCAINE*
NOTE: Behavior health medications (ex. diazepam) are carved out for HealthPlus Partners Medicaid and HealthPlus
MIChild/MIChild CSHCS.
*generic available
xvi
PHARMACY & THERAPEUTICS COMMITTEE

The Pharmacy & Therapeutics Committee is an interdisciplinary body made up of practicing
physicians and pharmacists from the community, in addition to staff. The committee may invite
persons within or outside the organization who can contribute specialized or unique knowledge,
skills, and judgments. The function of the committee is to serve in an evaluative, educational,
and advisory capacity to the physician providers in all matters pertaining to drug use. The
committee also provides strategic guidance for pharmacy programs. The committee is involved
in the development and updating of pharmaceutical management procedures. In addition, the
committee meets at least five times annually to evaluate drugs for inclusion in the formulary.
The recommendations of the Pharmacy & Therapeutics Committee are communicated to the
Medical Affairs Committee and finally sent to the Board of Directors for approval.
FORMULARY UPDATES AND REVISIONS
The Formulary is revised regularly through recommendations from the Pharmacy &
Therapeutics Committee. HealthPlus reviews medications and medication categories on an
ongoing basis to help ensure that the Drug Formulary provides an ample, up-to-date selection of
quality, cost-effective medication choices. The Formulary is revised and republished annually
with notification to providers, and is available with quarterly updates on the website at
www.healthplus.org; providers and members may also receive a printed copy upon request.
Quick-Check references that include formulary recommendations for the most-prescribed
categories are also available and updated regularly. HealthPlus routinely provides updated
information to physicians, pharmacies and members through letters, bulletins, e-mails, articles in
the newsletters, etc. The Formulary is also available for providers at www.epocrates.com for
downloading to a PDA or in an on-line version, and through various e-prescribing software
applications available to physicians.
Members may obtain up-to-date formulary and cost information specific to their benefit and
copays at www.healthplus.org. For more information, please contact the HealthPlus Pharmacy
Department at 1-810-230-2118.
Physician requests for additions to the Formulary must be made on a Request for Addition to
the Formulary form, which includes the reason for the request and any clinical data supporting
that request. Please refer to APPENDIX A (page 109) for a copy of the HEALTHPLUS
REQUEST FOR ADDITION TO THE FORMULARY form. Member requests for additions to the
formulary are forwarded to the Pharmacy Department for appropriate review and consideration.
xvii
SMOKING CESSATION PHARMACOTHERAPY

HealthPlus covers prescriptions for smoking cessation pharmacotherapy:
1. Smoking cessation pharmacotherapy may have duration or frequency limits.
2. Smoking cessation pharmacotherapy will be consistent with the HealthPlus Drug
Formulary, and may include various prescription and OTC products.
3. Smoking cessation products covered as a Preventative Medication as required by
Health Care Reform are listed on page 91.
For specific formulary recommendations and limitations, please see SMOKING CESSATION
PRODUCTS on page 85.
HealthPlus Partners Medicaid

For HealthPlus Partners Medicaid, all of the following OTC nicotine agents are covered to
promote smoking cessation: patch, inhaler, nasal spray, gum or lozenges. In addition, the
following non-nicotine prescription medications are covered: Chantix and Zyban (bupropion).
These products are covered with no copay and prior authorization is not required. Duration limits
may apply for specific products.
HealthPlus offers a Smoking Cessation program to members. The program includes: a free quit
kit, prescription coverage, phone/web coaching and reimbursement for community classes.
To enroll in the Smoking Cessation program, contact the Health & Lifestyle Management
Department at 1-866-810-4540.
xviii
FORMULARY KEY
Abbreviation
AG
DL
DME
DO
GEQ
GF
GM
HMO
M
M-NC
M-SUPP
MAND 90
MAND SPEC
MDCH
NA
NC
NF-NC
NF-PA
PA
PARTNERS
POS
PPO
QL
SP
SPEC
TPA
Description
Age Restriction
Duration Limit
Available through Durable Medical Equipment benefit only, with a copay as applicable.
Dose Optimization
Generically Available
Female Gender Restriction
Male Gender Restriction
Health Maintenance Organization
Medical injectable or infused drugs (not self-administered)
Medical benefit only, not processed by Pharmacy
HealthPlus Senior Program (non-Part D) Plan
Mandatory 90-Day Program (specific medications must be filled in a 90-day supply)
Mandatory Specialty Drug Program (specific medications must be obtained through a contracted
specialty pharmacy)
Michigan Department of Community Health (carve-out for specific medications)
Not Applicable
Not Covered, Excluded
Non-Formulary, Not Covered (for Signature PPO Closed formulary)
Non-Formulary, Prior Authorization Required (for Signature PPO Closed formulary)
Prior Authorization and/or Step Therapy Required
HealthPlus Partners Medicaid
Point of Service Plan
Preferred Provider Organization
Quantity Limit
Specialty Pharmacy Product with Limited Distribution (through a specific specialty pharmacy)
Specialty Drugs, self-injected or self-administered
Third Party Administrator
xix
FORMULARY DRUG PRODUCT

NOTES
BRAND NAME
ACIPHEX
AXID
CARAFATE
CARAFATE SUSP
CYTOTEC
DEXILANT
ESOMEPRAZOLE
STRONTIUM
GEQ
Y
Y
Y
FIRSTLANSOPRAZOLE
FIRSTOMEPRAZOLE
NEXIUM
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
GASTROINTESTINAL DRUGS
ANTI-ULCER AGENTS
PA, DO
PA, DO
PA, DO
SIGNATURE
PPO CLOSED
FORMULARY
PA, DO
PA, DO
PA, DO
NF-NC
1
1
2
1
NF-NC
PA, DO
PA, DO
PA, DO
NF-NC
LANSOPRAZOLE
PA, DO
PA, DO
PA, DO
NF-NC
OMEPRAZOLE
ESOMEPRAZOLE
OMEPRAZOLECLARITHROMYCINAMOXICILLIN
FAMOTIDINE
3
3
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
NF-NC
NF-NC
RABEPRAZOLE
NIZATIDINE
SUCRALFATE
SUCRALFATE
MISOPROSTOL
DEXLANSOPRAZOLE
2
1
1
2
1
3
ESOMEPRAZOLE
STRONTIUM
FAMOTIDINE
PREVACID
LANSOPRAZOLE
NF-NC
PREVACID
SOLUTAB
PRILOSEC 20MG
PRILOSEC 40MG
LANSOPRAZOLE
OMEPRAZOLE
OMEPRAZOLE
3
1
1
PA, DO
PA, DO
PA, DO
Y
Y
NF-NC
1
NF-NC
3
1
3
1
1
PA, DO
PA, DO
PA, DO
Y
Y
Y
Y
OMEPRAZOLE
MAGNESIUM
PANTOPRAZOLE
PANTOPRAZOLE
CIMETIDINE
RANITIDINE
PA, DO
PA, DO
PA, DO
NF-NC
NF-NC
NF-NC
1
1
th
th
*A 4 tier copay applies for plans that have a 4 tier.

#This drug is carved out to MDCH for MIChild CSHCS
PARTNERS
MAND
SPEC
NF-NC
NF-NC
OMECLAMOX-PAK
PEPCID RPD
PEPCID TABS,
SUSP
PRILOSEC DR
SUSP
PROTONIX TABS
PROTONIX PAK
TAGAMET
ZANTAC
MAND 90
MAND
SPEC
3
3
20

NOTES
BRAND NAME
ZANTAC
EFFERDOSE
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
RANITIDINE
NF-NC
OMEPRAZOLE/SODIUM
BICARBONATE
NF-NC
ZEGERID SUSP
OMEPRAZOLE/SODIUM
BICARBONATE
APRISO
ASACOL
ASACOL HD
MESALAMINE
MESALAMINE
MESALAMINE
2
2
2
2
2
2
SULFASALAZINE
MESALAMINE
1
2
1
2 DO
BALSALAZIDE
DISODIUM
HYDROCORTISONE
ACETATE
NF-NC
MESALAMINE
OLSALAZINE
BUDESONIDE
BALSALAZIDE
DISODIUM
MESALAMINE
MESALAMINE
MESALAMINE
2
3
1
2
NF-NC
MESALAMINE
BUDESONIDE
2
3
AMYLASE/ LIPASE/
PROTEASE
ZEGERID 40MG
CAPS
AZULFIDINE,
ENTAB
CANASA
COLAZAL
CORTIFOAM
DELZICOL
DIPENTUM
ENTOCORT EC
GIAZO
LIALDA
PENTASA
ROWASA ENEMA
SF ROWASA
ENEMA
*UCERIS
CREON
th
3
3
2
1
th

PA, DO
PA, DO
PA, DO
INFLAMMATORY BOWEL DISEASE
DO
PA
DO
PA
DO
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
Y
Y
Y
Y
Y
1
PA
PA
PA
PA
PA
PA
DIGESTIVE ENZYMES
PA
PA
PA
NF-NC
NF-NC
2
1
Y
Y
2
NF-NC
21

NOTES
BRAND NAME
GEQ
PANCREAZE
PERTZYE
ULTRASE
ULTRASE MT
ULTRESA
VIOKASE
ZENPEP 5,000
GENERIC NAME
ZENPEP 10,000,
15,000 AND 20,000
AMYLASE/ LIPASE/
PROTEASE
AMITIZA
LUBIPROSTONE
HYDROCORTISONE
SUPP
CROFELEMER
CROMOLYN SODIUM
ALOSETRON
PRAMOXINE
HYDROCORTISONE/
PRAMOXINE
ANUSOL HC
FULYZAQ
GASTROCROM
LOTRONEX
PROCTOFOAM
Y
Y
Y
PROCTOFOAM HC
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
TIER
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
3
HEMORRHOIDS AND OTHER GASTROINTESTINALS
PA
2
1
3
1
2
1
MAND
SPEC
PARTNERS
MAND
SPEC
2
1
NF-NC
1
NF-NC
1
2
ANTIEMETICS
ANTIVERT 12.5,
25MG
ANTIVERT 50MG
1
2
ANZEMET
MECLIZINE
MECLIZINE
DOLASETRON
MESYLATE
COMPAZINE
SYRUP
PROCHLORPERAZINE
th
th

1
2
PA
NF-NC
2
22

NOTES
BRAND NAME
COMPAZINE TABS,
SUPP
DICLEGIS
EMEND
PHENERGAN
SANCUSO
TIGAN
TRANSDERMSCOP
ZOFRAN, ODT
ZUPLENZ
REGLAN
GEQ
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PROCHLORPERAZINE
DOXYLAMINE/
PYRIDOXINE
APREPITANT
PROMETHAZINE
GRANISETRON
TRIMETHOBENZAMIDE
3
3
1
3
1
SCOPOLAMINE
ONDANSETRON
ONDANSETRON
2
1
3
METOCLOPRAMIDE
AG
AG
AG
AG
AG
AG
NF-NC
NF-NC
1 AG
NF-NC
1 AG
PA
2
1
NF-NC
PA
PA
PROMOTILITY AGENTS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ANTIDIARRHEALS
IMODIUM
LOPERAMIDE
LOMOTIL
MOTOFEN
DIPHENOXYLATE/
ATROPINE
DIFENOXIN/ ATROPINE
1
3
1
NF-NC
ANASPAZ
BENTYL
Y
Y
HYOSCYAMINE
DICYCLOMINE
1
1
CANTIL
CYSTOSPAZ M
MEPENZOLATE
BROMIDE
HYOSCYAMINE
3
3
DONNATAL TAB,
ELIXIR
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
NF-NC
DONNATAL ER
LEVSIN
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
HYOSCYAMINE
3
1
NF-NC
1
ANTISPASMODICS
th
th

1
1
PA
NF-NC
NF-NC
23

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
LIBRAX
NULEV
Y
Y
CLIDINIUM BROMIDE/
CHLORDIAZEPOXIDE
HYOSCYAMINE
1
1
1
1
PAMINE
METHSCOPOLAMINE
BROMIDE
PAMINE FORTE
METHSCOPOLAMINE
BROMIDE
METHSCOPOLAMINE
COMBO
NF-NC
PROPANTHELINE
HYOSCYAMINE
2
1
2
1
HYOSCYAMINE
PAMINE FQ
PRO-BANTHINE
7.5MG
SYMAX FASTABS
SYMAX DUOTAB
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
LAXATIVES/CATHARTICS
COLYTE
PEG3350/NA
SULF/BICARB/CL/KCL
GOLYTELY
#LACTULOSE
SOLN
PEG3350/NA
SULF/BICARB/CL/KCL
LACTULOSE
MOVIPREP
PEG3350/SOD
SUL/NACL/ASB/CL/KCL
PA
NF-NC
OSMOPREP
NAPHOS MBMH/NAPHOS, DI-BA
PA
NF-NC
PREPOPIK
NA PICOSUL/MAG-OX/
CITRIC ACID
NF-NC
SUCLEAR
PEG3350/NA SULF/
BICARB/KCL
NF-NC
SUPREP
SODIUM
/POTASSIUM/MAG
SULFATES
NF-NC
th
th

24

NOTES
BRAND NAME
GEQ
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
CARDIOVASCULAR AGENTS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
NF-NC
1
2
1
2
Y
Y
TIER
MAND
SPEC
PARTNERS
MAND
SPEC
NITRATES
ISOSORBIDE
DINITRATE/
HYDRALAZINE
ISOSORBIDE
DINITRATE
BIDIL
DILATRATE-SR
IMDUR
ISORDIL 10MG
ISOSORBIDE
DINITRATE
ISORDIL 40MG
MONOKET
NITRO-BID OINT
NITRO-DUR
PATCHES 0.1, 0.2,
0.4, 0.6MG/HR
NITRO-DUR
PATCHES 0.3,
0.8MG/HR
NITROLINGUAL
SPRAY
NITROSTAT
PAPAVERINE
ISOSORBIDE
MONONITRATE
ISOSORBIDE
DINITRATE
ISOSORBIDE
MONONITRATE
NITROGLYCERIN
NITROGLYCERIN
TRANSDERMAL
NITROGLYCERIN
TRANSDERMAL
RECTIV OINT
PA
NITROGLYCERIN
NITROGLYCERIN
SUBLINGUAL
PAPAVERINE
3
1
NF-NC
1
Y
Y
NITROGLYCERIN
NF-NC
1
1
1
1
Y
Y
Y
Y
ANTIARRHYTHMICS
BETAPACE, AF
CALAN
CORDARONE
LANOXIN
th
Y
Y
Y
Y
SOTALOL
VERAPAMIL
AMIODARONE
DIGOXIN
1
1
1
1
th

25

NOTES
BRAND NAME
MULTAQ
NORPACE
NORPACE CR
PACERONE
PRONESTYL
RANEXA
RYTHMOL, SR
SECTRAL
TAMBOCOR
TIKOSYN
GEQ
Y
Y
Y
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
2
1
2
1
DISOPYRAMIDE
AMIODARONE
PROCAINAMIDE
RANOLAZINE
PROPAFENONE
ACEBUTOLOL
FLECAINIDE
DOFETILIDE
3
1
3
2
1
1
1
3
NF-NC
DIGOXIN
GENERIC NAME
DRONEDARONE
HYDROCHLORIDE
DISOPYRAMIDE
TIER
PPO
PARTNERS
MEDICAID
1
NF-NC
PA
2
1
1
1
NF-NC
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
CARDIAC GLYCOSIDES
LANOXIN
DIURETICS
ALDACTAZIDE
25/25
ALDACTAZIDE
50/50
ALDACTONE
CHLORTHALIDON
E
DEMADEX
DYAZIDE
DYRENIUM
INSPRA
LASIX
LOZOL
MAXZIDE
ZAROXOLYN
ACCUPRIL
th
SPIRONOLACTONE/
HCTZ
SPIRONOLACTONE/
HCTZ
SPIRONOLACTONE
3
1
NF-NC
1
Y
Y
1
1
1
1
1
1
NF-NC
3
1
1
1
1
1
1
1
1
1
1
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
CHLORTHALIDONE
TORSEMIDE
TRIAMTERENE/ HCTZ
TRIAMTERENE
EPLERENONE
FUROSEMIDE
INDAPAMIDE
TRIAMTERENE/ HCTZ
METOLAZONE
QUINAPRIL
1
th

26

NOTES
BRAND NAME
GEQ
ACCURETIC
ACEON
ALTACE
CAPOTEN
EPANED
SOLUTION
LOTENSIN
LOTENSIN HCT
Y
Y
Y
Y
LOTREL
MAVIK
MONOPRIL
MONOPRIL HCT
PRINIVIL
PRINZIDE
Y
Y
Y
Y
Y
Y
TARKA
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
Y
Y
Y
Y
QUINAPRIL/ HCTZ
PERINDOPRIL
RAMIPRIL
CAPTOPRIL
1
1
1
1
1
1
1
1
3
1
1
NF-NC
1
1
Y
Y
Y
1
1
1
1
1
1
1
1
1
1
1
1
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
ENALAPRIL
BENAZEPRIL
BENAZEPRIL/ HCTZ
AMLODIPINE/
BENAZEPRIL
TRANDOLAPRIL
FOSINOPRIL
FOSINOPRIL/ HCTZ
LISINOPRIL
LISINOPRIL/ HCTZ
TRANDOLAPRIL/
VERAPAMIL
MOEXIPRIL/ HCTZ
MOEXIPRIL
ENALAPRIL/ HCTZ
ENALAPRIL
LISINOPRIL/ HCTZ
2
1
1
1
1
1
2
1
1
1
1
1
Y
Y
Y
Y
Y
Y
ZESTRIL
LISINOPRIL
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs)
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
Y
Y
Y
Y
CANDESARTAN
CANDESARTAN
IRBESARTAN/ HCTZ
IRBESARTAN
AMLODIPINE/
OLMESARTAN
OLMESARTAN
OLMESARTAN/ HCTZ
1
1
1
1
1 DO
1
1
1 DO
Y
Y
Y
Y
2
2 DO
2
Y
Y
Y
AZOR
BENICAR
BENICAR HCT
th
Y
Y
th

2
2
2
DO
DO
DO
DO
DO
DO
DO
DO
DO
MAND
SPEC
PARTNERS
MAND
SPEC
27

NOTES
BRAND NAME
COZAAR
DIOVAN
DIOVAN HCT
GEQ
Y
GENERIC NAME
TIER
EXFORGE
LOSARTAN
VALSARTAN
VALSARTAN/ HCTZ
AZILSARTAN
MEDOXOMIL
AZILSARTAN
MEDOXOMIL/
CHLORTHALIDONE
AMLODIPINE/
VALSARTAN
EXFORGE HCT
HYZAAR
MICARDIS
MICARDIS HCT
TEVETEN
AMLODIPINE/
VALSARTAN/HCTZ
LOSARTAN/ HCTZ
TELMISARTAN
TELMISARTAN/ HCTZ
EPROSARTAN
EDARBI
EDARBYCLOR
TEVETEN HCT
EPROSARTAN/ HCTZ
OLMESARTAN MED/
AMLODIPINE/HCTZ
TELMISARTAN/
AMLODIPINE
ALISKIREN/
VALSARTAN
TRIBENZOR
TWYNSTA
VALTURNA
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
DO
1
2 DO
1
MAND 90
Y
Y
Y
PA, DO
PA, DO
NF-NC
PA, DO
PA, DO
NF-NC
2
1
3
3
1
PA, DO
PA
DO
PA, DO
PA
DO
PA, DO
PA
DO
2
1
NF-NC
NF-NC
1 DO
Y
Y
Y
Y
Y
PA
PA
PA
NF-NC
NF-NC
2
1
1
3
1
2
1
1
NF-NC
1
Y
Y
Y
Y
Y
1
2
1
DO
DO
PA, DO
PA, DO
2
3
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
VASODILATORS
APRESOLINE
HYDRALAZINE
1
CALCIUM CHANNEL BLOCKERS
ADALAT CC
AMTURNIDE
CALAN, SR
CARDENE
CARDENE SR
CARDIZEM
th
Y
Y
Y
NIFEDIPINE
ALISKIREN/
AMLODIPINE/HCTZ
VERAPAMIL
NICARDIPINE
NICARDIPINE
DILTIAZEM
th

28

NOTES
BRAND NAME
CARDIZEM CD 120,
180, 240, 300, 360
CARDIZEM LA
120MG
CARDIZEM LA 180,
240, 300, 360
420MG
CARTIA XT
COVERA HS
DILACOR XR
DYNACIRC CR
ISOPTIN SR
LOTREL
NIMOTOP
NORVASC
PROCARDIA, XL
SULAR 8.5, 17,
25.5, 34
TEKAMLO
VERELAN, PM
GEQ
Y
GENERIC NAME
TIER
DILTIAZEM
Y
Y
Y
Y
Y
Y
Y
PPO
PARTNERS
MEDICAID
DILTIAZEM
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
1
1
NF-NC
1
NF-NC
1
Y
Y
Y
Y
Y
Y
DILTIAZEM
DILTIAZEM
VERAPAMIL
DILTIAZEM
ISRADIPINE
VERAPAMIL
AMLODIPINE/
BENAZEPRIL
NIMODIPINE
AMLODIPINE
NIFEDIPINE
1
1
3
1
3
1
1
1
1
1
1
1
1
1
NISOLDIPINE
ALISKIREN/
AMLODIPINE
VERAPAMIL
2
1
2
1
Y
Y
TIMOLOL
NEBIVOLOL
CARVEDILOL
CARVEDILOL
NADOLOL
NADOLOL/
BENDROFLUMETHIAZIDE
METOPROLOL/HCTZ
PROPRANOLOL
BETAXOLOL
1
2
1
3
1
1
2 DO
1
NF-NC
Y
Y
Y
Y
Y
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
BETA-BLOCKERS
BLOCADREN
BYSTOLIC
COREG
COREG CR
CORGARD
CORZIDE
DUTOPROL
INDERAL LA
KERLONE
th
Y
Y
Y
Y
th

1
3
1
1
DO
DO
DO
PA
PA
PA
1
NF-NC
1
1
Y
Y
Y
Y
29

NOTES
BRAND NAME
LEVATOL
LOPRESSOR
LOPRESSOR HCT
NORMODYNE
SECTRAL
GEQ
Y
Y
Y
Y
TENORETIC
TENORMIN
Y
Y
TOPROL XL
TRANDATE
ZEBETA
ZIAC
Y
Y
Y
Y
GENERIC NAME
PENBUTOLOL
METOPROLOL
METOPROLOL/ HCTZ
LABETALOL
ACEBUTOLOL
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
1
1
1
MAND 90
Y
Y
Y
Y
Y
1
1
1
1
Y
Y
1
1
1
1
1
1
1
1
Y
Y
Y
Y
1
NF-NC
1
Y
Y
Y
2
1
TIER
3
1
1
1
1
ATENOLOL/
CHLORTHALIDONE
ATENOLOL
METOPROLOL
SUCCINATE
LABETALOL
BISOPROLOL
BISOPROLOL/ HCTZ
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
Y
ALPHA BLOCKERS
CARDURA
CARDURA XL
FLOMAX
JALYN
MINIPRESS
Y
Y
DOXAZOSIN
DOXAZOSIN
TAMSULOSIN
1
3
1
DUTASTERIDE/
TAMSULOSIN
PRAZOSIN
2
1
PA
PA
PULMONARY ANTIHYPERTENSIVES
*ADCIRCA
*REVATIO
*TRACLEER
TYVASO
ALDOMET
ALDOMET 125
ALDORIL-D
CATAPRES, TTS
DIBENZYLINE
th
TADALAFIL
SILDENAFIL CITRATE
BOSENTAN
TREPROSTINIL/NEBULI
ZER KIT
3
1
2
METHYLDOPA
METHYLDOPA
METHYLDOPA/ HCTZ
CLONIDINE
PHENOXYBENZAMINE
1
2
3
1
3
th

PA
PA
SP
PA
PA
SP
PA
PA
SP
SP
SP
SP
MISCELLANEOUS ANTIHYPERTENSIVES
NF-NC
1 PA
4 SP
NF-NC
1
2
NF-NC
Y
Y
1
NF-NC
30

NOTES
BRAND NAME
INSPRA
NEXICLON XR
TEKTURNA
TEKTURNA HCT
TENEX
GEQ
Y
VALTURNA
GENERIC NAME
TIER
EPLERENONE
CLONIDINE
ALISKIREN
ALISKIREN/ HCTZ
GUANFACINE
ALISKIREN/
VALSARTAN
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
3
2
2
1
SIGNATURE
PPO CLOSED
FORMULARY
1
NF-NC
2
2
1
MAND 90
Y
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
NF-NC
NF-NC
Y
Y
Y
ANTIHYPERLIPIDEMICS
ADVICOR
ALTOPREV
ANTARA
CADUET
COLESTID
COLESTID 7.5
CRESTOR
FENOGLIDE
FIBRICOR
Y
Y
Y
*JUXTAPID
*KYNAMRO
LESCOL
LESCOL XL
LIPITOR
LIPOFEN
Y
Y
LIPTRUZET
LIVALO
LOFIBRA
LOPID
LOVAZA
th
Y
Y
NIACIN/LOVASTATIN
LOVASTATIN
FENOFIBRATE
AMLODIPINE/
ATORVASTATIN
COLESTIPOL
COLESTIPOL
ROSUVASTATIN
FENOFIBRATE
FENOFIBRIC ACID
LOMITAPIDE
MESYLATE
MIPOMERSEN
FLUVASTATIN
FLUVASTATIN
ATORVASTATIN
FENOFIBRATE
EZETIMIBE/
ATORVASTATIN
PITAVASTATIN
CALCIUM
FENOFIBRATE
GEMFIBROZIL
OMEGA-3-ACID ETHYL
ESTERS
th

3
3
1
PA, DO
PA, DO
1
1
3
2
3
1
DO
PA, DO
PA, DO
PA, DO
PA, DO
1
DO
DO
1 DO
1
NF-NC
2 PA, DO
NF-NC
1
Y
Y
Y
Y
Y
Y
PA, DO
PA
PA, DO
PA
PA, DO
PA
PA, SP
PA, SP
PA, SP
NF-NC
3
1
3
1
3
PA, SP
DO
PA, DO
DO
PA
PA, SP
DO
PA, DO
DO
PA
PA, SP
DO
PA, DO
DO
PA
NF-NC
1
NF-NC
1 DO
NF-NC
Y
Y
Y
Y
DO
DO
DO
2 DO
3
1
1
PA, DO
PA, DO
PA, DO
NF-NC
1
1
Y
Y
Y
PA
PA
PA
NF-NC
31

NOTES
BRAND NAME
GEQ
MEVACOR
NIASPAN
PRAVACHOL
PREVALITE
QUESTRAN BULK
SIMCOR
TRICOR
TRIGLIDE
TRILIPIX
TIER
PPO
DO
PARTNERS
MEDICAID
DO
DO
DO
DO
LOVASTATIN
NIACIN
PRAVASTATIN
CHOLESTYRAMINE/
ASPARTAME
CHOLESTYRAMINE
POWDER
NIACIN/ SIMVASTATIN
FENOFIBRATE
FENOFIBRATE
1
2
1
FENOFIBRIC ACID
1
3
PA
PA
2
2
2
1
DO
DO
ICOSAPENT ETHYL
EZETIMIBE/
SIMVASTATIN
COLESEVELAM
EZETIMIBE
SIMVASTATIN
VASCEPA
VYTORIN
WELCHOL
ZETIA
ZOCOR
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
DO
1
1
2
1
3
DO
DO
DO
PA
PA
PA
PA
DO
PA
PA
PA
PA
DO
DO
DO
ANTIMICROBIALS AND INFECTIOUS DISEASE
SIGNATURE
PPO CLOSED
FORMULARY
1 DO
2
1 DO
MAND 90
Y
Y
Y
1
2 DO
1
NF-NC
Y
Y
Y
Y
NF-NC
2 DO
2
2 PA
1 DO
Y
Y
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
PENICILLINS
AMOXIL
AUGMENTIN
CHEW TABS, 12531.25 SUSP
AUGMENTIN XR
AUGMENTIN, ES,
250-62.5 SUSP
MOXATAG 775 MG
ER
CECLOR
CEDAX
CEFTIN TABS
th
AMOXICILLIN
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN
TRIHYDRATE
NF-NC
CEFACLOR
CEFTIBUTEN
CEFUROXIME
1
3
1
th

PA
PA
CEPHALOSPORINS
PA
NF-NC
1
NF-NC
1
32

NOTES
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
BRAND NAME
GEQ
KEFLEX
SPECTRACEF
SUPRAX
Y
Y
CEPHALEXIN
CEFDITOREN
CEFIXIME
1
1
3
ADOXA, PAK , 150
DOXYCYCLINE
DOXYCYCLINE/SALICY
/OCT/ZINC OX
NF-NC
Y
Y
1
1
3
1
3
1
3
1
PA
1
1
NF-NC
1
NF-NC
PA
1
NF-NC
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
MINOCYCLINE
MINOCYCLINE KIT
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
MINOCYCLINE
MINOCYCLINE
TETRACYCLINE
TETRACYCLINE
DOXYCYCLINE
3
1
1
1
NF-NC
Y
Y
Y
Y
DOXYCYCLINE
DOXYCYCLINE
PPO
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
NF-NC
TETRACYCLINES
AVIDOXY DK
DORYX 100MG
DORYX 150MG
DORYX 200MG
MINOCIN
MINOCIN PAC
MONODOX
ORACEA
PERIOSTAT
SOLODYN 45, 90,
135
SOLODYN 55,65,
80, 105, 115
SUMYCIN SUSP
TETRACYCLINE
VIBRAMYCIN
VIBRAMYCIN
SUSP
VIBRAMYCIN
SYRUP
Y
Y
PA
PA
PA
1
1
1
NF-NC
MACROLIDES
BIAXIN, XL
DIFICID
E.E.S.
th
CLARITHROMYCIN
FIDAXOMICIN
ERYTHROMYCIN
ETHYLSUCCINATE
1
th

1
PA
PA
PA
NF-NC
1
33

NOTES
BRAND NAME
E.E.S. GRANULES
E-MYCIN
ERYPED CHEW
TABS
ERY-TAB
ERYTHROCIN
KETEK
PCE
ZITHROMAX
GEQ
ZMAX
GENERIC NAME
TIER
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN BASE
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN BASE
ERYTHROMYCIN
STEARATE
TELITHROMYCIN
ERYTHROMYCIN BASE
AZITHROMYCIN
AZITHROMYCIN
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
3
3
NF-NC
NF-NC
1
2
1
2
1
3
3
1
1
NF-NC
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
3
SULFONAMIDES
BACTRIM DS,
SEPTRA DS
BACTRIM, SEPTRA
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
SULFAMETHOXAZOLE/
TRIMETHOPRIM
1
QUINOLONES
AVELOX
CIPRO
CIPRO SUSP
FACTIVE
LEVAQUIN
NOROXIN
PROQUIN XR
MOXIFLOXACIN
CIPROFLOXACIN
2
1
CIPROFLOXACIN
GEMIFLOXACIN
MESYLATE
LEVOFLOXACIN
NORFLOXACIN
CIPROFLOXACIN
2
3
1
3
2
PA
2
1
2
PA
PA
PA
NF-NC
1
NF-NC
NF-NC
MISCELLANEOUS ANTIBIOTICS
CLEOCIN 75, 150,
300MG
FLAGYL 250, 500
FLAGYL 375MG
FLAGYL ER
th
Y
Y
CLINDAMYCIN
METRONIDAZOLE
METRONIDAZOLE
METRONIDAZOLE
1
1
3
3
th

PA
1
1
NF-NC
NF-NC
34

NOTES
BRAND NAME
FUROXONE
HIPREX
MACROBID
MACRODANTIN
25MG
MACRODANTIN 50,
100MG
MONUROL
VANCOCIN
XIFAXAN
ZYVOX
GEQ
Y
Y
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
FURAZOLIDONE
METHENAMINE
NITROFURANTOIN
3
1
1
AG
AG
AG
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
1
1 AG
NITROFURANTOIN
AG
AG
AG
2 AG
NITROFURANTOIN
FOSFOMYCIN
TROMETHAMINE
VANCOMYCIN, ORAL
RIFAXIMIN
LINEZOLID
AG
AG
AG
1 AG
GENERIC NAME
PPO
PARTNERS
MEDICAID
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
1
NF-NC
2
3
1
3
2
URINARY ANTI-INFECTIVES (UTI)
BACTRIM DS,
SEPTRA DS
BACTRIM, SEPTRA
CIPRO
Y
Y
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
SULFAMETHOXAZOLE/
TRIMETHOPRIM
CIPROFLOXACIN
CIPRO SUSP
MACROBID
CIPROFLOXACIN
NITROFURANTOIN
2
1
AG
AG
AG
2
1 AG
NITROFURANTOIN
AG
AG
AG
2 AG
1
1
AG
AG
AG
1 AG
MACRODANTIN
25MG
MACRODANTIN 50,
100MG
TRIMETHOPRIM
Y
Y
UTA
VIBRAMYCIN
Y
Y
NITROFURANTOIN
TRIMETHOPRIM
METHENAMINE/METH
BLUE/SALICYLATE
METHENAMINE/METH
BLUE/SALICYLATE/NA
PHOS/HYOSCY
DOXYCYCLINE
ANCOBON
FLUCYTOSINE
URELLE
1
1
1
1
1
1
1
1
ORAL ANTIFUNGALS
th
th

35

NOTES
BRAND NAME
GEQ
DIFLUCAN
FULVICIN U/F
GRIFULVIN-V
GRIS-PEG
LAMISIL
MYCELEX
TROCHES
NOXAFIL
ONMEL
ORAVIG
SPORANOX CAPS
SPORANOX SOLN
VFEND TABS
Y
Y
INH
MYAMBUTOL
MYCOBUTIN
PRIFTIN
PYRAZINAMIDE
RIFADIN
Y
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
FLUCONAZOLE
GRISEOFULVIN,
ULTRAMICROSIZE
GRISEOFULVIN
GRISEOFULVIN,
ULTRAMICROSIZE
TERBINAFINE
CLOTRIMAZOLE
TROCHES
POSACONAZOLE
ITRACONAZOLE
MICONAZOLE
ITRACONAZOLE
ITRACONAZOLE
VORICONAZOLE
2
1
2
1
1
1
1
1
1
3
3
3
1
3
1
1
NF-NC
NF-NC
NF-NC
ISONIAZID
ETHAMBUTOL
RIFABUTIN
RIFAPENTINE
PYRAZINAMIDE
RIFAMPIN
1
1
3
3
1
1
1
1
NF-NC
NF-NC
RIFAMPIN/ ISONIAZID
RIFAMPIN/ INH/
PYRAZINAMIDE
NF-NC
NF-NC
CYCLOSERINE
BEDAQUILINE
FUMARATE
ETHIONAMIDE
3
3
NF-NC
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
1
ANTITUBERCULOSIS AGENTS
Y
Y
RIFAMATE
RIFATER
SEROMYCIN
PULVULES
*SIRTURO
TRECATOR
1
1
ANTIVIRALS
AMANTADINE
th
AMANTADINE
1
th

36

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
FAMVIR
FLUMADINE TABS
RELENZA
TAMIFLU
VALTREX
ZOVIRAX CREAM
ZOVIRAX OINT
Y
Y
FAMCICLOVIR
RIMANTADINE
ZANAMIVIR
OSELTAMIVIR
VALACYCLOVIR
ACYCLOVIR
ACYCLOVIR
1
1
2
2
1
2
1
ARALEN
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
2
2
1
2
1
ANTIMALARIALS/ANTIPROTOZOALS
COARTEM
DARAPRIM
MALARONE
MEPRON
CHLOROQUINE
ARTEMETHER/
LUMEFANTRINE
PYRIMETHAMINE
ATOVAQUONE/
PROGUANIL
ATOVAQUONE
3
2
NF-NC
2
1
3
1
NF-NC
NEBUPENT
PENTAMIDINE
ISETHIONATE
NF-NC
PLAQUENIL
PRIMAQUINE
TINDAMAX
HYDROXYCHOLOROQUINE
PRIMAQUINE
TINIDAZOLE
1
2
1
1
2
1
Y
Y
ANTIHELMINTICS
ALBENZA
ALINIA
BILTRICIDE
STROMECTOL
ALBENDAZOLE
NITAZOXANIDE
PRAZIQUANTEL
IVERMECTIN
NF-NC
NF-NC
3
3
2
3
2
NF-NC
AMEBICIDES
ARALEN
ERY-TAB
FLAGYL
FLAGYL ER
th
Y
Y
Y
CHLOROQUINE
ERYTHROMYCIN BASE
METRONIDAZOLE
METRONIDAZOLE
th

1
1
1
3
PA
1
1
1
NF-NC
37

NOTES
BRAND NAME
GEQ
YODOXIN
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
IODOQUINOL
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANALGESICS
DOLOBID
DIFLUNISAL
ANAPROX, DS
ANSAID
Y
Y
ARTHROTEC
CATAFLAM
CELEBREX
CLINORIL
DAYPRO
FELDENE
Y
Y
NAPROXEN SODIUM
FLURBIPROFEN
DICLOFENAC/
MISOPROSTOL
DICLOFENAC
CELECOXIB
SULINDAC
OXAPROZIN
PIROXICAM
FLECTOR
INDOCIN SUSP
INDOMETHACIN
MOBIC
MOTRIN
NAPRELAN CR
NAPROSYN
PONSTEL
RELAFEN
TORADOL
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
VIMOVO
VOLTAREN GEL
VOLTAREN XR
ZIPSOR
th
1
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
DICLOFENAC
EPOLAMINE
INDOMETHACIN
INDOMETHACIN
MELOXICAM
IBUPROFEN
NAPROXEN SODIUM
NAPROXEN
MEFENAMIC ACID
NABUMETONE
KETOROLAC
ESOMEPRAZOLE/
NAPROXEN
DICLOFENAC
DICLOFENAC,
EXTENDED RELEASE
DICLOFENAC
POTASSIUM
th

1
1
1
1
2
1
1
1
1
1
1
PA
DO
PA
DO
PA
NF-NC
PA, DO
1
2 DO
1
1
1
3
3
1
1
1
3
1
1
1
1
PA
AG
AG
DO
PA
AG
AG
DO
PA
AG
AG
DO
NF-NC
NF-NC
1 AG
1 DO
PA
PA
PA
1
NF-NC
AG
AG
AG
1
1
1
1 AG
3
3
PA
PA
PA
PA
PA
NF-NC
NF-NC
1
3
1
PA
PA
PA
NF-NC
38

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
NARCOTIC ANALGESICS
SIGNATURE
PPO CLOSED
FORMULARY
FENTANYL SL
FENTANYL CITRATE
3
1
PA
PA
PA
PA
PA
PA
NF-NC
1 PA
PA
PA
PA
NF-NC
BUTRANS
CODEINE
CONZIP
DEMEROL
DILAUDID
DILAUDID 5 LIQUID
DOLOPHINE
3
2
3
1
1
1
1
PA
PA
PA
Y
Y
Y
Y
MORPHINE SULFATE
BUPRENORPHINE
PATCH
CODEINE
TRAMADOL
MEPERIDINE
HYDROMORPHONE
HYDROMORPHONE
METHADONE
NF-NC
2
NF-NC
1
1
1
1
DURAGESIC
PATCH
PA, QL
PA, QL
PA
NF-NC
NF-NC
NF-NC
FENTANYL
MORPHINE SULFATE/
NALTREXONE
HYDROMORPHONE
FENTANYL CITRATE
BUTALBITAL/
ACETAMINOPHEN/
CAFFEINE
BUTALBITAL/
ACETAMINOPHEN/
CAFFEINE
BUTALBITAL/ ASPIRIN/
CAFFEINE/ CODEINE
HYDROCODONE/
IBUUPROFEN
ABSTRAL
ACTIQ
AVINZA
EMBEDA
EXALGO
FENTORA
FIORICET 50-32540
FIORICET 50-30040
FIORINAL
W/CODEINE #3
IBUDONE
KADIAN 10. 20, 30,
50, 60, 80, 100MG
KADIAN 40, 70,
200MG
*KADIAN 130,
150MG
th
3
3
3
PA, QL
PA
PA, QL
PA
NF-NC
MORPHINE SULFATE
MORPHINE SULFATE
NF-NC
MORPHINE SULFATE
NF-NC
th

MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
39

NOTES
BRAND NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
FENTANYL
ACETAMINOPHEN/
HYDROCODONE
METHADONE
3
1
1
1
1
1
1
NF-NC
MORPHINE
MORPHINE SULFATE
TAPENTADOL
HYDROCHLORIDE
TAPENTADOL
HYDROCHLORIDE
OXYMORPHONE
FENTANYL CITRATE
OXYMORPHONE
3
3
3
1
NF-NC
NF-NC
NF-NC
1
OXYMORPHONE
GEQ
LAZANDA
LORCET, PLUS
METHADONE
MORPHINE
TABLETS
MS CONTIN
Y
Y
Y
Y
NUCYNTA
NUCYNTA ER
NUMORPHAN
ONSOLIS
OPANA
OXYMORPHONE
ER (NON-CRUSH
RESISTANT)
OPANA ER
(CRUSH
RESISTANT)
ORAMORPH SR
ORBIVAN CF
OXYCONTIN
PERCOCET
PERCODAN
Y
Y
REPREXAIN
RYBIX ODT
RYZOLT
*SUBSYS
th
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
NF-NC
QL
QL
QL
1 QL
1
PA
PA
PA
PA, QL
PA, QL
PA, QL
1 PA, QL
OXYMORPHONE
MORPHINE,
SUSTAINED RELEASE
BUTALBITAL/
ACETAMINOPHEN
OXYCODONE
ACETAMINOPHEN/
OXYCODONE
ASPIRIN/ OXYCODONE
IBUPROFEN/
HYDROCODONE
PA, QL
PA, QL
PA, QL
NF-NC
TRAMADOL
TRAMADOL ER
FENTANYL SL SPRAY
th

2
3
2
1
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
QL
QL
PA, QL
NF-NC
NF-NC
QL
QL
QL
1 QL
1
1
PA
PA
NF-NC
1
PA
PA
PA
NF-NC
40

NOTES
BRAND NAME
GEQ
TYLENOL
W/CODEINE
TYLOX
ULTRACET
ULTRAM
Y
Y
ULTRAM ER
VICODIN 5/500
VICODIN ES
7.5/750
VICODIN HP 10/660
VICODIN 5/300
VICODIN ES
7.5/300
VICODIN HP 10/300
VICOPROFEN
XODOL
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
ACETAMINOPHEN/
CODEINE
ACETAMINOPHEN/
OXYCODONE
TRAMADOL/
ACETAMINOPHEN
TRAMADOL
TRAMADOL SUST.
RELEASE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
IBUPROFEN/
HYDROCODONE
HYDROCODONE BIT/
ACETAMINOPHEN
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
QL
QL
QL
1 QL
QL
QL
QL
1 QL
1
1
QL
QL
QL
1 QL
1
PARTNERS
MAND
SPEC
1
1
QL
QL
QL
1 QL
QL
QL
QL
1 QL
QL
QL
QL
1 QL
PA, QL
PA, QL
PA, QL
1 PA, QL
PA, QL
PA, QL
PA, QL
1 PA, QL
PA, QL
PA, QL
PA, QL
1 PA, QL
1
1
MAND 90
MAND
SPEC
1
QL
QL
RESPIRATORY DRUGS
QL
1 QL
ALLERGIES
ACCOLATE
ALAVERT OTC
ALLEGRA OTC
BENADRYL
CLARINEX
TABS/REDITABS
CLARITIN OTC
PHENERGAN
th
Y
Y
Y
Y
ZAFIRLUKAST
LORATADINE
FEXOFENADINE
DIPHENHYDRAMINE
1
1
1
1
Y
Y
Y
DESLORATIDINE
LORATADINE
PROMETHAZINE
1
1
1
th

1
NC
NC
1
NC
NC
DO
DO
DO
AG
AG
AG
NC
NC
1 AG
41

NOTES
HMO
POS
TPA
M-SUPP RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
BRAND NAME
GEQ
GENERIC NAME
TIER
SINGULAIR
TAVIST
XYZAL TABS
ZYRTEC OTC
Y
Y
Y
Y
MONTELUKAST
CLEMASTINE
LEVOCETIRIZINE
CETIRIZINE
1
1
1
1
ASTELIN
ASTEPRO
ATROVENT NASAL
SPRAY
1
2
1
2
VERAMYST
AZELASTINE
AZELASTINE
IPRATROPIUM
BROMIDE
BECLOMETHASONE,
AQUEOUS
AZELASTINE/
FLUTICASONE
FLUTICASONE
TRIAMCINOLONE,
AQUEOUS
MOMETASONE
CICLESONIDE
OLOPATADINE
BECLOMETHASONE
DIPROPIONATE
BUDESONIDE
FLUTICASONE
FUROATE
ZETONNA
CICLESONIDE
BECONASE AQ
DYMISTA
FLONASE
NASACORT AQ
NASONEX
OMNARIS
PATANASE
Y
Y
QNASL
RHINOCORT AQUA
TUSSIONEX
PENNKINETIC
VITUZ
ALLEGRA-D 12
HOUR OTC
th
HYDROCODONE/
CHLORPHEN POLIS
HYDROCODONE/
CHLORPHENIRAMINE
FEXOFENADINE/
PSEUDOEPHEDRINE
th

NC
PPO
1
1
1
NC
NC
NASAL SPRAYS
PA
PA
PA
NF-NC
3
1
PA
PA
PA
NF-NC
PARTNERS
MAND
SPEC
1
3
3
3
PA
PA
PA
PA
PA
PA
1
NF-NC
NF-NC
NF-NC
3
3
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
ANTIHISTAMINE/ANTITUSSIVES
NF-NC
NC
NF-NC
PA
PA
NC
DECONGESTANT/ANTIHISTAMINES
NF-NC
MAND 90
Y
MAND
SPEC
NC
NC
NC
42

NOTES
BRAND NAME
ALLEGRA-D 24
HOUR OTC
GEQ
GENERIC NAME
FEXOFENADINE/
PSEUDOEPHEDRINE
PSEUDOEPHEDRINE/
DESLORATADINE
LORATIDINE/
PSEUDOEPHEDRINE
PHENYLEPHRINE/
CHLORPHENIRAMINE
PSEUDOEPHEDRINE/
CHLORPHENIRAMINE
CLARINEX-D
CLARITIN-D OTC
DECONAMINE
SYRUP
DECONAMINE
TABS
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
NC
NC
PA
PA
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
NC
NC
1
1
NC
NC
SEMPREX-D
ENTEX LA
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
ENTEX LQ
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
ZOTEX GP
GUAIFENESIN/
PHENYLEPHRINE
NC
NF-NC
BROMFED-DM
TESSALON
PERLES
NC
3
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT
GUAIFENESIN/
PHENYLEPHRINE
BROMPHENIRAMINE/
PSEUDOEPHEDRINE/
DEXTROMETHORPHA
N
BENZONATATE
PARTNERS
MAND
SPEC
NC
PSEUDOEPHEDRINE/
ACRIVAS
ZOTEX
MAND 90
MAND
SPEC
NC
1
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES
NC
NF-NC
1
1
ORALLY INHALED DRUGS

ACCUNEB
ADVAIR
ALVESCO
th
ALBUTEROL SULFATE
FLUTICASONE/
SALMETEROL
CICLESONIDE
th

2
3
2
NF-NC
43

NOTES
BRAND NAME
GEQ
ARCAPTA
ASMANEX
ATROVENT HFA
BREO ELLIPTA
BROVANA
COMBIVENT
COMBIVENT
RESPIMAT
CROMOLYN SOLN
DULERA
DUONEB
FLOVENT HFA
FORADIL
ISOETHARINE
MAXAIR
PROAIR HFA
PROVENTIL HFA
PULMICORT
0.25MG/2ML AND
0.5MG/2ML
RESPULE
PULMICORT
1MG/2ML
RESPULE AND
FLEXHALER
PULMOZYME
th
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
INDACATEROL
MOMETASONE
FUROATE
IPRATROPIUM
BROMIDE
FLUTICASONE/
VILANTEROL
ARFORMOTEROL
ALBUTEROL/
IPRATROPIUM
ALBUTEROL/
IPRATROPIUM
3
2
NF-NC
CROMOLYN SODIUM
MOMETASONE/
FORMOTEROL HFA
IPRATROPIUM/
ALBUTEROL SULFATE
FLUTICASONE
1
2
1
2
FORMOTEROL
FUMARATE
ISOETHARINE
PIRBUTEROL
ALBUTEROL
ALBUTEROL
2
1
3
3
3
2
1
NF-NC
NF-NC
NF-NC
BUDESONIDE
BUDESONIDE
DORNASE ALFA
2
2
2
2
th

MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
QL
PA
PA
QL
PA
PA
QL
PA
PA
2 QL
44

NOTES
BRAND NAME
GEQ
QVAR
SEREVENT
DISKUS
SPIRIVA
SYMBICORT
TUDORZA
PRESSAIR
VENTOLIN HFA
XOPENEX HFA
XOPENEX NEB
SOLN
GENERIC NAME
BECLOMETHASONE
DIPROPIONATE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
SALMETEROL
TIOTROPIUM BROMIDE
BUDESONIDE/
FORMOTEROL
2
2
2
2
ACLIDINIUM BROMIDE
ALBUTEROL
LEVALBUTEROL
2
2
3
2
2
NF-NC
LEVALBUTEROL
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
OTHER BRONCHODILATORS, ORAL
DALIRESP
METAPROTERENOL SYRUP
VENTOLIN
VOSPIRE ER
Y
Y
Y
ROFLUMILAST
METAPROTERENOL,
10MG/5ML
ALBUTEROL
ALBUTEROL
1
1
1
1
1
1
AMINOPHYLLINE
ELIXOPHYLLIN
ELIXIR
THEO-24 SR
THEOPHYLLINE
AMINOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
2
2
1
2
2
1
Y
Y
Y
ACCOLATE
SINGULAIR
ZYFLO, CR
Y
Y
ZAFIRLUKAST
MONTELUKAST
ZILEUTON
1
1
3
1
1
NF-NC
Y
Y
DORNASE ALFA
THEOPHYLLINES
LEUKOTRIENE RECEPTOR ANTAGONISTS
PULMOZYME
th
th

PA
PA
MUCOLYTICS
PA
45

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
DERMATOLOGICS
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
TOPICAL STEROIDS
ACLOVATE
APEXICON OINT
APEXICON E
CLOBEX SPRAY
CLODERM
CORDRAN
4MCG/SQ CM
TAPE
CORDRAN, SP
CUTIVATE
CUTIVATE 0.05%
LOTION
DERMASMOOTHE-FS
0.01% OIL
DESONATE GEL
DESOWEN
DESOWEN
COMBO
DIPROSONE
ELOCON
HALOG
KENALOG
KENALOG
AEROSOL SPRAY
LOCOID, CREAM,
OINT, SOL.
th
Y
Y
ALCLOMETASONE
DIFLORASONE
DIACETATE
DIFLORASONE
DIACETATE
CLOBETASOL
PROPIONATE
CLOCORTOLONE
PIVALATE
FLURANDRENOLIDE
FLURANDRENOLIDE
FLUTICASONE
PROPIONATE
FLUTICASONE
PROPIONATE
FLUOCINOLONE
ACETONIDE
DESONIDE
DESONIDE
DESONIDE/EMOLLIENT
COMBO
BETAMETHASONE
DIPROPIONATE
MOMETASONE
FUROATE
HALCINONIDE
TRIAMCINOLONE
TRIAMCINOLONE
ACETONIDE
HYDROCORTISONE
BUTYRATE 0.1%
th

PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
2
3
PA
PA
PA
2
NF-NC
1
3
1
PA
PA
PA
1
NF-NC
1
PA
PA
PA
NF-NC
1
2
1
1
2
1
3
1
PA
PA
PA
NF-NC
1
46

NOTES
BRAND NAME
LOCOID LOTION,
LIPOCREAM
LUXIQ
GEQ
MOMEXIN
NUCORT
OLUX
OLUX-E
Y
Y
PANDEL
PEDIADERM HC
2% KIT
PEDIADERM TA
SYNALAR KIT
TEMOVATE
TOPICORT BRAND
ONLY PRODUCTS
TOPICORT
GENERIC
PRODUCTS
U-CORT 1%-10%
CREAM
Y
Y
ULTRAVATE PAC
VANOXIDE-HC
0.5%-5% LOTION
VANOS
VERDESO
WESTCORT
th
GENERIC NAME
TIER
HYDROCORTISONE
BUTYRATE/ EMOLL
BETAMETHASONE
MOMETASONE
FUROATE/AMMONIUM
LAC
HYDROCORTISONE/
ALOE VERA
CLOBETASOL
PROPIONATE
CLOBETASOL EMOLL
HYDROCORTISONE
PROBUTATE
HYDROCORTISONE/
EMOLLIENT
TRIAMCINOLONE/
EMOLLIENT
FLUOCINOLONE SOLN/
CLEANSER
CLOBETASOL
PROPIONATE
3
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NF-NC
PA
NF-NC
NF-NC
1
1
1
1
PA
PA
PA
NF-NC
PA
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
1
PA
PA
PA
NF-NC
DESOXIMETASONE
DESOXIMETASONE
HYDROCORTISONE/
UREA
HALOBETASOL PROP/
AMMONIUM LAC
HYDROCORTISONE/
BENZOYL PEROXIDE
FLUOCINONIDE
DESONIDE
HYDROCORTISONE
VALERATE
th

PA
PA
PA
NF-NC
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
NF-NC
PARTNERS
MAND
SPEC
MAND 90
MAND
SPEC
47

NOTES
BRAND NAME
GEQ
AMLACTIN 12%
GENERIC NAME
TIER
AMMONIUM LACTATE
DL-E AC/ GRAPE/
HYALURONIC ACID
UREA
EMOLLIENT COMBO
UREA
UREA
EMOLLIENT COMBO
EMOLLIENT COMBO
UREA
UREA
UREA/LACTIC AC/ZN
UNDECYLENATE
UREA/ LACTIC ACID/
SALICYL ACID
AMMONIUM LACTATE
EMOLLIENT COMBO
PROMISEB
ATOPICLAIR
CARMOL
EPICERAM
GORDONS UREA
HYDRO 35, 40
HYLATOPIC
HYLATOPIC PLUS
KERAFOAM
KERALAC
KEROL AD
KEROL 50%
SUSPENSION
LAC-HYDRIN
NEOSALUS
Y
Y
3
1
3
3
1
3
3
3
1
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
TOPICAL EMOLLIENTS
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
PA
PA
PA
1
1
NF-NC
NF-NC
1
NF-NC
NF-NC
NF-NC
1
1
1
1
3
PA
1
1
NF-NC
EMOLLIENT COMBO
PA
NF-NC
PROMISEB
COMPLETE
EMOLLIENT COMBO
PA
NF-NC
TROPAZONE
EMOLLIENT COMBO
PA
NF-NC
UREA
1
3
1
1
PA
Y
Y
UREA
UREA
UREA
NF-NC
1
1
UREA
UREA
UREA
UREA
3
1
3
1
PA
NF-NC
PA
1
NF-NC
UMECTA
SUSPENSION
UMECTA
EMULSION
URAMAXIN
URAMAXIN GT
URAMAXIN GT KIT
UREA
UTOPIC
X-VIATE
th
Y
Y
th

PARTNERS
MAND
SPEC
Y
Y
MAND 90
MAND
SPEC
48

NOTES
BRAND NAME
ZENIEVA
GEQ
Y
GENERIC NAME
TIER
EMOLLIENT COMBO
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
TOPICAL IMMUNOMODULATORS
ELIDEL
PIMECROLIMUS
PA
QL
QL
QL
1
1 QL
1 QL
1 QL
PSORIASIS
ANTHRALIN
ANTHRALIN
CALCIPOTRIENE
DOVONEX CRM
DOVONEX SOLN
Y
Y
Y
CALCIPOTRIENE
CALCIPOTRIENE
CALCIPOTRIENE
1
1
1
FABIOR FOAM
METHOTREXATE
SORIATANE
TAZAROTENE
METHOTREXATE TABS
ACITRETIN
3
1
3
BETAMET DIPROP/
CALCIPOTRIENE
TAZAROTENE
ANTHRALIN SHAMPOO
3
3
3
TACLONEX OINT,
SCALP SUSP
TAZORAC
ZITHRANOL
QL
QL
QL
QL
QL
QL
NF-NC
1
NF-NC
QL
QL
QL
NF-NC
NF-NC
NF-NC
PA
NF-NC
1
ANTI-INFECTIVES (TOPICAL)
ALTABAX
BACTROBAN OINT
BACTROBAN CRM
BACTROBAN
NASAL OINT
CORTISPORIN
GARAMYCIN
SULFAMYLON
RETAPAMULIN
MUPIROCIN
3
1
MUPIROCIN
MUPIROCIN
HYDROCORTISONE/
NEOMYCIN/POLYMYXIN/ BACITRACIN
GENTAMICIN
MAFENIDE ACETATE
PA
PA
1
PA, QL
PA, QL
PA, QL
2
1
3
2 PA, QL
2
1
NF-NC
BURN PREPARATIONS
SILVADENE
SILVER SULFADIAZINE
1
ANTIFUNGALS (TOPICAL)
CICLODAN KIT
th
CICLOPIROX OLAMINE
CREAM/ CLEANSER
th

PA
PA
PA
NF-NC
49

NOTES
BRAND NAME
GEQ
CNL 8 NAIL KIT

ERTACZO
EXELDERM
EXTINA
KETODAN KIT
LAMISIL SOLN
LOPROX
LOTRIMIN
LOTRISONE
MENTAX
METROGEL 0.75%
METROGEL 1%
MYCOSTATIN
NAFTIN
NIZORAL
OXISTAT
PEDIADERM AF
PENLAC
ROSADAN KIT
Y
Y
Y
Y
Y
Y
Y
GENERIC NAME
CICLOPIROX SOLN 8%/
LACQUER REMOVAL
PADS
OXICONAZOLE NITRATE
NYSTATIN/EMOLLIENT
CICLOPIROX
METRONIDAZOLE/
CLEANSER
VUSION
XOLEGEL/
COREPAK
KETOCONAZOLE
th
SERTACONAZOLE
NITRATE
SULCONAZOLE
NITRATE
KETOCONAZOLE
KETOCONAZOLE
FOAM/ CLEANSER
TERBINAFINE
CICLOPIROX OLAMINE
CLOTRIMAZOLE 1%
CLOTRIMAZOLE/
BETAMETHASONE
BUTENAFINE
METRONIDAZOLE
METRONIDAZOLE
NYSTATIN
NAFTIFINE
KETOCONAZOLE
TERBINAFINE/
HYDROXYCHITOSAN
SELENIUM SULFIDE
MICONAZOLE
NITRATE/ZINC OXIDE
TERBINEX
TERSI
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
th

PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
3
1
PA
PA
PA
NF-NC
1
3
3
1
1
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
1
3
1
1
1
3
1
3
3
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
1
NF-NC
1
1
1
NF-NC
1
NF-NC
NF-NC
NC
NF-NC
3
3
3
PA
PA
PA
PA
PA
PA
NC
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
50

NOTES
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
PA
NF-NC
DAPSONE
TRETINOIN
AZELAIC ACID
CLINDAMYCIN/
BENZOYL PEROXIDE
ERYTHROMYCIN/
BENZOYL PEROXIDE
ERYTHROMYCIN
BASE/ BENZOYL
PEROXIDE
3
3
3
PA
PA, AG
PA
PA, AG
PA
PA, AG
NF-NC
NF-NC
NF-NC
BENZOYL PEROXIDE
BENZIQ WASH
BREVOXYL
CLEOCIN-T
CLINDACIN PAC
CLINDAGEL
DESQUAM X
DIFFERIN 0.1%
CREAM, GEL
DIFFERIN 0.1%
LOTION
DIFFERIN 0.3%
GEL
Y
Y
Y
BENZOYL PEROXIDE
BENZOYL PEROXIDE
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
BENZOYL PEROXIDE
1
1
1
3
3
1
1
1
1
NF-NC
NF-NC
1
ADAPALENE
ADAPALENE
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
DUAC
ADAPALENE
CLINDAMYCIN
PHOSPHATE-BENZOYL
PEROXIDE
ADAPALENE/BENZOYL
PEROXIDE
AZELAIC ACID
BENZOYL PEROXIDE/
SULFUR
BRAND NAME
GEQ
CLINDAMYCIN/
BENZOYL PEROXIDE
ACANYA
ACZONE 5% GEL
ATRALIN
AZELEX
BENZACLIN 1%-5%
GEL
BENZAMYCIN GEL
BENZAMYCINPAK
BENZEFOAM
ULTRA
EPIDUO
FINACEA
NUOX GEL
th
GENERIC NAME
th

PPO
ACNE
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
PA
PA
PA
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
3
PA
PA
PA
NF-NC
NF-NC
PA
PA
PA
NF-NC
51

NOTES
BRAND NAME
PACNEX
PACNEX MX
RETIN A
RETIN A MICRO
0.04%
RETIN A MICRO
0.1%
GEQ
Y
Y
Y
AG
AG
AG
1
1
1 AG
PA, AG
PA, AG
PA, AG
NF-NC
AG
AG
AG
1 AG
BENZOYL PEROXIDE
SULFACETAMD/
SULFR/ SKNCLNSR10
TRETINOIN
BENZOYL PEROXIDE
BENZOYL PEROXIDE/
HC/SKIN CLNSR NO. 14
CLINDAMYCIN/
TRETINOIN
BENZOYL PEROXIDE/
HYALURONT
CLINDAMYCIN/
TRETINOIN
SULFANILAMIDE
CLINDAMYCIN
CLINDAMYCIN
FLUCONAZOLE
METRONIDAZOLE
METRONIDAZOLE
3
1
1
3
NF-NC
Y
Y
METRONIDAZOLE
NYSTATIN
1
1
VELTIN
ZACARE KIT
ZIANA
th
PPO
SIGNATURE
PPO CLOSED
FORMULARY
1
1
1
VANOXIDE HC
AVC CREAM
CLEOCIN VAGINAL
CREAM
CLEOCIN VAGINAL
OVULE
DIFLUCAN
FLAGYL
FLAGYL ER
METROGELVAGINAL 0.75%
MYCOSTATIN
TIER
PARTNERS
MEDICAID
BENZOYL PEROXIDE
BENZOYL PEROXIDE
TRETINOIN
TRETINOIN
MICROSPHERES
TRETINOIN
MICROSPHERES
RIAX
ROSANIL
TRETIN X
TRIAZ
CLEANER/PADS/
FOAMING CLOTHS
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
Y
Y
th

3
3
PARTNERS
MAND
SPEC
NF-NC
PA, AG
PA, AG
PA, AG
NF-NC
NF-NC
PA
PA
PA
NF-NC
PA, AG
PA, AG
PA, AG
NF-NC
PA
PA
PA
NF-NC
MAND 90
MAND
SPEC
PA, AG
PA, AG
PA, AG
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS
PA
NF-NC
1
1
NF-NC
1
1
52

NOTES
BRAND NAME
NYSTATIN
VAGINAL TABS
TERAZOL
GEQ
GENERIC NAME
TIER
Y
Y
NYSTATIN
TERCONAZOLE
1
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
SCABICIDES & PEDICULOCIDES
EURAX
OVIDE
SKLICE
ULESFIA
CROTAMITON
MALATHION
IVERMECTIN
BENZYL ALCOHOL
NF-NC
1
NF-NC
NF-NC
3
1
3
3
TOPICAL ENZYMES
GRANULEX
OPTASE
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
2
OTHER AGENTS
ALDARA
CONDYLOX GEL
CONDYLOX
SOLUTION
MIRVASO
PANRETIN
PROTOPIC
SOLARAZE
TARGRETIN
VECTICAL
ZYCLARA
IMIQUIMOD
PODOFILOX
1
3
1
NF-NC
PODOFILOX
BRIMONIDINE
ALITRETINOIN
TACROLIMUS
DICLOFENAC SODIUM
BEXAROTENE
CALCITRIOL
IMIQUIMOD
1
3
2
3
2
2
3
3
1
NF-NC
PA
PA
QL
QL
PA
PA
BLOOD MODIFIERS
PA
QL
PA
2
NF-NC
2
2
NF-NC
NF-NC
ANTICOAGULANTS
BRILINTA
COUMADIN
ELIQUIS
th
TICAGRELOR
WARFARIN
3
1
PA, DO
PA, DO
PA, DO
NF-NC
1
APIXABAN
PA, DO
PA, DO
PA, DO
NF-NC
th

53

NOTES
BRAND NAME
PRADAXA 150mg
XARELTO 10mg
GENERIC NAME
DALTEPARIN
SODIUM,PORCINE
ENOXAPARIN
DABIGATRAN
ETEXILATE MESYLATE
DABIGATRAN
ETEXILATE MESYLATE
RIVAROXABAN
XARELTO 15mg ,
20mg
RIVAROXABAN
FRAGMIN
LOVENOX
GEQ
PRADAXA 75mg
AGGRENOX
AGRYLIN
EFFIENT
PERSANTINE
PLAVIX
PLETAL
Y
Y
Y
ASPIRIN/
DIPYRIDAMOLE
ANEGRELIDE
PRASUGREL
HYDROCHLORIDE
DIPYRIDAMOLE
CLOPIDOGREL
CILOSTAZOLE
TRENTAL
PENTOXIFYLLINE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
3
1
NF-NC
1
2
2
2
PA
QL
PA
QL
PA
QL
PA, DO
PA, DO
PA, DO
ANTI-PLATELET DRUGS
3
1
2
1
1
1
AG
AG
AG
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
2 PA
2 QL
2 PA, DO
NF-NC
1
Y
Y
2
1 AG
1
1
Y
Y
Y
HEMORRHEOLOGIC AGENTS
1
COLONY STIMULATING FACTORS
LEUKINE
250MCG/ML
*LEUKINE
500MCG/ML
*NEUPOGEN
SARGRAMOSTIM
4 SPEC
SARGRAMOSTIM
FILGRASTIM
2
2
4 SPEC
4 SPEC
ERYTHROCYTE STIMULATORS
ARANESP
EPOGEN
PROCRIT
#AMICAR
th
DARBEPOETIN ALFA IN
POLYSORBATE
EPOETIN ALFA
EPOETIN ALFA
3
2
2
AMINOCAPROIC ACID
th

PA
PA
PA
PA
PA
PA
HEMOSTATICS
PA
PA
PA
NF-NC
4 SPEC PA
4 SPEC PA
1
54

NOTES
BRAND NAME
GEQ
#AMICAR 1,000MG
GENERIC NAME
TIER
AMINOCAPROIC ACID
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
NF-NC
1
2
1
NF-NC
MAND
SPEC
PARTNERS
MAND
SPEC
EENT DRUGS
GLAUCOMA AGENTS
ALPHAGAN P
0.15%
ALPHAGAN P 0.1%
ATROPINE
AZOPT
BETAGAN
BETIMOL
BETOPIC 0.5%
BETOPTIC S
COSOPT
Y
Y
Y
th
3
1
2
1
3
PA
PA
PA
PA
Y
Y
Y
Y
Y
Y
1
3
1
NF-NC
1
NF-NC
Y
Y
Y
CYCLOPENTOLATE
CYCLOPENTOLATE
ACETAZOLAMIDE
APRACLONIDINE
APRACLONIDINE
2
1
1
1
3
2
1
1
1
NF-NC
Y
Y
CARBACHOL
CARBACHOL
NF-NC
HOMATROPINE
HOMATROPINE
TIMOLOL
BIMATOPROST
BIMATOPROST
3
3
2
3
ISOPTO
CARBACHOL 8%
ISOPTO
HOMATROPINE 5%
ISOPTO
HOMATROPINE 2%
ISTALOL
LUMIGAN 0.01%
LUMIGAN 0.03%
BETAXOLOL
BETAXOLOL
TIMOLOL/ DORZOLAM
DORZOLAMIDE/TIMOL
OL
COSOPT PF
CYCLOGYL 0.5%,
CYCLOGYL 1%, 2%
DIAMOXSEQUELS
IOPIDINE 0.5%
IOPIDINE 1%
ISOPTO
CARBACHOL1%,
2%, 4%
BRIMONIDINE
TARTRATE
BRIMONIDINE
TARTRATE
ATROPINE SULFATE
BRINZOLAMIDE
LEVOBUNOLOL
TIMOLOL
th

PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
2 PA
NF-NC
Y
Y
55

NOTES
BRAND NAME
GEQ
METIPRANOLOL
MYDRIACYL
NEPTAZANE
Y
Y
Y
PHOSPHOLINE
IODIDE SOLN
PILOCAR
PILOPINE HS
PROPINE
SIMBRINZA
TIMOPTIC
TIMOPTIC
OCUDOSE
TIMOPTIC XE
TRAVATAN Z
TRUSOPT
XALATAN
ZIOPTAN
Y
Y
Y
ALREX
DECADRON
FLAREX
FML
FML FORTE
FML S.O.P.
LOTEMAX
MAXIDEX
PRED FORTE
PRED MILD
th
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
Y
METIPRANOLOL
TROPICAMIDE
METHAZOLAMIDE
1
1
1
1
1
1
ECHOTHIOPHATE
PILOCARPINE
PILOCARPINE
DIPIVEFRIN
BRINZOLAMIDE/
BIMONIDINE
TARTRATE
TIMOLOL
2
1
2
3
2
1
2
NF-NC
Y
Y
Y
3
1
NF-NC
Y
Y
TIMOLOL
TIMOLOL
TRAVOPROST
DORZOLAMIDE
LATANOPROST
TAFLUPROST
1
3
1
1
3
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
PREDNISOLONE
PREDNISOLONE
th

PA
PA
PA
PA, DO
PA, DO
PA, DO
TOPICAL OPHTHALMIC STEROIDS
1
1
NF-NC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
3
3
3
3
3
2
3
2
1
2
1
NF-NC
MAND
SPEC
2
PA
NF-NC
2
1
2
56

NOTES
BRAND NAME
GEQ
VEXOL
GENERIC NAME
TIER
RIMEXOLONE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
TOPICAL OPHTHALMIC ANTIBIOTICS
ZYLET
DOXYCYCLINE/
EYELID CLNS NO.2&3
AZITHROMYCIN
BESIFLOXACIN
HYDROCHLORIDE
SULFACETAMIDE
SODIUM
CIPROFLOXACIN
CIPROFLOXACIN
ERYTHROMYCIN
GENTAMICIN
ERYTHROMYCIN
LEVOFLOXACIN
NATAMYCIN
POLYMYXIN/
BACITRACIN/
NEOMYCIN
OFLOXACIN
POLYMYXIN/
BACITRACIN
POLYMYXIN/
TRIMETHOPRIM
LEVOFLOXACIN
TOBRAMYCIN
TOBRAMYCIN
MOXIFLOXACIN
TRIFLURIDINE
TOBRAMYCIN/
LOTEPRED ETAB
BLEPHAMIDE
SULFACETAMIDE/
PREDNISOLONE
ALODOX
AZASITE
BESIVANCE
BLEPH-10
CILOXAN GEL
CILOXAN SOLN
ERYTHROMYCIN
GARAMYCIN
ILOTYCIN
IQUIX
NATACYN
NEOSPORIN
OCUFLOX
Y
Y
POLYSPORIN
POLYTRIM
QUIXIN
TOBREX OINT
TOBREX SOLN
VIGAMOX
VIROPTIC
Y
Y
th
Y
Y
Y
Y
Y
Y
3
3
NF-NC
NF-NC
NF-NC
1
3
1
1
1
1
3
3
1
NF-NC
1
1
1
1
1
1
2
1
2
1
1
1
2
1
2
1
NF-NC
3
TOPICAL OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY
2
th
1
1
1
1
NF-NC
NF-NC

57

NOTES
BRAND NAME
BLEPHAMIDE
S.O.P.
GEQ
CORTISPORIN
MAXITROL
RESTASIS
TOBRADEX SUSP
TOBRADEX OINT
TOBRADEX ST
ALOCRIL
ALOMIDE
BEPREVE
ELESTAT
EMADINE
LASTACAFT
OPTIVAR
PATADAY
PATANOL
ZADITOR OTC
GENERIC NAME
SULFACETAMIDE/
PREDNISOLONE
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN/
BACITRACIN
DEXAMETHASONE/
NEOMYCIN/
POLYMYXIN
CYCLOSPORINE
DEXAMETHASONE/
TOBRAMYCIN
DEXAMETHASONE/
TOBRAMYCIN
TOBRAMYCIN/
DEXAMETHASONE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
2
1
2 QL
QL
QL
PA, QL
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
3
TOPICAL OPHTHALMIC VASOCONSTRICTORS/ANTIHISTAMINES
NEDOCROMIL SODIUM
LODOXAMIDE
TROMETHAMINE
BEPOTASTINE
BESILATE
EPINASTINE
EMEDASTINE
DIFUMARATE
ALCAFTADINE
AZELASTINE
OLOPATADINE
OLOPATADINE
KETOTIFEN
PA
PA
PA
NC
PA
PA
PA
NC
3
1
PA
PA
PA
NC
1
3
3
1
3
2
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
NC
NC
NC
NC
NC
1
TOPICAL OPHTHALMIC NSAIDS

ACULAR, LS
ACUVAIL
th
KETOROLAC
TROMETHAMINE
KETOROLAC
TROMETHAMINE
1
3
th

1
PA
NF-NC
58

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
BROMDAY
ILEVRO
NEVANAC
PROLENSA
BROMFENAC SODIUM
NEPAFENAC
NEPAFENAC
BROMFENAC SODIUM
AURALGAN
BENZOCAINEANTIPYRINE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
3
3
2
3
PARTNERS
MEDICAID
PA
PA
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
NF-NC
2
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
OTIC AGENTS
CETRAXAL
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN
CORTISPORIN-TC
DOMEBORO
TREAGAN OTIC
TRIOXIN
VOSOL
Y
Y
VOSOL HC
CIPROFLOXACIN
CIPROFLOXACIN HCL/
HC
CIPROFLOXACIN/
DEXAMETH
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
ACETIC ACID
ANTIPYRINEBENZOCAINEPOLYCOSANOL
CHLOROXYLENOL/
BENZOC/HYDROCORT
ACETIC ACID
ACETIC ACID/
HYDROCORTISONE
NF-NC
NF-NC
PA
3
2
NF-NC
2
PA
1
PA
3
1
NF-NC
1
1
1
1
1
1
BEHAVIORAL HEALTH
DEPRESSION
NOTE: FOR HEALTHPLUS MICHILD/MICHILD CSHCS, MEDICATIONS FOR ADD/ADHD WRITTEN BY THE PCP OR PLAN SPECIALIST ARE COVERED BY HEALTHPLUS.
ALL OTHER BEHAVIORAL HEALTH MEDICATIONS ARE COVERED BY COMMUNITY MENTAL HEALTH (CMH).
AMITRIPTYLINE
ANAFRANIL
th
Y
Y
AMITRIPTYLINE
CLOMIPRAMINE
1
1
th

AG
AG
MDCH
MDCH
1 AG
1
59

NOTES
BRAND NAME
APLENZIN
BRISDELLE
CELEXA
CYMBALTA
EFFEXOR XR
EMSAM PATCH
GEQ
Y
Y
FORFIVO XL
LEXAPRO
LUVOX CR
NARDIL
NORPRAMIN
Y
Y
Y
OLEPTRO ER
PAMELOR
PARNATE
PAXIL, CR
PEXEVA
Y
Y
Y
PRISTIQ
PROZAC
PROZAC WEEKLY
REMERON
SARAFEM
DOXEPIN
SURMONTIL
TOFRANIL, PM
VIIBRYD
VIVACTIL
WELLBUTRIN, SR
th
Y
Y
Y
Y
Y
Y
Y
Y
GENERIC NAME
TIER
BUPROPION
PAROXETINE
CITALOPRAM
DULOXETINE
VENLAFAXINE
SELEGILINE
3
3
1
2
1
3
BUPROPION
ESCITALOPRAM
FLUVOXAMINE
MALEATE
PHENELZINE
DESIPRAMINE
TRAZODONE
HYDROCHLORIDE
EXTENDED RELEASE
NORTRIPTYLINE
TRANYLCYPROMINE
PAROXETINE
PAROXETINE
3
1
DESVENLAFAXINE
SUCCINATE
FLUOXETINE
FLUOXETINE
MIRTAZAPINE
FLUOXETINE
DOXEPIN
TRIMIPRAMINE
MALEATE
IMIPRAMINE PAMOATE
VILAZODONE
PROTRIPTYLINE
BUPROPION
th

HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PPO
PA
PA
DO
PA
DO
DO
1
1
1
PA, DO
PA, DO
3
1
1
1
3
PA
2
1
1
1
3
1
1
1
3
1
1
PA, DO
DO
DO
PA
PA
AG
PA, DO
PA
AG
PA, DO
PARTNERS
MEDICAID
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
NF-NC
1
2 PA
1
NF-NC
MDCH
MDCH
NF-NC
1 DO
MDCH
MDCH
MDCH
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2 DO
MDCH
MDCH
MDCH
MDCH
MDCH
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
1
1
1
NF-NC
1
1
1
NF-NC
1
1
1 AG
NF-NC
1
1
60

NOTES
BRAND NAME
WELLBUTRIN XL
ZOLOFT
GEQ
Y
Y
GENERIC NAME
TIER
BUPROPION
SERTRALINE
1
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
DO
PPO
DO
PARTNERS
MEDICAID
MDCH
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
1 DO
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANXIETY
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
1
1
1
NF-NC
1
1
AG
1 AG
MDCH
MDCH
ATIVAN
BUSPAR
MILTOWN
NIRAVAM
SILENOR
TRANXENE T
VALIUM
Y
Y
Y
Y
VISTARIL
XANAX
ALPRAZOLAM
XANAX XR
ALPRAZOLAM
AMBIEN, CR
Y
Y
Y
ZOLPIDEM
LORAZEPAM
DIPHENHYDRAMINE
1
1
1
DO
ZOLPIDEM TARTRATE
ZOLPIDEM SL
3
3
PA, DO
PA, DO
PA, DO
PA, DO
ESZOPICLONE
PA, DO
PA, DO
TEMAZEPAM
DO
RAMELTEON
PA, DO
Y
Y
LORAZEPAM
BUSPIRONE
MEPROBAMATE
ALPRAZOLAM
DOXEPIN
CLORAZEPATE
DIAZEPAM
HYDROXYZINE
PAMOATE
1
1
1
1
3
1
1
1
PA, DO
PA, DO
AG
AG
1
INSOMNIA
ATIVAN
BENADRYL
EDLUAR
INTERMEZZO
LUNESTA
RESTORIL
ROZEREM
SOMNOTE
CHLORAL HYDRATE
SONATA
ZOLPIMIST
ZALEPLON
ZOLPIDEM TARTRATE
1
3
th
th

DO
PA, DO
DO
PA, DO
PA, DO
MDCH
MDCH
1 DO
MDCH
MDCH
MDCH
NF-NC
NF-NC
MDCH
MDCH
NF-NC
MDCH
MDCH
MDCH
1
NF-NC
1
1
NF-NC
61

NOTES
HMO
POS
TPA
SIGNATURE
PARTNERS
M-SUPP RDS
PARTNERS
PPO CLOSED
MAND
MAND
BRAND NAME
GEQ GENERIC NAME
TIER
MICHILD
PPO
MEDICAID
FORMULARY
MAND 90
SPEC
SPEC
PSYCHOSIS/MANIC DEPRESSIVES
MDCH
DO
ABILIFY
ARIPIPRAZOLE
2
2
MDCH
Y
CLOZAPINE
CLOZAPINE
1
1
MDCH
Y
CLOZARIL
CLOZAPINE
1
1
MDCH
Y
ESKALITH, CR
LITHIUM
1
1
MDCH
NF-NC
FANAPT
ILOPERIDONE
3
MDCH
FAZACLO
CLOZAPINE
2
2
ZIPRASIDONE
MDCH
Y
GEODON
MESYLATE
1
1
MDCH
Y
HALDOL
HALOPERIDOL
1
1
MDCH
INVEGA
PALIPERIDONE
2
2
MDCH
PA
PA
NF-NC
LATUDA
LURASIDONE
3
MDCH
Y
LITHOBID
LITHIUM
1
1
MDCH
Y
LOXITANE
LOXAPINE
1
1
MDCH
NF-NC
MOBAN
MOLINDONE
3
MDCH
Y
NAVANE
THIOTHIXENE
1
1
MDCH
NAVANE 20
THIOTHIXENE
2
2
MDCH
ORAP
PIMOZIDE
2
2
MDCH
Y
RISPERDAL
RISPERIDONE
1
1
RISPERDAL
CONSTA
RISPERIDONE
MICROSPHERES
SAPHRIS
ASENAPINE
QUETIAPINE
FUMARATE
MDCH
MDCH
MDCH
SEROQUEL XR
QUETIAPINE
FUMARATE
MDCH
SYMBYAX
OLANZAPINE/
FLUOXETINE
MDCH
OLANZAPINE
MDCH
SEROQUEL
ZYPREXA, ZYDIS
th
th

SP
DO
SP
62

NOTES
HMO
POS
TPA
SIGNATURE
PARTNERS
M-SUPP RDS
PARTNERS
PPO CLOSED
MAND
MAND
BRAND NAME
GEQ GENERIC NAME
TIER
MICHILD
PPO
MEDICAID
FORMULARY
MAND 90
SPEC
SPEC
ATTENTION DEFICIT DISORDER/NARCOLEPSY
AMPHETAMINE/
DEXTROAMPHETMDCH
ADDERALL, XR
Y
1
AMINE
1
METHYLPHENIDATE,
MDCH
Y
CONCERTA
SUST. RELEASE
1
1
METHYLPHENIDATE
MDCH
PA
PA
NF-NC
DAYTRANA
PATCH
3
MDCH
Y
DESOXYN
METHAMPHETAMINE
1
1
DEXMETHYLPHENIMDCH
Y
FOCALIN
DATE
1
1
DEXMETHYLPHENIMDCH
PA
PA
NF-NC
FOCALIN XR
DATE
3
MDCH
PA
PA
NF-NC
INTUNIV
GUANFACINE
3
MDCH
NF-NC
KAPVAY
CLONIDINE
3
MDCH
Y
METADATE CD
METHYLPHENIDATE
1
1
METHYLPHENIDATE
MDCH
METHYLPHENIDATE
MDCH
NF-NC
1
2
1
MDCH
MDCH
MDCH
1
2 PA
1
NF-NC
1
1
1
2 PA
VYVANSE
METHYLPHENIDATE
ARMODAFINIL
MODAFINIL
METHYLPHENIDATE
ORAL SUSP
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE
ATOMOXETINE
LISDEXAMFETAMINE
DIMESYLATE
*XYREM
SODIUM OXYBATE
METADATE ER
METHYLIN CHEW
TAB
METHYLIN SOLN
5MG/5ML
NUVIGIL
PROVIGIL
QUILLIVANT XR
RITALIN
RITALIN LA
RITALIN SR
STRATTERA
th
Y
Y
Y
Y
Y
th

PA, DO
PA, DO
3
1
1
1
3
PA
PA
PA
PA
MDCH
MDCH
MDCH
MDCH
MDCH
PA
PA
MDCH
NF-NC
PA, DO
PA, DO
MDCH
NF-NC
63

NOTES
BRAND NAME
ZENZEDI 2.5,
7.5MG
GEQ
GENERIC NAME
DEXTROAMPHETAMINE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MDCH
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANTICONVULSANTS
BANZEL
CARBATROL
CELONTIN
DEPAKENE
DEPAKOTE
DIASTAT
DIASTAT ACUDIAL
DILANTIN 100MG
CAPS
DILANTIN 30
KEPSEAL
DILANTIN 50
INFATAB
FANATREX
FELBATOL
GABITRIL
GABITRIL12,16MG
KEPPRA
KEPPRA XR
KLONOPIN
LAMICTAL 5, 25MG
DISPER TABLET
LAMICTAL/XR
LAMICTAL ODT
LAMICTAL/XR
STARTER KIT
LYRICA
MYSOLINE
NEURONTIN
th
Y
Y
Y
Y
RUFINAMIDE
CARBAMAZEPINE
METHSUXIMIDE
VALPROIC ACID
DIVALPROEX SODIUM
DIAZEPAM
DIAZEPAM
2
1
2
1
1
1
3
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2
1
2
1
1
1
NF-NC
PHENYTOIN
MDCH
MDCH
NF-NC
PHENYTOIN
Y
Y
Y
PHENYTOIN
GABAPENTIN
FELBAMATE
TIAGABINE
TIAGABINE
LEVETIRACETAM
LEVETIRACETAM
CLONAZEPAM
1
2
1
1
2
1
1
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
2
1
1
2
1
1
1
LAMOTRIGINE
MDCH
LAMOTRIGINE
LAMOTRIGINE
1
2
MDCH
MDCH
1
2
LAMOTRIGINE
PREGABALIN
PRIMIDONE
GABAPENTIN
2
2
1
1
MDCH
MDCH
MDCH
MDCH
2
2
1
1
Y
Y
Y
Y
Y
th

QL
64

NOTES
BRAND NAME
ONFI TABLETS
ONFI
SUSPENSION
OXTELLAR XR
PEGANONE
PHENOBARBITAL
POTIGA
SABRIL
TEGRETOL, XR
TEGRETOL XR
100MG
TOPAMAX
TRILEPTAL
TROKENDI XR
VIMPAT
ZARONTIN
ZONEGRAN
GEQ
Y
Y
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
CLOBAZAM
PARTNERS
MEDICAID
MDCH
CLOBAZAM
OXCARBAZEPINE
ETHOTOIN
PHENOBARBITAL
EZOGABINE
VIGABATRIN
CARBAMAZEPINE
3
3
2
1
3
2
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
NF-NC
NF-NC
2
1
NF-NC
2
1
CARBAMAZEPINE
TOPIRAMATE
OXCARBAZEPINE
TOPIRAMATE
LACOSAMIDE
ETHOSUXIMIDE
ZONISAMIDE
1
1
1
3
2
1
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
1
1
NF-NC
2
1
1
QL
PA, QL
1 QL
NF-NC
GENERIC NAME
TIER
PPO
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
MIGRAINE MEDICATIONS
AMERGE
AXERT
CAFERGOT
CAMBIA
FIORINAL
FROVA
IMITREX
INJECTION
IMITREX SPRAY
IMITREX TABLET
PROPRANOLOL
Y
Y
Y
th
QL
PA, QL
QL
PA, QL
NARATRIPTAN
ALMOTRIPTAN
ERGOTAMINE/
CAFFEINE
DICLOFENAC
POTASSIUM
BUTALBITAL/ ASA/
CAFFEINE
1
3
FROVATRIPTAN
SUMATRIPTAN
INJECTION
SUMATRIPTAN NASAL
SPRAY
SUMATRIPTAN TABLET
PROPRANOLOL
PA, QL
PA, QL
PA, QL
NF-NC
QL
QL
QL
1 QL
1
1
1
QL
QL
QL
QL
QL
QL
1QL
1 QL
NF-NC
3
3
PA
PA
PA
th

NF-NC
1
65

NOTES
BRAND NAME
GEQ
INDERAL LA
MAXALT, MLT
MIGRANAL NASAL
SPRAY
Y
Y
PRODRIN
RELPAX
SUMAVEL
DOSEPRO
TREXIMET
ZOMIG NASAL
SPRAY
ZOMIG, ZMT
AMRIX
BACLOFEN
COMFORT PACTIZANIDINE
DANTRIUM
FLEXERIL
FEXMID
LORZONE
NORFLEX
PARAFON FORTE
DSC
ROBAXIN
SKELAXIN
SOMA
ZANAFLEX
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
1
QL
QL
QL
1
1 QL
PA, QL
PA, QL
PA, QL
NF-NC
1
2
QL
QL
PA, QL
1
2 QL
PA, QL
PA, QL
PA, QL
NF-NC
PA, QL
PA, QL
PA, QL
NF-NC
PROPRANOLOL SR
RIZATRIPTAN
DIHYDROERGOTAMINE
ACETAMINOPHENISOMETHEPTENECAFFEINE
ELETRIPTAN
SUMATRIPTAN
INJECTION
SUMATRIPTAN/
NAPROXEN
ZOLMITRIPTAN NASAL
SPRAY
ZOLMITRIPTAN
CYCLOBENZAPRINE
BACLOFEN
3
1
TIZANIDINE COMBO
DANTROLENE
CYCLOBENZAPRINE
CYCLOBENZAPRINE
CHLORZOXAZONE
ORPHENADRINE
3
1
1
1
3
1
Y
Y
Y
Y
CHLORZOXAZONE
METHOCARBAMOL
METAXALONE
CARISOPRODOL
1
1
1
1
TIZANIDINE
Y
Y
Y
3
1
QL
QL
QL
QL
QL
QL
SKELETAL MUSCLE RELAXANTS
PA, AG
AG
PA, AG
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
1 QL
NF-NC
1
NF-NC
AG
AG
AG
1
1 AG
AG
AG
AG
AG
AG
AG
1
NF-NC
1 AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
NC
1 AG
1 AG
1 AG
NF-NC
1
MISCELLANEOUS AUTONOMIC AGENTS

MESTINON
th
PYRIDOSTIGMINE
1
th

66

NOTES
BRAND NAME
GEQ
MESTINON 180
GENERIC NAME
TIER
PYRIDOSTIGMINE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
PARKINSON'S DISEASE (PD)

APOKYN
AZILECT
COGENTIN
COMTAN
LODOSYN
MIRAPEX
MIRAPEX ER
NEUPRO
Y
Y
Y
PARCOPA
PARLODEL
REQUIP
REQUIP XL
Y
Y
Y
Y
SINEMET, CR
STALEVO
TASMAR
ZELAPAR
APOMORPHINE
RASAGILINE
BENZTROPINE
ENTACAPONE
CARBIDOPA
PRAMIPEXOLE
PRAMIPEXOLE DI-HCL
ROTIGOTINE
CARBIDOPA/
LEVODOPA
BROMOCRIPTINE
ROPINIROLE
ROPINIROLE
LEVODAPA/
CARBIDOPA
CARBIDOPA/
LEVODOPA/
ENTACAPONE
TOLCAPONE
SELEGILINE
3
2
1
1
3
1
3
3
PA
PA
PA
MDCH
NF-NC
2
1
1
NF-NC
1
NF-NC
NF-NC
1
1
1
1
1
1
1
1
2
3
3
2
NF-NC
NF-NC
ALZHEIMER'S DISEASE
ARICEPT
EXELON
CAPSULES
EXELON SOLN
AND PATCH
NAMENDA
NAMENDA XR
RAZADYNE ER
th
DONEPEZIL
RIVASTIGMINE
2
2
3
1
2
2
NF-NC
RIVASTIGMINE
MEMANTINE
MEMANTINE
GALANTAMINE
th

67

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
HORMONES
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ORAL ADRENAL CORTICOSTEROIDS

ARISTOCORT
CELESTONE
CORTEF TABS
CORTISONE
MEDROL,
DOSEPAK
PEDIAPRED
LIQUID
PREDNISOLONE
2
2
1
1
2
2
1
1
TRIAMCINOLONE
BETAMETHASONE
HYDROCORTISONE
CORTISONE ACETATE
METHYLPREDNISOLONE
Y
Y
PREDNISOLONE
PREDNISOLONE
1
1
1
1
Y
Y
ORAL CONTRACEPTIVES, GF
APRI
ARANELLE
AVIANE
BEYAZ
CAMILA
CRYSELLE
DESOGEN
ENPRESSE
th
ETHINYL ESTRADIOL
30MCG
DESOGESTREL
0.15MG
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
20MCG
LEVONORGESTREL
0.1MG
DROSPIR/ETH
ESTRA/LEVOMEF OL
CA
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
30MCG
DESOGESTREL
0.15MG
ETHINYL ESTRADIOL
LEVONORGESTREL
th

NF-PA
PA
PA
PA
68

NOTES
BRAND NAME
GEQ
ERRIN
ESTROSTEP FE
FEMCON FE
GENERESS FE
GENERIC NAME
NORETHINDRONE
0.35MG
NORETH A-ET
ESTRA/FE FUMARATE
NORETH-ETHINYL
ESTRADIOL/IRON
NORETH-ETHINYL
ESTRADIOL/IRON
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
TIER
PA
PPO
PA
PARTNERS
MEDICAID
PA
JOLIVETTE
NORETHINDRONE
0.35MG
KARIVA
ETHINYL ESTRADIOL
DESOGESTREL
LESSINA
LEVORA
ETHINYL ESTRADION
20MCG
LEVONORGESTREL
0.1MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
LO/OVRAL
LOESTRIN FE 1/20
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
LOESTRIN 21
1.5/30
LOESTRIN 21 1/20
th
th

MAND
SPEC
PARTNERS
MAND
SPEC
69

NOTES
BRAND NAME
GEQ
LOESTRIN 24 FE
LO MINASTRIN FE
LOSEASONIQUE
LOW-OGESTREL
LYBREL
MICROGESTIN FE
1.5/30
MICROGESTIN FE
1/20
MIRCETTE
MODICON
MONONESSA
NATAZIA
th
GENERIC NAME
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
10MCG
NORETHINDRONE
1MG
L-NORGEST-ETH
ESTR/ETHIN ESTRA
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
ETHINYL ESTRADIOL
LEVONORGESTREL
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
ETHINYL ESTRADIOL
20MCG/ FE/
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
DESOGESTREL
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ESTRADIOL
VALERATE/DIENOGEST
th

PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
PA
PA
PA
NF-PA
PA
PA
PA
NF-PA
NF-PA
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
70

NOTES
BRAND NAME
GEQ
NECON 0.5/35
NECON 1/35
NECON 1/50
NECON 10/11
GENERIC NAME
NORTREL 0.5/35
NORTREL 1/35
ETHINYL ESTRADIOL
NORETHINDRONE
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
NORTREL 7/7/7
ETHINYL ESTRADIOL
NORETHINDRONE
NECON 7/7/7
NORA-BE
NORDETTE
NORINYL 1/35
NORINYL 1+50
th
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
TIER
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
NORETHINDRONE
th

HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PPO
PA
PARTNERS
MEDICAID
PA
MAND
SPEC
PARTNERS
MAND
SPEC
71

NOTES
BRAND NAME
OGESTREL
ORTHO
MICRONOR
ORTHO TRICYCLEN
ORTHO TRICYCLEN LO
ORTHO-CYCLEN
ORTHO-NOVUM
1/35
ORTHO-NOVUM
1/50
ORTHO-NOVUM
7/7/7
GEQ
Y
Y
Y
Y
Y
ORTHO-CEPT
OVCON 35
OVCON 50
th
GENERIC NAME
ETHINYL ESTRADIOL
50MCG
NORGESTREL 0.5MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
1MG
MESTRANOL 50MCG
NORETHINDRONE
1MG
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
30MCG
DESOGESTREL
0.15MG
ETHINYL ESTRADIOL
35MCG
NORETHINDRONE
0.4MG
ETHINYL ESTRADIOL
50MCG
NORETHINDRONE
1MG
th
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
NF-PA
TIER
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG

HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
PPO
PA
PA
PARTNERS
MEDICAID
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
72

NOTES
BRAND NAME
PORTIA
GEQ
SAFYRAL
SEASONALE
SEASONIQUE
SPRINTEC
TRINESSA
TRI-NORINYL
TRI-SPRINTEC
TRIVORA
YASMIN
YAZ
ZOVIA 1/35
ZOVIA 1/50
th
GENERIC NAME
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
DROSPIR/ETHESTRA/L
EVOMEFOL CA
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
L-NORGEST-ETH
ESTR/ETHIN ESTRA
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
LEVONORGESTREL
ETHINYL ESTRADIOL
30MCG
DROSPIRENONE 3MG
ETHINYL ESTRADIOL
20MCG
DROSPIRENONE 3MG
ETHINYL ESTRADIOL
35MG
ETHYNODIOL
DIACETATE 1MG
ETHINYL ESTRADIOL
50MCG
ETHYNODIOL
DIACETATE 1MG
th
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-PA
TIER

HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
1
3
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
73

NOTES
BRAND NAME
GEQ
ESTRADIOL,
TRANSDERMAL
CONJUGATED
ESTROGENS
ESTRADIOL,
TRANSDERMAL
ESTRADIOL
CONJUGATED
ESTROGENS
ESTRADIOL
ESTRADIOL
ESTRADIOL,
TRANSDERMAL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTROGENS
ESTROPIPATE
ALORA
CENESTIN
ENJUVIA
ESTRACE TABS
ESTRACE
VAGINAL CREAM
ESTRADERM
ESTRASORB
ESTRING
ESTROGEL GEL
FEMRING
FEMTRACE
MENEST
OGEN
TIER
ETONOGESTREL
ETHINYL ESTRADIOL
ETHINYL ESTRADIOL
NORELGESTROMIN
NUVARING
ORTHO EVRA
PATCH
CLIMARA
DIVIGEL
GENERIC NAME
PA
PA
AG
PA
PA
NF-PA
AG
AG
2AG
AG
AG
PA, AG
NF-NC
1
3
AG
AG
AG
1 AG
NF-NC
3
1
AG
AG
AG
AG
PA, AG
AG
NF-NC
1 AG
Y
Y
PA
ESTROGENS, GF
AG
AG
AG
AG
AG
AG
AG
AG
AG
PREMARIN VAG
CREAM
VAGIFEM
CONJUGATED
ESTROGENS
ESTRADIOL
2
3
MAND
SPEC
PARTNERS
MAND
SPEC
2
3
3
3
3
3
3
1
CONJUGATED
ESTROGENS
th
MAND 90
NF-PA

SIGNATURE
PPO CLOSED
FORMULARY
PA
PREMARIN ORAL
th
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
NON-ORAL CONTRACEPTIVES, GF
AG
AG
Y
Y
Y
AG
AG
AG
2 AG
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
1 AG
PA, AG
2 AG
2
NF-NC
Y
Y
Y
Y
Y
Y
74

NOTES
BRAND NAME
GEQ
VIVELLE-DOT
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
ESTRADIOL,
TRANSDERMAL
AG
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
AG
2 AG
1
1
Y
Y
1AG
1 AG
NF-NC
NF-NC
2 AG
NF-NC
NF-NC
AYGESTIN
PROMETRIUM
Y
Y
NORETHINDRONE
ACETATE
PROGESTERONE
1
1
PROVERA
MEDROXYPROGESTERONE/ MPA
PPO
AG
PROGESTINS
MAND
SPEC
PARTNERS
MAND
SPEC
COMBINATION ESTROGEN/ANDROGEN
ESTRATEST
ACTIVELLA
ESTERIFIED
ESTROGENS/
METHYLTESTOSTERO
NE
ESTRADIOL/
NORETHINDRONE
ACETATE
ANGELIQ
CLIMARA PRO
COMBIPATCH
FEMHRT 1MG5MCG
FEMHRT 0.5MG2.5MCG
PREFEST
PREMPHASE
th
ESTRADIOL/
DROSPIRENONE
ESTRADIOL/
LEVONORGESTREL
ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
ESTRADIOL/
NORGESTIMATE
CONJUGATED
ESTROGEN/ MPA
th

AG
AG
AG
COMBINATION ESTROGEN/PROGESTINS
AG
AG
AG
AG
AG
AG
AG
AG
PA, AG
75

NOTES
BRAND NAME
GEQ
PREMPRO
DDAVP NASAL
SPRAY
DDAVP RHINAL
TUBE
Y
Y
GENERIC NAME
CONJUGATED
ESTROGEN/ MPA
TIER
2
DESMOPRESSIN
ACETATE
DESMOPRESSIN
ACETATE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
AG
AG
PA, AG
DDAVP-DESMOPRESSIN ACETATE
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ANDROGENS, GM
NF-NC
ANDROID
ANDROXY
TESTOSTERONE
TESTOSTERONE,
TRANSDERMAL
METHYLTESTOSTERONE
FLUOXYMESTERONE
2
3
2
NF-NC
Y
Y
AXIRON
TESTOSTERONE
NF-NC
FORTESTA
TESTOSTERONE
METHYLTESTOSTERONE
OXANDROLONE
NF-NC
3
1
NF-NC
1
Y
Y
TESTOSTERONE
METHYLTESTOSTERONE
NF-NC
NF-NC
ANDRODERM
ANDROGEL
METHITEST
OXANDRIN
TESTIM
TESTRED
3
INFERTILITY
UROFOLLITROPIN
(FSH)
*BRAVELLE
*CETROTIDE
*CLOMID
*FOLLISTIM AQ
*GONAL-F
th
CETRORELIX
ACETATE
CLOMIPHENE
FOLLITROPIN
BETA,RECOMB
FOLLITROPIN
ALPHA,RECOMB
th

PA
PA
NC
NC
3
1
PA
PA
PA
PA
NC
NC
NC
NC
Y
Y
PA
PA
NC
NC
PA
PA
NC
NC
76

NOTES
BRAND NAME
*LUPRON DEPOT
3.75 KIT
GEQ
*NOVAREL
*OVIDREL
*PREGNYL
*REPRONEX
*LUPRON DEPOT
3.75 KIT
SYNAREL NASAL
SPRAY
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
LEUPROLIDE ACETATE
GONADOTROPIN,
CHORIONIC,HUMAN
HCG
ALPHA,RECOMBINANT
GONADOTROPIN,
CHORIONIC,HUMAN
MENOTROPINS
LEUPROLIDE ACETATE
NAFARELIN ACETATE
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NC
NC
PA
PA
NC
NC
PA
PA
NC
NC
3
3
PA
PA
NC
NC
NC
NC
Y
Y
PA
4 SPEC
PA
PA
ENDOMETRIOSIS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
OSTEOPOROSIS
SELECTIVE ESTROGEN RECEPTOR MODULATOR
EVISTA
RALOXIFENE
OSPHENA
OSPEMIFENE
PA
NF-NC
BISPHOSPHONATES
ACTONEL
ATELVIA
BINOSTO
BONIVA
DIDRONEL
*FORTEO
FORTICAL
FOSAMAX
FOSAMAX PLUS D
MIACALCIN NASAL
th
Y
Y
NF-NC
3
1
1
3
3
1
NF-NC
1
1
NF-NC
NF-NC
1
RISEDRONATE
RISEDRONATE
SODIUM
ALENDRONATE
IBANDRONATE
ETIDRONATE
TERIPARATIDE
CALCITONIN
ALENDRONATE
ALENDRONATE/
VITAMIN D3
CALCITONIN
3
1
th

PA
PA
NF-NC
1
Y
Y
Y
Y
Y
Y
Y
Y
77

NOTES
BRAND NAME
GEQ
ARMOUR
THYROID
CYTOMEL
GENERIC NAME
MAND 90
1 AG
1
1
1
1
Y
Y
1
1
2
1
1
2
Y
Y
Y
LEVOTHROID
LEVOXYL
METHIMAZOLE
PROPYLTHIOURACIL
Y
Y
LEVOTHYROXINE
SODIUM
LEVOTHYROXINE
SODIUM
METHIMAZOLE
PROPYLTHIOURACIL
SYNTHROID
TAPAZOLE
THYROLAR
Y
Y
TIROSINT
ZEMPLAR
SIGNATURE
PPO CLOSED
FORMULARY
TIER
THYROID,
DESSICATED
LIOTHYRONINE
SODIUM
LEVOTHYROXINE
SODIUM
METHIMAZOLE
LIOTRIX
LEVOTHYROXINE
SODIUM
PARICALCITOL
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
THYROID DISORDERS
AG
AG
AG
PA
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
2
3
2
DIABETES
INSULINS
APIDRA
APIDRA
SOLOSTAR
HUMALOG
HUMALOG MIX
HUMULIN
INSULINS
LANTUS
LANTUS
SOLOSTAR
LEVEMIR
LEVEMIR
FLEXPEN
th
INSULIN GLULISINE
PA
PA
PA
NF-NC
INSULIN GLULISINE
INSULIN LISPRO
INSULIN
3
2
2
PA
PA
PA
NF-NC
2
2
INSULIN
INSULIN GLARGINE
2
2
2
2
Y
Y
INSULIN GLARGINE
INSULIN DETEMIR
2
2
2
2
Y
Y
INSULIN DETEMIR
th

78

NOTES
BRAND NAME
NOVOLIN
INSULINS
NOVOLOG
INSULINS
NOVOLOG MIX
INSULIN
SYRINGES
GEQ
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
INSULIN
PA
INSULIN ASPART
INSULIN
3
3
PA
PA
PA
PA
NEEDLES/SYRINGES
SYRINGES
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
PA
PA
NF-NC
PA
PA
NF-NC
NF-NC
1
1 AG
1
Y
Y
Y
1 AG
1 AG
Y
Y
1 AG
Y
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
SULFONYLUREAS
AMARYL
DIABETA
GLUCOTROL, XL
GLYNASE
PRESTAB
MICRONASE
Y
Y
Y
GLIMEPIRIDE
GLYBURIDE
GLIPIZIDE
1
1
1
Y
Y
GLYBURIDE
GLYBURIDE
1
1
DIABINESE
FORTAMET
GLUCOPHAGE, XR
Y
Y
Y
CHLORPROPAMIDE
METFORMIN
METFORMIN
1
1
1
AG
GLUCOVANCE
GLUMETZA
GLYBURIDE/
METFORMIN
METFORMIN
1
3
AG
PA
INVOKANA
CANAGLIFLOZIN
NF-NC
*KORLYM
MIFEPRISTONE
REPAGLINIDE/
METFORMIN
REPAGLINIDE
NATEGLINIDE
NF-NC
3
1
1
NF-NC
1
1
Y
Y
Y
NF-NC
PRANDIMET
PRANDIN
STARLIX
Y
Y
AG
AG
AG
AG
AG
AG
AG
AG
AG
ORAL ANTIHYPERGLYCEMICS
AG
AG
1
1
AG
AG
PA
1 AG
NF-NC
DPP-4 INHIBITORS
JANUMET, XR
th
SITAGLIPTIN /
METFORMIN
3
th

PA
PA
PA
79

NOTES
BRAND NAME
GEQ
JANUVIA
JENTADUETO
JUVISYNC
KAZANO
KOMBIGLYZE XR
NESINA
ONGLYZA
OSENI
TRADJENTA
ACTOPLUS MET
ACTOPLUS MET
XR
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
DUETACT
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
SITAGLIPTIN
LINAGLIPTIN/
METFORMIN
SITAGLIPTIN/
SIMVASTATIN
ALOGLIPTIN/
METFORMIN
SAXAGLIPTIN/
METFORMIN
ALOGLIPTIN/
BENZOATE
PA, DO
SAXAGLIPTIN
ALOGLIPTIN/
PIOGLITAZONE
LINAGLIPTIN
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
PA, DO
PA, DO
NF-NC
2
3
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
PA, DO
PA, DO
PA, DO
NF-NC
PA, DO
PA, DO
PA, DO
NF-NC
PA
DO
NF-NC
2 DO
Y
Y
3
1
NF-NC
1
Y
Y
NF-NC
3
3
NF-NC
NF-NC
Y
Y
3
2
PIOGLITAZONE/
METFORMIN
PIOGLITAZONE/
METFORMIN
PIOGLITAZONE
ROSIGLITAZONE/
METFORMIN
ROSIGLITAZONE/
GLIMEPIRIDE
ROSIGLITAZONE
PIOGLITAZONE/
GLIMEPIRIDE
PA
PA
DO
DO
THIAZOLIDINEDIONES
MAND
SPEC
PARTNERS
MAND
SPEC
MISCELLANEOUS
BYDUREON
BYETTA
FREESTYLE
LITE/INSULINX,
th
EXENATIDE
EXTENDED RELEASE
EXENATIDE
2
2
TEST STRIPS
0
th

2
2
DO
DO
DO
0 DO
80

NOTES
BRAND NAME
PRECISION XTRA
GLUCOSE TEST
STRIPS (no copay
at a pharmacy)
ALL OTHER TEST
STRIPS (covered at
DME only with a
copay as applicable)
GLYSET
LANCETS
PRECOSE
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
TEST STRIPS
MIGLITOL
LANCETS
ACARBOSE
DME
NF-NC
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
3
2
1
NF-NC
NF-NC
2
1
Y
Y
Y
PPO
PARTNERS
MEDICAID
NF-NC
NF-NC
SYMLIN
PRAMLINTIDE
ACETATE
SYMLINPEN
VICTOZA
PRAMLINTIDE
ACETATE
LIRAGLUTIDE
2
2
2
2
MAND
SPEC
PARTNERS
MAND
SPEC
GLUCAGON
GLUCAGON
GLUCAGON
2
ANTI-GOUT DRUGS
COLCRYS
INDOCIN SUSP
INDOMETHACIN
PROBENECID
ULORIC
ZYLOPRIM
Y
Y
Y
COLCHICINE 0.6MG
INDOMETHACIN
INDOMETHACIN
PROBENECID
FEBUXOSTAT
ALLOPURINOL
2
2
1
1
2
1
AG
AG
AG
AG
AG
AG
DO, PA
DO, PA
DO, PA
2
2 AG
1 AG
1
NF-NC
1
Y
Y
SUPPLEMENTS
ANTI-ANEMIA DRUGS
FOLIC ACID
FOLIC ACID
1
PRENATAL VITAMINS
ATABEX EC
BAL-CARE DHA
ESSENTIAL
th
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
th

81

NOTES
BRAND NAME
B-NEXA
CITRANATAL
ASSURE
CITRANATAL BCALM
CITRANATAL
HARMONY
COMPLETE-RF
PRENATAL
CONCEPT OB,
DHA
DUET DHA
BALANCED
GESTICARE DHA
HEMENATAL OB
MIS + DHA
HEMOCYTE-F
TABLET
NATALVIT
NATELLE ONE
NESTABS
NESTABS DHA
NEXA SELECT
OB COMPLETE,
PREMIER, ONE,
400, DHA
OBSTETRIX EC
PREFERA OB
PREFERA-OB ONE
PREFERA-OB
PLUS DHA
PRENATA
PRENATAL
COMPLETE
th
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITMAINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
3
PA
PA
NF-NC
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
PREP
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
PA
NF-NC
PA
PA
PA
PA
PA
1
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
1
3
3
PA
PA
PA
NF-NC
1
NF-NC
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
th

1
3
3
3
3
3
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
82

NOTES
BRAND NAME
PRENATAL PLUS
GEQ
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
VITAMINS, PRENATAL
PRENATE ELITE,
DHA, ESSENTIAL
VITAMINS, PRENATAL
PA
NF-NC
PRENATE MINI
VITAMINS, PRENATAL
PA
NF-NC
PRENEXA
PREQUE 10
SELECT-OB
SELECT-OB + DHA
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
3
3
3
PA
PA
PA
PA
NF-NC
NF-NC
NF-NC
NF-NC
VITAFOL-OB
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
VITAMINS, PRENATAL
VITAFOL-ONE
VITAMINS, PRENATAL
PA
NF-NC
VITAFOL-PLUS
VITAMED MD ONE
RX/QUATREFOLIC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMED MD PLUS
VITAMED MD
REDICHEW
RX/QUATREFOLIC
VIVA CT
PRENATAL
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
VITAMINS, PRENATAL
PA
NF-NC
POTASSIUM
KLOR-CON
POTASSIUM
CHLORIDE
POTASSIUM
PHOSPHATE
POTASSIUM
CHLORIDE
SSKI SOLUTION
POTASSIUM IODIDE
NEURIN-SL
CYANOCOBALAMIN/ME
COBALAMIN
K-PHOS ORIGINAL
MICRO-K
VITAMIN B
2
2
VITAMIN D
ROCALTROL
th
CALCITRIOL
1
th

83

NOTES
BRAND NAME
GEQ
FLUORABON
DROPS
GENERIC NAME
TIER
SODIUM FLUORIDE
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
VITAMINS WITH FLUORIDE
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
3
TOPICAL FLUORIDE
PREVIDENT 5000
BOOSTER GEL
PREVIDENT 5000
PLUS CREAM
PREVIDENT
DENTAL RINSE
PREVIDENT GEL
PREVIDENT 5000
SENSITIVE 1.1%5%
SODIUM FLUORIDE
SODIUM FLUORIDE
Y
Y
SODIUM FLUORIDE
SODIUM FLUORIDE
1
1
1
1
SODIUM FLUORIDE
1
VITAMIN K
MEPHYTON
PHYTONADIONE
2
MISCELLANEOUS AGENTS
HEAVY METAL ANTAGONISTS
CUPRIMINE
PENICILLAMINE
NF-NC
DESFERAL
*EXJADE
DEFEROXAMINE
MESYLATE
DEFERASIROX
1
2
1
2
QUININE SULFATE
QUININE SULFATE
QUININE SULFATE
1
ALKALINIZING AGENTS
UROCIT-K 5,
10MEQ
UROCIT-K 15MEQ
POTASSIUM CITRATE
POTASSIUM CITRATE
1
3
1
NF-NC
AMINO ACID DERIVATIVES
#CARNITOR
LEVOCARNITINE
1
GALLSTONE SOLUBILIZERS
ACTIGALL
th
URSODIOL
1
th

84

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
SMOKING CESSATION PRODUCTS
VARENICLINE
TARTRATE
DL
NICOTINE
POLACRILEX
Covered for MiChild
NICOTINE
POLACRILEX
NICOTINE PATCH
Y
NICOTROL NS
ZYBAN
ANTABUSE
METHADONE
REVIA
CHANTIX
NICORETTE GUM
OTC
DL
DL
SIGNATURE
PPO CLOSED
FORMULARY
PARTNERS
MAND
SPEC
2 DL
NC
NC
NF-NC
Covered for MiChild
NC
NF-NC
PA, DL
PA, DL
PA, DL
NF-NC
NICOTINE PATCH OTC
DL
DL
DL
1 DL
NF-NC
3
1
NF-NC
NICOTINE INHALER
NICOTINE NASAL
SPRAY
BUPROPION
Y
Y
Y
DISULFIRAM
METHADONE
NALTREXONE
1
1
1
MDCH
MDCH
MDCH
1
1
1
BUPRENORPHINE/
NALOXONE
MDCH
BUPRENORPHINE/
NALOXONE
MDCH
MDCH
ZUBSOLV
BUPRENORPHINE
BUPRENORPHINE/
NALOXONE
MDCH
ERECTILE DYSFUNCTION (ED)
CAVERJECT
ALPROSTADIL
GM, QL
CIALIS 10, 20mg
TADALAFIL
AG, GM, PA, QL
NICOTINE
LOZENGE OTC
NICOTINE PATCH,
RX
NICOTINE PATCH
OTC
NICOTROL
INHALER
MAND 90
MAND
SPEC
NC
1
SUBSTANCE ABUSE DETERRENTS
SUBOXONE
SUBOXONE SL
SUBUTEX
th
th

GM, QL
AG,
GM,
PA, QL
NF-NC
NC
NC
NC
NC
85

NOTES
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
CIALIS 2.5, 5MG
TADALAFIL
PA, QL
PA, QL
NC
NC
EDEX
ALPROSTADIL
GM, QL
NC
NC
LEVITRA
VARDENAFIL
AG, GM, PA, QL
GM, QL
AG,
GM,
PA, QL
NC
NC
MUSE
ALPROSTADIL
GM, QL
NC
NC
STAXYN
VARDENAFIL
NC
NC
VIAGRA
SILDENAFIL
NC
NC
AZASAN
AZATHIOPRINE
CELLCEPT
MYCOPHENOLATE
MOFETIL
GENGRAF
IMURAN
MYFORTIC
Y
Y
CYCLOSPORINE
AZATHIOPRINE
MYCOPHENOLATE
1
1
2
1
1
2
Y
Y
Y
NEORAL
PROGRAF
RAPAMUNE
SANDIMMUNE
Y
Y
CYCLOSPORINE
TACROLIMUS
SIROLIMUS
CYCLOSPORINE
1
1
2
1
1
1
2
1
Y
Y
Y
Y
EVEROLIMUS
EVEROLIMUS
BRAND NAME
GEQ
ZORTRESS
0.25MG
*ZORTRESS 0.5,
0.75MG
GENERIC NAME
GM, QL
AG,
GM,
AG, GM, PA, QL
PA, QL
AG,
GM,
AG, GM, PA, QL
PA, QL
IMMUNE SUPPRESSANTS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
RHEUMATOLOGIC MEDCATIONS
ARAVA
*CIMZIA
*ENBREL
th
LEFLUNOMIDE
CERTOLIZUMAB
PEGOL
ETANERCEPT
1
3
2
th

1
PA
PA
PA
PA
PA
PA
NF-NC
4 SPEC PA
86

NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
*HUMIRA
*#KINERET
*ORENCIA SQ
RAYOS
RIDAURA
*SIMPONI
ADALIMUMAB
ANAKINRA
ABATACEPT
PREDNISONE
AURANOFIN
GOLIMUMAB
2
3
3
3
2
3
*XELJANZ
TOFACITINIB
LIDOCAINE
LIDOCAINE
LIDOCAINE/
TETRACAINE
LIDODERM 5%
PATCH
LIDORX GEL
PLIAGLIS
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PA
PA
PA
PPO
PA
PA
PA
PA
PARTNERS
MEDICAID
PA
PA
PA
PA
PA
PA
PA
SPEC,
SPEC, PA
PA
SPEC, PA
LOCAL ANESTHETICS
PA
PA
PA
SIGNATURE
PPO CLOSED
FORMULARY
4 SPEC PA
NF-NC
NF-NC
NF-NC
2
NF-NC
MAND 90
NF-NC
MAND
SPEC
Y
Y
Y
PARTNERS
MAND
SPEC
Y
Y
Y
1 PA
NF-NC
NF-NC
3
POTASSIUM REMOVING RESINS
KAYEXALATE
SODIUM
POLYSTYRENE
SULFONATE
1
UROLOGY
AVODART
CARDURA
CARDURA XL
DETROL
DETROL LA
DITROPAN XL
ELMIRON
ENABLEX
FLOMAX
th
DUTASTERIDE
DOXAZOSIN
DOXAZOSIN
TOLTERODINE
TARTRATE
TOLTERODINE
TARTRATE
OXYBUTYNIN
PENTOSAN
POLYSULFATE
SOLIFENACIN
SUCCINATE
TAMSULOSIN
2
1
3
2
1
NF-NC
2 DO
1 DO
Y
Y
2
1
DO
DO
DO
DO
DO
DO
2
3
1
th

2
DO
DO
DO
NF-NC
1
Y
Y
87

NOTES
BRAND NAME
GEQ
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
NF-NC
JALYN
GENERIC NAME
OXYBUTYNIN
CHLORIDE
DUTASTERIDE/
TAMSULOSIN
MYRBETRIQ
OXYTROL PATCH
PROSCAR
PYRIDIUM
RAPAFLO
SANCTURA
SANCTURA XR
3
3
1
1
3
1
1
DO
DO
DO
PA
PA
PA
PA
Y
Y
MIRABEGRON
OXYBUTYNIN
FINASTERIDE
PHENAZOPYRIDINE
SILODOSIN
TROSPIUM CHLORIDE
TROSPIUM CHLORIDE
TOVIAZ
URECHOLINE
2
1
DO
FESOTERODINE
FUMARATE
BETHANECHOL
UROXATRAL
GELNIQUE
Y
Y
VESICARE
METHERGINE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
3
2
ALFUZOSIN
DARIFENACIN
HYDROBROMIDE
METHYLERGONOVINE
MAND
SPEC
PARTNERS
MAND
SPEC
MAND 90
2
NF-NC
NF-NC
1
1
NF-NC
1
1
DO
DO
DO
OXYTOCICS
DO
DO
Y
Y
Y
Y
Y
Y
2 DO
1
2 DO
1
HEPATITIS C PRODUCTS
*COPEGUS
RIBAVIRIN
*INCIVEK
TELAPREVIR
PA
PA
PA
4 SPEC PA
*PEGASYS,
PROCLICK
PA
PA
PA
4 SPEC PA
*PEG-INTRON
PEGINTERFERON
ALFA-2A
PEGINTERFERON
ALFA-2B
PA
PA
PA
NF-NC
REBETOL ORAL
SOLUTION
*REBETOL
*RIBAPAK
RIBASPHERE
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
NF-NC
1
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
th
Y
Y
3
1
3
1
th

88

NOTES
BRAND NAME
*RIBATAB
*VICTRELIS
VIRAZOLE
AMITIZA
LINZESS
LOTRONEX
GEQ
Y
GENERIC NAME
TIER
RIBAVIRIN
BOCEPREVIR
RIBAVIRIN
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
1
PA
PA
PA
4 SPEC PA
2
NF-NC
3
IRRITABLE BOWEL SYNDROME/CHRONIC CONSTIPATION
LUBIPROSTONE
LINACLOTIDE
ALOSETRON
2
3
2
MAND 90
MAND
SPEC
Y
Y
PARTNERS
MAND
SPEC
Y
Y
PA
2
NF-NC
NF-NC
MDCH
MDCH
PA
2 PA
2
NF-NC
MDCH
NF-NC
PA
NF-NC
FIBROMYALGIA
CYMBALTA
LYRICA
SAVELLA
DULOXETINE
PREGABALIN
MILNACIPRAN
2
2
3
PA
QL
PA
*#KALYDECO
IVACAFTOR
PA
*TOBI SOLUTION/
PODHALER
TOBRAMYCIN
PA
PA
MULTIPLE SCLEROSIS
3
3
2
3
PA, SP
PA
PA
PA
PA, SP
PA
PA
PA
PA, SP
PA
PA
PA
NF-NC
NF-NC
4 SPEC PA
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
*COPAXONE
DALFAMPRIDINE
TERIFLUNOMIDE
INTERFERON BETA-1A
INTERFERON BETA-1B
GLATIRAMER
ACETATE
PA
PA
PA
4 SPEC PA
*EXTAVIA
INTERFERON BETA-1B
PA
PA
PA
NF-NC
*GILENYA
PA, DO
PA, DO
PA, DO
NF-NC
*REBIF
FINGOLIMOD
INTERFERON BETA1A/ALBUMIN
PA
PA
PA
4 SPEC PA
*TECFIDERA
DIMETHYL FUMERATE
NF-NC
GRALISE
GABAPENTIN
PA
PA
PA
NF-NC
HORIZANT
GABAPENTIN
ENACARBIL
PA, DO
PA, DO
PA, DO
NF-NC
*AMPYRA
*AUBAGIO
*AVONEX
*BETASERON
th
th

PA
PA
CYSTIC FIBROSIS
PA
PA
PA
PA
NEUROLOGICAL MISCELLANEOUS
89

NOTES
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
NUEDEXTA
DEXTROMETHORPHAN/QUINIDINE
PA
*XENAZINE
TETRABENAZINE
FOSRENOL
PHOSLO
RENAGEL
LANTHANUM
CARBONATE
CALCIUM ACETATE
SEVELAMER
2
1
2
BRAND NAME
GEQ
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NF-NC
PA
PA
PA
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
MAND
SPEC
PARTNERS
MAND
SPEC
2
NF-NC
2
2
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NF-NC
2
1
2
*#COMETRIQ
DROXIA
SEVELAMER
CARBONATE
2
2
ONCOLOGY-ONCOLOGY DRUGS ARE ON FORMULARY UNLESS LISTED OTHERWISE
CABOZANTINIB
2
2
HYDROXYUREA
2
2
*#ICLUSIG
*JAKAFI
*#XALKORI
*XTANDI
PONATINIB
RUXOLITINIB
CRIZOTINIB
ENZALUTAMIDE
2
3
2
2
*#ZELBORAF
VEMURAFENIB
RENVELA
MAND 90
PA
PA
PA
GROWTH HORMONES
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
4 SPEC PA
2
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
HIV ALL HIV SELF-ADMINISTERED DRUGS ARE ON FORMULARY
*EGRIFTA
*GENOTROPIN
*HUMATROPE
*NORDITROPIN
*NUTROPIN
*OMNITROPE
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
#FUZEON
ENFUVIRTIDE
PA
PA
PA
2 PA
#TRUVADA
EMTRICITABINE/TENO
FOVIR DISOPROXIL
FUMARATE
PA, DO
PA, DO
MDCH
2 PA, DO
th
th

90

NOTES
BRAND NAME
GEQ
BOTOX, DYSPORT,
XEOMIN
IMMUNE
GLOBULIN
ORENCIA IV
REMICADE
RITUXAN
SYNAGIS
TYSABRI
FOLIC ACID
(FEMALE ONLY)
IRON
SUPPLEMENTS
(AGES 6 MONTHS
TO 1 YEAR)
ORAL FLUORIDE
(AGES 6 MONTHS
TO 6 YEARS)
OTC ASPIRIN
(AGES 45-79
YEARS)
OTC NICOTINE
PATCHES
th
HMO
POS
TPA
SIGNATURE
M-SUPP RDS
PARTNERS
PPO CLOSED
GENERIC NAME
TIER
MICHILD
PPO
MEDICAID
FORMULARY
MEDICAL PRIOR AUTHORIZATION DRUGS WITH A MEDICAL BENEFIT COPAY
BOTULISM TOXIN
TYPE A
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
M-NC PA
PA
PA
M-NC PA
M
PA
IVIG
M-NC PA
M
PA
PA
PA
ABATACEPT
M-NC PA
M
PA
PA
PA
INFLIXIMAB
M-NC PA
M
PA
PA
PA
RITUXIMAB
M-NC PA
M
PA
PA
PA
PALIVIZUMAB
M-NC PA
M
PA
PA
PA
NATALIZUMAB
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM COVERED AT A ZERO COPAY WITH PRESCRIPTION
Y
NA
NA
NA
NA
NA
th

91
PHARMACOLOGIC STEP PROTOCOL

FOR TYPE 2 DIABETES MELLITUS
Initial Therapy
Metformin plus
Lifestyle Intervention (Meal
Planning and Physical)
Activity)
Glycemic
goals not
achieved
Addition of
Oral Agent
OR
Consider insulin if:
Very Symptomatic
Severe
Hyperglycemia
Ketoacidosis
Possible Type 1
Pregnancy
Elevated A1c
Rapid
Short
Intermediate
Long
Acting
Acting
Acting
Acting
lispro
regular
NPH
glargine
aspart
70/30
detemir
glulisine
(See the American Diabetes Association Position Statements,
Insulin Administration, and Continuous Subcutaneous
Insulin Infusion, for further discussion on this subject.)
Addition
of
Insulin
Glycemic
goals not
achieved
Addition of
Third Agent **
Glycemic
goals not
achieved
Intensify
Insulin
Therapy
Insulin Options
Basal insulin once or twice daily
Basal insulin + 1 (mealtime) rapidacting injection
Intermediate twice daily
Basal insulin + 2 (mealtime) rapidacting injections
Continuous insulin infusion pump
- Add on therapy is indicated if glycemic goals are not reached/maintained after 36 months treatment
- Insulin therapy is eventually required due to progressive nature of T2DM
- Glycemic goals: A1C < 7%, or individualize to a goal < 8% based on complex
patient factors.
- More stringent goals (i.e. <6.5%) for patients if results can be achieved without
risk of hypoglycemia
- Check A1C every 3 months as therapy is changing or if goal is not met; once
goal is met, may check every 6 months
- Preprandial Plasma Glucose goal of 70-130 mg/dL
- Peak Postprandial Plasma Glucose goal of <180
** Initiation of insulin therapy is preferred over the use of three oral agents
FORMULARY ANTIDIABETIC AGENTS

Sulfonylureas
Biguanides
Insulin
Amaryl* (glimepiride)
Diabinese* (chlorpropamide)
Glucotrol*/Glucotrol XL* (glipizide)
Glynase* (glyburide)
Micronase* (glyburide)
Orinase* (tolbutamide)
Tolinase* (tolazamide)
Glucophage* (metformin)
Glucophage XR*, Fortamet* (metformin ER)
Humulin
Humalog (lispro)
Lantus (insulin glargine)
Levemir (insulin detemir)
Alpha-Glucosidase Inhibitors
Precose* (acarbose)
GLP-1 Receptor Agonists
Byetta (exenatide)
Bydureon (exenatide once-weekly)
Victoza (liraglutide)
Thiazolidinediones
Avandia (rosiglitazone)
Actos (pioglitazone)*
Combination Products
Actoplus MET (pioglitazone/metformin)*

#
Avandamet (rosiglitazone/metformin)
#
Avandaryl (rosiglitazone/glimepiride)
Duetact (pioglitazone/glimepiride)*
Glucovance* (glyburide/metformin)
Metaglip* (glipizide/metformin)
Misc
Symlin (pramlintide)
Welchol (colesevelam)
Starlix* (nateglinide)
*available in generic
#
The FDA limits the use of rosiglitazone-containing products through a restricted distribution Risk Evaluation and Mitigation
Strategy (REMS) program effective 11/2011.
References:
Diabetes Care ,vol 35, supplement 1, January 2012
Diabetes Care, June 2012. vol. 35, no. 6. 1364-1379 (Position Statement)
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults. Institute for Clinical Systems Improvement, July 2010
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013;36:S11-66.
Revised date: 7/2013
92
HYPERTENSION STEP PROTOCOL

PHARMACOLOGIC THERAPY
LIFESTYLE MODIFICATIONS
Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for CKD; <140/80 mmHg for diabetes)
INITIAL DRUG CHOICES
Without Compelling Indications
Stage 1
Hypertension
With Compelling Indications
Stage 2
Hypertension
(SBP =140-159 or DBP =90-99 mmHg)

Thiazide-type diuretics for most. May
consider ACEI, ARB, BB, CCB, or
combination.
(SBP > 160 or DBP > 100mmHg)

Two-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB).
Drug(s) for the compelling

indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB,
CCB, or combination.
NOT AT GOAL BLOOD PRESSURE

Optimize dosages or add additional drugs until goal blood pressure is
achieved. Consider consultation with hypertension specialist.
Compelling indications for individual drug classes
RECOMMENDED DRUGS
Compelling Indication*
Diuretic
BB
ACEI
ARB
Heart Failure
x
x
x
x
Postmyocardial infarction
x
x
High coronary disease risk
x
x
x
Diabetes
x
x
x
x
Chronic kidney disease
x
x
Recurrent stroke prevention
x
x
CCB
ALDO ANT
x
x
x
x
* Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling
indication is managed in parallel with the BP.
Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; Aldo ANT, aldosterone antagonist; BB,
beta-blocker; CCB, calcium channel blocker.
Formulary Drugs
Diuretics
Beta-Blockers
ACE Inhibitors
ARBs
Calcium Channel
Blockers
Direct Renin Inhibitor
Aldactone*,
Bumex*,
Demadex*, Dyazide*,
Hydro-Diuril*,
Hygroton*
Inspra*, Lasix*,
Lozol*,Maxide*,
Zaroxolyn*
Blocadren*, Bystolic,
Coreg*, Corgard*,
Inderal*, Inderal LA*,
Kerlone*,
Lopressor*,
Normodyne*,
Sectral*, Tenormin*,
Toprol XL*,
Trandate*,
Visken*, Zebeta*,
Accupril*,
Aceon*, Altace*
Capoten*,
Lotensin*,
Mavik*
Monopril*,
Univasc*
Vasotec*,
Zestril*
Benicar (HCT)
Cozaar*/Hyzaar*
Diovan (HCT)*
Avapro*
Avalide*
Atacand HCT*
Adalat CC*
Cardene*
DynaCirc*
Nimotop*
Norvasc*
Plendil*
Procardia XL*
Sular*
Cardizem (CD)*
Cartia XT*
Calan SR*
Isoptin SR*
Tekturna (HCT)
Combination Agents
Azor
(amlodipine/olmesartan)
Exforge
(Diovan/Norvasc)
Lotrel*
(Lotensin/Norvasc)
* Generic available
Adapted from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII), May 2003**
Drugs for Hypertension. Treatment Guidelines from the Medical Letter, Vol. 10, Issue 113, January 2012
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013;36:S11-66
***JNC 8 currently in progress. Watch for current updates.

Review Date: 7/2013
93
Pharmacologic Step Protocol for Heart Failure (HF)

Pharmacologic Therapy
Based on symptoms or ACC/AHA and NYHA classification
Stage A
At high risk for HF but
without structural heart
disease or symptoms
of HF
Class I
Stage B
Structural heart disease but
without signs or symptoms
of HF
Patients with:
- Previous MI
- LV remodeling
including LVH and
low ejection fraction
- Asymptomatic
valvular disease
Patients with:
- Hypertension
- Atherosclerotic disease
- Diabetes mellitus
- Obesity
- Metabolic syndrome
- Family history of
cardiomyopathy
- Exposure of cardiotoxins
Patients with:
- Known structural
heart disease
- Shortness of breath,
fatigue, and reduced
exercise tolerance
Class IV
Stage D
Refractory HF requiring
specialized
interventions
Patients who have

marked symptoms at
rest despite maximal
medical therapy
Goals
- All goals under Stages A and B
- Dietary salt restriction
Goals
All goals under Stage A
Goals
- Control hypertension
- Encourage smoking cessation
- Control lipid disorders
- Encourage regular exercise
- Discourage alcohol, illicit drugs
- Control metabolic syndrome
- Control blood sugar
- Treat thyroid disorders
Class II & III

Stage C
Structural heart disease with
prior or current symptoms of
HF
Drugs
- ACEI or ARB^
- Beta-Blockers
Devices in Selected
Patients
- Implantable
Defibrillators
Drugs
- ACEI or ARB^
Goals
Appropriate measures under
Stages A, B, and C
Drugs
- Diuretics for fluid retention
- Use ACEI or ARB^
- Use Beta-Blockers
Drugs in select patients
- Aldosterone antagonist
- ARB
- Digitalis #
- Hydralazine/Nitrates
Options
- End-of-life care
options/hospice
Devices in Selected Patients

-Biventricular Pacing
-Implantable Defibrillators
- Extraordinary measures
* Heart transplant
* Chronic inotropes
* Permanent mechanical
support
* Experimental surgery
or drugs
Patients at stage B or higher whose condition is worsening should be referred to a specialist

^Consider an Angiotensin II Receptor Blocker (e.g., Benicar, Cozaar*, Diovan) for patients who are contraindicated or intolerant to an ACE Inhibitor.
* Generic available
# Digoxin has a narrow therapeutic range and the toxicity is affected by individual hydration/electrolytes status. Frequent renal function and digoxin
monitoring is highly recommended. The use of digoxin at a 0.25 mg dose or higher should be avoided in the elderly and in patients with renal insufficiency.
FORMULARY AGENTS
Cardiovascular Medications Indicated for Treatment of Various Stages of HF
ACE Inhibitors
Stage B
Stage C
Capoten* (captopril)
Post MI
HF
Vasotec* (enalapril)
Asymptomatic LVSD HF
Monopril* (fosinopril)
HF
Zestril* (lisinopril)
Post MI
HF
Accupril* (quinapril)
HF
Altace* (ramipril)
Post MI
Post MI
Mavik* (trandolapril)
Post MI
Post MI
ARBs
Cozaar* (losartan potassium)
Benicar (olmesartan)
Diovan (valsartan)
Post MI
Post MI, HF
Avapro* (irbesartan)
Beta Blockers Recommended for HF
Coreg* (carvedilol)
Toprol XL* (metoprolol)
Zebeta* (bisoprolol)
Aldosterone Antagonists for HF
Aldactone* (spironolactone)
Inspra* (eplerenone)
Common Diuretics for HF
Lasix* (furosemide)
Bumex* (bumatanide)
Zaroxolyn* (metolazone)
Microzide* (hydrochlorothiazide)
Aldactone* (spironoloactone)
References:
2009 Focused Update American College of Cardiology/American Heart Association Guideline Update for the Diagnosis and
Management of Chronic Heart Failure in Adults. Circulation 2009;119;1977-2016.
Review Date: 7/2013
94
PHARMACOLOGIC STEP PROTOCOL

FOR MIGRAINE
Make or confirm migraine diagnosis (Consider co-morbid conditions and treat, e.g., HTN)
Key migraine signs/symptoms:
Symptoms not usually associated with migraine:
Chronic, episodic headache

Duration of 4 to 72 hours
Pulsatile/throbbing pain
Unilateral or bilateral location
Aggravated by light and/or sound
Nausea and/or vomiting
Onset age 12-44 years
First headache >50 years

Abnormal headache pattern
Worst ever experience
Abrupt onset
Pain progressively worsens over time
Abnormal medical evaluation
Abnormal neurological exam
Assess frequency, severity, and disability

Assess management needs and set individual goals; define action plan
Self-care techniques (Non-pharmacologic management)
Initiate pharmacologic management for
abortive treatment based on STEP CARE for
4
MIDAS Questionnaire grade I (score 0-5)
NSAIDs (First Line):

(e.g., ibuprofen, naproxen, ketorolac,
diclofenac)
Simple Analgesics:
(e.g., aspirin, Excedrin)
Initiate pharmacologic management for abortive

treatment based on STRATIFIED CARE for MIDAS
4
Questionnaire grades II-IV (score 6-21+)
Mild Intensity, Low Disability
(MIDAS Scale Grade II)
NSAIDs (First Line):
(e.g., ibuprofen, naproxen, ketorolac,
diclofenac)
Simple Analgesics:
(e.g., aspirin, Excedrin,)
No relief 2 hours later

2
Anti-migraine (triptan therapy)
Stronger analgesics may be used if antimigraine therapy is contraindicated
Moderate to Severe
Intensity/Disability (MIDAS
Scale Grade III & IV) or
Non-Responsive to NSAIDs
Anti-migraine (triptan)
2
therapy
Stronger analgesics may be
used if anti-migraine therapy
is contraindicated
Considerations:
I. Ergotamine products may be used in patients that respond poorly to NSAIDs and triptans
(note: CYP3A4 inhibitor interaction possible).
II. Avoid the long-term prescribing of opiates and barbiturates.
3
Initiate pharmacologic management for prophylactic treatment (low dose, titrate slow)
Beta-Blocker (e.g., propranolol 40-240 mg/day or Timolol 5-30 mg/day)

Calcium Channel Blocker (e.g., verapamil 120 mg/day) - modest effect
Antidepressant (e.g., TCA, amitriptyline 10-150 mg/day, Doxepin 25-100mg QHS and Nortriptyline 10-150mg QHS)
Anti-epileptic agent (Depakote 500-1250 mg/day or Depacon 500-1250 mg/day, Gabapentin 900-2400mg/day [titrate from 300mg],
Topamax 50-200mg/day [titrate slowly from 15-25mg])
Principles of Treatment
1. Self-care techniques include avoidance of any aggravating factors associated with migraine (e.g., stress, environmental, dietary).
2. HPM formulary anti-migraine agents include: Amerge, Imitrex, and Relpax. Quantities greater than 9 tablets of anti-migraine agents per month require prior
authorization. Non-formulary triptans (Axert, Frova, , Zomig/ZMT, Treximet) require Prior Authorization.
3. Prophylactic treatment is used to reduce the frequency and severity of attacks. Consider using prophylactic treatment when patient has two or more severe migraines
per month with the attacks producing disability for three or more days per month, use of abortive medication more than twice a week, failure of or contraindication to
acute treatments, or presence of uncommon migraine conditions (eg. Prolonged aura, migrainous infarction, hemiplegic migraine).
4. The MIDAS Questionnaire assesses the impact a patients migraine has on their work and social life to aid in their treatment plan. It is available at:
http://www.achenet.org/tools/migraine/index.asp
References:
AAFP/ACP-ASIM release guidelines on the management and prevention of migraines. Am Fam Physician, Mar 2003
Stratified Care vs. Step Care Strategies for Migraine, JAMA Nov 2000
Saper JR, Magee KR. Freedom From Headaches. First Fireside Edition. New York: Simon & Schuster, Inc; 1981
Comparison of Available Triptans, Pharmaceutical Letter/Prescribers Letter, 2009; 25(5); 250509
Diagnosis and Treatment of Headache. Institute for Clinical System Improvement. January 2011.
NOTE: Behavioral health medications are carved out to the State for HealthPlus Partners Medicaid and to CMH for MIChild.
Reviewed: 7/2013
95
HYPERLIPIDEMIA
PHARMACOLOGIC TREATMENT RECOMMENDATIONS
Risk Category
No CHD with 0-1 risk factors
No CHD with > 2 risk factors
With CHD or CHD risk equivalents
Formulary Agents
Generic Mevacor*
(lovastatin)
Generic Pravachol*
(pravastatin)
Generic Zocor*
(simvastatin)
Crestor**
(rosuvastatin)
Generic Lipitor*
(atorvastatin)
+
Zetia (ezetimibe)
Vytorin
(ezetimibe/simvastatin)
Liptruzet
(ezetimibe/atorvastatin)
Simcor
(ER niacin + simvastatin)
*
+
DOSE
LDL Level at Which to Consider

Drug Therapy
>190 mg/dL
drug optional if 160-189 mg/dL
>160 mg/dL
(> 130mg/dL if 10 year risk 10-20%)
>130 mg/dL
(drug optional if 100-129 mg/dL)
LDL
1.
10 mg
20 mg
40 mg
10 mg
20 mg
40 mg
80 mg
5 mg
10 mg
20 mg
40 mg
80 mg#
5 mg
10 mg
20 mg
40 mg
10 mg
20 mg
40 mg
80 mg
10 mg
10/10
10/20
10/40
10/80#
10/10
10/20
10/40
10/80
500/20
750/20
1000/20
21%
24%
30%
22%
32%
34%
37%
26%
30%
38%
28- 41%
36- 47%
28- 45%
45- 52%
31- 55%
43- 63%
27- 39%
30-43%
50%
41- 60%
20%
46%
52%
56%
60%
53%
54%
56%
61%
--11.9%
Generic available
Prior authorization is required for Zetia monotherapy or
dose >10 mg/d
2.
3.
4.
5.
Treatment LDL Goal

<160 mg/dL
<130 mg/dL
<100 mg/dL
More stringent recommendation
<70 mg/dL
Treatment Recommendations
Therapeutic lifestyle changes remain an essential
modality in clinical management (i.e., cholesterollowering diet).
If pharmacologic therapy is indicated, consider
HMG CoA reductase inhibitors, niacin, bile acid
sequestrants, and fenofibrates when appropriate.
When prescribing an HMG CoA reductase inhibitor,
consider the percent reduction required, the potency
of the medication, and appropriate dosing for the
medication.
Non-HDL (VLDL + LDL-C) goal: if TG200 mg/dL
then non-HDL-C goal is [LCL-C goal + 30mg/dL]
Diabetics statin regardless of LDL if overt CVD or
age>40 with 1+ CVD risk factors; goal of therapy is
LDL <100
Other Formulary Antihyperlipidemics

Nicotinic Acid:
Niaspan (niacin ER)
Bile Acid Sequestrants:
Colestid* (colestipol)
Questran* (cholestyramine)
Prevalite* (cholestyramine/aspartame)
Fibric Acid Derivatives:
Lofibra* (fenofibrate)
Fibricor* (fenofibric acid)
FDA Simvasatin Safety Guidelines
-Contraindicted in combination with - itraconazole, ketoconazole,
posaconazole, erythromycin, clarithromycin, telithromycin, HIV
protease inhibitors, nefazodone, gemfibrozil, danazol
-Do not exceed 10 mg simvastatin verapamil, diltiazem
-Do not exceed 20 mg simvastatin amiodarone, amlodipine,
ranolazine
# Do not start any new patient on simvastatin 80 mg due to an
increased risk of muscle damage
** Branded Statin therapy requires:

1. The patient must have documented failure or Rx claim(s) for generic Zocor, OR
2. The patient is currently receiving a medication that
potentiates simvastatin levels (i.e., itraconazole, ketoconazole, HIV protease inhibitors, erythromycin, gemfibrozil,
cyclosporine, amiodarone, verapamil, diltiazem, amlodipine, ranolazine).
References:
1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults, September 2001.
2. US Drug Product Labeling.
3. Implications of recent clinical trials for the National Cholesterol Education Program ATP III Guidelines. J Am Coll
Cardiol, Aug 2004
4. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013;36:S11-66
5. FDA Drug Safety Communication. http://www.fda.gov/Drugs/DrugSafety/ucm256581.htm#sa
Revised date 7/2013
96
CHRONIC PAIN MANAGEMENT

PHARMACOLOGIC THERAPY
INITIAL ASSESSMENT OF PAIN
1)
2)
3)
4)
5)
6)
7)
8)
9)
Determine causes of pain: (Malignant vs. Non-malignant)

Differentiate type of pain: Structural (MRI) vs. Functional (EMG)
Screen for alcohol use (AUDIT tool).
Screen for depression (PHQ-2, PHQ-9).
Screen for addiction/abuse risk (DAST, DIRE)
Urine Drug Screen and blood work (e.g., CBC, ESR, LFT, BUN/SCr)
Evaluate history of pain and results of previous treatments. Evaluate fatigue for malignant pain.
Evaluate the effect of co-existing illness related to pain.
Psycho-social evaluations (e.g., impact of life, family or work, potential addiction)
If decision is made to start chronic opioid therapy (for pain greater than 3 months
duration), a written contractual agreement between patient and physician is
recommended.
FIRST STEP:
NON-OPIOIDS:
1) NSAIDs
2) Acetaminophen
3) Tramadol
+ ADJUNCTS^
Note:
NSAIDs may cause GI
bleeding/pain/ulcer
Tramadol may be
preferred for neurological
pain
SECOND STEP:
THIRD STEP:
OPIOIDS:
1) Codeine with
acetaminophen/aspirin
OPIOIDS:
1) Long-acting opioids (e.g.,
Morphine SR, Kadian, fentanyl,
extended release oxycodone,
methadone)
2) Hydrocodone or
oxycodone with
acetaminophen/aspirin
2) Short-acting opioids for

breakthrough pain (as needed)
+ NON-OPIOIDS
+ NON-OPIOIDS
+ ADJUNCTS
+ ADJUNCTS^
Note:
Potential risk for
acetaminophen toxicity or
opioid addiction
Short-acting opioids
require frequent dosing
Note:
There are no dosage limits for
opioids and opioids should be
titrated to response
Adjuncts should be utilized to
minimize opioid dosage increases
Monitor potential addiction
^ADJUNCTS (see Table 7):

1) Consider diet, exercise (especially for weight bearing joints),
heat/cold applications, smoking cessation or physical therapy if needed.
2) Antidepressants (i.e., SNRI) or anticonvulsants (i.e., Neurontin, Lyrica) may be helpful for neurological type of pain.
3) Short-term muscle relaxants may be used for spasm-related pain; long-term use for pain management is NOT
recommended.
A written contractual agreement may include the following discussion:
Goals of therapy (pain relief, physical improvement or social functioning)

The requirement for a single provider or treatment team
A prohibition on use of alcohol, other sedating or illegal medications without discussing with providers
(e.g., urine drug screening and alcohol testing)
The limitation on dose, quantities or refills of prescribed medications (e.g., pill counts, no early refills).
Against changing dosage or quantities without permission
Prohibition of selling, sharing, lending or giving prescribed medications to others
Agree to keep medication safe and secure and understand the potential side effects and dependence
The option of sharing information with family members and other providers if necessary
Compliance with all components of overall treatment plan and need for periodic reevaluation
Consequences of non-adherence
Reference: 1. Assessment and Management of Chronic Pain. Institute for Clinical Systems Improvement. November 2011
2. Opioid Treatment Guidelines. The Journal of Pain. Vol 10, No 2. February 2009
3. WHO Pain Relief Ladder
Revised date: 7/2013
97
TABLE 1. Comparison of Non-opioid Analgesics

Chemical
Class
Drug Name
HalfLife
(hr)
2-4h
Recommended
Starting Dose
Aspirin
Diflunisal
(Dolobid)
Choline
magnesium
trisalicylate
(Trilisate)
Ibuprofen
(Motrin, Advil)
Naproxen
(Naprosyn)
Naproxen
sodium
(Anaprox)
Oxaprozin
(Daypro)
Ketoprofen
(Orudis)
Flurbiprofen
(Ansaid)
Indomethacin
(Indocin)
Diclofenac
(Voltaren)
Etodolac
(Lodine)
Ketorolac
(Toradol)
3-12h
8-12h
650mg q4-6h
500mg q12h
4000mg
1500mg
Consider a maximum of 2-3

gm/day for chronic use to avoid
the risk of liver toxicity. Lack of
anti-inflammatory effects
Risk of GI bleed
Less GI toxicity than aspirin
8-12h
1000mg q12h
4000mg
Less GI toxicity than aspirin
3-4h
400mg q6-8h
3200mg
13h
250mg q12h
1000mg
275mg q12h
1100mg
4250h
2-3h
1200mg q24h
1800mg
200mg q6h
ER-Extended Release
IR-Immediate Release
5-6h
50mg q8-12h
200mg ER
300mg IR
300mg
4-5h
25mg q8-12h
200mg
High risk of GI toxicity. CNS

side effects. Avoid in elderly.
2h
25mg q6-8h
200mg
7h
200mg q6-8h
1200mg
Less risk of GI toxicity
4-7h
10mg q6h
40mg
Sulindac
(Clinoril)
14h
150mg q12h
400mg
High risk of GI toxicity. FDA

recommends not to exceed 5
days therapy
Possibly less renal toxicity than
other NSAIDs. Metabolized via
liver. Good choice for patients
also on beta-blocker.
Piroxicam
(Feldene)
Meloxicam
(Mobic)
Nabumetone
(Relafen)
Meclofenamate
(Meclomen)
Celecoxib
(Celebrex)
45h
20mg q24h
20mg
20h
7.5mg q24h
15mg
2035h
2-4h
1000mg q24h
2000mg
50mg q4-6h
400mg
9-10h
200mg q24h
400mg
Acetaminophen
Salicylates
Propionic
Acid
Acetic Acid
Oxicams
Naphthylalkanone
Fenamate
Cox-2
Inhibitors
325-650mg q46h
Maximum
Recommended
Dose (mg/day)
4000mg
3,4
Note:
Less risk of GI toxicity (lowdose).
No more effective than other

NSAIDs.
Prior Authorization required.
Acetaminophen is considered as a first-line for treating osteoarthritis pain in elderly.

The initial dose should be reduced to 30-50% of recommended starting dose in elderly or patients with
renal dysfunction.
All nonsteroidal anti-inflammatory drugs (NSAIDs) including Cox-2 inhibitors include a boxed warning of
increased risk of cardiovascular events and serious, potential life-threatening gastrointestinal bleeding
associated with their use.
When switching to different NSAIDs due to efficacy or side effects, consider selecting one from different
chemical class.
Consider PPI (i.e., generic Prilosec RX 20mg) for patients with risk of GI bleed requiring long-term NSAID
therapy.
98
TABLE 2. Comparison of Oral Opioid Analgesics3,4,5,6,7

Plasma
Oral
Equianalgesic Half-Life
(hr)
Dose (mg)
Short-Acting Opioids (For breakthrough pain)
Codeine
200mg
3h
(alone or in
combination with
APAP or ASA)
Usual
Starting Dose
Usual Dosing
Frequency
(hr)
Notes
30mg
4 6h
Fentanyl
(Actiq)
Oral lozenge
Hydrocodone
200mcg
Limited dosing due to potential

acetaminophen toxicity with which it is
often combined. (see Table 6)
Not recommended for long-term use.
Analgesia does not increase with doses
>200 mg (ceiling dose).
Must be metabolized to active metabolite
(morphine). Little-no response may be
present in poor metabolizers of 2D6
Difficult to predict the daily maintenance
dose. Handle and dispose of in a manner
that is child-safe.
Opioid Agonist
NA
(see Table 3)
30mg
2 4h
5 10mg
15 minutes
and may
repeat
4 6h
8mg
2 3h
2mg
4 6h
300mg
3 4h
50mg
3 4h
Poor oral absorption, short half-life, longlasting active neurotoxic metabolite

NOT recommended for chronic pain.
Active metabolite. May accumulate in
patients with renal impairment.
Active metabolite, oxymorphone.
Efficacy decreased in patients taking
CYP 2D6 inhibitors.*
Slower initiation and titration improves
tolerability. Efficacy decreased in patients
taking CYP 2D6 inhibitors.* Risk of seizure
may be increased in patients taking SSRI,
MAO, TCA.
(alone or in combination
with APAP or ASA)
Hydromorphone
(Dilaudid)
Meperidine
(12 16h
normeperidine)
Morphine
30mg
2 3.5h
10 30mg
4h
Oxycodone (alone or
in combination with
APAP or ASA)
Tramadol
(Ultram)
20mg
2 3h
5mg
6h
150mg
6 7h
50mg
4-6h
25mcg patch =
45-134mg/24h
PO morphine
4mg acute
1mg chronic
20mg acute
3mg chronic
17h
25 mcg
72h
Consider in patients who cannot tolerate

oral long-acting morphine or methadone.
12 16h
2mg
6 8h
15 30h
2.5mg
6 8h
Morphine
Oramorph SR
MS Contin
Kadian
30mg
2 3.5h
15 30mg
Oxycodone
(Oxycontin)
20mg
2 3h
10mg
12h
(Oramorph)
(MS Contin)
24h
(Kadian)
12h
Risk of accumulation. Requires careful

titration.
Risk of accumulation. Requires careful
titration. Good choice for opioid rotation.
QTc interval prolongation, hypotension &
cardiac dysrhythmias can occur.
Recommend consult with pain specialist for
prescribing. Baseline ECG prior to
initiation of methadone, repeated after 30
days and then annually.
GOLD standard therapy
Due to prolonged absorption of the drug,
the dosage should not be adjusted more
frequently than every 48 hours. Adjust
dosage in renal impairment.
Consider in patients who cannot tolerate
oral long-acting morphine or methadone.
Conversion to the active metabolite,
oxymorphone. Efficacy decreased in
patients taking CYP 2D6 inhibitors.*
Long-Acting Opioids
Fentanyl
(Duragesic)
topical patch
Levorphanol
Methadone
* Examples of CYP 2D6 inhibitors: SSRIs, ketoconazole, cimetidine, amiodarone, Haldol, Benadryl.
99
Starting dose should be determined at 50%-75% of calculated dose from equianalgesic

conversion.
If pain is constant or recurring, consider dosing around-the-clock. Most patients with malignant pain
require fixed-schedule dosing to manage the constant pain and prevent the pain from worsening.
Determine the total 24-hour dose of the current opioid. Using the estimated equianalgesic dose, calculate
the equivalent dose of the new opioid. The starting conversion dose of the new opioid should be 50%75% of the equianalgesic dose to prevent overshooting the analgesic needs.
As needed breakthrough or rescue doses (non-opioid medications analgesics or short-acting opioids) are
helpful in titration to the optimal dose. When using short-acting for breakthrough, give opioid doses
equivalent to approximately 10% of the daily opioid dose as needed.
While treating breakthrough pain with short-acting opioids, consider using the same ingredient as the longacting opioid. Then, the total daily dose of the short-acting opioids can be calculated into the appropriate
dose for the long-acting opioids.
Dose adjustment may need to be considered in elderly or patients with renal or liver impairment.
There is no maximum dose for most opioids. Titrate the current therapy to patients response or tolerance
before switching to a different agent.
The accurate assessment of opiate allergy is necessary to distinguish a true allergy from a side effect.
These opioids are NOT recommended for chronic pain: Meperidine (Demerol, poor oral absorption, short
half-life, and neurotoxic metabolite), opioid agonist/antagonist (pentazocine, nalbuphine).
Management of Side Effects of Opioids:
- Nausea/ vomiting: Reglan 10 mg q6-8h or Compazine 10 mg q6-8h or Phenergan 25 mg q8h

- Constipation: Diet and/or Colace 200 mg BID or Senokot 2 tablets BID (may increase to 4 tablets BID)
or Dulcolax suppositories, 1 prn daily
- Pruritis: hydroxyzine 25 - 100 mg q6-8h
- Anxiety: hydroxyzine 25 - 100 mg q6-8h or Phenergan 25 50 mg q8h
- Sedation, CNS side effects: Prevention and recognition of the risks (e.g., elderly, post-surgery, impaired
renal function, combination with other sedatives)
- Opiate overdose (i.e., respiratory depression): Reverse opioids with naloxone 0.4-2 mg SC/IV/IM q2-3
minutes; if no response after 10 minutes, diagnosis should be questioned.
A sudden stop or reduction in a dose of opioid after prolonged use may result in withdrawal symptoms
(e.g., sweating, restlessness, anxiety, stomach or leg cramps, unable to sleep, increased heart rate or
blood pressure, hot or cold flashes). Death may occur. Without treatment, most symptoms may disappear
in 5 to 14 days; some symptoms (e.g., insomnia, irritability, and muscle aches) may last 2 to 6 months.
After 72 hours of withdrawal, it is unlikely that withdrawal symptoms will worsen.
100
TABLE 3. Quick Conversion Table
6,8
Fentanyl Transdermal Dosing Conversion

Convert FROM oral Morphine
TO Fentanyl Transdermal Patch
Oral Daily
Fentanyl
Morphine (mg/d) (mcg/h) Q 72 hr
45 134
25
135 224
50
225 314
75
315 404
100
405 494
125
495 584
150
TABLE 4. Suggested Maximum Daily Opioid Doses for Primary Care Clinicians
Opioid
Morphine
Methadone
Oxycodone
Fentanyl (transdermal)
Oxymorphone
13
Dose
200 mg/day
40 mg/day
120 mg/day
100mcg/hour
30mg/day
*Higher doses require close, careful documentation and may prompt consultation with a pain specialist.
TABLE 5. Equianalgesic Dosing of Opioids for Pain Management

Refer to Table 6 for detailed doses of hydrocodone or oxycodone in acetaminophen containing products
Hydrocodone
Total daily dose
30 mg
90 mg
120 mg
Hydrocodone
Products
Example
Vicodin 5/300 6 tabs /
day
Endocet 10/325 6 tabs /
day
Norco 10/325
12 tabs / day
Oxycodone
Total daily dose
Morphine
Equivalent dose per DAY
20 mg
30 mg
60 mg
90 mg
80 mg
120 mg
101
TABLE 6. Dosing Guideline for Acetaminophen Containing Analgesics

Brand Name
Acetaminophen
(Tylenol) mg/tab
Other Ingredient(s)
Max QTY/day (Based on safety

Max QTY/day
recommendation of 4gm/day with (3gm/day with
short-term use: 1-3 mo)
long-term use)
12
9
Anexsia
325 mg
hydrocodone 5 mg
Anexsia
325 mg
hydrocodone 7.5 mg
12
Endocet 5-325
325 mg
oxycodone 5 mg
12
Endocet 10-325
325 mg
oxycodone 10 mg
12
Endocet 7.5-325
325 mg
oxycodone 7.5 mg
12
Fioricet w/ codeine
325 mg
12
Norco
325 mg
butalbital/caffeine/ codeine
30 mg
hydrocodone 5 mg
12
Norco
325mg
hydrocodone 7.5 mg
12
Norco
325 mg
hydrocodone 10 mg
12
Percocet
325 mg
oxycodone 5 or 10mg
12
Percocet 2.5-325
325 mg
oxycodone 2.5 mg
12
Roxicet
325 mg
oxycodone 5 mg
12
Tylenol #2
300 mg
codeine 15 mg
13
10
Tylenol #3
300 mg
codeine 30 mg
13
10
Tylenol #4
300 mg
codeine 60 mg
13
10
Ultracet
325 mg
tramadol 37.5 mg
VIcodin
300 mg
hydrocodone 5 mg
12
*8
9
*8
Vicodin ES
300 mg
hydrocodone 7.5 mg
*6
*6
Vicodin HP
300 mg
hydrocodone 10 mg
*6
*6
*This quantity is based on manufacturer daily dosing recommendations.
102
TABLE 7. Example of Adjuvant Analgesics
Class
Antidepressants
Drug
Amitriptyline(Elavil)
Doxepin (Sinequan)
Imipramine (Tofranil)
Venlafaxine (Effexor XR)
Duloxetine (Cymbalta)
Initial Dose
10 25 mg PO qHS
25 mg PO qHS
50 75 mg PO qHS
37.5 150 mg PO QD
60 mg QD
Anticonvulsants
Carbamazepine
(Tegretol)
Gabapentin (Neurontin)
Clonazepam (Klonopin)
Pregabalin (Lyrica)
Lorazepam (Ativan)
100 mg PO BID TID
Dexamethasone
Baclofen
Methylphenidate (Ritalin)
4 mg PO TID-QID
5 mg PO TID
5 mg PO QAM
Pamidronate (Aredia)
60-90 mg IV infusion
monthly
Others
100 mg PO TID
0.25 mg PO BID
75 mg BID
1 mg PO BID
Note
Useful for neuropathic pain, or
pain complicated by
depression or insomnia. SSRI
or SNRI may also be helpful.
Black Box Warning: SNRIs
increase suicidal behavior in
young adults
Monitor serum level, liver
function, CBC for Tegretol.
Comprehensive (including est.
GFR) for all.
Anxiety. Increased sedation.
Potential addiction.
Advanced, malignant pain.
Lacerating neuropathic pain.
Reserve use, opioid-induced
daily sedation in intolerant pt.
Malignant, bone pain
Long-term use of opioids in patients with chronic, non-malignant pain is controversial. Patients treated for
prolonged periods with opiate drugs for non-malignant pain fail to demonstrate the need for escalating doses in
order to achieve pain relief. Therefore, monitoring for dependence or addiction is important.
2,3
Behaviors that Require Attention:

Requesting specific drugs
Requesting appointment(s) at the end
of day
Aggressive complaining about needing
more of the drug
Obtaining similar drugs from different
prescribers
Missing appointment(s) or not following
other components of the treatment
plan (e.g., physical therapy or
exercise)
Resistance to a change in therapy
(expression of anxiety)
Increasing dosage or using the drug to
treat another symptom without
consulting physicians on more than
one occasion
2,3
Predictors of Opioid Misuse:

History of illegal behavior (e.g., selling, forgery,
or stealing)
Dangerous behavior (e.g., motor vehicle
accidents, alcohol intoxication, or
aggressive/threatening/violent behaviors)
Obtaining opioids from multiple prescribers
(including emergency room) or filling
prescriptions at different pharmacy locations
Multiple episodes of prescription loss
Concurrent abuse of alcohol or illegal drugs
Unexpected results from urine drug screen
Evidence of sudden deterioration in the ability to
function at work or socially, which appears to be
related to drug use
Repeated requests for dose increases, early
refills, or resistance to change in therapy
You may obtain a complete list of controlled substances filled for a patient in Michigan by requesting a
Patient Controlled Substance Prescription report from the Michigan Automated Prescription System
(MAPS). (Request Form for MAPS report is attached). Information is available at
http://www.michigan.gov/mdch/0,1607,7-132-27417_27648---,00.html
If opioid misuse or dependence is identified and the patient no longer needs opioids, treatment options include:
9
clonidine, naltrexone, methadone, or buprenorphine/naloxone (Suboxone). (Table 8)
103
Table 8. Example of Detoxification Schedule for Opioid Dependency: 10

Buprenorphine/Naloxone (Suboxone) dose (mg), sublingual tablet
Day Number
10-day schedule
7-day schedule
3-day schedule
1
8
8
4+8 (stat and 24h)
2
6
6
8 (48h)
3
4
4
8 (72h)
4
4
4
5
4
2
6
2
2
7
2
0
8
2
9
2
10
0
*Doses may be adjusted to titrate off opioid in longer period of time.
To locate the physician(s) authorized to prescribe buprenorphine, go to
http://buprenorphine.samhsa.gov/bwns_locator/index.html
*Sublingual tablets available as generic; sublingual film available as brand only
104
Table 9. Pharmaceutical Interventions for Neuropathic Pain13
Drug
Formulary
Status
Dosage
Side effects, Contraindications &

Comments
ANTICONVULSANTS
Gabapentin*
(Neurontin)
Formulary
100 to 300 mg at bedtime;

increase by 100-300 mg every 3
days up to 1,800 to 3,600 mg per
day taken in divided doses three
times daily. Higher doses might
be used.
Initial drug of choice. Side effects: drowsiness,

dizziness, fatigue, nausea, sedation, edema, weight
gain. No significant drug-drug interactions. Reduce
dose/increase interval in renal failure (give 10x
1
creatinine clearance per day).
Pregabalin*
(Lyrica)
Formulary
50 mg 75 mg twice daily-three
times daily to start. Up to 200 mg
three times daily.
Lamotrigine
(Lamictal)
Formulary
25 mg per day; increase by 25

mg-50 mg every 1-2 weeks up to
400 mg per day.
Oxcarbazepine
(Trileptal)
Formulary
Start 150 mg - 300 mg twice

daily. Increase by 600 mg per
day each week to max 1200 mg
twice daily.
Initial drug of choice. Side effects: drowsiness,

dizziness, fatigue, nausea, sedation, edema, weight
gain. No drug-drug interactions. Reduce dose/increase
interval in renal failure (give 5x creatinine clearance per
1
day). Schedule V medication.
Side effects: Stevens-Johnson syndrome, rare lifethreatening rash unlikely with gradual dose titration.
Dizziness, drowsiness, headache, nausea,
1
blurred/double vision.
Initial drug of choice for trigeminal neuralgia. Similar
adverse effects to carbamazepine but less likely. Fewer
1
drug-drug interactions.
Carbamazepine*
(Tegretol)
Formulary
200 mg-400 mg twice daily.

Increase to max 600 mg twice
daily.
Topiramate
(Topamax)
Formulary
25 mg twice daily to start;

increase by 25-50 mg per week
up to 200-400 mg per day.
Duloxetine *
(Cymbalta)
Formulary, PA
required
Initial drug of choice. Side effects: nausea, dry mouth,

2
constipation, dizziness, insomnia.
Venlafaxine
(Effexor)
Formulary
20 to 60 mg per day taken once

or twice daily in divided doses
(for depression); 60 mg twice
daily for fibromyalgia.
37.5 mg per day; increase by
37.5 mg per week up to 300 mg
per day.
Formulary
10 to 25 mg at bedtime; increase
by 10 to 25 mg per week up to 75
to 100 mg at bedtime or a
therapeutic drug level.
Initial drug of choice. Tertiary amines have greater

anticholinergic side effects and may cause arrhythmia,
orthostatic hypotension; therefore, these agents should
2
not be used in elderly patients.
Formulary
25 mg in the morning or at
bedtime; increase by 25 mg per
week up to 100 mg per day or a
therapeutic drug level.
Secondary amines have fewer anticholinergic side

effects, but should still be used cautiously in elderly
2
patients.
Non-formulary
PA Required
Up to 3 patches to intact skin 12

hrs per day (12 hrs on/12 hrs off)
Indicated for postherpetic neuralgia. Commonly used for

other neuropathic conditions. May be used daily or as
needed.
Over-theCounter
0.025% or 0.075% apply to intact

skin 3-4 times per day
Burning irritation of skin, eyes, airway. Requires regular

application for four to six weeks to achieve effect; then
maintenance.
Initial drug of choice for trigeminal neuralgia. Watch

for hyponatremia, leucopenia, allergic rash (StevensJohnson syndrome). Other side effects: dizziness,
drowsiness, blurred/double vision, ataxia. Not favored
for other neuropathic pain. Available in extended
1,3
release.
Most evidence is for migraine prevention, other
neuropathic pains may respond. Side effects:
drowsiness, abnormal thinking, weight loss, urinary tract
1
stones, increased intraocular pressure.
ANTIDEPRESSANTS
(SNRIs)
Tricyclics**
Amitriptyline (Elavil),
Desipramine
(Norpramin)
Nortriptyline (Pamelor)
TOPICAL MEDICATIONS
Lidocaine 5% Patch*
(Lidoderm)
Capsaicin
(Capzasin-HP,
Capzasin-P, DiabetAid
Pain and Tingling Relief,
SalonpasHot, Zostrix)
Side effects: headache, nausea, sweating, sedation,

hypertension, seizures. Serotonergic properties in
dosages below 150 mg per day; mixed serotonergic and
noradrenergic properties in dosages above 150 mg per
2
day. Available in extended-release formulation.
105
Drug
Formulary
Status
AS-NEEDED MEDS
Tramadol (Ultram);
(Ultram ER)
Formulary
Ultracet
Formulary
Oxycodone
w/ Acetaminophen
(Endocet)
w/Ibuprofen
(Combunox)
with Aspirin
(Percodan)
Formulary
Dosage
Side effects, Contraindications, and

Comments
50-100 mg 4 times daily as

needed. Max 400 mg per day
Side effects: abdominal discomfort, dizziness,

constipation, seizures. May interact with other
serotonergic drugs to cause serotonin syndrome. Abuse
potential despite unscheduled status
5 mg-10 mg (oxycodone) every 4

hours as needed.
Maximum daily doses:
- Acetaminophen & Aspirin
4000mg
- Ibuprofen 3200mg
Schedule II medication. Side effects: constipation,

drowsiness, confusion, nausea, itching, dependence,
abstinence syndrome upon abrupt withdrawal at doses >
20 mg per day.
*Approved by the U.S. Food and Drug Administration for treatment of neuropathic pain
**Not recommended in patients > 65 years of age
1 FDA alert: Increased risk of suicidal behavior or ideation.
2 Black box warning: Increased suicidal behavior in young adults
3 Two black box warnings on carbamazepine: Aplastic anemia and agranulocytosis have been reported in association with the use of
carbamazepine. The genetic testing is recommended prior to initiation of therapy in most patients of Asian ancestry for the presence
of the HLA-B*1502 allele genetic marker to decrease the risk of developing Stevens-Johnson syndrome (SJS) and/or toxic epidermal
necrolysis (TEN). Drugs labeled initial drug of choice based on a combination of evidence for efficacy from randomized controlled
trials and safety profile. It does not imply superiority.
References:
1. World Health Organization. Cancer Pain Relief 1996
2. http://www.oqp.med.va.gov/cpg/cpg.htm
3. http://www.guideline.gov/summary/summary.aspx?doc_id=4218&nbr=3226&string=opioid+and+%22pain+management%22
4. http://cancertrials.nci.nih.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/page3/print
5. Pain Relief Connection Vol 1 #6, June 18, 2002. Pain Topics and Pain Relief Connections are services of MGH Cares About
Pain Relief
http://www.massgeneral.org/painrelief/mghpain_equichart.htm
http://www.guideline.gov/summary/summary.aspx?doc_id=3365&nbr=2591&string=opioid+and+%22pain+management%22
http://www.vapbm.org/archive/methadonedosing.pdf#search='methadone%20dose%20conversion
NEJM. 2002 Sept. (347): 817-823
Drug and Alcohol Dependence 2003 (70): S59-77
http://www.rsdfoundation.org/en/en_opoid_treatment_protocol.html
Refer to HealthPlus Clinical Practice Guideline for additional information on diagnosis and management of acute low back
pain, substance abuse disorders, major depression, smoking cessation and pharmacologic step protocol for migraine
treatment.
13. Assessment and Management of Chronic Pain. 5th Ed. Institute for Clinical Systems Improvement. pp. 106-107. November
2011
6.
7.
8.
9.
10.
11.
12.
106
TABLE 10. Narcotic Prescribing Assessment Tools

click on the tool name to access the form
Evaluation
Type
Tool Name
Chronic Pain
Evaluation
Description
A sample pain evaluation form for chart documentation.
(HPM Sample)
PDI
Wong-Baker Faces
Helpful for assessing persons with moderate to severe dementia who have lost
much of their ability to use language to describe pain.
DAST-10
Drug Abuse Screening Test

A yes/no self-report for identifying patients with existing drug abuse or
addiction problems.
DIRE
Diagnosis, Intractability, Risk, Efficacy

This is a clinician-rated, 7-item scale to screen for the appropriateness of
long-term opioid therapy in patients with chronic noncancer pain, taking into
account the likelihood of drug abuse, misuse, addiction, or drug diversion.
Pain
Assessment
SISAP
5-Point
AUDIT
Alcohol Use
The Pain Disability Index

Measures the impact that pain has on the ability of a person to participate in
essential life activities. This can be used to evaluate patients initially, to monitor
them over time, and to judge the effectiveness of interventions.
Screening Instrument for Substance Abuse Potential

Five questions to address concerns about alcohol, marijuana, and cigarette
use in order to stratify patients with chronic non-cancer pain according to
potential risks of developing problematic behaviors during opioid therapy.
Prescription Opiate Abuse Checklist
A brief checklist is based on DSM-III-R parameters to gauge a patients level
of adherence to a current opioid analgesia regimen.
Alcohol Use Disorders Identification Test
The AUDIT questionnaire was developed by the World Health Organization
(WHO) as a simple method of screening for excessive drinking as the cause of
the presenting illness.
CAGE
A 4-question self-test to help patients become aware of alcohol abuse. This test
specifically focuses on alcohol use, and not on the use of other drugs.
TWEAK Test
An alcohol screening tool to be used for pregnant women
107
PHQ-2
Depression
Screening
PHQ-9
Patient Health Questionnaire

This 2-question tool is used as the initial screening test for major depressive
episode.
Patient Health Questionnaire

A nine item depression scale for assisting in diagnosing depression as well as
selecting and monitoring treatment.
MDQ
Mood Disorder Questionnaire

This tool assists in the accurate diagnosis of bipolar disorder.
Zung
Zung Self-Rating Depression Scale

A short self-administered survey to quantify the depressed status of a patient.
108
APPENDIX A
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY
Completed forms will be reviewed by the Pharmacy & Therapeutics Committee. The need for
the drug, alternative therapy available, efficacy, safety and cost-effectiveness will be considered.
It is essential that this form be completed for proper evaluation.
1. Generic Names: ___________________________________________________________
2. Brand Name & Manufacturer: _________________________________________________
3. Dosage Form(s) & Strength(s): ________________________________________________
4. Specific pharmacologic action and indications for use:
_________________________________________________________________________
_________________________________________________________________________
5. Comparable drugs currently on the Formulary: ____________________________________
_________________________________________________________________________
6. If the requested drug is used, which of the drugs above may be deleted from the Formulary?
_________________________________________________________________________
7. List the therapeutic advantages of the requested drugs over those already listed on the
Formulary. Supply references to support these advantages:
_________________________________________________________________________
_________________________________________________________________________
8. Estimate the anticipated cost impact if the requested drug is added to the Formulary:
_________________________________________________________________________
________________________________
DATE
___________________________________
PRINT NAME
_________________________________________________________________________
SIGNATURE
Send to: HealthPlus
ATTN: Pharmacy Department
2050 S Linden Road; PO Box 1700
Flint, MI 48501-1700
FAX: 810-720-2757
E-MAIL: rx@healthplus.org
109
APPENDIX B
HEALTHPLUS PARTNERS (MEDICAID) OVER-THE-COUNTER (OTC) MEDICATIONS
Michigan Medicaid regulations include a requirement for coverage of selected over-the-counter
(OTC) medications as part of the prescription benefit. OTC products covered by Michigan
Medicaid are covered for members in the HealthPlus Partners program only, with a written
prescription. If the OTC product is available as a generic, the generic product is covered. A
summary list (alphabetic by brand name) of covered OTC products is included below:
Allegra (fexofenadine)
Allegra-D (fexofenadine/pseudoephedrine)
Artificial Tears solution
Aspirin tablets (regular, buffered and enteric-coated), suppositories
Bacitracin ointment
Benadryl (diphenhydramine) capsules, elixir
Calcium carbonate tablets, suspension
Chlor-Trimeton (chlorpheniramine) tablets, syrup
Claritin (loratadine) tablets, reditabs, syrup
Claritin-D (loratadine/pseudoephedrine)
Colace (docusate sodium) capsules, liquid
Condoms, latex
Dulcolax (bisacodyl) tablets, suppositories
Ferrous gluconate
Ferrous sulfate tablets, solution
Gyne-Lotrimin (vaginal cream, suppositories)
Hydrocortisone cream, ointment
Imodium caplet
Imodium AD (loperamide) liquid
Maalox (aluminum/magnesium hydrox) suspension
Metamucil (psyllium) powder
Monistat-7 (miconazole) vaginal cream, suppositories
Motrin (ibuprofen) tablets, suspension, chewables
Neosporin (bacitracin/neomycin/polymixin) ointment
Nicotine patch, inhaler, nasal spray, gum/lozenges
Nix (permethrin cream rinse)
Pepto-Bismol caplet, chewable, suspension
Peri-Colace (docusate sodium w/ casanthranol) capsules
Prevacid 24 Hour (lansoprazole) capsules
Tavist (clemastine) tablets, syrup
Tylenol (acetaminophen) tablets, drops, elixir, suppositories
Zaditor (ketotifen)
Zyrtec (cetirizine) tablets, chewable, liquid gels, solution
Note: This is a summary list and does not include all covered OTC products.
110
STATUS
APPENDIX C
PHARMACY PRIOR AUTHORIZATION FORM

Forward form to the HealthPlus Pharmacy Department via facsimile:
Flint facsimile: 810-720-2757
For questions or to request via telephone:
Flint local phone: 810-720-2758
Toll free phone: 877-710-0993
FOR A TIMELY RESPONSE, PLEASE PROVIDE COMPLETE INFORMATION.
HealthPlus ID#:
Date of Birth:
Patient Name:
Height:
This is a request for (check one):
Weight:
DAW
MedicarePlus Advantage Part D:

Signature PPO Closed Formulary:
BMI:
Medication Requiring P/A
Exception Request
P/A for Dosage Regimen
Medically Urgent
Exception Request
Prescribed Drug and Dosing Regimen:

Reason for Use (Diagnosis):
Previous Medications:
Please attach pertinent laboratory test(s) or procedure(s): (if applicable)
Reason why an alternative drug (or dosing regimen) cannot be used:
DEA#:
Office Phone: (_____)
Pharmacy Name (optional):
HealthPlus Provider ID#:

Office Facsimile: (_____)
Pharmacy Phone:
Infusions/Injections (if applicable)

Place of Infusion/injection: ________________________
Provider ID: ____________________________________
Lab Results (if applicable)

CrCL: _________________
TG: ____________________
I represent to the best of my knowledge and belief that the information provided is true, complete, and
fully disclosed. A person may be committing insurance fraud if false or deceptive information with the
intent to defraud is provided.
Physicians Name (please print) ____________________ Physicians Signature
Office Contact Person:
Request Date:
For HealthPlus Use Only

LOB:
Non-Urgent Request:
Urgent Request:
CPhT Review Time
RPh Review Time
Med Dir Review Time
Comments:
Approved
Partial Approval
Denied
Approved by:
Reason for Denial:
Effective Date:
Faxed to Indigent Program:
If you would like to discuss this case with a physician reviewer, please call (800) 332-9161.
**THIS DOCUMENT MAY BE PHOTOCOPIED, or you may request additional copies by calling the HealthPlus
Pharmacy Department at the telephone number(s) listed above.
Rev June 2013
111
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD

DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
COMMERCIAL/MEDICARE (NON PART-D)/PPO/TPA PRIOR AUTHORIZATION CRITERIA
DRUG/CATEGORY
QTY
LIMIT
ADD Medications
Vyvanse
(lisdexamfetamine dimesylate)
Strattera (atomoxetine)
CRITERIA
1. The patient must have a chart documented trial or Rx claims
for generic Adderall or Adderall XR in the past 120 days.
Focalin XR
(dexmethylphenidate)
1. The patient must have documented failure based on chart

documentation or Rx claims with the generic form of both
Ritalin AND Adderall.
1. The patient must have chart documented trial or Rx claims for
a generic methylphenidate in the past 120 days.
Daytrana
(methylphenidate patch)
Quillivant XR (methylphenidate
suspension)
1. The patient is at least six years of age and has a documented

diagnosis of ADD/ADHD; AND
2. The patient must have a chart documented trial or Rx claims
for a generic methylphenidate in the past 120 days; OR
For Daytrana only:
If the patient has a chart documented inability to swallow, a trial
of oral methylphenidate is not required.
documentation or Rx claims with the generic form of Ritalin
and Adderall.
Intuniv (guanfacine)
Allergy Medications
Clarinex (desloratadine)
Clarinex-D
(desloratadine/pseudoephedrine)
Limited to
a qty of 30
units per
month
1. The patient must have documented failure or Rx claims for
generic OTC Claritin D or OTC generic Claritin in combination
with OTC generic pseudoephedrine in the past year.
NOTE: For Clarinex-D, prior authorization is only required for
patients over 12 years of age. Generic Claritin and Claritin-D
OTC products are covered with a prescription; OTC
pseudoephedrine is not a covered benefit.
All Brand Nasal Steroids

Beconase AQ
(beclomethasone dipropionate)
Nasonex
(mometasone furoate)
Omnaris (ciclesonide)
Qnasl (beclomethasone
dipropionate)
Rhinocort Aqua (budesonide)
Veramyst (fluticasone furoate)
Zetonna (ciclesonide)
All Brand Nasal Steroids,
Dymista (azelastine/fluticasone
propionate)

two generic nasal steroids (i.e., Flonase, flunisolide) in the
past year.

a generic nasal steroid (i.e., Flonase, flunisolide, Nasacort
AQ) in the past year.
112
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
For MIChild/MIChild CSHCS, all behavioral health medications and services, except for ADHD, are carved out to CMH.

APPENDIX D
DRUG/CATEGORY
Analgesics
On Formulary with PA:
Actiq (fentanyl citrate oral
transmucosal)
Non-Formulary with PA:
Abstral (fentanyl sl)
Fentora
(fentanyl citrate buccal tablet)
Lazanda (fentanyl nasal spray)
Onsolis (fentanyl soluble film)
Subsys (fentanyl sublingual
spray)
Opana ER (Crush Resistant)
(oxymorphone)
Oxymorphone ER (Non-Crush
Resistant) (oxymorphone)
QTY
LIMIT
1. The patient has a documented current diagnosis of cancer.

2. The patient is already receiving and is tolerant to opioid
therapy for underlying persistent cancer pain.
NOTE: System will automatically approve if written by an
oncologist (or if there are prescription claims for chemotherapyrelated medications) and the patient is receiving opioid pain
medications.
Abstral, Lazanda and Subsys New Starts Only
Qty is
limited to
60 units
per 30
days
1. The patient has a documented current diagnosis of active

cancer.
oncologist or if there are previous claims for chemotherapyrelated medications.
For indications other than cancer:
1. The patient must have documented failure or prescription
claims for at least two formulary alternatives within the last 3
months (including generic MS Contin and short-acting
narcotic analgesic) OR
2. Based on chart documentation, all formulary alternatives are
inappropriate.
oncologist or if there are prescription claims for chemotherapyrelated medications.
New Starts Only
Qty is
limited to
30 units
per 30
days
1. The patient has a documented current diagnosis of active

cancer.
2. System will automatically approve if written by an oncologist
or if there are previous claims for chemotherapy-related
medications.
1. The patient must have documented failure or Rx claims with
generic Ultram in the past 60 days, or
2. The patient must have documented inability to swallow or
absorb oral medications.
Butrans (buprenorphine patch)
Avinza (morphine sulfate,

sustained release)
Rybix ODT (tramadol)
All acetaminophen-containing
narcotic analgesics
CRITERIA
DOSE OPTIMIZATION ONLY

NOTE: System edits apply for prescription claims with a
monthly quantity that exceeds the MAX recommended dose
of 4gm/day of acetaminophen. Physician must submit signed
request stating he/she is allowing the patient to exceed the
MAX recommended dose of acetaminophen.
113

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Analgesics, continued
Oxycontin (oxycodone)
Exalgo (extended release

hydromorphone)
Vicodin 5/300
(hydrocodone/acetaminophen)
Vicodin ES 7.5/300
Vicodin HP 10/300
All Non-Formulary Angiotensin

II Receptor BlockersMicardis
(telmisartan)
Micardis HCT (telmisartan)
Teveten HCT
(eprosartan mesylate)
Twynsta
(telmisartan/amlodipine)
Edarbi (azilsartan medoxomil)
Edarbyclor (azilsartan
medoxomil/chlorthalidone)
Qty is
limited to
30 units
per 30
days
Vicodin
5/300 limit
8 tabs/day
VIcodin
ES
7.5/300 &
Vicodin
HP 10/300
limit 6
tabs/day
All ARBs
except
Cozaar
(not
combos)
are limited
to a qty of
30 units
per month
Qty is
limited to
30 units
per 30
days
CRITERIA
NOTE: System edits apply for prescription claims submitted for
more than twice daily dosing. Criteria for quantities that exceed
70 per month:
OxyContin twice daily therapy plus short-acting pain
medications for breakthrough, OR
2. The patient has received an oncology or HIV-related
pharmacy claims during the past 365 days, OR
3. The patient has received a prescription claim from an
oncologist or infectious disease physician in the past 365
days (system-automated so care will not be interrupted),
OR
4. Documented blood plasma levels indicate the drug is not
lasting 12 hours, OR
5. For all other medical necessities, physician will be referred to
the HealthPlus Pain Management Guideline for
recommendation of alternatives.
Requires prior authorization for indications other than cancer.
System will automatically approve if written by an oncologist or if
there are previous claims for chemotherapy-related medications.
generic Dilaudid (hydromorphone) and generic Duragesic
(fentanyl).
1. Physician must provide chart documentation that shows that a
product with 325mg acetaminophen (i.e. generic Norco) is
contraindicated in this patient but that a product with 300mg
acetaminophen is not contraindicated
Note: Acetaminophen is not recommended for patients with liver
disease.

all formulary ARBs or ARB combination products (i.e.,
Benicar/HCT, or Diovan/HCT).
NOTE: If patient is a first time ARB user, patient should have
documented failure or Rx claims for at least one generically
available ACE inhibitor previous to ARB therapy.
1. The patient must have documented failure or Rx claim(s) for

at least one formulary ARB or ARB combination product (i.e.,
generic Cozaar/Hyzaar, Benicar/HCT or Diovan/HCT).
114

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
CRITERIA
Antibiotics
Oracea
(doxycycline monohydrate)
1. The patient must have documented failure or Rx claim for

generic Vibramycin.
Dificid (fidaxomicin)
1. Patient has documented diagnosis of C. difficile associated

diarrhea, AND
2. Patient has tried and failed an adequate trial of vancomycin,
OR
3. Patient has a contraindication or intolerance to vancomycin,
OR
4. Patient has been recently discharged from a hospital or a
medical facility and has had documented treatment with
Dificid or vancomycin.
New Starts Only
Moxatag ER
(amoxicillin trihydrate)
1. The patient must have documented failure or Rx claim for a

generic amoxicillin product in the past 14 days.
Minocin PAC (minocycline kit)
1. The patient must have documented failure or Rx claims for a

generic tetracycline AND minocycline in the past 60 days.
Factive
(gemifloxacin mesylate)

formulary fluoroquinolone (e.g., generic Cipro, Levaquin or
Avelox) in the past 60 days.
NOTE: Individual requests are reviewed to include
consideration of the diagnosis, culture and sensitivity, and other
documentation.
Tobi Solution/Podhaler
1. The patient must have a diagnosis of Cystic Fibrosis; AND

2. The drug is given for 28 days followed by 28 days off, in
repeat cycles.
Anticoagulant
Brilinta (ticagrelor)
Qty is
limited to
60 units
per 30
days
1. The patient has a documented diagnosis of acute coronary

syndrome (unstable angina, non-STEMI, or STEMI), AND
2. Patient is receiving a total daily dose of aspirin 100mg/day,
AND
claims with generic Plavix, OR
4. The patient is not an appropriate candidate for generic Plavix
based on documentation provided (i.e., patient is identified
as CYP2C19 poor metabolizer, or on concomitant medication
that reduce the antiplatelet activity of Plavix).
Eliquis (apixaban)
Qty is
limited to
60 units
per 30
days
1. The patient must have a diagnosis of non-valvular atrial

fibrillation; AND
2. The patient must have a recent (within the last month)
CrCl>15ml/min.
Approval of prior authorization requests is limited to 12 months.
115

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Anticoagulant, continued
Pradaxa 150mg (dabigatran)
Xarelto (rivaroxaban)
Antidepressants
Luvox CR
(fluvoxamine ext. release)
Pexeva (paroxetine mesylate)
Viibryd (vilazodone)
Prozac Weekly (fluoxetine)
Qty for
10mg is
limited to
35 units
Limited to
a qty of
30 units
per month
Aplenzin (bupropion hbr)

fibrillation; AND
CrCl>30ml/min; AND
3. The patient must not be concurrently receiving a medication
that is contraindicated with Pradaxa; AND
4. If the patient has a recent CrCl 30-50ml/min and is
concurrently receiving a P-gp inhibitor such as Multaq or
Ketoconazole, documentation of a review by a cardiologist
recommending use must be provided.
New Starts Only
NOTE: Prior authorization requests are approved for 12- month
duration.
1. For the 10mg dose, quantity is limited to 35 units per episode
of DVT prophylaxis; OR
2. The patient has a FDA approved diagnosis (e.g., non-valvular
atrial fibrillation, DVT, or PE);AND
3. The patient has a recent CrCl (within the last month); AND
4. Dosing is adjusted for the patients recent CrCl.
For DVT or PE, the patient has a recent CrCl 30ml/min;
For atrial fibrillation, 15mg dose, the patient must have a CrCl
15ml/min.
50ml/min.
New Starts Only
Prior authorizarion requests are approved for a 12-month
duration.
1. The patient must have documented failure with dose titration
and Rx claims for at least two generic SSRI medications (i.e.,
Prozac, Celexa, Paxil and Zoloft).
1. The patient has a diagnosis of depression, AND

2. The patient has been treated with fluoxetine 20mg daily for at
least 13 weeks, based on Rx claims, and has responded to
treatment with symptom control.
generic Prozac.

Sarafem (fluoxetine)
Effexor XR
(venlafaxine, ext. release)
Lexapro (escitalopram oxalate)
Pristiq
(desvenlafaxine succinate)
Oleptro ER (trazodone
hydrochloride extended release)
CRITERIA
Limited to
a qty of
30 units
per month

more than once daily dosing.

generic Desyrel (trazodone).
claims at an equivalent dosage of bupropion HCl extendedrelease (24hr) in the past year.
116

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
CRITERIA
Antidepressants, continued
Wellbutrin XL
(bupropion, ext. release)

1. For Wellbutrin XL 150mg tablets are limited to Once Daily
2. Dosing. Wellbutrin XL 300mg requires the physician to
prescribe a 300mg tablet (not 2 of the 150mg tablets) once
daily to optimize the dose.
3. Dosages greater than 450mg per day will require the
physician to submit medical necessity for that dosing
regimen.
Antiemetic
Zuplenz (ondansetron)
1. The patient must try and fail an adequate course of therapy

with generic Zofran ODT.
Antineoplastic
Jakafi (ruxolitinib)
1. Patient must have a diagnosis of myelofibrosis with a risk

category of intermediate (2 prognostic factors) or high (3 or
more prognostic factors) based on the International Working
Group Consensus Criteria (IWG). Prognostic factors include:
1. Age >65 years old
9
2. WBC > 25 X 10 /L
3. Hgb < 10g/dl
4. Peripheral blasts 1% or higher
5. Constitutional symptoms (e.g., fatigue, weakness,
shortness of breath, weight loss, night sweats, or bone
pain), AND
2. Prescription must be prescribed by an Oncologist or
Hematologist, AND
3. Patient must have documented palpable splenomegaly
5cm below costal margin, AND
4. Patient must have a recent (with in the last month) creatinine
clearance >15 ml/min, AND
5. Patient must have a recent (with in the last month) CBC with
9
platelet count >50 X 10 /L.
6. Duration of approval is for 12 months.
7. For purposes of re-authorization, there is documentation
supporting reduction of spleen size or symptom
improvement.
New Sarts Only
NOTES:
A. System edits apply for prescription claims submitted for more
than twice daily dosing.
B. Jakafi is considered a specialty drug and will be included in

the Mandatory Specialty Program.
claims for at least two formulary atypical antipsychotic
alternatives (e.g., geq Risperdal, geq Clozaril, geq Geodon or
geq Seroquel).
New Starts Only
Antipsychotics, Atypical
Latuda (lurasidone)
Abilify (aripiprazole)
Zyprexa/Zydis (olanzapine)
Limited to
a qty of
30 units
per month

117

APPENDIX D
DRUG/CATEGORY
Asthma/COPD
Combivent Respimat (albuterol/
ipratropium)
QTY
LIMIT
Limited to
6 doses
per day
Proventil HFA (albuterol)

ProAir HFA (albuterol)
Xopenex/HFA (levalbuterol)
Limited to
a qty of
30 units
per month
Coreg CR (carvedilol phosphate

controlled release)
Cardizem LA
(diltiazem, long-acting)

Advicor (lovastatin/niacin)
Altoprev (lovastatinSR)
Lescol XL (fluvastatin)
Livalo (pitavastatin calcium)
Liptruzet
Lovaza
(omega-3-acid ethyl esters)
Vascepa (icosapent ethyl)

1. The patient must have documented failure on immediate
release carvedilol of equivalent dose and attempted at least
one dose increase (6.25mg/day IR = 10mg/day ER when
converting).
release isradipine of equivalent dose and attempted at least
one dose increase AND
2. The patient must have documented failure/contraindication to
three generically available dihydropyridine CCB agents (e.g.,
nisoldipine, nifedipine, amlodipine, nicardipine, felodipine) in
the past year.
Calcium Channel Blockers

Dynacirc CR
(isradipine controlled release)
Cholesterol Medications
Crestor (rosuvastatin)

more than 6 doses a day.
1. Patient has a documented contraindication to the preferred
formulary albuterol inhaler (i.e. Ventolin HFA)
1. The patient must have documented intolerant side effects to
albuterol (e.g., palpitations, tremors and tachycardia).
1. The patient must have a diagnosis of asthma; AND
2. The patient must be 12 years of age or older; AND
3. The patient must have chart documented failure or
prescription claims for generic Singulair or Accolate.
Zyflo/CR (zileuton)
Beta Blockers
Bystolic (nebivolol)
CRITERIA
1. The patient must have documented failure or Rx claims for at

least two generically available formulary alternatives (e.g.,
Cardizem CD, Cardizem SR and Dilacor XR).
All HMGs
are
limited to
a qty of
30 units
per month

generic Zocor, OR
2. The patient is currently receiving a medication that
potentiates simvastatin levels (i.e., itraconazole,
ketoconazole, HIV protease inhibitors, erythromycin,
gemfibrozil, cyclosporine, amiodarone, verapamil, diltiazem,
amlodipine, ranolazine).
Limited to
a qty of
30 units
per month
1. DOSE OPTIMIZATION ONLY

NOTE: System edits apply for prescription claims submitted
for more than once daily dosing.
1. The patient's triglyceride (TG) levels are >500mg/dL (with
chart documentation provided) OR
2. The patient must have documented failure or Rx claims in the
past six months for at least two or more lipid-lowering agents,
with at least one being a generic product (e.g., statins,
fenofibrate, nicotinic acid).
118

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Cholesterol Medications,
continued
Fenoglide (fenofibrate)
Lipofen (fenofibrate)
Triglide (fenofibrate)
Zetia (ezetimibe)
CRITERIA
formulary fenofibrate (i.e., generic Lofibra) in the past year
with at least one documented dosage increase.
AUTHORIZATION IS ONLY REQUIRED FOR THE FOLLOWING:
1. If the patient has not had an Rx claim for an HMG statin

medication in the previous year. Criteria for authorization for
monotherapy include a documented contraindication for both
hydrophilic (Pravachol, Lescol) and lipophilic (Zocor, Lipitor)
statins, elevated liver enzymes, etc.
2. A dose >10mg per day requires documentation to support
safety and efficacy.
Contraceptives
All Brand Contraceptives
Beyaz
LoEstrin 24 Fe 1/20
Natazia
Ovcon-50
Safyral
NuvaRing
Ortho Evra
Ortho Tri-Cyclen Lo
Cough and Cold
Vituz
1. The patient must have a documented trial or Rx claims for at

least two generically available oral contraceptives in the past
year before any brand product will be covered.
Dermatologicals
Altabax (retapamulin)
1. The patient must have a documented treatment failure with

generic Bactroban ointment for each instance of impetigo
AND
2. A diagnosis of impetigo.
Bactroban Nasal Ointment

(mupirocin)
Lidoderm (lidocaine)
Vusion
(miconazole nitrate/zinc oxide)
Zyclara (imiquimod)
NOTE: Injectable generic Depo-Provera is an alternative if

compliance is a potential issue.
1. The patient must have documented failure or Rx claims for 2

generically available cough suppressants in the past month.
10 grams
(10, 1gm)
tubes per
month
1. The patient must have a chart documented nasal colonization

with methicillin-resistant S. aureus (MRSA); AND
2. The patient must have Rx claims for generic mupirocin
ointment in the past 7 days.
Criteria for more than 10 grams per month
1. The patient must have chart documented nasal recolonization
of MRSA.
1. The patient must have a diagnosis of post-herpetic neuralgia
(document previous diagnosis or titer).
1. The patient must be an infant greater than 4 weeks old with a
diagnosis of candidal diaper dermatitis or candidal infection.
1. The patient must have a diagnosis of actinic keratosis and
documented treatment failure or Rx claims for geq Aldara;
OR
2. The patient must have a diagnosis of condyloma acuminate
and documented treatment failure or Rx claims for geq
Condylox or geq Aldara.
New Starts Only
119

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
CRITERIA
Dermatologicals, continued
All Branded Topical Antifungal
Agents
Ciclodan Kit (ciclopirox olamine
cream/cleanser)
CNL Nail Kit (ciclopirox/lacquer
removal pads)
Ertaczo
(sertaconazole nitrate)
Exelderm (sulconazole nitrate)
Ketodan Kit (ketoconazole
foam/cleanser)
Lamisil Soln
(terbinafine soln)
Mentax (butenafine)
Naftin (naftifine)
Oxistat (oxiconazole nitrate)
Pediaderm AF
(nystatin/emollient)
Terbinex
(terbinafine/hydroxychitosan)
Tersi (selenium sulfide)
Xolegel/Corepak
(ketoconazole)
All Branded Topical
Clindamycin Products
Clindagel 1% Gel (clindamycin)
1. The patient must have documented failure and Rx claims for

four generic antifungals (e.g., Loprox, Nizoral, Spectazole
and Grifulvin V).
All Brand Benzoyl Peroxide

Acanya 1.2%-2.5%
(clindamycin/benzoyl peroxide)
Benzamycin Pak 3%-5% Gel
(erythromycin base/benzoyl
peroxide)
Duac (clindamycin/benzoyl
peroxide)
All Brand Topical Adapalene
and Dapsone Products
Aczone 5% Gel (dapsone)
Differin 0.1% Lotion (adapalene)
Differin 0.3% Gel (adapalene)
Epiduo 0.1%-2.5% Gel
(adapalene/benzoyl peroxide)
All Tretinoin Products
1. Patient must have documented failure or Rx claim(s) for a

generic combination product in the past 90 days (i.e., GEQ
Benzaclin, GEQ Benzamycin.
1. Patient must have documented failure or Rx claim(s) for

topical generic clindamycin product in the past 90 days (e.g.,
GEQ Cleocin T).

a generic tretinoin (e.g., Avita, Retin-A).
Age Restriction: Patients > 25 years of age must have a

documented diagnosis of acne.
120

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
All Brand Tretinoin Products
Atralin (tretinoin)
Retin A Micro 0.04% (tretinoin)
Tretin-X (tretinoin)
Veltin (tretinoin/clindamycin)
Ziana (tretinoin/clindamycin)
All Brand Topical Steroids
Clobex Spray (clobetasol
propionate)
Synalar TS
(fluocinolone/cleanser)
Ultravate PAC Kit (halobetasol
propionate/ammonium lactate)
Vanos Cream (fluocinonide)
Kenalog Aerosol Spray
(triamcinolone acetonide)
Pandel Cream (hydrocortisone
probutate)
Pediaderm TA (triamcinolone)
Topicort Spray
(desoximetasone)
Cloderm Cream (clocortolone
pivalate)
Cordran Lotion (flurandrenolide)
Cordran SP Cream
(flurandrenolide)
Locoid Lotion, Lipocream
(hydrocortisone butyrate)
Desonate Gel (desonide)
Desowen Combo
(desonide/emollient)
Pediaderm HC (hydrocortisone)
Vanoxide-HC Lotion
(hydrocortisone/benzoyl peroxide)
Verdeso Foam (desonide)
Protopic (tacrolimus)
Dovonex (calcipotriene)
Taclonex
(betamethasone/calcipotriene)
Vectical (calcitriol)
CRITERIA
generic tretinoin product (e.g., Retin-A, Avita) in the past 90
days.
NOTE: Age restriction for all topical tretinoin products for age >
25 based on a diagnosis of acne.
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g.,
Temovate, Ultravate, Diprolene) in the past 60 days.

Elocon, Westcort and Synalar) in the past 60 days.

generic topical steroid in the same potency class (e.g., BetaVal Cr, Cutivate Cr, Dermatop Cr) in the past 60 days.

Aclovate, Desowen and Synalar) in the past 60 days.
Safety
limited to
a qty of <
100g per
7 days
Safety
limited to
a qty of <
200g per
7 days

at least two generically available topical steroids AND
pimecrolimus in the past 180 days.
QUANTITY LIMITS ONLY
121

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Diabetes
Glumetza (metformin)
Janumet, XR
(sitagliptin/metformin)
Juvisync (sitagliptin/simvastatin)
Kazano (alogliptin/metformin)
Kombiglyze XR
(saxagliptin/metformin)
Oseni (alogliptin/pioglitazone)
Januvia (sitagliptin)
Nesina (alogliptin benzoate)
Onglyza (saxagliptin)
Tradjenta (linagliptin)
Apidra
Novolin Insulins (insulin)
Novolog Insulins (insulin aspart)
Novolog Mix (insulin)
Glucose Test Strips
Freestyle Lite
Freestyle Insulinx
Precision Xtra
Erectile Dysfunction
On Formulary:
Cialis 10, 20MG (tadalafil)
Viagra (sildenafil)
Non-Formulary:
Caverject, Edex, Muse
(alprostadil)
ED meds are covered when
written by PCP or in-plan
urologist. Males Only. Limit 6
units per 30 days (for all ED drugs
combined).
CRITERIA
past year for generic Glucophage AND generic Glucophage
XR.
1. The patient must have documented failure or Rx claims with a
preferred formulary DPP-4 inhibitor (i.e. Tradjenta,
Jentadueto).
Limited to
a qty of
30 units
per month
Limited to
a qty of
30 units
per month

Jentadueto).
1. Patient has a documented contraindication to a
comparable preferred formulary insulin (i.e. Humulin
and Humalog products),
Limited
qty of 150
units per
30 days
or 450
units per
90 days
All ED
meds are
limited to
a qty of 6
units per
month
PRIOR AUTHORIZATION IS ONLY REQUIRED IN THE

FOLLOWING INSTANCES:
1. If the patient <35, the patient must have a documented
diagnosis of ED OR a history of ED with contributing OR
concomitant disease state.
2. If the patient has a history of nitrate use, and the physician
is prescribing Cialis, Levitra, or Viagra:
Criteria:
a. The physician must submit a written request
stating that the patient is no longer using
nitrates.
**Request must be on physician letterhead with physician's
signature**
122

APPENDIX D
DRUG/CATEGORY
Erectile Dysfunction, continued
Levitra (vardenafil)
Staxyn (vardenafil)
ED meds are covered for males
only. Limit 6 units per 30 days
(for all ED drugs combined).
Genitourinary Medications
Detrol LA
(tolterodine, long-acting)
Ditropan XL
(oxybutynin, sust. release)
Enablex
Myrbetriq (mirabegron)
(darifenacin hydrobromide)
Toviaz (fesoterodine)
Vesicare (solifenacin)
Cialis 2.5, 5MG (tadalafil)
Rapaflo (silodosin)
QTY
LIMIT
All ED
meds are
limited to
a qty of 6
units per
month
Limited to
a qty of
30 units
per month
Limited to
30 tablets
per month
for
indication
of BPH
**No addl
qty of
drugs for
ED
approved
when
receiving
Cialis
daily for
BPH
CRITERIA
both sildenafil (Viagra) AND tadalafil (Cialis) in the past 180
days.
2. If the patient <35, the patient must have a documented
diagnosis of ED OR a history of ED with contributing OR
concomitant disease state. The prescription must be written
by a PCP or in plan urologist (this does not apply to PPO
members).
3. Prior Authorization is also required if patient has a history of
nitrate use.
1. The patient must have a chart documented diagnosis of

benign prostatic hyperplasia (BPH); AND
2. The patient must have documented failure or contraindication
to at least one formulary alternative from either of the
following classes of medication:
a. Alpha-1 Adrenergic Blockers (i.e., alfuzosin, doxazosin,
tamsulosin, or terazosin)
b. 5-Alpha Reductase Inhibitors (i.e., finasteride or
Avodart); AND
3. If the patient has a history of nitrate use
a. The physician must submit a written request on
physician letterhead stating that the patient is no longer
using nitrates; AND
b. The physician must hand-sign the request.

documentation or Rx claims for a generically available
alpha1-blocker indicated for BPH (i.e., generic Cardura, Hytrin
or Flomax).
123

APPENDIX D
DRUG/CATEGORY
HIV Medications
Truvada (emtricitabine/tenofovir
disoproxil fumarate)
QTY
LIMIT
Limited to
a qty of
30 units
per month
CRITERIA
1.
2.
3.
4.
The patient is confirmed to be HIV (+); AND

The patient has been screened for hepatitis B; AND
The patient is receiving another antiviral medication; AND
The patient has a recent (within the last 6 months) CrCl
30ml/min.OR
1. The patient is confirmed to be HIV (-); AND
2. The patient has been screened for hepatitis B; AND
3. If female, the patient is screened for pregnancy; AND
4. The patient has a recent (within the last 6 months) CrCl
60ml/min.
NOTE: When using Truvada in HIV (-) patients, it is
recommended that laboratory screening is provided every 3
months for HIV, Hepatitis B, and pregnancy. It is recommended
that CrCl be checked every 6 months for all patients.
Infertility
All medications for infertility
(subject to the members benefit).
Confirmation of Coverage:
1. The patients benefit includes coverage for infertility, AND
2. There is an appropriate referral, if applicable, AND
3. The service/procedure is a covered benefit.
All Human Chorionic

Gonadotropin Products
Novarel (chorionic
gonadotropin)
Ovidrel (choriogonadotropin
alfa)
Pregnyl (chorionic
gonadotropin)
1. Patient must have documentation of an FDA-approved

indication (i.e., prepubertal cryptorchidism, hypogonadotropic
hypogonadism, or anovulation in females with infertility).
Migraine Medications
Axert (almotriptan)
Frova (frovatriptan)
Treximet
(sumatriptan/naproxen)
Cambia (diclofenac potassium)
Note: All Human Chorionic Gonadotropin products are included

in the Mandatory Specialty Program.
All
triptans
combined
are
limited to
a qty of 9
tablets
per month
1. The patient must have documented failure or Rx claims for all

formulary alternatives (i.e., Amerge, Imitrex, and Relpax), or
formulary alternatives must be inappropriate with chart
documentation provided.
NOTE: Formulary triptans are limited to nine tablets (cumulative
with all oral products)
CRITERIA FOR MORE THAN NINE TABLETS PER MONTH
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than nine tablets per month.
2. Patient has had documented failure of all options for migraine
prophylaxis and still requires more than nine tablets per
month.
1. The patient must have a diagnosis of migraine headaches;
AND
generic diclofenac; AND
least one additional non-steroidal anti-inflammatory drug (i.e.,
ibuprofen, naproxen sodium).
124

APPENDIX D
DRUG/CATEGORY
QTY LIMIT
CRITERIA
Migraine Medications,
continued
Imitrex Injection (sumatriptan
injection)
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
Sumavel (sumatriptan injection)
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
Criteria for more than 6 injections per month

days and still requires more than 6 injections per month, OR
2. Patient has had documented failure or contraindication to all
options for migraine prophylaxis and requires more than 6
injections per month.
claims for generic Imitrex injection.
Imitrex Nasal Spray

(sumatriptan)
Zomig Nasal Spray
(zolmitriptan)
Migranal (dihydroergotamine)
including generics
Muscle Relaxants
Amrix (cyclobenzaprine ext
release)
Miscellaneous
Cardura XL
(doxazosin mesylate ext. release)
All nasal
triptan
products
are limited
to a
quantity of
6 per
month
8 units (ml)
per month

injections per month.
Criteria for more than 6 units per month
days and still requires more than 6 units per month, OR
units per month.
AND
prescription claims for an oral generic triptan medication (i.e.
generic Imitrex, generic Amerge); AND
prescription claims for generic Imitrex nasal spray or injection;
OR
4. The patient has a chart documented contraindication or
intolerance to triptan medications.
days and still requires more 8 units per month.
prophylaxis and still requires more than 8 units per month.
with at least two generic prescription muscle relaxants (i.e.,
Flexeril, Norflex).
1. The patient must have documented failure or Rx claim in the
past year for a generically available alpha 1-adrenergic
antagonist (i.e., Cardura or Hytrin).
125

APPENDIX D
DRUG/CATEGORY
QTY LIMIT
Miscellaneous, continued
Lyrica (pregabalin)
Nuvigil (armodafinil)
Xyrem (sodium oxybate)

Revatio (sildenafil)
Adcirca (tadalafil)
Savella (milnacipran)
Cymbalta (duloxetine)
Quantity
limit of
540mls
every 30
days
CRITERIA
Quantity limits/dose optimization:
1. The 25, 50, 75, 100, 150 and 200mg capsules are limited to
a quantity of 90 per month.
2. The 225 and 300mg capsules are limited to a quantity of 60
per month.
1. The patient has a documented diagnosis of narcolepsy, or
excessive daytime sleepiness associated with obstructive
sleep apnea/hypopnea syndrome (OSAHS) or shift work
sleep disorder (SWSD).
1. The patient is 16 years of age or older AND
2. The patient has documented sleep study results resulting in
a diagnosis of narcolepsy and has one of the following:
a. Episodes of cataplexy demonstrated by chart
documentation, OR
b. Excessive daytime sleepiness with symptoms that limit
the ability to perform normal daily activities demonstrated
by chart documentation and:
i. Provigil or Nuvigil therapy has been ineffective or
contraindicated AND
ii. Methylphenidate, amphetamine salts, or
dextroamphetamine therapy has been ineffective or
contraindicated AND
3. The patient is not being treated with a sedative hypnotic
agent AND
4. The patient does not have a succinic semialdehyde
dehydrogenase deficiency AND
5. The patient does not have a history of substance abuse.
1. The patient must have a documented diagnosis of pulmonary
arterial hypertension.
2. If the patient has a history of nitrate use, the physician must
submit a written request on his/her letterhead stating that the
patient is no longer using nitrates.
1. The patient must have a documented diagnosis of
fibromyalgia, OR
2. Documentation of all of the following:
a. Widespread pain for at least 3 months, AND
b. Pain on both sides of the body, above and below the
waist, AND
c. Abnormal tenderness in at least 11 of the 18
anatomically-defined body sites.
1. Specific to diagnosis of fibromyalgia, the patient must have
documented failure, contraindication to, or prescription
claims for Lyrica.
NOTE: To minimize disruption with use of Cymbalta for a
diagnosis of depression, the claims processing system will
automatically approve the claim if there are prescription
claims for an antidepressant in the last year.
126

APPENDIX D
DRUG/CATEGORY
QTY LIMIT
CRITERIA
Uloric (febuxostat)
Limited to
a qty of 30
units per
month
Neurological Miscellaneous
Horizant (gabapentin enacarbil)
Limited to
a qty of 30
units per
30 days.
1. Patient must have documented failure or prescription claims

with allopurinol, OR
2. The patient cannot tolerate therapeutic doses or is not an
appropriate candidate for allopurinol based on
1. The patient must have a diagnosis of restless legs syndrome,
AND
2. The patient must have documented failure and Rx claims
with generic Neurontin, AND
generic Requip or generic Mirapex.
Gralise (gabapentin)
Nuedexta
(dextromethorphan/quinidine)
NSAIDs
Arthrotec
(diclofenac/misoprostol)
Naprelan CR (naproxen
sodium)
Limited to
a qty of 60
units per
30 days.
All Cox-2
drugs and
Mobic are
limited to a
qty of 30
units per
month

postherpetic neuralgia, AND
2. The patient must have documented failure and Rx claims
with generic Neurontin, AND
a generic tricyclic antidepressant.
pseudobulbar affect; AND
2. The patient must be 18 years or older; AND
3. Patient is not currently receiving quinidine, quinine,
mefloquine, an MAOI, or any drug that prolongs QT interval
and is metabolized by CYP2D6 (e.g., thioridazine or
pimozide); AND
4. Patient must have recent (within the past three months)
platelet count, liver function panel, and ECG if patient has
left ventricular dysfunction/hypertrophy.
Prior authorizarion requests are approved for a 6 month
duration.
1. Documented indication for acute or chronic treatment of the
signs and symptoms of osteoarthritis or rheumatoid arthritis,
AND
an adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
3. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following
risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
4. Active ulcer or recent documented history of ulcer (within
months) on history of GI bleed/perforation.
127

APPENDIX D
DRUG/CATEGORY
QTY LIMIT
CRITERIA
Vimovo
(esomeprazole/naproxen)
1. The patient must have a documented diagnosis of arthritis,

AND
2. The patient must be high risk for developing GI
complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous
ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy
3. The patient must fail all formulary proton pump inhibitor
alternatives (i.e., Omeprazole, Aciphex, generic Prevacid,
generic Protonix) in combination with generic naproxen.
Flector (diclofenac epolamine

transdermal patch)

complications:
a. Age over 60 years old AND any one of the following risks:
NSAIDS OR
3. Active ulcer or recent documented history of ulcer (within 6
months) or history of GI bleed/perforation.
Rayos

rheumatoid arthritis; AND
generically available oral corticosteroids (i.e., prednisone,
methylprednisolone).
piroxicam, ketoprofen, diclofenac, etc.).
Voltaren Gel
(diclofenac sodium)
Zipsor (diclofenac potassium)

piroxicam, ketoprofen, diclofenac, etc.), and one must be
generic Voltaren. Adequate course of therapy is defined as a
full therapeutic dose on a scheduled basis for at least 1-2
weeks.
128

APPENDIX D
DRUG/CATEGORY
QTY LIMIT
Ophthalmic Products
All Brand Topical Ophthalmic
Antihistamines
Patanol (olopatadine)
Alocril (nedocromil sodium)
Alomide
(lodoxamide tromethamide)
Bepreve
(bepotastine besilate)
Emadine
(emedastine difumarate)
Lastacaft (alcaftadine)
Pataday (olopatadine)
Restasis (cyclosporine)
Betimol (timolol)
Istalol (timolol maleate)
Prostaglandin Analogs
Lumigan 0.01%
(bimatoprost)
Lumigan 0.03%
(bimatoprost)
Travatan Z (travoprost)
Zioptan (tafluprost)
Proton Pump Inhibitors
Aciphex (rabeprazole)
Esomeprazole Strontium
(esomeprazole strontium)
Dexilant (dexlansoprazole)
First-Lansoprazole
(lansoprazole)
First-Omeprazole (omeprazole)
Nexium (esomeprazole)
Prevacid Solutab (lansoprazole)
Prilosec DR Susp (omeprazole
magnesium)
Protonix Pak (pantoprazole)
Zegerid Susp
(omeprazole/sodium bicarbonate)
CRITERIA
generic OTC Zaditor in the past 90 days (covered with
written prescription).
2. If the patient fails treatment with generic OTC Zaditor, then
Patanol is the second-line formulary alternative with prior
authorization required.
the formulary alternatives (OTC Zaditor and Patanol) before
a non-formulary drug will be approved.
Qty is
limited to 2
units per
day
Zioptan is
limited to a
qty of 1 unit
per day
Brand PPIs
are limited
to a qty of
30
tabs/caps
per month

generic Timolol (i.e., Timoptic).
claims for a generic prostaglandin analog (i.e., generic
Xalatan).
2. If the patient fails treatment with all generic prostaglandin
analogs, then Lumigan 0.01% is the second-line formulary
alternative with prior authorization required.
claims for all formulary alternatives (generic Xalatan AND
branded Lumigan 0.01%) before a non-formulary brand drug
will be approved.
omeprazole and generic Protonix.
2. If the patient fails treatment with omeprazole and generic
Protonix, then Aciphex is the second-line alternative with
prior authorization required.
3. The patient must fail all formulary alternatives based on
documentation or Rx claims before a non-formulary PPI will
be approved, AND
4. Specifically for Nexium and esomeprazole strontium, the
patient must have a current documented diagnosis of
Barrett's Esophagus, Zollinger-Ellison or Erosive
Esophagitis. Approved automatically for children under 2
years of age.
5. Specifically for Dexilant, the patient must have a current
documented diagnosis of Erosive Esophagitis.
6. Specifically for liquid or soluble preparations, the patient
must have documented inability to swallow a solid dosage
form.
129

APPENDIX D
DRUG/CATEGORY
Sleeping Aids
Edluar SL (zolpidem)
Intermezzo (zolpidem)
Lunesta (eszopiclone)
Rozerem (ramelteon)
Silenor (doxepin)
Zolpimist (zolpidem)
QTY LIMIT
CRITERIA
Quantity is
limited to
30 per
month
1. If there is no contraindication present, the patient must have

documented failure or Rx claim(s) for three generically
available sleeping agents (e.g., Ambien, Desyrel, Halcion,
Prosom, Restoril or Sonata).
2. If a contraindication to benzodiazepines is present, the
patient must try and fail an adequate course of therapy with
generic Ambien AND Sonata.
NOTE: Limited to1 unit per day. Prior Authorization for more
than 1 unit per day is based on a specific review of medical
necessity.
Quantity Limits Only
NOTE: Limited to 1 unit per day. Prior Authorization is only
required for quantities that exceed the limit, and is based on
a specific review of medical necessity.
generic OTC nicotine patches in the past year.
NOTE: Generic OTC nicotine patches are a covered benefit.
Coverage for smoking cessation is limited to 1 course of
therapy per year.
DURATION LIMITS ONLY
Coverage for smoking cessation is limited to one course of
therapy per year (the course of therapy for Chantix is
routinely defined as 24 weeks).
at least two formulary agents (e.g., generic Azulfidine,
Colazal, or Asacol) in the past year.
Ambien/CR (zolpidem)
Restoril (temazepam)
Sonata (zaleplon)
Smoking Cessation
All prescription nicotine patches
Chantix (varenicline)
Inflammatory Bowel Disease,

all branded non-formulary oral
agents
Dipentum (olsalazine sodium)
Giazo (balsalazide)
Lialda (mesalamine)
Uceris (budesonide)
Canasa (mesalamine)
New Starts Only
Limited to a
qty of 30
units per
month

130

APPENDIX D
DRUG/CATEGORY
Weight Management
All medications for the treatment
of obesity
Examples:
Adipex (phentermine)
Belviq (lorcaserin)
Diethylpropion (diethylpropion)
Qsymia (phentermine/
topiramate)
Suprenza (phentermine)
Xenical (orlistat)
QTY
LIMIT
CRITERIA
1. The patient is an adult 18 years of age; AND
2
2. The patient has a body mass index (BMI) of >30kg/m , OR
2
3. The patient has a body mass index (BMI) of >27kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
4. The patient has a body mass index (BMI) of >27kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis, pregnancy, and/or lacation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician-supervised diet and exercise program
consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet and a
regular exercise program. AND
5. If the medication is a brand name product, the patient must
have tried a generically available product (i.e. phentermine,
diethylpropion) in the past year.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total
coverage.
131

APPENDIX D
DRUG/CATEGORY
Non-Sterile Compounded
Prescriptions
Non-Formulary with PA
QTY
LIMIT
CRITERIA
1. The compounded product contains at least one FDA-approved
prescription ingredient; AND
2. Each prescription drug or active ingredient in the compounded
product is approved by the Food & Drug Administration (FDA) for
medical use in the United States; AND
3. The active prescription medication component(s) are in therapeutic
amounts; AND
4. The compounded product is not a copy of any commercially available
FDA-approved drug product; AND
5. The use for which the compounded product is being prescribed is
supported by FDA approval of the active ingredient(s), or is supported
by two or more articles from peer reviewed journals demonstrating
the safety and efficacy of the prescribed therapy for that diagnosis
and method or route of delivery; AND
6. If any prescription ingredient in the compounded product is included
in the HealthPlus Prior Authorization program, the patient must meet
the criteria designated for that prescription ingredient.
Based on limitations or exclusions in the subscriber certificate,
coverage will NOT be provided for compounds under the following
circumstances:
1. Any compound that does not contain a FDA-approved prescription
ingredient otherwise covered by the plan; OR
2. Any compound that contains a non-FDA approved or non-HealthPlus
covered prescription ingredient.
3. Compounded formulations that contain any bulk powders that are not
FDA approved or HealthPlus approved; OR
4. Compounded formulations that are being used for cosmetic purposes;
OR
5. Compounded formulations that are using prescription ingredients for
non-FDA approved indications or purposes that are not supported by
peer-reviewed literature; OR
6. Compounded formulations that may be considered investigational or
experimental; OR
7. Compounded formulations that use drugs withdrawn or removed from
the market for safety reasons; OR
8. Prescription ingredient(s) compounded for the purpose of
convenience only.
a. Exceptions include:
i. Compounded medications for those patients that cannot
swallow or have trouble swallowing and require
administration with an oral liquid, or administration by topical,
rectal or other appropriate non-oral routes;
ii. Compounded medications for those patients who have
sensitivity to dyes, preservatives, or fillers in commercial
products and require allergy-free medications as documented
in the medical record;
iii. Compounded medications for children who require
prescription medications for which there are no liquid
formulations available.
132

APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Dispense as Written DAW

Specific request for a brand
name product when a generic is
available
CRITERIA
1. The benefit covers generic products when a generically
equivalent product is available.
2. In general, prior authorization is required for all brand name
drugs (when the drug is available and covered as a generic
medication). The physician may submit a prior authorization
request form for the brand name drug (when a generic
equivalent is available), but this must be substantiated by
medical necessity. If medical necessity is based on a trial and
failure of the generic medication, a prescription claim for the
generic drug must be present or chart notes documenting the
failure must be provided.
3. If a physician submits a prior authorization request form for
coverage of a brand name drug (when a generic equivalent is
available), the request is reviewed through the same process
as all other drugs that require prior authorization.
4. The member may still choose to receive a brand product
without medical necessity, but would be responsible for
additional costs based on their benefit (i.e., the difference in
cost between the brand and generic product plus their usual
copayment; or, a higher copayment).
1. The physician must provide documentation of the clinical
rationale for requesting a dosage, quantity, or duration of
medication greater than the criteria specified in the formulary.
2. If the dosage exceeds the manufacturer product
labeling/prescribing information, the physician must submit
documentation of two articles from peer reviewed journals
demonstrating the safety and efficacy of the prescribed
therapy.
Quantity Limit QL
Specific request for a dose,
quantity or duration that exceeds
the established limits
Medical Exception Requests

Signature PPO Closed Formulary/or Specific Excluded Non-Formulary Drugs
DRUG/CATEGORY
Exceptions Criteria
(for all non-formulary drugs in
a closed formulary)
QTY
LIMIT
CRITERIA
1. Formulary drugs/alternatives are not appropriate, are
contraindicated or are unsafe for the patient based on specific
documented patient circumstances, OR
2. The patient has a documented trial and failure (or prescription
claims) for all of the formulary drugs/alternatives.
133

APPENDIX D
HEALTHPLUS OF MICHIGAN
High Risk Medications in the Elderly (66 years old)
HealthPlus Commercial/Medicare (non-Part D)/PPO/TPA
Based on the availability of safer alternatives, the following medications have been added to the Prior Authorization Program for members 66 years of age and
older for HealthPlus Commercial/Medicare (non-Part D) and PPO with the following criteria:
1) The recommended alternative treatment(s) are not appropriate, are contraindicated or are unsafe for the patient based on specific documented patient
circumstances, OR
2) The patient has a documented trial and failure (or prescription claims) for the recommended alternative treatment(s).
Name
Concern
Estrogens all oral and

topical patches only
(Premarin, estradiol,
Estratest, Vivelle-Dot, etc.)
Promethazine (Phenergan)
including all combinations
Promethazine w/ Codeine
Evidence of breast/Endometrial cancer;

No cardio or cognitive protection in older women
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Thyroid USP (Armour

Thyroid, Desiccated)
Glyburide (Micronase)
Cardiac adverse effects
Anticholinergic effects (i.e., urinary retention, confusion, sedation)
Alternative Treatment
Hot flashes: non-pharmacological therapy, Zoloft, Paxil,
Effexor
2
Bone density: Calcium with vitamin D , Fosamax,
1
1
Boniva , Evista
1,2
2
Antihistamine: Claritin , Zytrec
1
Antiemetic: Antivert, Zofran
Cough: Dextromethorphan
Depends on site of infection, culture, and sensitivity.
1
Bactrim, Vibramycin, Azithromycin, Fluoroquinolone
Levothyroxine (LT4): Synthroid, Levoxyl
Associated with an increased risk of hypoglycemia compared to

other agents
Diabetes: Glucotrol, Amaryl, Metaglip
Hydroxyzine (Vistaril, Atarax)
Anticholinergic effects, urinary retention, confusion, sedation
Antihistamine: Claritin , Zyrtec
Carisoprodol (Soma)
Anticholinergic effects, sedation, cognitive impairment, weakness,

urinary retention
Physiotherapy: correct seating & footwear

Spasticity: Baclofen, Zanaflex. Treat underlying
problems
Glyburide-Metformin
(Glucovance)
Chlorpropamide (Diabinese)
Cyclobenzaprine (Flexeril)
Orphenadrine (Norflex)
Chlorzoxazone (Parafon
Forte)
Methocarbamol (Robaxin)
Skelaxin (Metaxalone)
134

APPENDIX D
Name
Amitriptyline (Elavil)
Concern
Highly anticholinergic, sedating, and causes orthostatic hypotension
Depression: Zoloft, Paxil, Effexor
Trimethobenzamide (Tigan)
Extrapyramidal side effects, poor efficacy
Nausea: Zofran, Compazine, or Reglan
Ketorolac (Toradol)
GI bleeding
Pain: Tylenol , Motrin , Norco
Orthostatic hypotension, poor efficacy
For secondary prevention of non-cardioembolic

stroke or TIA: Plavix, Aggrenox, Aspirin
2
Indomethacin
Dipyridamole (Persantine)
1
2
Drug may require prior authorization or may have limited coverage depending on members benefit plan
Available OTC
135
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY

PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
MEDICAID PRIOR AUTHORIZATION CRITERIA

CATEGORY/DRUG
QTY
LIMIT
Acne
Clindagel
(clindamycin phosphate)
All Brand Topical Adapalene
and Dapsone Products
Aczone 5% Gel (dapsone)
Differin 0.1% Lotion
(adapalene)
Differin 0.3% Gel (adapalene)
Epiduo 0.1%-2.5% Gel
(adapalene/benzoyl peroxide)
All Branded Benzoyl Peroxide
Acanya 1.2%-2.5%
(clindamycin/benzoyl peroxide)
Benzamycin Pak 3%-5% Gel
(erythromycin base/benzoyl
peroxide)
Duac (clindamycin/benzoyl
peroxide)

topical generic clindamycin (e.g., Cleocin T) in the past 90
days.
1. The patient must have documented failure or Rx claim(s) for a
generic tretinoin (e.g., Avita, Retin-A).
1. Patient must have documented failure or Rx claim(s) for a

generic combination product in the past 90 days (i.e., GEQ
Benzaclin, GEQ Benzamycin).
All Tretinoin Products

All Brand Tretinoin Products
Atralin (tretinoin)
Retin A Micro 0.04% (tretinoin)
Tretin-X (tretinoin)
Veltin (tretinoin/clindamycin)
Ziana (tretinoin/clindamycin)
Allergy Medications
Clarinex (desloratadine)
Clarinex-D
(desloratadine/pseudoephedrine)
CRITERIA
Age Restriction: Patients > 25 years of age must have a

documented diagnosis of acne.
generic tretinoin product (e.g., Retin-A, Avita) in the past 90
days.
NOTE: Age restriction for all topical tretinoin products for age >
25 based on a diagnosis of acne.
Limited to
a qty of
30 units
per
month for
generic OTC Claritin D OR OTC generic Claritin in
combination with OTC generic pseudoephedrine (all are
covered with written prescription) in the past year.
If the patient fails treatment with a generic OTC Claritin
combination, then generic Allegra in combination with OTC
pseudoephedrine is the second line alternative.
NOTE: Prior authorization is only required for patients over 12
years of age.
136

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Allergy Medications,
continued
All Brand Nasal Steroids
Beconase AQ
(beclomethasone dipropionate)
Nasonex
(mometasone furoate)
Omnaris (ciclesonide)
Qnasl (beclomethasone
dipropionate)
Rhinocort Aqua (budesonide)
Veramyst (fluticasone furoate)
Zetonna (ciclesonide)
All Brand Nasal Steroids,
Dymista (azelastine/fluticasone
propionate)
Analgesics
Actiq (fentanyl citrate oral
transmucosal)
Abstral (fentanyl sl)
Fentora
(fentanyl citrate buccal tablet)
Lazanda (fentanyl nasal spray)
Onsolis (fentanyl soluble film)
Subsys (fentanyl sublingual
spray)
All acetaminophen-containing
narcotic analgesics
CRITERIA
1. The patient must have documented failure or Rx claims for two
generic nasal steroids (i.e., Flonase, flunisolide) in the past
year.

generic nasal steroid (i.e., Flonase, flunisolide, Nasacort AQ)
in the past year.
1. The patient has a documented current diagnosis of cancer.
2. The patient is already receiving and is tolerant to opioid
therapy for underlying persistent cancer pain.
oncologist (or if there are prescription claims for
chemotherapy-related medications) and the patient is
receiving opioid pain medications.
Abstral, Lazanda and Subsys New Starts Only

NOTE: System edits apply for prescription claims with a monthly
quantity that exceeds the MAX recommended dose of 4gm/day of
acetaminophen. Physician must submit signed request stating
that he/she is allowing the patient to exceed the MAX
recommended dose of acetaminophen.
Duragesic Patches (fentanyl)
Qty limit
of 1
patch per
72 hours
OxyContin (oxycodone)
Qty limit
60 in 30
days

claims for at least two formulary alternatives (including
generic MS Contin, and short-acting narcotic analgesic) OR
inappropriate.
1. The patient must have a current documented diagnosis of
active cancer.
oncologist (or if there are prescription claims for chemotherapyrelated medications) and the patient is receiving opioid pain
medications.
137

APPENDIX D
CATEGORY/DRUG
Analgesics, continued
Avinza (morphine sulfate)
QTY
LIMIT
Qty is
limited to
30 units
per 30
days
Butrans (buprenorphine patch)
Opana ER (Crush Resistant)

(oxymorphone)
Oxymorphone ER (Non-Crush
Resistant) (oxymorphone)
CRITERIA
active cancer.
oncologist or if there are previous claims for chemotherapyrelated medications.
claims for at least two formulary alternatives (including generic
MS Contin and short-acting narcotic analgesic) within the last
3 months OR
inappropriate.
New Starts Only
Qty is
limited to
60 units
per 30
days
Rybix ODT (tramadol)

active cancer.
NOTE: Prior authorization applies to new start patients only.
generic Ultram in the past 60 days, OR
2. The patient must have documented inability to swallow or
absorb oral medications.
Exalgo (extended release

hydromorphone)
Qty is
limited to
30 units
per 30
days
Requires prior authorization for indications other than cancer.

generic Dilaudid (hydromorphone) and generic Duragesic
(fentanyl).
Vicodin 5/300
Vicodin ES 7.5/300
Vicodin HP 10/300
Vicodin
5/300
limit 8
tabs/day
VIcodin
ES
7.5/300 &
Vicodin
HP
10/300
limit 6
tabs/day
1. Physician must provide chart documentation that shows that a

product with 325mg acetaminophen (i.e. generic Norco) is
contraindicated in this patient but that a product with 300mg
acetaminophen is not contraindicated
Note: Acetaminophen is not recommended for patients with liver
disease.
138

APPENDIX D
CATEGORY/DRUG
All Non-Formulary
Angiotensin II Receptor
Blockers
Micardis (telmisartan)
Micardis HCT (telmisartan)
Teveten HCT
(eprosartan mesylate)
Twynsta
(telmisartan/amlodipine)
Edarbi (azilsartan medoxomil)

Edarbyclor (azilsartan
medoxomil/chlorthalidone)
QTY
LIMIT
All ARBs
except
Cozaar
(not
combos)
are
limited to
a qty of
30 units
per
month
Qty is
limited to
30 units
per 30
days
CRITERIA
formulary ARBs or ARB combination products (i.e.,
Benicar/HCT, or Diovan/HCT).
NOTE: If patient is a first time ARB user, patient should have
documented failure or Rx claims for at least one generically
available ACE inhibitor previous to ARB therapy.
1. The patient must have documented failure or Rx claim(s) for at

least on formulary ARB or ARB combination product (i.e.,
generic Cozaar/Hyzaar, Benicar/HCT or Diovan/HCT).
Antibiotics
Oracea
(doxycycline monohydrate)

generic Vibramycin.
Moxatag ER (amoxicillin
trihydrate)

generic amoxicillin product in the past 14 days.
Dificid (fidaxomicin)
1. Patient has documented diagnosis of C. difficile associated

diarrhea, AND
2. Patient has tried and failed an adequate trial of vancomycin,
OR
3. Patient has a contraindication or intolerance to vancomycin,
OR
4. Patient has been recently discharged from a hospital or a
medical facility and has had documented treatment with Dificid
or vancomycin.
New Starts Only
Minocin PAC (minocycline kit)

generic tetracycline AND minocycline in the past 60 days.
Avelox (moxifloxacin)
Factive (gemifloxacin)

generic quinolone (i.e.; ciprofloxacin, levofloxacin) in the past
60 days before any other brand quinolone will be covered.
NOTE: Individual requests are reviewed to include consideration
of the diagnosis, culture and sensitivity, and other documentation.
Flagyl ER (metronidazole)

generic metronidazole.
Tobi Solution/Podhaler
1. The patient must have a diagnosis of Cystic Fibrosis; AND

2. The drug is given for 28 days followed by 28 days off, in
repeat cycles.
139

APPENDIX D
CATEGORY/DRUG
Anticoagulants
Brilinta (ticagrelor)
Eliquis (apixaban)
QTY
LIMIT
Qty is
limited to
60 units
per 30
days
Qty is
limited to
60 units
per 30
days
Antiemetic
Zuplenz (ondansetron)
1. The patient has a documented diagnosis of acute coronary

syndrome (unstable angina, non-STEMI, or STEMI), AND
2. Patient is receiving a total daily dose of aspirin 100mg/day,
AND
claims with generic Plavix, OR
4. The patient is not an appropriate candidate for generic Plavix
based on documentation provided (i.e., patient is identified as
CYP2C19 poor metabolizer, or on concomitant medication that
reduce the antiplatelet activity of Plavix).
fibrillation; AND
CrCl>15ml/min.
Approval of prior authorization requests is limited to 12 months.
fibrillation; AND
CrCl>30ml/min; AND
3. The patient must not be concurrently receiving a medication
that is contraindicated with Pradaxa; AND
4. If the patient has a recent CrCl 30-50ml/min and is
concurrently receiving a P-gp inhibitor such as Multaq or
Ketoconazole, documentation of a review by a cardiologist
recommending use must be provided.
Pradaxa 150mg (dabigatran)
Xarelto (rivaroxaban)
CRITERIA
Qty for
10mg is
limited to
35 units
New Starts Only

NOTE: Prior authorization requests are approved for 12-month
duration
1. For the 10mg dose, quantity is limited to 35 units per episode
of DVT prophylaxis; OR
2. The patient has a FDA approved diagnosis (e.g., non-valvular
atrial fibrillation, DVT, or PE); AND
3. The patient has a recent CrCl (within the last month); AND
4. Dosing is adjusted for the patients recent CrCl.
For DVT or PE, the patient has a recent CrCl 30ml/min;
15ml/min.
50ml/min.
New Starts Only
NOTE: Prior authorizarion requests are approved for 12-month
duration.
with generic Zofran ODT.
140

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Anti-Nausea
Anzemet
(dolasetron mesylate)
Requires prior authorization for indications other than cancer. If

the patient has cancer (and related medication), the system will
allow the claim to pay at a limited quantity.
with two generically available products (e.g., Reglan, Tigan or
Compazine).
1. Patient must have a diagnosis of myelofibrosis with a risk
category of intermediate (2 prognostic factors) or high (3 or
more prognostic factors) based on the International Working
Group Consensus Criteria (IWG). Prognostic factors include:
a. Age >65 years old
b. WBC > 25 X 109/L
c. Hgb < 10g/dl
d. Peripheral blasts 1% or higher
e. Constitutional symptoms (e.g., fatigue, weakness,
shortness of breath, weight loss, night sweats, or bone
pain), AND
2. Prescription must be prescribed by an Oncologist or
Hematologist, AND
3. Patient must have documented palpable splenomegaly 5cm
below costal margin, AND
4. Patient must have a recent (with in the last month) creatinine
clearance >15 ml/min, AND
5. Patient must have a recent (with in the last month) CBC with
platelet count >50 X 109/L.
6. Duration of approval is for 12 months.
7. For purposes of re-authorization, there is documentation
supporting reduction of spleen size or symptom improvement.
New Starts Only
NOTES:
A. System edits apply for prescription claims submitted for more
than twice daily dosing.
B. Jakafi is considered a specialty drug and will be included in
the Mandatory Specialty Program.
Antineoplastic
Jakafi (ruxolitinib)
Asthma/COPD
Combivent Respimat
(albuterol/ ipratropium)
Proventil HFA (albuterol)
ProAir HFA (albuterol)
CRITERIA
Limited to
6 doses
per day

more than 6 doses a day.
1. Patient has a documented contraindication to the preferred
formulary albuterol inhaler (i.e. Ventolin HFA)
Xopenex/HFA (levalbuterol)
1. The patient must have documented intolerant side effects to

albuterol (e.g., palpitations, tremors and tachycardia).
Zyflo/CR (zileuton)
1. The patient must have a diagnosis of asthma; AND

2. The patient must be 12 years of age or older; AND
3. The patient must have chart documented failure or prescription
claims for generic Singulair or Accolate.
141

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Beta Blockers
Levatol (penbutolol)
Coreg CR (carvedilol
phosphate controlled release)
Bystolic (nebivolol)
Limited
to a qty
of 30
units per
month
Limited
to a qty
of 30
units per
month
CRITERIA
1. The patient must have documented failure or Rx claims
with at least three generically available beta blockers (e.g.,
Inderal, Tenormin, Lopressor, Corgard).
release carvedilol of equivalent dose and attempted at least
one dose increase (6.25/day IR = 10mg/day ER when
converting).
Calcium Channel Blockers

Dynacirc CR
(isradipine controlled release)

release isradipine of equivalent dose and attempted at least
one dose increase AND
2. The patient must have documented failure/contraindication to
three generically available dihydropyridine CCB agents (e.g.,
nisoldipine, nifedipine, amlodipine, nicardipine, felodipine) in
the past year.
Cardizem LA
(diltiazem, long-acting)

least two generically available formulary alternatives (e.g.,
Cardizem CD, Cardizem SR, Dilacor XR).
Cholesterol Medications
Crestor (rosuvastatin)
Advicor (lovastatin/niacin)
Altoprev (lovastatin SR)
Lescol XL (fluvastatin)
Livalo (pitavastatin calcium)
Liptruzet
All HMGs
are
limited to
a qty of
30 units
per
month

generic Zocor, OR
2. The patient is currently receiving a medication that potentiates
simvastatin levels (i.e., itraconazole, ketoconazole, HIV
protease inhibitors, erythromycin, gemfibrozil, cyclosporine,
amiodarone, verapamil, diltiazem, amlodipine, ranolazine).
Limited to
a qty of
30 units
per
month

1. The patient must have a diagnosis of diabetes and

documented failure or Rx claim(s) for Metformin OR
2. The patient must have documented failure of both generic
Questran AND generic Colestid.
Lovaza
(omega-3-acid ethyl esters)
Vascepa (icosapent ethyl)
1. The patient's triglyceride (TG) levels are >500mg/dL (with

chart documentation provided) OR
past six months for at least two or more lipid-lowering agents,
with at least one being a generic product (i.e., statins,
fenofibrate, nicotinic acid).
Fenoglide (fenofibrate)
Lipofen (fenofibrate)
Triglide (fenofibrate)

formulary fenofibrate (i.e., generic Lofibra) in the past year with
at least one documented dosage increase.
142

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Cholesterol Medications,
continued
On Formulary:
Zetia (ezetimibe)
CRITERIA
AUTHORIZATION IS ONLY REQUIRED FOR THE
FOLLOWING:
1. If the patient has not had an Rx claim for an HMG statin
medication in the previous year. Criteria for authorization for
monotherapy include a documented contraindication for both
hydrophilic (Pravachol, Lescol) and lipophilic (Zocor, Lipitor)
statins, elevated liver enzymes, etc.
2. A dose >10mg per day requires documentation to support
safety and efficacy.
Contraceptives
All Brand Oral Contraceptives
Beyaz
LoEstrin 24 Fe 1/20
Natazia
NuvaRing
Ortho Evra
Ortho Tri-Cyclen Lo
Ovcon-50
Safyral
Dermatologicals
Elidel (pimecrolimus)
1.The patient must have a documented trial or Rx claims for at

least two generically available oral contraceptives in the past
year before any brand product will be covered.

least two generically available steroid creams in the past 6
months OR
2. Be under the treatment of a dermatologist.
Protopic (tacrolimus)
1. The patient must have documented failure or Rx claims with at

least two generically available topical steroids AND
pimecrolimus in the past 180 days.
Dovonex (calcipotriene)
Taclonex
(betamethasone/calcipotriene)
Safety
limited to
a qty of <
100g per
7 days
Vectical (calcitriol)
Safety
limited to
a qty of <
200g per
7 days
Lidoderm Patch (lidocaine)
1. The patient must have a diagnosis of post herpetic neuralgia

(document previous diagnosis or titer).
Zyclara (imiquimod)
1. The patient must have a diagnosis of actinic keratosis and

documented treatment failure or Rx claims for geq Aldara; OR
2. The patient must have a diagnosis of condyloma acuminate
and documented treatment failure or Rx claims for geq
Condylox or geq Aldara.
New Starts Only
143

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
All Branded Topical Antifungal
Agents
Ciclodan Kit (ciclopirox olamine
cream/cleanser)CNL Nail Kit
(ciclopirox/lacquer removal pads)
Ertaczo
(sertaconazole nitrate)
Exelderm (sulconazole nitrate)
Ketodan Kit (ketoconazole
foam/cleanser)Lamisil Soln
(terbinafine soln)
Mentax (butenafine)
Naftin (naftifine)
Oxistat (oxiconazole nitrate)
Pediaderm AF
(nystatin/emollient)
Terbinex
(terbinafine/hydroxychitosan)
Tersi (selenium sulfide)
Xolegel/Corepak
(ketoconazole)
Vusion
(miconazole nitrate/zinc oxide)
Altabax (retapamulin)
Bactroban Nasal Ointment

(mupirocin)
CRITERIA
four generic antifungals (e.g., Loprox, Nizoral, Spectazole
and Grifulvin V).
10 grams
(10, 1gm)
tubes per
month
1. The patient must be greater than 4 weeks old with a diagnosis

of candidal diaper dermatitis or candidal infection.
1. The patient must have a documented treatment failure with
generic Bactroban ointment for each instance of impetigo
AND
2. A diagnosis of impetigo.
1. The patient must have a chart documented nasal colonization
with methicillin-resistant S. aureus (MRSA); AND
2. The patient must have Rx claims for generic mupirocin
ointment in the past 7 days.
Criteria for more than 10 grams per month
1. The patient must have chart documented nasal recolonization
of MRSA.

Clobex Spray (clobetasol
propionate)
Synalar TS
(fluocinolone/cleanser)
Ultravate PAC Kit (halobetasol
propionate/ammonium lactate)
Vanos 0.1% Cream
(fluocinonide)
Kenalog Aerosol Spray
(triamcinolone acetonide)
Pandel
(hydrocortisone probutate)
Pediaderm TA (triamcinolone)
Topicort Spray
(desoximetasone)

Temovate, Ultravate, Diprolene) in the past 60 days.

Elocon, Westcort and Synalar) in the past 60 days.
144

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Cloderm Cream (clocortolone
pivalate)
Cordran Lotion
(flurandrenolide)
Cordran SP Cream
(flurandrenolide)
Locoid Lotion, Lipocream
(hydrocortisone butyrate)
Momexin (mometasone
furoat/ammonium lac)

generic topical steroid in the same potency class (e.g., BetaVal Cr, Cutivate Cr, Dermatop Cr) in the past 60 days.
Desonate Gel (desonide)

Desowen Combo
(desonide/emollient)
Pediaderm HC
(hydrocortisone)
Vanoxide-HC Lotion
(hydrocortisone/benzoyl
peroxide)
Verdeso Foam (desonide)

Aclovate, Desowen and Synalar) in the past 60 days.
All Brand Topical Emollients

Atopiclair (emollient)
Epiceram (emollient combo)
Gordons Urea (urea)
Hylatopic (emollient combo)
Kerafoam (urea)
Neosalus (emollient combo)
Promiseb (emollient combo)
Promiseb Complete (emollient
combo)
Umecta (urea)
Umecta PD (urea)
Uramaxin GT Kit
(urea/emollient)
Utopic (urea)
Diabetes
Glumetza (metformin)

generic topical emollient (e.g., Carmol, Lac-Hydrin, Mectalyte
and Vanamide) in the past 60 days.
Janumet, XR
(sitagliptin/metformin)
Juvisync
(sitagliptin/simvastatin)
Kazano (alogliptin/metformin)
Kombiglyze XR
(saxagliptin/metformin)
Oseni (alogliptin/pioglitazone)
Januvia (sitagliptin)
Nesina (alogliptin benzoate)
Onglyza (saxagliptin)

Jentadueto).

past year for generic Glucophage and generic Glucophage
XR.
Limited to
a qty of 30
units per
month

Jentadueto).
145

APPENDIX D
Tradjenta (linagliptin)
Apidra (insulin glulisine)

Novolin Insulins (insulin)
Novolog Insulins (insulin
aspart)
Novolog Mix (insulin)
Glucose Test Strips
Freestyle Lite
Freestyle Insulinx
Precision Xtra
Limited to
a qty of 30
units per
month
1. Patient has a documented contraindication to a

comparable preferred formulary insulin (i.e. Humulin
and Humalog products),
Limited
qty of 150
units per
30 days or
450 units
per 90
days
Endometriosis
Lupron Depot 3.75 Kit
(leuprolide acetate)

Axert (almotriptan)
Frova (frovatriptan)
Treximet
(sumatriptan/naproxen)
1. Confirmation of diagnosis.
NOTE: Not covered for infertility (infertility services are
excluded).
both generically available estrogen products (i.e., Estrace,
Ogen).
Hormone Replacement
Cenestin
(estrogens, conj synthetic)
Premarin
(conjugated estrogens)
Premphase (conj
estrogens/medroxypro)
Prempro
(conj estrogens/medroxypro)
Enjuvia
(conjugated estrogen, synthetic)
Migraine Medications
Formulary with PA:
Relpax (eletriptan)

1. The patient must have documented treatment failure with

generic Estrace, Ogen and Premarin (which requires Prior
Authorization).
Qty for all
triptans
combined
are limited
to 9
tablets per
month
For Relpax:
generic triptans (i.e., Amerge, Imitrex, Maxalt, Zomig); OR
2. Generic alternatives must be inappropriate with chart
For Non-Formulary Products:
formulary alternatives (i.e., Amerge, Imitrex, Maxalt, Relpax
and Zomig); OR
2. Formulary alternatives must be inappropriate with chart
CRITERIA FOR MORE THAN NINE TABLETS PER MONTH
days and still requires more than nine tablets per month.
prophylaxis and still requires more than nine tablets per
month.
146

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Migraine Medications,
continued
Cambia (diclofenac potassium)

AND
generic diclofenac; AND
least one additional non-steroidal anti-inflammatory drug (i.e.,
ibuprofen, naproxen sodium).
Imitrex Injection (sumatriptan

injection)
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
Sumavel (sumatriptan
injection)
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
Imitrex Nasal Spray

(sumatriptan)
Zomig Nasal Spray
(zolmitriptan)
Migranal (dihydroergotamine)
including generics
CRITERIA
All nasal
triptan
products
are limited
to a
quantity of
6 per
month
8 units
(ml) per
month

injections per month
claims for generic Imitrex injection.
injections per month
days and still requires more than 6 units per month, OR
units per month
AND
prescription claims for an oral generic triptan medication (i.e.
generic Imitrex, generic Amerge); AND
prescription claims for generic Imitrex nasal spray or injection;
OR
4. The patient has a chart documented contraindication or
intolerance to triptan medications.
days and still requires more 8 units per month.
prophylaxis and still requires more than 8 units per month.
147

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Muscle Relaxants
Amrix (cyclobenzaprine ext
release)

with at least two generic prescription muscle relaxants (i.e.,
Flexeril, Norflex).
Miscellaneous
Cantil (mepenzolate bromide)

least three generically available antispasmotics (i.e., Bentyl,
Levsinex, Librax) in the past year.
generically available alpha 1-adrenergic antagonist (e.g.,
Cardura or Hytrin) in the past year.
Cardura XL (doxazosin
mesylate ext. release)
Ranexa (ranolazine)
1. The patient must have a documented diagnosis of chronic

angina; in addition, there must be a pharmacy claim for
amlodipine or beta-blocker or non-acute nitrates.
Nitroglycerin Patches

generic oral nitroglycerin in the past 90 days.

Revatio (sildenafil)
1. The patient must have a documented diagnosis of pulmonary

arterial hypertension.
2. If the patient has a history of nitrate use, the physician must
submit a written request on his/her letterhead stating that the
patient is no longer using nitrates.
fibromyalgia, OR
2. Documentation of all of the following:
a. Widespread pain for at least 3 months, AND
b. Pain on both sides of the body, above and below the waist,
AND
c. Abnormal tenderness in at least 11 of the 18 anatomicallydefined body sites.

Adcirca (tadalafil)
Savella (milnacipran)
Thyrolar (liotrix)

least two generically available thyroid preparations in the past
year.
Amitiza (lubiprostone)
1. The patient must have documented treatment failure with at

least 2 generic/OTC cathartics (e.g., bisacodyl, docusate
sodium, lactulose, mineral oil, etc) OR
2. A documented D(x) of constipation predominant IBS.
Moviprep (peg 3350/ sod

sul/nacl/asb/c/kcl)
Osmoprep (naphos
mb0mh/naphos, di-ba)
1. The patient must have documented contraindication or

treatment failure or Rx claims with two generic polyethylene
glycol.electrolyte powders (e.g., Coylte, Golytely, Nulytely and
Trilyte).
Uloric (febuxostat)
Limited to
a qty of 30
units per
month
1. Patient must have documented failure or prescription claims

with allopurinol, OR
2. The patient cannot tolerate therapeutic doses or is not an
appropriate candidate for allopurinol based on documentation
provided.
148

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Neurological Miscellaneous
Gralise (gabapentin)
CRITERIA
postherpetic neuralgia, AND
2. The patient must have documented failure and Rx claims with
generic Neurontin, AND
generic tricyclic antidepressant.
Horizant (gabapentin
enacarbil)
Limited to
a qty of 30
units per
30 days.
1. The patient must have a diagnosis of restless legs syndrome,

AND
2. The patient must have documented failure and Rx claims with
generic Neurontin, AND
generic Requip or generic Mirapex.
Nuedexta
(dextromethorphan/quinidine)
Limited to
a qty of 60
units per
30 days.

pseudobulbar affect; AND
2. The patient must be 18 years or older; AND
3. Patient is not currently receiving quinidine, quinine,
mefloquine, an MAOI, or any drug that prolongs QT interval
and is metabolized by CYP2D6 (e.g., thioridazine or
pimozide); AND
4. Patient must have recent (within the past three months)
platelet count, liver function panel, and ECG if patient has left
ventricular dysfunction/hypertrophy.
Prior authorizarion requests are approved for a 6 month duration.
NSAIDs
Celebrex (celecoxib)
Cox-2
drugs and
Mobic are
limited to
a qty of 30
units per
month
1. Documented indication for acute or chronic treatment of the

signs and symptoms of osteoarthritis or rheumatoid arthritis,
AND
2. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
complications:
risks:
NSAIDS OR
4. Active ulcer or recent documented history of ulcer (within
6 months) or history of GI bleed/perforation.

Arthrotec
(diclofenac/misoprostol)
Naprelan CR (naproxen
sodium)
149

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
NSAIDs, continued
Flector (diclofenac epolamine
transdermal patch)

complications:
risks:
NSAIDS OR
3. Active ulcer or recent documented history of ulcer (within 6
months) on history of GI bleed/perforation.
Vimovo
(esomeprazole/naproxen)
1. The patient must have a documented diagnosis of arthritis,

AND
2. The patient must be high risk for developing GI complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy
3. The patient must fail all formulary proton pump inhibitor
alternatives (i.e., Omeprazole, Aciphex, generic Prevacid,
generic Protonix) in combination with generic naproxen.
Rayos
1. The patient must have a documented diagnosis of rheumatoid

arthritis; AND
2. The patient must have documented failure and Rx claims for 2
generically available oral corticosteroids (i.e., prednisone,
methylprednisolone).
Voltaren Gel
(diclofenac sodium)

piroxicam, ketoprofen, diclofenac, etc.).
Zipsor (diclofenac potassium)

piroxicam, ketoprofen, diclofenac, etc.), and one must be
generic Voltaren. Adequate course of therapy is defined as a
full therapeutic dose on a scheduled basis for at least 1-2
weeks.
150

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Ophthalmics
Antihistamines
Patanol (olopatadine)

generic OTC Zaditor in the past 90 days (covered with written
prescription).
2. If the patient fails treatment with generic OTC Zaditor, then
Patanol is the second-line formulary alternative with prior
authorization required.
3. The patient must have documented failure or Rx claims for the
formulary alternatives (OTC Zaditor and Patanol) before a
non-formulary drug will be approved.

Alocril (nedocromil sodium)
Alomide
(lodoxamide tromethamide)
Bepreve
(bepotastine besilate)
Emadine
(emedastine difumarate)
Lastacaft (alcaftadine)
Pataday (olopatadine)
Restasis (cyclosporine)
CRITERIA
Qty is
limited to
2 units per
day
Alphagan P 0.1% (brimonidine

tartrate)

keratoconjunctivitis sicca.
1. The patient must have documented contraindication or

documented treatment failure with the use of generic
brimonidine ophth.
1. The patient must have documented failure or Rx claim for at
least one generic formulary topical ophthalmic steroid (e.g.,
Pred Forte, Inflamase Forte, FML suspension).
Lotemax
(loteprednol etabonate)
Betimol (timolol)
Istalol (timolol maleate)

least one generic Timolol (e.g., Timoptic) ophthalmic product.

NSAIDs
Acuvail
(ketorolac tromethamine)
Bromday (bromfenac sodium)
Ilevro (nepafenac)
Nevanac (nepafenac)
Prolensa (bromfenac sodium)

least two formulary topical ophthalmic NSAIDs (e.g., generic
Voltaren, generic Ocufen, Acular, Acular LS) before any other
topical ophthalmic NSAIDs will be covered.

Prostaglandin Analogs
Lumigan 0.01% (bimatoprost)
Lumigan 0.03% (bimatoprost)
Travatan Z (travoprost)
Zioptan (tafluprost)
Zioptan is
limited to
a qty of 1
unit per
day

claims for a generic prostaglandin analog (i.e., generic
Xalatan).
2. If the patient fails treatment with all generic prostaglandin
analogs, then Lumigan 0.01% is the second-line formulary
alternative with prior authorization required.
claims for all formulary alternatives (generic Xalatan AND
branded Lumigan 0.01%) before a non-formulary brand drug
will be approved.
151

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Osteoporosis
Actonel (risedronate sodium)
Evista (raloxifene)

generic Fosamax in the past year.
NOTE: Exceptions will be made for patients in active treatment
for cancer. Applies to new start patients only.
osteoporosis (active or prevention).
NOTE: Applies to new start patients only.
least two generically available products in the past 90 days
before any brand otic product will be covered.
Forteo (teriparatide)
Otic Products
Cipro HC (ciprofloxacin)
Coly-mycin S (colistin/
hc ace/neo sulfate/
thonzonium bromide)
Cortisporin-TC (colistin/
hc ace/neo sulfate/
thonzonium bromide)
Proton Pump Inhibitors
Aciphex (rabeprazole)
Esomeprazole Strontium
(esomeprazole strontium)
Dexilant (dexlansoprazole)
First-Lansoprazole
(lansoprazole)
First-Omeprazole (omeprazole)
Nexium (esomeprazole)
Prevacid Solutab
(lansoprazole)
Prilosec DR Susp
(omeprazole magnesium)
Protonix Pak (pantoprazole)
Zegerid Susp
(omeprazole/sodium
bicarbonate)
Smoking Cessation
All prescription nicotine patches
(OTC patches are covered
without prior authorization)
CRITERIA
Brand
PPIs are
limited to
a qty of
30
tabs/caps
per
month
For Aciphex:
generic proton pump inhibitors (generic omeprazole,
lansoprazole, pantoprazole).
Limited to
1 course
of
therapy
per year

generic OTC nicotine patches in the past year.
For all Non-Formulary Products:

1. The patient must fail all formulary alternatives (generic PPIs
and Aciphex) based on documentation or Rx claims before a
non-formulary PPI will be approved; AND
2. Specifically for Nexium and esomeprazole strontium, the
patient must have a current documented diagnosis of Barrett's
Esophagus, Zollinger-Ellison or Erosive Esophagitis. Approved
automatically for children under 2 years of age.
3. Specifically for Dexilant, the patient must have a current
documented diagnosis of Erosive Esophagitis.
4. Specifically for liquid or soluble preparations, the patient must
have documented inability to swallow a solid dosage form.
Chantix (varenicline)
DURATION LIMITS ONLY

Coverage for smoking cessation is limited to one course of
therapy per year (the course of therapy for Chantix is routinely
defined as 24 weeks).

All Branded Non-Formulary
Oral Agents
Dipentum (olsalazine sodium)
Giazo (balsalazide)
Lialda (mesalamine)
Uceris (budesonide)

least two formulary agents (e.g., generic Azulfidine, Colazal, or
Asacol) in the past year.
152

APPENDIX D
CATEGORY/DRUG
continued
Canasa (mesalamine)
QTY
LIMIT
Limited to
a qty of
30 units
per
month
Urology
Gelnique (oxybutynin chloride)
Oxytrol Patch (oxybutynin)
Rapaflo (silodosin)
Detrol LA
(tolterodine, long-acting)
Ditropan XL
(oxybutynin, sust. release)
Enablex
(darifenacin hydrobromide)
Myrbetriq (mirabegron)
Toviaz (fesoterodine)
Vesicare (solifenacin)
Vitamins
All Brand Prenatal Vitamins
Atabex
Bal-Care DHA Essential
B-Nexa
Citranatal Assure
Citranatal B-Calm
Citranatal Harmony
Duet DHA Balanced
Gesticare DHA
Natalvit
Natelle One
Nexa Select
OB Complete
Obtrex
Obstetrix DHA
Prefera OB
Prenata
Prenate Elite, DHA, Essential
Prenexa
Preque 10
Select OB
Vitafol-Plus
Vitafol-One
Vitamed MD One
Rx/Quatrefolic
Vitamed MD Plus
CRITERIA

generic Ditropan tablets in the past year.
Limited to
a qty of
30 units
per
month

documentation or Rx claims for a generically available alpha1blocker indicated for BPH (i.e., generic Cardura, Hytrin or
Flomax).

least one generic prenatal vitamin in the past 90 days.
153

APPENDIX D
CATEGORY/DRUG
Weight Management
All medications for the treatment
of obesity
Examples:
Adipex (phentermine)
Belviq (lorcaserin)
Diethylpropion (diethylpropion)
Qsymia (phentermine/
topiramate)
Suprenza (phentermine)
Xenical (orlistat)
QTY
LIMIT
CRITERIA
1. The patient is an adult 18 years of age; AND
2
2. The patient has a body mass index (BMI) of >30kg/m , OR
2
3. The patient has a body mass index (BMI) of >27kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
4. The patient has a body mass index (BMI) of >27kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis, pregnancy, and/or lactation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician supervised diet and exercise
program consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet, and a
regular exercise program. AND
5. If the medication is a brand name product, the patient must
have tried a generically available product (i.e. phentermine,
diethylpropion) in the past year.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total
coverage.
154

APPENDIX D
CATEGORY/DRUG
Non-Sterile Compounded
Prescriptions
QTY
LIMIT
CRITERIA
1. The compounded product contains at least one FDA-approved
prescription ingredient; AND
2. Each prescription drug or active ingredient in the compounded
product is approved by the Food & Drug Administration (FDA) for
medical use in the United States; AND
3. The active prescription medication component(s) are in therapeutic
amounts; AND
4. The compounded product is not a copy of any commercially available
FDA-approved drug product; AND
5. The use for which the compounded product is being prescribed is
supported by FDA approval of the active ingredient(s), or is supported
by two or more articles from peer reviewed journals demonstrating
the safety and efficacy of the prescribed therapy for that diagnosis
and method or route of delivery; AND
6. If any prescription ingredient in the compounded product is included
in the HealthPlus Prior Authorization program, the patient must meet
the criteria designated for that prescription ingredient.
Based on limitations or exclusions in the subscriber certificate,
coverage will NOT be provided for compounds under the following
circumstances:
1. Any compound that does not contain a FDA-approved prescription
ingredient otherwise covered by the plan; OR
2. Any compound that contains a non-FDA approved or non-HealthPlus
covered prescription ingredient.
3. Compounded formulations that contain any bulk powders that are not
FDA approved or HealthPlus approved; OR
4. Compounded formulations that are being used for cosmetic purposes;
OR
5. Compounded formulations that are using prescription ingredients for
non-FDA approved indications or purposes that are not supported by
peer-reviewed literature; OR
6. Compounded formulations that may be considered investigational or
experimental; OR
7. Compounded formulations that use drugs withdrawn or removed from
the market for safety reasons; OR
8. Prescription ingredient(s) compounded for the purpose of
convenience only.
a. Exceptions include:
i. Compounded medications for those patients that cannot
swallow or have trouble swallowing and require
administration with an oral liquid, or administration by topical,
rectal or other appropriate non-oral routes;
ii. Compounded medications for those patients who have
sensitivity to dyes, preservatives, or fillers in commercial
products and require allergy-free medications as documented
in the medical record;
iii. Compounded medications for children who require
prescription medications for which there are no liquid
formulations available.
155

APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Dispense as Written DAW

Specific request for a brand
name product when a generic is
available
1. The benefit covers generic/specific OTC products when a

generically equivalent product is available.
2. In general, prior authorization is required for all brand name
drugs (when the drug is available and covered as a generic
medication). The physician may submit a prior authorization
request form for the brand name drug (when a generic
equivalent is available), but this must be substantiated by
medical necessity. If medical necessity is based on a trial and
failure of the generic medication, a prescription claim for the
generic drug must be present or chart notes documenting the
failure must be provided.
3. If a physician submits a prior authorization request form for
coverage of a brand name drug (when a generic equivalent is
available), the request is reviewed through the same process
as all other drugs that require prior authorization.
4. The member may still choose to receive a brand product
without medical necessity, but would be responsible for the
entire cost of the prescription.
Quantity Limit QL
Specific request for a dose,
quantity or duration that exceeds
the established limits
1. The physician must provide documentation of the clinical

rationale for requesting a dosage, quantity, or duration of
medication greater than the criteria specified in the formulary.
2. If the dosage exceeds the manufacturer product
labeling/prescribing information, the physician must submit
documentation of two articles from peer reviewed journals
demonstrating the safety and efficacy of the prescribed
therapy.
156

APPENDIX D
HEALTHPLUS PARTNERS
High Risk Medications in the Elderly (66 years old)
Based on the availability of safer alternatives, the following medications have been added to the Prior Authorization Program for members 66 years of age and
older for HealthPlus Partners (Medicaid) with the following criteria:
1) The recommended alternative treatment(s) are not appropriate, are contraindicated or are unsafe for the patient based on specific documented patient
circumstances, OR
2) The patient has a documented trial and failure (or prescription claims) for the recommended alternative treatment(s).
Name
Concern
Estrogens all oral and

topical patches only
(Premarin, estradiol, Estratest,
Vivelle-Dot, etc.)
Promethazine (Phenergan)
Evidence of breast/Endometrial cancer;

No cardio or cognitive protection in older women
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Thyroid USP
(Armour Thyroid, Desiccated)
Cardiac adverse effects
Glyburide (Micronase)
Glyburide-Metformin
(Glucovance)
Chlorpropamide (Diabinese)
Hydroxyzine (Vistaril, Atarax)
Cyclobenzaprine (Flexeril)
Orphenadrine (Norflex)
Chlorzoxazone (Parafon Forte)
Methocarbamol (Robaxin)
Skelaxin (Metaxalone)
Trimethobenzamide (Tigan)
Ketorolac (Toradol)
Indomethacin
Dipyridamole (Persantine)
Associated with an increased risk of hypoglycemia compared

to other agents
Diabetes: Glucotrol, Amaryl, Metaglip
Anticholinergic effects, urinary retention, confusion, sedation

Anticholinergic effects, sedation, cognitive impairment,
weakness, urinary retention

Physiotherapy: correct seating & footwear
Spasticity: Baclofen, Zanaflex. Treat underlying
problems
Extrapyramidal side effects, poor efficacy

GI bleeding
Nausea: Zofran, Compazine, or Reglan

2
2
Pain: Tylenol , Motrin , Norco
Orthostatic hypotension, poor efficacy
For secondary prevention of non-cardioembolic

stroke or TIA: Plavix, Aggrenox, Aspirin
Anticholinergic effects (i.e., urinary retention, confusion,

sedation)
Hot flashes: non-pharmacological therapy, Zoloft,

Paxil, Effexor
2
Bone density: Calcium with vitamin D , Fosamax,
1
Boniva, Evista
1,2
2
1
Antiemetic: Antivert, Zofran
Cough: Dextromethorphan
Depends on site of infection, culture, and
sensitivity.
1
Bactrim, Vibramycin, Azithromycin, Fluoroquinolone
Levothyroxine (LT4): Synthroid, Levoxyl
Drug may require prior authorization or may have limited coverage depending on members benefit plan, 2 Available OTC
157
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
SPECIALTY INJECTABLE PRIOR AUTHORIZATION CRITERIA

Brand (generic) Name
Antihyperlipidemics
Juxtapid (lomitapide
mesylate)
Criteria
1. The patient must be over 18 years old; AND
2. The patient must have a previous Rx claim
for a HMG-CoA reductase inhibitor (i.e.
statin); AND
3. The patient must have clinical and/or
laboratory determined presence of
homozygous familial hypercholesterolemia.
Acceptable documentation includes*:
a. Chart documentation confirming the
presence of xanthomas before the age
of 10, an untreated LDL of >500mg/dL, a
treated LDL of 300mg/dL, or a treated
non-HDL 330mg/dL; OR
b. Genetic testing showing 2 mutated
alleles at the LDL-Receptor, ApoB,
PCSK9, or ARH adaptor protein gene
locus; AND
4. If the patient is female and of childbearing
potential, a negative pregnancy test must
be completed just prior to initiating therapy;
AND
5. The patient must have ALT, AST, alkaline
phosphate, total bilirubin, INR, and SCr
testing obtained just prior to initiating
therapy; AND
6. The results from liver function tests must
be normal (no clinically significant or
unexplainable abnormalities); AND
7. The dose must be appropriate based on
manufacturer recommendations.
Duration of Approval
Approval of prior
authorization requests is
limited to 12 months.
Notes
Recent lab results (within
3 months) are required
for each renewal.
158
HEALTHPLUS
APPENDIX D
Antihyperlipidemics,
continued
Kynamro (mipomersen)
1.
2.
3.
4.
5.
6.
Criteria
The patient must be over 18 years old;
AND
The patient must have a previous Rx claim
for a HMG-CoA reductase inhibitor (i.e.
statin); AND
The patient must have clinical and/or
laboratory determined presence of
homozygous familial hypercholesterolemia.
Acceptable documentation includes*:
a. Chart documentation confirming the
presence of xanthomas before the age
of 10, an untreated LDL of >500mg/dL,
a treated LDL of 300mg/dL, or a
treated non-HDL 330mg/dL; OR
b. Genetic testing showing 2 mutated
alleles LDL-Receptor, ApoB, PCSK9, or
ARH adaptor protein gene locus; AND
The patient must have ALT, AST, alkaline
phosphate, total bilirubin, INR, and SCr
testing obtained just prior to initiating
therapy; AND
The results from liver function tests must
be normal (no clinically significant or
unexplainable abnormalities); AND
The dose must be appropriate based on
manufacture recommendations
Approval of prior
authorization requests is
limited to 12 months.
Notes
Recent lab values (within
3 months) are required
for each renewal.
Discontinuation of
treatment should be
considered if patient
does not have a
sufficient response to
warrant the potential risk
of liver toxicity after 6
months.
159
HEALTHPLUS
APPENDIX D
Antivirals
Fuzeon (enfuvirtide)
Criteria
1. For new starts, patient must have a
diagnosis of HIV-1; AND
2. Fuzeon must be used in combination with
other anti-retroviral agents; AND
3. Patient must be anti-retroviral treatmentexperienced; AND
4. Evidence of HIV-1 replication despite
ongoing anti-retroviral therapy; AND
5. Patient or caregiver is able to demonstrate
appropriate techniques for administration of
Fuzeon.
Incivek (telaprevir)
1. Patient must have a documented diagnosis

of Hepatitis C (HCV) genotype 1, AND
2. Patient has concurrent therapy with both
ribavirin and pegylated interferon, AND
3. Patient has not received HCV treatment
with a protease inhibitor in the past, AND
4. Viral loads (HCV-RNA test) must be drawn
at 4 and 12 weeks after starting therapy.
Treatment is considered futile and prior
authorization will be rescinded if HCV-RNA
level is >1000 IU/ml after 4 weeks.
5. Initial duration of approval is for 6
weeks. Authorization is renewed for an
additional 6 weeks provided HCV-RNA
levels at week 4 are not indicative of
treatment futility.
New Starts Only
Long-term
Notes
Is included in the
Mandatory Specialty
Program.
Utilization will be monitored
to prevent deviation from
recommended dosing
guidelines.
160
HEALTHPLUS
APPENDIX D
Antivirals, continued
Victrelis (boceprevir)
Infergen
(interferon alfacon-1)
Criteria
1. Patient must have a documented diagnosis
of Hepatitis C (HCV) genotype 1, AND
2. Patient has concurrent therapy with both
ribavirin and pegylated interferon, AND
3. Patient has not received HCV treatment
with a protease inhibitor in the past, AND
4. Viral loads (HCV-RNA test) must be drawn
at 12, 24, and 36 weeks after starting
therapy. Treatment is considered futile and
prior authorization will be rescinded if
HCV-RNA level is >100IU/ml after 12 or
24 weeks.
5. Initial duration of approval is for 14 weeks.
Authorization is renewed for an additional
18 weeks (or an additional 30 weeks if
patient has documented cirrhosis) provided
HCV-RNA levels at week 12 are not
indicative of treatment futility.
New Starts Only
1. The patient must be >18 years of age, AND
2. A diagnosis of hepatitis C, AND
3. Documented failure of, or intolerance to,
interferon alfa (Intron A, Roferon A, or
Pegasys).
(Treatment failure is defined as an increase in
aminotransferase or viral RNA levels while on,
or after, interferon alfa-2b therapy.)
Initial authorization approved

for 6 months.
Renewal approved for 6
months.
-renewal permitted if the
patient has Genotype 1
HCV; or has initial viral load
>2 million copies/mL.
Notes
Interferons are usually

dosed three times a week
for 6 to 18 months.
Treatment nave patients
usually start with the 9mcg
dose and non-treatment
nave patients usually start
with the 15mcg dose.
161
HEALTHPLUS
APPENDIX D
Intron A
(interferon alpha-2b)
Roferon A
(interferon alpha-2a)

Pegasys, Proclick
(pegylated interferon alfa-2a)
Peg-Intron
(pegylated interferon alfa-2b)
Criteria
1. For diagnosis of hairy cell leukemia, malignant
melanoma, follicular lymphoma, AIDS related
Kaposi's Sarcoma and CML, patients must be
>18 years of age; OR
2. For the diagnosis of condylomata acuminata,
documented failure of, or intolerance to,
traditional treatment modalities (e.g., podofilox,
imiquimod, acid-therapy, or surgical options); OR
3. For the diagnosis of chronic hepatitis B, patients
must have documented liver disease and
hepatitis B viral replication; OR
4. For the diagnosis of chronic hepatitis C, allow 6month initial authorization and 6-month renewal
permitted if the patient has Genotype 1 HCV; or
has initial viral load >2 million copies/mL.
1. Patient has diagnosis of Hepatitis B or C, AND

2. Peg-Intron requires prior authorization for
documented failure of or intolerance to Pegasys,
AND
3. Approval is for 48 weeks provided that HCVRNA levels are not indicative of treatment futility.
Viral loads (HCV RNA test) must be drawn to
evaluate treatment futility.
a. For pegylated interferon in combination
with ribavirin, prior authorization will be
rescinded if HCV-RNA is detectable after
24 weeks.
b. For combination therapy involving a
protease inhibitor, patient must meet
criteria associated with the protease
inhibitor. Prior authorization will be
rescinded if:
1. HCV-RNA level is >1000 IU/ml after 4
weeks of combination therapy with
Incivek
2. HCV-RNA level is >100 IU/ml after 12
or 24 weeks of combination therapy
with Victrelis
New Starts Only
Approvals for diagnosis of
condylomata acuminata
should be approved for 4
months.
Notes
Approvals for all other

diagnoses should be
approved for 6 months.
Initial authorization approved

for 6 months.
Renewal approved for 6
months.
-renewal permitted if the
patient has Genotype 1
HCV; or has initial viral load
>2 million copies/mL.
162
HEALTHPLUS
APPENDIX D
Synagis (palivizumab)
Criteria
1. Infants and children younger than 2

years of age with documented chronic lung
disease (CLD), formerly known as
bronchopulmonary dysplasia (BPS), who
have required medical therapy (e.g.,
supplemental oxygen, bronchodilator,
diuretics, or corticosteroid therapy) for their
CLD within 6 months before the anticipated
RSV season may receive a maximum of 5
monthly doses; OR
2. Infants born at 28 weeks gestation (up to and
including 28 weeks, 6 days) or earlier without
CLD and who are 12 months of age or younger
may receive a maximum of 5 monthly doses; OR
3. Infants born between 29 and 32 weeks gestation
(29 weeks, 0 days thru 31 weeks, 6 days or less)
or earlier without CLD and who are 6 months of
age or younger may receive a maximum of 5
monthly doses; OR
4. Infants born between 32 to 35 weeks (32 weeks,
0 days thru 34 weeks, 6 days) gestation without
CLD, are 3 months of age or younger, and have
at least 1 of the following risk factors may
receive a maximum of 3 monthly doses or until 3
months of age (whichever comes first):
a. Infant is attending child care
b. Infant has a sibling younger than 5 years
of age OR
5. Infants and children who are 2 years or younger
with hemodynamically significant cyanotic or
acyanotic congenital heart disease (CHD) or
severe immunodeficiencies may receive a
maximum of 5 doses.
6. Infants and children who have either congenital
abnormalities of the airway or a neuromuscular
condition that compromises handling of
respiratory secretions may receive a maximum
of 5 doses during the first year of life.
Approved for 5 months interval,

during the region's RSV
season, beginning as soon as
October and ending as late as
April.
Notes
163
HEALTHPLUS
APPENDIX D

Bisphosphonates
Reclast (zoledronic acid)
Cystic Fibrosis Treatments

Kalydeco (ivacaftor)
Criteria
1. Creatinine clearance is > 35 ml/min; AND
2. Documented failure of, or intolerance to, an
oral bisphosphonate agent; AND
3. Patient has a diagnosis of osteoporosis or is
postmenopausal with osteopenia as
indicated by a t-score <-1; OR
4. Diagnosis of Pagets disease; OR
5. Patient is considered high-risk (e.g., recent
low-trauma hip fracture) and Reclast is
indicated for secondary fracture
prophylaxis.
1. Patient has a diagnosis of cystic fibrosis

with documentation of a G551D mutation
in the CFTR gene; AND
2. Patient must be 6 years of age or older;
AND
3. Patient must have a recent (within the
Last 3 months) liver function panel.
Note: Kalydeco is carved out to MDCH for
HealthPlus Partners Medicaid members.
Approved for 1 year
Dose optimization not to
exceed 5mg once a year
(with the exception of
Pagets disease)
Notes
Retreatment may be
necessary for patients with
Pagets disease who have
relapsed, so there is no
defined dosing frequency.
When treating Pagets
disease, patients should
receive 1500 mg elemental
calcium daily in divided
doses (750 mg two times a
day, or 500 mg three times
a day) and 800 IU vitamin
D daily, particularly in the 2
weeks following
administration to prevent
hypocalcemia.
Approved for 1 year
For osteoporosis treatment

(postmenopausal, in men,
and glucocorticoid
induced), concomitant
treatment with an average
of at least 1200 mg calcium
and 800-1000 IU vitamin D
daily is recommended
(dietary + supplemental).
Quantity is limited to 60
units per 30 days.
164
HEALTHPLUS
APPENDIX D
Enzymes
Ceredase (alglucerase)
Cerezyme (imiglucerase)
VPRIV
(velaglucerase alfa)
Criteria
1. The patient must have a diagnosis of Type
1 (non-neuronopathic or adult) Gaucher's
disease with evidence of at least 1 of the
following:
- Moderate to severe anemia OR
- Thrombocytopenia OR
- Bone disease OR
- Hepatomegaly OR
- Splenomegaly
Long-term
Evaluate initially at 3 month
intervals for maintenance
dose reductions/
development of sensitivity
Fabrazyme (agalsidase)
1. The patient must have diagnosis of Fabry

disease
Evaluate in 3 months for

response/development of
sensitivity
Myozyme
(alglucosidase alfa)
1. The patient must have diagnosis of Pompe

disease (GAA deficiency)
Evaluate in 3 months for

response/development of
sensitivity
Notes
Recommended dose:
Ceredase and Cerezyme
Initial dosage may begin at
2.5 units/kg of body weight
infused 3 times a week up
to as much as 60 units/kg
administered as frequently
as once a week or as
infrequently as every 4
weeks.
Precaution: Patients may
develop antibodies to
Ceredase
VPRIV
Dose 60units/kg IVPB
every other week.
Recommended dose:
1mg/kg infused once every
2 weeks
Pt should receive
antipyretics prior to infusion
Precaution:
Most patients will develop
IgG antibodies to
Fabrazyme; physicians
should periodically monitor
IgE levels/Fabrazyme
sensitivity
Recommended dose:
20 mg/kg body weight
infused every 2 weeks
Precaution:
Risk of hypersensitivity and
sudden cardiac death
165
HEALTHPLUS
APPENDIX D
Erythrocyte Stimulating
Agents
Aranesp (darbepoetin alfa)
Epogen (epoetin alfa)
Procrit (epoetin alfa)
Growth Factor,
Recombinant Insulin-like
Increlex (mecasermin [rDNA
origin] injection)
Criteria
1. The patient must have a diagnosis of
anemia associated with
a. chronic renal failure, OR
b. cancer treated with chemotherapy, OR
c. zidovudine-treated HIV infection, OR
d. hepatitis C, OR
e. chronic disease, OR
f. prematurity, OR
g. myelodysplastic syndrome, OR
h. rheumatoid arthritis, AND
2. Hgb level is < 11g/dL.
OR
1. Treatment is needed to reduce the need for
allogenic blood transfusion prior to surgery
for anemic patients (Hgb >10 to < 13g/dL)
who are at high risk for perioperative blood
loss from elective, non-cardiac, nonvascular surgery.
1. Patient has a diagnosis of primary
IGF-1 deficiency or GH gene deletion, AND
2. Increlex is prescribed by or after
consultation with a pediatric endocrinologist,
AND
3. Patient is 2 years to 18 years of age, AND
4. Epiphyses are open, AND
5. Patients bone age is < 16 years for
males or < 14 years for females
1 year
Notes
For each of the conditions
listed (except for allogenic
blood transfusion), therapy
is to be discontinued when
Hgb level > 11g/dL OR
after 8 weeks of therapy if
there has been no
response as measured by
hemoglobin levels.
Starting dose: 0.04 to 0.08

mg/kg (40 to 80 mcg/kg)
subcutaneously twice daily.
If well-tolerated for at least
one week, the dose may be
increased by 0.04 mg/kg
per dose, to the maximum
dose of 0.12 mg/kg given
twice daily.
Funduscopic exam is
recommended at the
initiation
Limitations of use:
Increlex is not a
substitute to GH for
approved GH
indications.
166
HEALTHPLUS
APPENDIX D
Growth Hormones
Norditropin Products
(somatropin)
All other somatropin products
Egrifta
Genotropin
Humatrope
Omnitrope
Nutropin
Nutropin AQ
Nutropin AQ NuSpin
Saizen
Serostim
Tev-Tropin
Zorbtive
Criteria
Pediatric patients:
1. Diagnosis of chronic renal failure and growth
retardation; OR
2. Diagnosis of hypothalamic-pituitary lesions or
panhypopituitarism; OR
3. Diagnosis of growth hormone (GH) deficiency; AND
Patient must meet 3 of the 4 following criteria for
documentation of growth failure:
a. Height is >2 standard deviations below the mean
for age and sex (less than 5th percentile for age);
AND
b. Growth velocity is subnormal (age specific growth
rate at less than the 25th percentile); AND
c. Bone age is delayed; AND
d. Documented failure of at least one GH stimulation
tests (defined as a peak growth hormone level of
less than 10mcg/L after GH stimulation by insulin,
arginine, clonidine, glucagon, or levodopa). GH
stimulation tests not required with diagnosis of
Turner Syndrome, Noonan Syndrome, or PraderWilli Syndrome; OR
4. Diagnosis of Idiopathic Short Stature (ISS); AND
a. Height is >2 standard deviations below the mean
for age and sex (less than 5th percentile for age);
AND
b. Documentation that epiphyses are not closed.
Adult patients:
1. Diagnosis of HIV and an unintentional weight loss of
10% over 12 months, 7.5% over 6 months or a BMI
<20mg/kg; OR
2. Diagnosis of hypothalamic-pituitary lesions or
panhypopituitarism; OR
3. Documented GH deficiency; OR
4. Diagnosis of Short Bowel Syndrome; AND
5. Patient is currently receiving specialized nutrition
support directed by a healthcare professional (Total
Parenteral Nutrition (TPN), Peripheral Parenteral
Nutrition (PPN), or high-complex carbohydrate, low-fat
diet)
Both Pediatric and Adult patients:
1. Patient must have documented failure of, or
intolerance to Norditropin before a non-preferred
recombinant human growth hormone product will be
approved.
Approved for 1 year
Documentation required for
pediatric renewal:
1. Growth rate has exceeded
2.5cm/year
2. Epiphyses remain open
Notes
Contraindicated for:
-Diabetic retinopathy
-Epiphyseal closure
-Respiratory insufficiency
-Sleep Apnea
-Product specific
hypersensitivities (Cresol,
Benzyl Alcohol,Glycerin)
-Active neoplastic disease
-Intracranial hypertension
167
HEALTHPLUS
APPENDIX D
Hormones
Lupron Depot (leuprolide)
Criteria
1. The patient must have a diagnosis of uterine
fibroid tumors, endometriosis, ovarian
cancer or prostate cancer; AND
2. The patient must be 18 years of age or
older.
Lupron Depot-Ped
(leuprolide)
1. The patient has Central Precocious Puberty

(CPP) and displays onset of secondary
sexual characteristics earlier than age 8 for
girls and 9 for boys; AND
2. The patient is less than 13 years old; AND
3. Diagnosis is confirmed by a pubertal
gonadal sex steroid level or a pubertal LH
response to stimulation by native GnRH;
AND
4. Tumor has been ruled out by lab tests, CT,
MRI or ultrasound.
Notes
168
HEALTHPLUS
APPENDIX D
Immunomodulators
Actemra (tocilizumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be
initiated before treatment with Actemra; AND
3. Patient has no active infection (including
bacterial sepsis, tuberculosis, invasive fungal
and other opportunistic infections; AND
3
4. Patient has ANC >2000/mm AND Platelets
3
>100,000/mm AND ALT or AST <1.5x upper
limits of normal; AND
5. Patient is not also receiving TNF antagonists, or
other biologics (Enbrel, Humira, Remicade,
Simponi, Cimzia, Kineret, Rituxan, Orencia), or
live vaccines and diagnostic specific criteria are
met.
Notes
The dose of Actemra is
4mg/kg IV every 4 weeks;
may increase to 8 mg/kg IV
based on clinical response
(Max: 800mg per infusion).
Infuse over 60 minutes with
infusion set.
Rheumatoid Arthritis:
6. Diagnosis of moderate to severe rheumatoid
arthritis; AND
7. Patient has documented failure of, or intolerance
to, both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
8. The patient is not physically able to administer or
is not an appropriate candidate for a
subcutaneously administered biologic agent
(e.g., Humira, Enbrel); AND
9. Documented failure of, intolerance or
contraindication to, two other disease modifying
antirheumatic drugs (DMARDS) (e.g.,
methotrexate, sulfasalazine, azathioprine, or
hydroxychloroquine).
Juvenile Idiopathic Arthritis (JIA)/Juvenile
Rheumatoid Arthritis (JRA) / polyarticular
juvenile idiopathic arthritis (PJIA):
6. Patient is > 2 years old; AND
7. Patient has a diagnosis of active systemic
JIA/JRA/PJIA. AND
8. Patient has documented failure of, or
intolerance to, both formulary subcutaneous
biologic agents (e.g., Humira and Enbrel).
169
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Amevive (alefacept)
Criteria
1. Documentation of a negative TB test before
initiating therapy; AND
2. Patient does not have a diagnosis of human

immunodeficiency virus (HIV) infection or
acquired immunodeficiency syndrome (AIDS);
AND
influenza, systemic fungal or bacterial infections,
or acute hepatitis B or C viral infections); AND
4. Documentation of CD4+ T-cell count
>500cells/uL; AND diagnosis specific criteria are
met.
Approval for 6 months
Notes
Amevive has not been
studied for use in pediatric
populations; geriatric
populations have not been
large enough to establish
safety or efficacy data.
Data on retreatment
beyond 2 cycles are
limited.
Psoriasis:
5. Diagnosis of chronic moderate to severe plaque

psoriasis or scalp psoriasis; AND

contraindication to, at least 2 traditional therapies
(e.g., PUVA, UVB, methotrexate, or
cyclosporine); AND
7. Prescription is written by a dermatologist; AND
8. Dose of Amevive is 15 mg IM or 7.5 mg IV once
weekly for 12 weeks.
Psoriatic arthritis:
contraindication to, methotrexate (MTX) therapy;
AND
6. Documented failure of, or intolerance to, one
other disease modifying antirheumatic drugs
(DMARDS) (e.g., sulfasalazine, azathioprine,
hydroxychloroquine). AND
to both formulary subcutaneous biologic agents
is not an appropriate candidate for a
(e.g., Humira, Enbrel); AND
9. Dose of Amevive is 15 mg IM or 7.5 mg IV once
weekly for 12 weeks.
170
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Berinert (C1 esterase
inhibitor)
Cinryze (C1 esterase
inhibitor)
Firazyr (icatibant)
Criteria
1. The patient must have a diagnosis of
hereditary angiodema or C1 inhibitor
deficiency
2. The prescription must be written by an
allergist, immunologist, or hematologist
3. For Firazyr, the patient must be 18 years of
age or older.
Cimzia
(certolizumab pegol)
1. A negative TB test before initiating therapy;

OR
initiated before treatment with Cimzia; AND
influenza, systemic fungal or bacterial
infections, or acute hepatitis B or C viral
infections); AND
4. Patient is not also receiving Orencia,
Kineret, Enbrel, Remicade or other anti-TNF
therapy; AND diagnosis specific criteria are
met.
Crohns Disease:
5. Diagnosis of moderate to severe active
Crohns disease with documented failure of,
intolerance or contraindication to,
conventional therapy (azathioprine,
mesalamine, mercaptopurine, sulfasalazine,
methotrexate, corticosteroids).
intolerance to, Humira.
5. Diagnosis of moderately to severely active
rheumatoid arthritis. AND
intolerance to Humira and Enbrel.
Approved for 1 year
Notes
1. Cimzia is given as two

subcutaneous injections
of 200 mg initially, and
again at weeks 2 and 4.
2. In patients who obtain a
clinical response, the
recommended
maintenance regimen is
400 mg every four
weeks.
Cimzia has not been
studied for use in pediatric
populations; geriatric
populations have not been
large enough to establish
safety or efficacy data.
171
HEALTHPLUS
APPENDIX D
Immunomodulators ,
continued
Enbrel (etanercept)
1.
2.
3.
4.
Criteria
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Enbrel; AND
Patient has no active infection (including
infections); AND
Patient is not also receiving Orencia,
Kineret, Humira, Remicade or other antiTNF therapy; AND diagnosis specific
criteria are met.
Approved for 1 year
Dose Optimization not to
exceed 50mg twice a week
Notes
Patients with a latex allergy
or sensitivity should not
handle the prefilled syringe
or autoinjector syringe
since the needle cap(s)
contain latex.
Arthritis:
5. Diagnosis of rheumatoid arthritis (RA),
juvenile RA (JRA), juvenile idiopathic
arthritis (JIA), or psoriatic arthritis (JRA/JIA
approved for ages 2-17).
Psoriasis:
5. Diagnosis of plaque psoriasis; AND
6. Prescription is written by a dermatologist;
AND
contraindication to, at least 2 traditional
therapies (e.g., PUVA, UVB, methotrexate,
or cyclosporine).
Spondylitis:
5. Diagnosis of ankylosing spondylitis or
juvenile spondyloarthropathy.
172
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Humira (adalimumab)
Criteria
initiated before treatment with Humira; AND
4. Patient is not also receiving Orencia, Kineret,
Enbrel, Remicade or other anti-TNF therapy;
AND diagnosis specific criteria are met.
Approved for 1 year
Notes
handle the needle cover of
the syringe as it contains
latex.
Ankylosing Spondylitis OR Psoriatic Arthritis:

5. Diagnosis of ankylosing spondylitis or psoriatic
arthritis.
6. The dose of Humira is 40mg administered
subcutaneously every other week.
Crohns Disease:
5. Diagnosis of moderate to severe Crohns
disease; AND
contraindication to, conventional therapy
(azathioprine, mesalamine, mercaptopurine,
sulfasalazine, methotrexate, corticosteroids);
AND
7. The dose of Humira is 160mg on day 1, 80mg on
day 15 and then 40mg every other week starting
on day 28.
Rheumatoid Arthritis (JRA):
5. Patient is 4 years of age and older; AND
6. Patient has moderately to severely active
polyarticular JIA/JRA.
7. The dose of Humira for patients:
- 15 kg (33 lbs) to <30 kg (66 lbs) is 20 mg
administered subcutaneously every other week.
- 30 kg (66 lbs) is 40 mg administered
subcutaneously every other week.
173
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Humira (adalimumab),
continued
Criteria
Notes
Psoriasis:
5. Diagnosis of chronic moderate to severe plaque
psoriasis; AND
contraindication to, at least 2 traditional therapies
(e.g. PUVA, UVB, methotrexate, or
cyclosporine); AND
7. Prescription is written by a dermatologist.
8. The dose of Humira is 80 mg subcutaneously
followed by 40 mg every other week starting 1
week after the initial dose.
5. Diagnosis of rheumatoid arthritis; AND
6. The dose of Humira is 40mg every other week.
Ulcerative Colitis:
5. Diagnosis of moderate-to-severe ulcerative
colitis; AND
contraindication to, conventional therapy
(azathioprine, mesalamine, mercaptopurine,
sulfasalazine, methotrexate, corticosteroids);
AND
7. The dose of Humira is 160mg on day 1, 80mg on
day 15 and then 40mg every other week
thereafter.
Documentation of clinical remission must be
submitted to continue therapy beyond 12 weeks.
174
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
(FDA approved indications

vary by product)
Immune Globulin (IM)
GamaSTAN
Immune Globulin (IV)
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
Immune Globulin (SQ)
Gamunex-C
Hizentra
Criteria
Primary Immunodeficiencies [X-linked
(congenital) agamma-globulinemia, X-linked
(congenital) immunodeficiency with hyper-IgM,
Hypogammaglobulinemia, Common variable
immunodeficiency, and Combined
immunodeficiency syndromes including:
Wiskott-aldrich syndrome; severe combined
immunodeficiency syndrome (SCIDs)]
1 year
Notes
1. A serum trough IgG of 400 mg/dl.

(In rare circumstances where serum trough
level is recommended >600 mg/dl,
documentation should support rationale)
Selective IgG subclass deficiencies with
severe infection
including Specific Antibody Deficiency (SAD)
1 year
1. Documentation of IgG subclass deficiency

(Appendix 1), -or2. Documentation of severe polysaccharide
non-responsiveness (inability to make IgG
antibody against diphtheria and tetanus
toxoids, pneumococcal polysaccharide
vaccine, or both), -or3. Documentation of antigen testing with less
than 4 fold increase in specific antibody titer
and lack of protective antibody titer
(specific IgG antibody titer <1.3 mcg/ml),
-and4. Documented trial and failure of an antibiotic
within the last year (for initial authorization
only).
175
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued

vary by product)
GamaSTAN
Immune Globulin (IV),
continued
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
Gamunex-C
Hizentra
Criteria
Idiopathic Thrombocytopenia Purpura (ITP)
Acute ITP
1. Platelet count <50,000/ul and rapid rise in
platelet count is necessary prior to surgery,
or to avoid/defer splenectomy, or patient is
at risk for acute bleeding.
Chronic ITP
1. Platelet count is low < 30,000/ul, -and2. Age 10 years of age, -and3. Duration of illness > 6 months, -and4. Documented failure of, intolerance, or
contraindication to at least 3 of the
following: corticosteroids, rituximab,
danazol, colchicine, dapsone,
cyclophosphamide, azathioprine,
mycophenolate, cyclosporine,
chemotherapy -or5. Splenectomy
ITP in pregnancy
rd
1. Platelets <30,000/ul in 3 trimester, -or2. Previously delivered infants with
autoimmune thrombocytopenia and platelet
counts <75,000/ul during current
pregnancy, -and3. Documented failure of, intolerance, or
contraindication to corticosteroids, -or4. Splenectomy
Kawasaki syndrome/Mucocutaneous Lymph
Node Syndrome (MCLS)
1. Therapy is started within 10 days of fever, and2. Concurrent aspirin administration.
Acute ITP
1 week
Notes
Chronic ITP
1 year
ITP in pregnancy
1year
1 week
176
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
4 months

continued
Criteria
Allogeneic (genetically similar donor) bone
marrow transplant
1. Therapy is started within the first 100 days
post transplant, -or2. Patient is 100 days post transplant, -and3. IgG levels < 400 mg/dl (exception made for
patients who underwent transplantation for
multiple myeloma or malignant
macroglobulinemia because total IgG
concentration is affected by their underlying
paraproteinemia, -or4. Patient has history of CMV or RSV.
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
Chronic Lymphocytic Leukemia (CLL)

1. Immunoglobulin (IgG) level of < 600 mg/dl, and2. Documented trial and failure of an antibiotic
within the last year (for initial authorization
only)
1 year
Pediatric HIV infection

1. Documentation of 2 bacterial infections in
a 1 year period, -or2. Patient has HIV-associated
thrombocytopenia, -or3. Patient has bronchiectasis, -or3
4. Documentation of T4 cell count 200 /mm
1 year

vary by product)
GamaSTAN

Gamunex-C
Hizentra
Notes
177
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued

vary by product)
GamaSTAN
continued
Criteria
Acute and Chronic Inflammatory
Demyelinating Polyneuropathy
(CIDP)/Guillian-Barre Syndrome (GBS)
For Chronic CIDP:
1. Documented failure of, intolerance, or
contraindication to prednisone or
azathioprine, -or2. Documented plasma exchange.
Not limited
For GBS
1. Patient must initiate within first four weeks of
illness.
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
Post transfusion purpura

1. Platelet count less than 10,000/ul, -and2. Infusion must be within 14 days of bleeding
post transfusion, -and3. Documented failure of, intolerance, or
contraindication to corticosteroids, -or4. Documented plasma exchange.
1 month
(to account for relapse)
Multiple Sclerosis (MS)

1. Patient must have relapse-remitting MS only
(not primary or secondary progressive MS),
-and2. Documented treatment with, intolerance, or
contraindication to any interferon therapy
(Betaseron, Avonex, or Rebif).
1 year
Gamunex-C
Hizentra
Notes
178
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued

vary by product)
GamaSTAN
continued
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
Criteria
Myasthenia Gravis (MG) and Lambert-Eaton
(LE) Myasthenia
MG:
following: anticholinesterases (eg.,
Mestinon, Prostigmin), corticosteroids,
cyclosporine, cyclophosphamide, or
azathioprine.
LE :
contraindication to anticholinesterases (eg.
Mestinon,Prostigmin), -or2. Documented plasma exchange.
1 week
Dermatomyositis and Polymyositis

following: corticosteroids, methotrexate,
azathioprine, cyclophosphamide, or
cyclosporine.
6 months
Systemic Lupus Erythematosus (SLE)

1. Documentation of severe (solid organ
involvement), active SLE, -and2. Documented failure of, intolerance, or
following: corticosteroids. methotrexate,
azathioprine, or cyclophosphamide
Not limited
Notes

Gamunex-C
Hizentra
179
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Criteria
Autoimmune mucocutaneous blistering
diseases, including Pemphigus vulgaris,
Pemphigus foliaceus, Bullous pemphigoid,
Mucous membrane pemphigoid,
Epidermyolysis bullosa
contraindication to atleast 2 of the following:
corticosteroids. methotrexate, azathioprine,
or cyclophosphamide, -or2. Documentation of rapidly progressive
disease in which a clinical response could
not be affected quickly enough using
prerequisite therapies.
6 months
Multifocal Motor Neuropathy

1. Diagnosis is required
Not limited
Stiff Person Syndrome

Not limited
Not limited
Fetal/neonatal alloimmune
thrombocytopenia (FAIT/NAIT)
Gamunex-C
Hizentra
Hemolytic disease of the newborn

Not limited
Hemolytic Uremic Syndrome

Not limited
Complications of transplanted organs

(including solid organ and bone marrow)
Not limited

vary by product)
GamaSTAN
continued
Carimune NF
Flebogamma
Gammagard
Gammagard S/D
Gammaked
Gammaplex
Gamunex
Privigen
Notes
180
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Kineret (anakinra)
1.
2.
3.
4.
5.
Criteria
The patient must be > 18 years of age;
AND
A negative TB test before initiating therapy;
OR
Treatment for latent TB infections must be
initiated before treatment with Kineret; AND
Patient has no active infection (including
infections); AND
Patient is not also receiving Orencia,
Enbrel, Remicade or other anti-TNF
therapy; AND diagnosis specific criteria are
met.
Approved for 1 year
Notes
handle the Kineret needle
cover as it contains latex.
Kineret should not be given
by intravenous
administration or
intramuscular
administration.
methotrexate; AND
another disease modifying antirheumatic
drug (DMARD) (e.g., azathioprine,
leflunomide, cyclosporine, penicillamine,
sulfasalazine); AND
intolerance to Humira and Enbrel; AND
10. The dose of Kineret is 100mg administered
subcutaneously once daily.
181
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Orencia (abatacept)
Criteria
OR
initiated before treatment with Orencia;
AND
infections); AND
4. Patient is not also receiving Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF
therapy; AND
5. For infused Orencia, the patient has
documented failure of, intolerance to, or is
not physically able to administer the
subcutaneous formulation of Orencia; AND
diagnosis specific criteria are met.
Arthritis:
6. Diagnosis of moderate to severe rheumatoid
arthritis; OR
7. Diagnosis of moderate to severe
polyarticular juvenile rheumatoid arthritis
(JRA)/juvenile idiopathic arthritis (JIA);
(JRA/JIA approved for > 6 years of age).
8. Patient has documented failure of,
intolerance or contraindication to, two other
disease modifying antirheumatic drugs
(DMARDS) (e.g., methotrexate,
sulfasalazine, azathioprine, or
hydroxychloroquine); AND
intolerance to both formulary subcutaneous
Approved for 1 year
Notes
182
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Remicade (infliximab)
Criteria
initiated before treatment with Remicade; AND
Enbrel, or Humira or other anti-TNF therapy;
AND
5. The dose of Remicade is not to exceed 10mg/kg;
Approved for 1 year
Notes

arthritis; AND
to, or inability to inject a formulary
subcutaneously administered anti-TNF agent
(e.g., Humira, Enbrel).
Crohns Disease:
7. Patient has a diagnosis of moderate to severe
Crohns disease; OR
8. Diagnosis of Crohns disease with draining
enterocutaneous fistulae; AND
mesalamine and corticosteroids and 6mercaptopurine or azathioprine; AND
intolerance to, or inability to inject a formulary
subcutaneously administered anti-TNF agent
(e.g., Humira).
183
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Remicade (infliximab)
continued
Criteria
Notes
Psoriasis:
6. Prescription is written by a dermatologist; AND
7. Patient has diagnosis of chronic, severe (i.e.,
extensive and/or disabling) plaque psoriasis;
AND
8. Documented failure of, or intolerance to, at least
2 traditional therapies (e.g., PUVA, UVB,
methotrexate, or cyclosporine); AND
10. The patient is not physically able to administer
or is not an appropriate candidate for a
formulary subcutaneously administered biologic
agent (e.g., Humira, Enbrel).
to, two other disease modifying antirheumatic
drugs(DMARDS) (e.g., methotrexate,
hydroxychloroquine); AND
is not an appropriate candidate for a formulary
(e.g., Humira, Enbrel).
184
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Remicade (infliximab),
continued
Criteria
Notes
Ulcerative Colitis:
6. Patient has moderately to severely active
ulcerative colitis and required high dose systemic
corticosteroid use; OR
7. Patient has documented inadequate response to
conventional therapy (e.g., mesalamine (5-ASA),
azathioprine, mercaptopurine); AND
to formulary subcutaneous biologic agents
(e.g., Humira); OR
is not an appropriate candidate for a formulary
(e.g., Humira).
Uveitis:
6. Diagnosis of Uveitis Associated with Behcets
Syndrome
185
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Rituxan (rituximab)
Criteria
1. Prescription is written by an oncologist or
hematologist; OR
2. The patient has a diagnosis of moderate to
severe rheumatoid arthritis; AND
infections); AND
4. Patient is not also receiving Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF
therapy; AND
intolerance to both formulary subcutaneous
biologic agents (e.g., Humira and Enbrel);
OR
6. The patient is not physically able to
administer or is not an appropriate
candidate for a formulary subcutaneous
biologic agent (e.g., Humira, Enbrel); AND
7. Documented failure of, or intolerance to, two
other disease modifying antirheumatic
drugs (DMARDS) (e.g., methotrexate,
hydroxychloroquine).
For a diagnosis of RA:
Since safety and efficacy of
re-treatment have not been
established in controlled
trials and a limited number of
patients have received two
to five courses (two infusions
per course) of treatment in
an uncontrolled setting, the
duration of approval for RA
should be limited to 5
courses (3 months) with reevaluation based on
individual response.
Notes
The dose for use in RA is 2
x 1000mg IV infusions
separated by 2 weeks.
Glucocorticoids,
administered as
methylprednisolone 100mg
IV or its equivalent, given
30 minutes prior to each
infusion, are recommended
to reduce the incidence
and severity of infusion
reactions.
186
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Simponi (golimumab)
Criteria
initiated before treatment with Simponi; AND
Enbrel, Remicade or other anti-TNF therapy;
Approved for 1 year
Notes
handle the prefilled syringe
or autoinjector syringe
since the needle cover
contains latex.

arthritis; AND
to Humira and Enbrel; AND
7. The dose of Simponi is 50mg administered
subcutaneously once a month.
5. Diagnosis of moderately to severely active
rheumatoid arthritis; AND
6. Patient is receiving methotrexate concomitantly;
AND
to Humira and Enbrel; AND
8. The dose of Simponi is 50mg administered
subcutaneously once a month.
Ulcerative Colitis:
5. Diagnosis of moderate to severe active
ulcerative colitis disease with documented failure
of, intolerance or contraindication to,
conventional therapy (azathioprine, mesalamine,
mercaptopurine, sulfasalazine, methotrexate,
corticosteroids).
to, Humira.
7. The dose of Simponi is 200 mg administered
subcutaneously, followed by 100 mg at week 2,
and then 100 mg every 4 weeks, thereafter.
187
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Stelara (ustekinumab)
Criteria
OR
initiated before treatment with Stelara; AND
bacterial, fungal or viral); AND diagnostic
specific criteria are met
Psoriasis:
4. Diagnosis of moderate to severe plaque
psoriasis; AND
5. Prescription is written by a dermatologist;
AND
contraindication to, at least two traditional
therapies (e.g., PUVA, UVB, methotrexate,
or cyclosporine); AND
intolerance to Humira and Enbrel.
Notes
WT <100 kg - 45 mg
subcutaneously initially and
4 weeks later, followed by
45 mg every 12 weeks.
WT >100 kg 90 mg
subcutaneously initially and
4 weeks later, followed by
90 mcg every 12 weeks.
188
HEALTHPLUS
APPENDIX D
Immunomodulators,
continued
Tysabri (natalizumab)
Criteria
Notes
For patients with Multiple Sclerosis

1. Patient must have a diagnosis of a relapsing
form of multiple sclerosis; AND
2. Patient has had treatment failure,
contraindication, or intolerance to Copaxone
(glatiramer acetate); AND
3. Patient is intolerant to both Avonex (interferon
beta 1a) and Rebif (interferon beta 1a) (i.e.
severe or intolerable injection site reactions or
side effects); OR
contraindication, or allergy to interferon therapy;
AND
5. Patient must not be currently on combination
therapy with Avonex, Rebif, Betaseron, Extavia,
Copaxone, or Gilyena; AND
6. Patient must not be on concurrent
immunosuppressive therapy; AND
7. Documentation of an MRI scan must be
obtained for each patient with MS to help
differentiate potential, future symptoms from
progressive multifocal leukoencephalopathy
(PML).
For patients with Crohns Disease
1. Patient must have a diagnosis of moderate to
severe of Crohns disease; AND
2. Patient must have had documented failure of,
intolerance or contraindication to, conventional
Crohns disease therapy (i.e. azathioprine,
mesalamine, mercaptopurine, sulfasalazine,
methotrexate, corticosteroids); AND
3. Patient must have had documented failure of,
intolerance or contraindication to a, TNF-
inhibitor (i.e. Humira, Cimzia, Remicade); AND
4. Patient must not be currently on combination
therapy with immunosuppressants or TNF-
inhibitors.
New Starts Only
189
HEALTHPLUS
APPENDIX D
Immunomodulators
Xgeva (denosumab)
Criteria
1. Patient has a diagnosis of bone metastases
secondary to solid tumor.
1 year
Notes
Dose: 120 mg every 4
weeks subcutaneously.
Administer calcium and Vit
D PRN to treat or prevent
hypocalcemia
Not indicated in patients
with multiple myeloma.
Immunomodulators,
continued
Cryopyrin-Associated
Periodic Syndromes
Arcalyst (rilonacept)
1. Diagnosis of Cryopyrin-Associated Periodic

Syndromes (CAPS), including Familial Cold
Autoinflammatory Syndrome (FCAS) and
Muckle-Wells Syndrome (MWS) in adults
and children 12 years and older.
Evaluate in 3 months for to

determine patient response
Recommended dose:
Adults 18 yrs or older:
Loading dose: 320mg Sub Q
Maintenance dose:160mg
SubQ once weekly
Pediatric patients 12 to 17 yrs
old:
Loading dose:4.4mg/kg(to
max of 320mg) SQ
Maintenance dose: 2.2mg/kg
SubQ once weekly
*Dose should not be given
more than once per week
Precautions:
Arcalyst should not be
administered if patient has
active or chronic infection.
Patient should receive all
recommended vaccinations
prior to receiving Arcalyst.
190
HEALTHPLUS
APPENDIX D
Cryopyrin-Associated
Periodic Syndromes
Ilaris (canakinumab)
Criteria
1. Patient has no active or chronic infection
(including influenza, systemic fungal or
bacterial infections, or acute hepatitis B or C
viral infections); AND
2. Diagnosis specific criteria are met
Cryopyrin-Associated Periodic Syndromes
(CAPS), including Familial Cold
Autoinflammatory Syndrome (FCAS) and
Muckle-Wells Syndrome (MWS)
4. Patient has a diagnosis of CAPS, FCAS, or
MWS.
Long Term
Notes
Recommended dose:
Adults, Adolescents, and
Children >= 4 years of age
and > 40kg: 150mg SC
every 8 weeks.
Adults, Adolescents, and
Children >=4 years of age
and 15-40kg: 2mg/kg SC
every 8 weeks. Response
is inadequate in children in
this weight range, may
consider dose increase to
3mg/kg SC every 8 weeks.

Rheumatoid Arthritis (JRA)/ polyarticular
juvenile idiopathic arthritis (PJIA):
4. Patient has a diagnosis of active systemic
JIA/JRA. AND
intolerance to, both formulary subcutaneous
191
HEALTHPLUS
APPENDIX D
Multiple Sclerosis,
Adjunctive Agents
Non-Formulary
Ampyra (dalfampridine)
All Multiple Sclerosis,

Disease-Modifying Agents
On Formulary with PA
Avonex, Rebif
(interferon beta 1a)
Copaxone
(glatiramer acetate)
Aubagio (teriflunomide)
Betaseron, Extavia
(interferon beta 1b)
Tecfidera (dimethyl fumerate)
Criteria
1. The patient must have a diagnosis of Multiple
Sclerosis; AND
2. The patient is ambulatory; AND
3. The patient has no history of a seizure
disorder; AND
4. The patient must have a CrCl>50mL/min;
AND
5. The patient must be receiving concurrent
therapy with a disease modifying agent (i.e.,
Avonex, Betaseron, Copaxone); AND
6. The prescription is written by a neurologist;
AND
7. For renewal, the patient has a documented
20% or greater improvement from baseline
in a timed 25 foot
walk.
1. Patient has a diagnosis of multiple sclerosis;
OR
2. Patient has had signs and symptoms of
Clinically Isolated Syndrome (CIS)
suggestive of MS
6 months
Notes
Quantity is limited to 60 units
per 30 days.
Long-term
1. Patient has a diagnosis of multiple

sclerosis; OR
2. Patient has had signs and symptoms of
Clinically Isolated Syndrome (CIS)
suggestive of MS; AND
contraindication, or intolerance to
Copaxone (glatiramer acetate); AND
4. Patient is intolerant to both Avonex
(interferon beta 1a) and Rebif (interferon
beta 1a) (i.e. severe or intolerable injection
site reactions or side effects); OR
contraindication, or allergy to interferon
therapy.
192
HEALTHPLUS
APPENDIX D
Non-Formulary with PA,
continued
Gilenya (fingolimod)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Criteria
The patient must have documented diagnosis of a relapsing
form of multiple sclerosis;
There is documentation of the following within the last 6
months:
a. CBC, Liver Function Tests, and
b. Ophthalmologic Evaluation; and
Physician must submit documentation that the first dose is
administered in a setting with resources to appropriately
manage symptomatic bradycardia. Setting allows for hourly
patient monitoring of pulse and blood pressure for 6 hours for
signs and symptoms of bradycardia, including an
electrocardiogram prior to dosing, and at the end of the
observation period.
Patient has not had a recent (within the last six months)
occurrence of MI, unstable angina, stroke, TIA, decompensated
HF requiring hospitalization, or Class II/IV HF.
Patient does not have a history or presence of Mobitz Type II
2nd degree or 3rd degree AV block or sick sinus syndrome,
unless patient has a pacemaker.
Patient has a QTc interval >/500ms.
Patient is not receiving treatment with a Class 1a or Class III
antiarrhythmic drug.
Patients receiving concurrent therapy with drugs that slow heart
rate (e.g., beta blockers, heart-rate lowering calcium channel
blockers such as diltiazem or verapamil, or digoxin) must
receive overnight continuous ECG monitoring with
administration of first dose.
Patient has had treatment failure, contraindication, or
intolerance to Copaxone (glatiramer acetate); AND
Patient is intolerant to both Avonex (interferon beta 1a) and
Rebif (interferon beta 1a) (i.e. severe or intolerable injection site
reactions or side effects); OR
Patient has had treatment failure, contraindication, or allergy to
interferon therapy.
Notes
Quantity is limited
to 30 units per
month.
Patient should not
receive Gilenya
concomitantly with
another
immunomodulator
therapy for
multiple sclerosis
(e.g. Avonex,
Rebif, Betaseron,
Extavia,
Copaxone, or
Tysabri).
193
HEALTHPLUS
APPENDIX D
Neurological
Xenazine (tetrabenazine)
Criteria
1. The patient must have a diagnosis of chorea associated with
Huntingtons disease; AND
2. The patient must have documented failure of, intolerance to, or
contraindication to at least two of the following: amantadine, an
antipsychotic (fluphenazine, haloperidol, risperidone,
ziprasidone, quetiapine or olanzapine), riluzole, or a
benzodiazepine, AND
3. Prescription must be prescribed by a neurologist, AND
4. For doses greater than 50 mg/day, CYP2D6 genotyping is
required.
3 months
Notes
Patients who do
not express
CYP2D6 (i.e.,
poor metabolizers
of CYP2D6)
require a daily
dose of 37.550
mg, in 3 divided
doses.
Patients who do
express CYP2D6
(i.e., intermediate
or extensive
metabolizers of
CYP2D6) require
a daily dose of at
least 50 mg100mg in 3
divided doses.
Neuromuscular Blocking
Agent
Botox
Dysport
Xeomin
(botulism toxin type A)
Parkinsons
Apokyn (apomorphine)
1. Patient must have a documented diagnosis of cervical dystonia.
Approved 3 months
1. Diagnosis of Parkinson's Disease in advanced stages; AND

2. Documented two hours or more of "off" episodes ("end-of-dose
wearing off" and unpredictable "on/off" episodes) despite
aggressive oral therapy.
Long-term
Pulmonary
Cayston
(aztreonam for inhalation)
1. Patient must have pseudomonas aeruginosa in the lungs, AND

2. Patient must have cystic fibrosis, AND
3. Prescription must be written by a pulmonologist, or infectious
disease specialist, AND
4. Patient must be 7 years of age or older, AND
5. FEV1 must be >25% or <75%.
194
HEALTHPLUS
APPENDIX D
Pulmonary, continued
Xolair (omalizumab)
1.
2.
3.
4.
5.
Rheumatoid Arthritis Misc.

Xeljanz (tofacitinib)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Criteria
Patient is over 12 years of age; AND
Patient has a diagnosis of moderate to severe allergic asthma;
AND
A positive skin test or in vitro reactivity to a perennial
aeroallergen; AND
Failure of, or intolerance to, maximum dose of oral inhaled
steroids (medication compliance should be taken into
consideration); AND/OR
Patient required long-term (>3months) oral steroids previously
and had at least 1 ED or hospital admission during the last 6
months.
Diagnosis of moderate to severe rheumatoid arthritis; AND
A negative TB test before initiating therapy; OR
Treatment for latent TB infections must be initiated before
treatment with Xeljanz; AND
Patient has no active infection (including bacterial sepsis,
tuberculosis, invasive fungal and other opportunistic infections);
AND
3
Patient has a lymphocyte count >500 cells/mm , ANC > 1000
3
cells/mm , and hemoglobin level >9g/dL; AND
Patient is not also receiving TNF antagonists, or other biologics
(e.g. Enbrel, Humira, Remicade, Simponi, Cimzia, Kineret,
Rituxan, Orencia); AND
Patient has documented failure of, intolerance or
contraindication to, two other disease- modifying antirheumatic
drugs (DMARDS) (e.g., methotrexate, sulfasalazine,
azathioprine, or hydroxychloroquine); AND
Patient has documented failure of, or intolerance to, both
formulary subcutaneous biologic agents (e.g., Humira and
Enbrel); OR
The patient is not physically able to administer or is not an
appropriate candidate for a subcutaneously administered
biologic agent (e.g., Humira, Enbrel).
Approved 3 months to
determine patient
response.
Notes
The warnings for
Xolair include
malignancy and
anaphylaxis.
Renewals may be
authorized long-term.
195
HEALTHPLUS
APPENDIX 1
Appendix 1 (for Immune Globulin criteria):

Normal Immunoglobulin Levels (mg/dl)
Normal IgG Subclass Levels (mg/dl)
AGE
IgA
IgG
IgM
AGE
IgG1
IgG2
IgG3
IgG4
1 - 2 mo
1 - 53
251 - 906
20 - 87
cord
435 - 1084
143 - 453
27 - 146
1 - 47
2 - 3 mo
3 - 47
206 - 601
17 - 105
0 - 3 mo
218 - 496
40 - 167
4 - 23
1 - 33
3 - 4 mo
4 - 73
176 - 581
24 - 101
3 - 6 mo
143 - 394
23 - 147
4 - 100
1 - 14
4 - 5 mo
8 - 84
172 - 814
33 - 108
6 - 9 mo
190 - 388
37 - 60
12 - 62
1-1
5 - 6 mo
8 - 68
215 - 704
35 - 102
9 mo - 3 yr
286 - 680
30 - 327
13 - 82
1 - 65
6 - 8 mo
11 - 90
217 - 904
34 - 125
3 - 5 yr
381 - 884
70 - 443
17 - 90
1 - 116
8 mo 1 yr
16 - 84
294 - 1069
41 - 149
5 - 7 yr
292 - 816
83 - 513
8 - 111
1 - 121
1 - 2 yr
14 - 106 345 - 1213
43 - 173
7 - 9 yr
442 - 802
113 - 480
15 - 133
1 - 84
2 - 3 yr
14 - 123 424 - 1051
48 - 168
9 - 11 yr
456 - 938
163 - 513
26 - 113
1 - 121
3 - 4 yr
22 - 159 441 - 1135
47 - 200
11 - 13 yr
456 - 952
147 - 493
12 - 179
1 - 168
4 - 6 yr
25 - 154 463 - 1236
43 - 196
13 - 15 yr
347 - 993
140 - 440
23 - 117
1 - 183
6 - 9 yr
33 - 202 633 - 1280
48 - 207
15 yr & up
422 - 1292
117 - 747
41 - 129
1 - 291
9 - 11 yr
45 - 236 608 - 1572
52 - 242
11 yr & up
70 - 312 639 - 1349
56 - 352
196
PRESCRIPTION BENEFIT LIMITATIONS

APPENDIX E
GENERAL LIMITATIONS (All Lines of Business)
Michigan State Law Limitations:
Schedule II prescriptions are not refillable, and must be filled within 90 days of the date
prescription is actually written.
Schedule III, IV, & V prescriptions are only refillable for 6 months from the date of the
original prescription (if refills are indicated by the prescriber).
Non-Scheduled prescriptions are refillable for 1 year from the date the prescription was
actually written (if refills are indicated by the prescriber).
HealthPlus Contractual Exclusions:
Medications used for cosmetic purposes are not covered.
Medications used in conjunction with the in-vitro fertilization procedure are not covered.
Non-prescription drugs, dietary supplements and medical foods are not a covered
benefit, with the exception of OTC medications specifically added to coverage by
HealthPlus.
HealthPlus Administrative Limitations:
Prescription drugs are limited to the reasonable cost of generically-available products,
unless no generically-equivalent product exists or a member-specific review for medical
necessity determines the need for the brand name medication.
Prescription drugs are limited to FDA-approved indications when reviewed, unless a
member-specific review for medical necessity determines the need for a particular
medication for an off-label use.
Prescriptions written by a Dentist are limited to those medications on the HealthPlus
Dental Formulary.
Prescriptions for testosterone products are limited to male members only, unless a
member-specific review for a female member determines medical necessity or if the
medication is being used for an FDA-approved indication.
Prescriptions for products that contain estrogen are limited to female members only.
Prior Authorization based on specific criteria is required for medications included in the
Pharmacy Prior Authorization Program including the Dose Optimization Program.
Coverage for medications included in the Dose Optimization Program is limited to once
daily dosing, or maximum dose recommendations with quantity limits, unless a member
specific review determines medical necessity for the specified dosing regimen.
Coverage for specific migraine medications is limited to 9 tablets per month, unless a
member specific review determines that the member is also currently taking medication
for the prophylaxis of migraine and still requires more than 9 tablets per month.
Coverage for smoking cessation medications is limited to one course of therapy per year.
Prescription medications for weight loss require Prior Authorization, initiated through the
Pharmacy Department.
Prescriptions for compounded medications require Prior Authorization based on
established criteria for safety and appropriateness.
197

APPENDIX E
LIMITATIONS BY LINE OF BUSINESS
HealthPlus of Michigan (Commercial, PPO, HealthPlus Senior Program (non-Part D)
Limitations:
Prescription drugs for the treatment of impotency are covered for male members only and
are limited to a quantity of 6 units/tablets total (for all ED products combined) every 30
days. These drugs are limited to males 35 years of age and older. If a member-specific
review for a male member under 35 years of age meets medical necessity criteria, the
Primary Care Physician or participating treating urologist may obtain prior authorization
from HPM for coverage of the product. (The same limitations for quantity apply.) For
PPO members, any physician may prescribe ED medications.
Selected antipsychotic medications are limited to maximum daily dosage
recommendations from the manufacturer.
Selected sleeping medications are limited to a quantity of 30 in 30 days.
OTC Generic Nicotine Patches are a covered benefit, limited to the original prescription
plus two additional refills (12 weeks); prescription nicotine patches require prior
authorization.
Covered medications are limited to a 30-day supply (for some benefits up to a 34-day
supply) at participating 30-day supply retail pharmacies, and up to a 90-day supply
through participating HealthPlus Ask for 90 Rx retail pharmacies and the designated mail
service provider. Refills may be obtained when 80% of the day supply received has
passed. Specifically for the Ask for 90 Rx programs (mail service and retail pharmacies),
injectable medications are not covered with the exception of injectable diabetes
medications, Epipen, glucagon, and Imitrex.
Specifically for HealthPlus MIChild/MIChild CSHCS, covered medications are limited to a
34-day supply at participating 30-day supply retail pharmacies, and up to a 102 day
supply through participating HealthPlus Ask for 90 Rx retail pharmacies and the
designated mail service provider.
Prescription and non-prescription products for smoking cessation are covered as listed
on page 85.
HealthPlus Partners (Medicaid)
State Limitations and Exclusions:
Coverage is limited to the generic product when a generic product is available.
Combination cough and cold products are not a covered benefit.
Certain Over-the-Counter (OTC) products (as mandated by the State) are covered when
written as a prescription and dispensed by the pharmacy, with coverage limited to the
generic product when the product is generically available.
Male condoms (latex only) and the female condom are a covered benefit, limited to
members 10 years of age or older, and limited to a maximum of 12 condoms per
prescription and 36 condoms per month.
Prescription medications for weight loss require Prior Authorization, initiated through the
Pharmacy Department
OTC generic nicotine patches, lozenges, gum and other products for smoking cessation
are covered as listed on page 85; prescription brand only nicotine patches require Prior
Authorization.
Medications used to treat infertility are not a covered benefit.
Medications for erectile dysfunction are not a covered benefit.
Behavioral health medications, HIV medications and specific medications in other
categories are carved out to MDCH.
198

APPENDIX E
LIMITATIONS BY LINE OF BUSINESS
Administrative Limitations:
Covered medications are limited to a 31-day supply at participating retail pharmacies.
Refills may be obtained when 85% of the day supply received has passed.
There are no copays associated with covered medications.
HealthPlus Signature PPO
Limitations:
Prescription drug coverage is limited to those products that are listed on the PPO Closed
Formulary.
Exclusions:
Prescription drugs when there is a non-prescription drug available in the drug category.
Non-sedating antihistamines (NSAs) and NSA antihistamine decongestants
Ophthalmic antihistamines
Erectile dysfunction medications
Weight loss medications
Drugs for the treatment of infertility.
199
A
ABATACEPT........................................................................... 87, 91
ABILIFY........................................................................................62
ABSTRAL .....................................................................................39
ACANYA ......................................................................................51
ACARBOSE ..................................................................................81
ACCOLATE............................................................................. 41, 45
ACCUNEB ....................................................................................43
ACCUPRIL....................................................................................26
ACCURETIC .................................................................................27
ACEBUTOLOL ........................................................................ 26, 30
ACEON ........................................................................................27
ACETAMINOPHEN/ CODEINE .....................................................41
ACETAMINOPHEN/ HYDROCODONE .................................... 40, 41
ACETAMINOPHEN/ OXYCODONE ......................................... 40, 41
ACETAMINOPHEN-ISOMETHEPTENE-CAFFEINE .........................66
ACETAZOLAMIDE ........................................................................55
ACETIC ACID ...............................................................................59
ACETIC ACID/ HYDROCORTISONE ...............................................59
ACETONIDE .................................................................................46
ACIPHEX......................................................................................20
ACITRETIN...................................................................................49
ACLIDINIUM BROMIDE ...............................................................45
ACLOVATE ..................................................................................46
ACTIGALL ....................................................................................84
ACTIQ .........................................................................................39
ACTIVELLA 1.0-0.5 ......................................................................75
ACTONEL ....................................................................................77
ACTOPLUS MET ..........................................................................80
ACTOPLUS MET XR .....................................................................80
ACTOS .........................................................................................80
ACULAR LS ..................................................................................58
ACUVAIL .....................................................................................58
ACYCLOVIR .................................................................................37
ACZONE 5% GEL .........................................................................51
ADALAT CC .................................................................................28
ADALIMUMAB ............................................................................86
ADAPALENE ................................................................................51
ADAPALENE/BENZOYL PEROXIDE ...............................................51
ADCIRCA .....................................................................................30
ADDERALL XR..............................................................................63
ADOXA, PAK................................................................................33
ADVAIR .......................................................................................43
ADVICOR.....................................................................................31
AGGRENOX .................................................................................54
AGRYLIN .....................................................................................54
ALAVERT OTC .............................................................................41
ALBENDAZOLE ............................................................................37
ALBENZA .....................................................................................37
ALBUTEROL........................................................................... 44, 45
ALBUTEROL SULFATE ..................................................................43
ALBUTEROL/ IPRATROPIUM .......................................................44
ALCAFTADINE .............................................................................58
ALCLOMETASONE .......................................................................46
ALDACTAZIDE 25/25 ...................................................................26
ALDACTAZIDE 50/50 ...................................................................26
ALDACTONE ................................................................................26
ALDARA ......................................................................................53
ALDOMET ...................................................................................30
ALDOMET 125 ............................................................................30
ALDORIL-D ..................................................................................30
ALENDRONATE ...........................................................................77
ALENDRONATE/ VITAMIN D3 .....................................................77
ALFUZOSIN .................................................................................88
ALINIA .........................................................................................37
ALISKIREN ...................................................................................31
ALISKIREN/ ..................................................................... 28, 29, 31
ALISKIREN/ HCTZ ........................................................................31
ALITRETINOIN .............................................................................53
ALL OTHER TEST STRIPS (covered at DME only with a copay as
applicable) .............................................................................81
ALLEGRA OTC .............................................................................41
ALLEGRA-D .................................................................................43
ALLEGRA-D 12 HOUR ..................................................................42
ALLOPURINOL .............................................................................81
ALMOTRIPTAN............................................................................65
ALOCRIL ......................................................................................58
ALODOX ......................................................................................57
ALOGLIPTIN/ BENZOATE.............................................................80
ALOGLIPTIN/ METFORMIN .........................................................80
ALOGLIPTIN/ PIOGLITAZONE ......................................................80
ALOMIDE ....................................................................................58
ALORA ........................................................................................74
ALOSETRON .......................................................................... 22, 89
ALPHAGAN P ..............................................................................55
ALPRAZOLAM .............................................................................61
ALPROSTADIL........................................................................ 85, 86
ALREX .........................................................................................56
ALTABAX .....................................................................................49
ALTACE CAPS ..............................................................................27
ALTOPREV...................................................................................31
ALVESCO .....................................................................................43
AMANTADINE .............................................................................36
AMARYL ......................................................................................79
AMBIEN ......................................................................................61
AMERGE .....................................................................................65
AMICAR ......................................................................................54
AMICAR 1,000MG ......................................................................55
AMINOCAPROIC ACID ........................................................... 54, 55
AMINOPHYLLINE ........................................................................45
AMIODARONE ...................................................................... 25, 26
AMITIZA ................................................................................ 22, 89
AMITRIPTYLINE ...........................................................................59
AMLACTIN 12%...........................................................................48
AMLODIPINE...............................................................................29
AMLODIPINE/ .............................................................................28
AMLODIPINE/ ATORVASTATIN ...................................................31
AMLODIPINE/ BENAZEPRIL ................................................... 27, 29
AMLODIPINE/ OLMESARTAN......................................................27
AMLODIPINE/ VALSARTAN .........................................................28
AMMONIUM LACTATE ...............................................................48
AMOXICILLIN ..............................................................................32
AMOXICILLIN TRIHYDRATE .........................................................32
AMOXICILLIN/ CLAVULANATE ....................................................32
AMOXIL ......................................................................................32
200
AMPHETAMINE/ DEXTROAMPHETAMINE ..................................63

AMPYRA .....................................................................................89
AMRIX.........................................................................................66
AMTURNIDE ...............................................................................28
AMYLASE/ LIPASE/ PROTEASE .............................................. 21, 22
ANAFRANIL .................................................................................59
ANAKINRA ..................................................................................87
ANAPROX, DS .............................................................................38
ANASPAZ ....................................................................................23
ANCOBON...................................................................................35
ANDRODERM..............................................................................76
ANDROGEL .................................................................................76
ANDROID ....................................................................................76
ANDROXY ...................................................................................76
ANEGRELIDE ...............................................................................54
ANGELIQ .....................................................................................75
ANSAID .......................................................................................38
ANTABUSE ..................................................................................85
ANTARA ......................................................................................31
ANTHRALIN.................................................................................49
ANTHRALIN SHAMPOO ..............................................................49
ANTIPYRINE-BENZOCAINE-POLYCOSANOL .................................59
ANTIVERT 12.5, 25MG ................................................................22
ANTIVERT 50MG.........................................................................22
ANUSOL HC.................................................................................22
ANZEMET....................................................................................22
APEXICON ...................................................................................46
APEXICON OINT ..........................................................................46
APIDRA .......................................................................................78
APIDRA SOLOSTAR .....................................................................78
APIXABAN ...................................................................................53
APLENZIN....................................................................................60
APOKYN ......................................................................................67
APOMORPHINE ..........................................................................67
APRACLONIDINE .........................................................................55
APREPITANT ...............................................................................23
APRESOLINE ...............................................................................28
APRI ............................................................................................68
APRISO........................................................................................21
ARALEN.......................................................................................37
ARANELLE ...................................................................................68
ARANESP ....................................................................................54
ARAVA ........................................................................................86
ARCAPTA ....................................................................................44
ARFORMOTEROL ........................................................................44
ARICEPT ......................................................................................67
ARIPIPRAZOLE ............................................................................62
ARISTOCORT ...............................................................................68
ARMODAFINIL ............................................................................63
ARMOUR THYROID .....................................................................78
ARTEMETHER/ ............................................................................37
ARTHROTEC ................................................................................38
ASACOL .......................................................................................21
ASACOL HD .................................................................................21
ASENAPINE .................................................................................62
ASMANEX ...................................................................................44
ASPIRIN/ DIPYRIDAMOLE ...........................................................54
ASPIRIN/ OXYCODONE ...............................................................40
ASTELIN ......................................................................................42
ASTEPRO .....................................................................................42
ATABEX .......................................................................................81
ATACAND....................................................................................27
ATACAND HCT ............................................................................27
ATELVIA ......................................................................................77
ATENOLOL ..................................................................................30
ATENOLOL/ CHLORTHALIDONE ..................................................30
ATIVAN .......................................................................................61
ATOMOXETINE ...........................................................................63
ATOPICLAIR ................................................................................48
ATORVASTATIN ..........................................................................31
ATOVAQUONE ............................................................................37
ATOVAQUONE/ PROGUANIL ......................................................37
ATRALIN......................................................................................51
ATROPINE ...................................................................................55
ATROPINE SULFATE ....................................................................55
ATROVENT HFA ..........................................................................44
ATROVENT NASAL SPRAY ...........................................................42
AUBAGIO ....................................................................................89
AUGMENTIN CHEW TABS, 125-31.25 SUSP ................................32
AUGMENTIN XR ..........................................................................32
AUGMENTIN, ES .........................................................................32
AURALGAN .................................................................................59
AURANOFIN ................................................................................87
AVALIDE......................................................................................27
AVANDAMET ..............................................................................80
AVANDARYL ................................................................................80
AVANDIA ....................................................................................80
AVAPRO ......................................................................................27
AVC CREAM ................................................................................52
AVELOX.......................................................................................34
AVIANE .......................................................................................68
AVIDOXY DK................................................................................33
AVINZA .......................................................................................39
AVODART....................................................................................87
AVONEX ......................................................................................89
AXERT .........................................................................................65
AXID ............................................................................................20
AXIRON .......................................................................................76
AYGESTIN....................................................................................75
AZASAN ......................................................................................86
AZASITE ......................................................................................57
AZATHIOPRINE ...........................................................................86
AZELAIC ACID ..............................................................................51
AZELASTINE .......................................................................... 42, 58
AZELASTINE/ ...............................................................................42
AZELEX ........................................................................................51
AZILECT .......................................................................................67
AZILSARTAN MEDOXOMIL ..........................................................28
AZILSARTAN MEDOXOMIL/ ........................................................28
AZITHROMYCIN .................................................................... 34, 57
AZOPT .........................................................................................55
AZOR...........................................................................................27
AZULFIDINE, ENTAB ....................................................................21
B
BACLOFEN ..................................................................................66
BACTRIM DS, SEPTRA DS ...................................................... 34, 35
BACTRIM, SEPTRA ................................................................ 34, 35
BACTROBAN ...............................................................................49
BACTROBAN NASAL OINT ...........................................................49
BAL-CARE DHA ESSENTIAL ..........................................................81
201
BALSALAZIDE DISODIUM ............................................................21

BANZEL .......................................................................................64
BECLOMETHASONE DIPROPIONATE ..................................... 42, 45
BECLOMETHASONE, AQUEOUS ..................................................42
BECONASE AQ ............................................................................42
BEDAQUILINE FUMARATE ..........................................................36
BELLADONNA ALKALOIDS/ PHENOBARBITAL .............................23
BENADRYL ............................................................................ 41, 61
BENAZEPRIL ................................................................................27
BENAZEPRIL/ HCTZ .....................................................................27
BENICAR .....................................................................................27
BENICAR HCT ..............................................................................27
BENTYL .......................................................................................23
BENZACLIN 1%-5% Gel (pump) ...................................................51
BENZAMYCIN GEL .......................................................................51
BENZAMYCINPAK .......................................................................51
BENZEFOAM ...............................................................................51
BENZIQ WASH ............................................................................51
BENZOCAINE-ANTIPYRINE ..........................................................59
BENZONATATE ...........................................................................43
BENZOYL PEROXIDE .............................................................. 51, 52
BENZOYL PEROXIDE/ HC/SKIN CLNSR NO. 14 .............................52
BENZOYL PEROXIDE/ HYALURONT .............................................52
BENZOYL PEROXIDE/ SULFUR .....................................................51
BENZTROPINE .............................................................................67
BENZYL ALCOHOL .......................................................................53
BEPOTASTINE BESILATE ..............................................................58
BEPREVE .....................................................................................58
BESIFLOXACIN HYDROCHLORIDE ................................................57
BESIVANCE .................................................................................57
BETAGAN ....................................................................................55
BETAMET DIPROP/ .....................................................................49
BETAMETHASONE ................................................................ 47, 68
BETAMETHASONE DIPROPIONATE .............................................46
BETAPACE, AF .............................................................................25
BETASERON ................................................................................89
BETAXOLOL........................................................................... 29, 55
BETHANECHOL ...........................................................................88
BETIMOL .....................................................................................55
BETOPIC 0.5% .............................................................................55
BETOPTIC S .................................................................................55
BEXAROTENE ..............................................................................53
BEYAZ .........................................................................................68
BIAXIN, XL ...................................................................................33
BIDIL ...........................................................................................25
BILTRICIDE ..................................................................................37
BIMATOPROST............................................................................55
BINOSTO .....................................................................................77
BISOPROLOL ...............................................................................30
BISOPROLOL/ HCTZ ....................................................................30
BLEPH-10 ....................................................................................57
BLEPHAMIDE ..............................................................................57
BLEPHAMIDE S.O.P. ....................................................................58
BLOCADREN................................................................................29
B-NEXA .......................................................................................82
BOCEPREVIR ...............................................................................89
BONIVA.......................................................................................77
BOSENTAN..................................................................................30
BOTOX, DYSPORT, XEOMIN ........................................................91
BOTULISM TOXIN TYPE A ...........................................................91
BRAVELLE ...................................................................................76
BREO ELLIPTA .............................................................................44

BREVOXYL ...................................................................................51
BRILINTA .....................................................................................53
BRIMONIDINE .............................................................................53
BRIMONIDINE TARTRATE ...........................................................55
BRINZOLAMIDE ..........................................................................55
BRINZOLAMIDE/ BIMONIDINE TARTRATE ..................................56
BRISDELLE ...................................................................................60
BROMDAY...................................................................................59
BROMFED-DM ............................................................................43
BROMFENAC SODIUM ................................................................59
BROMOCRIPTINE ........................................................................67
BROMPHENIRAMINE/ PSEUDOEPHEDRINE/
DEXTROMETHORPHAN .........................................................43
BROVANA ...................................................................................44
BUDESONIDE .................................................................. 21, 42, 44
BUDESONIDE/ FORMOTEROL .....................................................45
BUPRENORPHINE .......................................................................85
BUPRENORPHINE PATCH............................................................39
BUPRENORPHINE/ NALOXONE ...................................................85
BUPROPION .................................................................... 60, 61, 85
BUSPAR ......................................................................................61
BUSPIRONE .................................................................................61
BUTALBITAL/ ACETAMINOPHEN ................................................40
BUTALBITAL/ ACETAMINOPHEN/ CAFFEINE ...............................39
BUTALBITAL/ ASA/ CAFFEINE .....................................................65
BUTALBITAL/ ASPIRIN/ CAFFEINE/ CODEINE ..............................39
BUTENAFINE ...............................................................................50
BUTRANS ....................................................................................39
BYDUREON .................................................................................80
BYETTA .......................................................................................80
BYSTOLIC ....................................................................................29
C
CABOZANTINIB ...........................................................................90
CADUET ......................................................................................31
CAFERGOT ..................................................................................65
CALAN.........................................................................................25
CALAN SR ....................................................................................28
CALCIPOTRIENE ..........................................................................49
CALCITONIN................................................................................77
CALCITRIOL ........................................................................... 53, 83
CALCIUM ACETATE .....................................................................90
CAMBIA ......................................................................................65
CAMILA .......................................................................................68
CANAGLIFLOZIN..........................................................................79
CANASA ......................................................................................21
CANDESARTAN ...........................................................................27
CANTIL ........................................................................................23
CAPOTEN ....................................................................................27
CAPTOPRIL..................................................................................27
CARAFATE ...................................................................................20
CARAFATE SUSP..........................................................................20
CARBACHOL................................................................................55
CARBAMAZEPINE.................................................................. 64, 65
CARBATROL ................................................................................64
CARBIDOPA ................................................................................67
CARBIDOPA/ LEVODOPA ............................................................67
CARBIDOPA/ LEVODOPA/ ENTACAPONE....................................67
CARDENE ....................................................................................28
202
CARDENE SR ...............................................................................28
CARDIZEM ..................................................................................28
CARDIZEM CD 120, 180, 240, 300 ..............................................29
CARDIZEM LA .............................................................................29
CARDURA ............................................................................. 30, 87
CARDURA XL ......................................................................... 30, 87
CARISOPRODOL ..........................................................................66
CARMOL .....................................................................................48
CARNITOR ...................................................................................84
CARTIA XT ...................................................................................29
CARVEDILOL ...............................................................................29
CATAFLAM ..................................................................................38
CATAPRES-TTS ............................................................................30
CAVERJECT..................................................................................85
CECLOR .......................................................................................32
CEDAX .........................................................................................32
CEFACLOR ...................................................................................32
CEFDITOREN ...............................................................................33
CEFIXIME ....................................................................................33
CEFTIBUTEN................................................................................32
CEFTIN ........................................................................................32
CEFUROXIME ..............................................................................32
CELEBREX....................................................................................38
CELECOXIB ..................................................................................38
CELESTONE .................................................................................68
CELEXA .......................................................................................60
CELLCEPT ....................................................................................86
CELONTIN ...................................................................................64
CENESTIN....................................................................................74
CEPHALEXIN ...............................................................................33
CERTOLIZUMAB PEGOL ..............................................................86
CETIRIZINE ..................................................................................42
CETRAXAL ...................................................................................59
CETRORELIX ACETATE .................................................................76
CETROTIDE .................................................................................76
CHANTIX .....................................................................................85
CHLORAL HYDRATE.....................................................................61
CHLOROQUINE ...........................................................................37
CHLOROXYLENOL/ ......................................................................59
CHLORPROPAMIDE.....................................................................79
CHLORTHALIDONE......................................................................26
CHLORZOXAZONE .......................................................................66
CHOLESTYRAMINE POWDER ......................................................32
CHOLESTYRAMINE/ ....................................................................32
CIALIS..........................................................................................85
CIALIS 2.5, 5MG ..........................................................................85
CICLESONIDE ........................................................................ 42, 43
CICLODAN KIT .............................................................................49
CICLOPIROX ................................................................................50
CICLOPIROX OLAMINE ................................................................50
CICLOPIROX OLAMINE CREAM/ CLEANSER ................................49
CICLOPIROX SOLN 8%/ LACQUER REMOVAL PADS.....................50
CILOSTAZOLE ..............................................................................54
CILOXAN GEL ..............................................................................57
CILOXAN SOLN............................................................................57
CIMETIDINE ................................................................................20
CIMZIA ........................................................................................86
CIPRO.................................................................................... 34, 35
CIPRO HC ....................................................................................59
CIPRO SUSP .......................................................................... 34, 35
CIPRODEX ...................................................................................59
CIPROFLOXACIN ....................................................... 34, 35, 57, 59

CIPROFLOXACIN HCL/ HC ...........................................................59
CIPROFLOXACIN/ DEXAMETH .....................................................59
CITALPRAM.................................................................................60
CITRACAL PRENATAL + DHA .......................................................82
CITRANATAL B-CALM..................................................................82
CITRANATAL HARMONY .............................................................82
CLARINEX TABS ...........................................................................41
CLARINEX-D ................................................................................43
CLARITHROMYCIN ......................................................................33
CLARITIN OTC .............................................................................41
CLARITIN-D OTC..........................................................................43
CLEMASTINE ...............................................................................42
CLEOCIN 150, 300MG .................................................................34
CLEOCIN VAGINAL CREAM .........................................................52
CLEOCIN VAGINAL OVULE ..........................................................52
CLEOCIN-T ..................................................................................51
CLIDINIUM BROMIDE/ CHLORDIAZEPOXIDE ..............................24
CLIMARA.....................................................................................74
CLIMARA PRO .............................................................................75
CLINDACIN PAC ..........................................................................51
CLINDAGEL .................................................................................51
CLINDAMYCIN ................................................................ 34, 51, 52
CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE .......................51
CLINDAMYCIN/ ..................................................................... 51, 52
CLINDAMYCIN/BENZOYL PEROXIDE ...........................................51
CLINORIL .....................................................................................38
CLOBAZAM .................................................................................65
CLOBETASOL EMOLL...................................................................47
CLOBETASOL PROPIONATE................................................... 46, 47
CLOBEX .......................................................................................46
CLOCORTOLONE PIVALATE .........................................................46
CLODERM ...................................................................................46
CLOMID ......................................................................................76
CLOMIPHENE ..............................................................................76
CLOMIPRAMINE .........................................................................59
CLONAZEPAM .............................................................................64
CLONIDINE...................................................................... 30, 31, 63
CLOPIDOGREL .............................................................................54
CLORAZEPATE .............................................................................61
CLOTRIMAZOLE 1%.....................................................................50
CLOTRIMAZOLE TROCHES ..........................................................36
CLOTRIMAZOLE/ BETAMETHASONE ...........................................50
CLOZAPINE .................................................................................62
CLOZARIL ....................................................................................62
CNL 8 NAIL KIT ............................................................................50
COARTEM ...................................................................................37
CODEINE .....................................................................................39
COGENTIN ..................................................................................67
COLAZAL .....................................................................................21
COLCHICINE 0.6MG ....................................................................81
COLCRYS .....................................................................................81
COLESEVELAM ............................................................................32
COLESTID ....................................................................................31
COLESTID 7.5 ..............................................................................31
COLESTIPOL ................................................................................31
COLY-MYCIN S ............................................................................59
COLYTE .......................................................................................24
COMBIPATCH .............................................................................75
COMBIVENT................................................................................44
COMBIVENT RESPIMAT ..............................................................44
203
COMETRIQ..................................................................................90
COMFORT PAC-TIZANIDINE ........................................................66
COMPAZINE SYRUP ....................................................................22
COMPAZINE TABS , SUPP ...........................................................23
COMPLETE-RF PRENATAL ...........................................................82
COMTAN.....................................................................................67
CONCEPT OB, DHA .....................................................................82
CONCERTA ..................................................................................63
CONDYLOX GEL...........................................................................53
CONDYLOX SOLUTION ................................................................53
CONJUGATED ESTROGEN/ MPA ........................................... 75, 76
CONJUGATED ESTROGENS .........................................................74
CONZIP .......................................................................................39
COPAXONE .................................................................................89
COPEGUS ....................................................................................88
CORDARONE...............................................................................25
CORDRAN 4MCG/SQ CM TAPE ...................................................46
CORDRAN, SP .............................................................................46
COREG ........................................................................................29
COREG CR ...................................................................................29
CORGARD ...................................................................................29
CORTEF TABS ..............................................................................68
CORTIFOAM................................................................................21
CORTISONE .................................................................................68
CORTISONE ACETATE .................................................................68
CORTISPORIN ................................................................. 49, 58, 59
CORTISPORIN-TC ........................................................................59
CORZIDE .....................................................................................29
COSOPT ......................................................................................55
COSOPT PF..................................................................................55
COUMADIN.................................................................................53
COVERA HS .................................................................................29
COZAAR ......................................................................................28
CREON ........................................................................................21
CRESTOR .....................................................................................31
CROFELEMER ..............................................................................22
CROMOLYN SODIUM ............................................................ 22, 44
CROMOLYN SOLN .......................................................................44
CROTAMITON .............................................................................53
CRYSELLE ....................................................................................68
CUPRIMINE .................................................................................84
CUTIVATE ...................................................................................46
CUTIVATE 0.05% LOTION............................................................46
CYANOCOBALAMIN/MECOBALAMIN .........................................83
CYCLOBENZAPRINE.....................................................................66
CYCLOGYL 0.5%, .........................................................................55
CYCLOGYL 1% .............................................................................55
CYCLOPENTOLATE ......................................................................55
CYCLOSERINE ..............................................................................36
CYCLOSPORINE ..................................................................... 58, 86
CYMBALTA ............................................................................ 60, 89
CYSTOSPAZ, M ............................................................................23
CYTOMEL ....................................................................................78
CYTOTEC .....................................................................................20
D
DABIGATRAN ETEXILATE MESYLATE ...........................................54
DALFAMPRIDINE ........................................................................89
DALIRESP ....................................................................................45
DALTEPARIN SODIUM,PORCINE .................................................54
DANTRIUM .................................................................................66
DANTROLENE .............................................................................66
DAPSONE ....................................................................................51
DARAPRIM ..................................................................................37
DARBEPOETIN ALFA IN POLYSORBATE .......................................54
DARIFENACIN HYDROBROMIDE .................................................88
DAYPRO ......................................................................................38
DAYTRANA..................................................................................63
DDAVP NASAL SPRAY .................................................................76
DDAVP RHINAL TUBE..................................................................76
DECADRON .................................................................................56
DECONAMINE SYRUP .................................................................43
DECONAMINE TABS ....................................................................43
DEFERASIROX .............................................................................84
DEFEROXAMINE MESYLATE ........................................................84
DELZICOL ....................................................................................21
DEMADEX ...................................................................................26
DEMEROL ...................................................................................39
DEPAKENE ..................................................................................64
DEPAKOTE ..................................................................................64
DERMA-SMOOTHE-FS 0.01% OIL................................................46
DESFERAL ...................................................................................84
DESIPRAMINE .............................................................................60
DESLORATIDINE ..........................................................................41
DESMOPRESSIN ACETATE ...........................................................76
DESOGEN ....................................................................................68
DESONATE GEL ...........................................................................46
DESONIDE ............................................................................. 46, 47
DESONIDE/EMOLLIENT COMBO .................................................46
DESOWEN...................................................................................46
DESOWEN COMBO .....................................................................46
DESOXIMETASONE .....................................................................47
DESOXYN ....................................................................................63
DESQUAM X ...............................................................................51
DESVENLAFAXINE SUCCINATE ....................................................60
DETROL .......................................................................................87
DETROL LA ..................................................................................87
DEXAMETHASONE ......................................................................56
DEXAMETHASONE/ NEOMYCIN/ POLYMYXIN ............................58
DEXAMETHASONE/ TOBRAMYCIN .............................................58
DEXILANT....................................................................................20
DEXLANSOPRAZOLE....................................................................20
DEXMETHYLPHENIDATE .............................................................63
DEXMETHYLPHENI-DATE ............................................................63
DEXTROAMPHET-AMINE ............................................................64
DIABETA .....................................................................................79
DIABINESE ..................................................................................79
DIAMOX SEQUELS ......................................................................55
DIASTAT ......................................................................................64
DIAZEPAM ............................................................................ 61, 64
DIBENZYLINE ..............................................................................30
DICLOFENAC ...............................................................................38
DICLOFENAC EPOLAMINE ...........................................................38
DICLOFENAC POTASSIUM ...........................................................65
DICLOFENAC SODIUM ................................................................53
DICLOFENAC, EXTENDED RELEASE .............................................38
DICLOFENAC/ MISOPROSTOL .....................................................38
DICLOFENAX POTASSIUM ...........................................................38
DICYCLOMINE .............................................................................23
DIDRONEL ...................................................................................77
DIFENOXIN/ ATROPINE...............................................................23
204
DIFFERIN 0.1% CREAM, GEL .......................................................51

DIFFERIN 0.1% LOTION ...............................................................51
DIFFERIN 0.3% GEL .....................................................................51
DIFICID ........................................................................................33
DIFLORASONE DIACETATE ..........................................................46
DIFLUCAN ............................................................................. 36, 52
DIFLUNISAL .................................................................................38
DIGOXIN ............................................................................... 25, 26
DIHYDROERGOTAMINE ..............................................................66
DILACOR XR ................................................................................29
DILANTIN 100MG CAPS ..............................................................64
DILANTIN 30 KEPSEAL.................................................................64
DILANTIN 50 INFATAB ................................................................64
DILATRATE-SR.............................................................................25
DILAUDID ....................................................................................39
DILAUDID 5 LIQUID.....................................................................39
DILTIAZEM ............................................................................ 28, 29
DIMETHYL FUMERATE ................................................................89
DIOVAN ......................................................................................28
DIOVAN HCT ...............................................................................28
DIPENTUM..................................................................................21
DIPHENHYDRAMINE ............................................................. 41, 61
DIPHENOXYLATE/ ATROPINE ......................................................23
DIPIVEFRIN .................................................................................56
DIPROSONE ................................................................................46
DIPYRIDAMOLE...........................................................................54
DISOPYRAMIDE ..........................................................................26
DISULFIRAM ...............................................................................85
DITROPAN XL ..............................................................................87
DIVALPROEX SODIUM ................................................................64
DIVIGEL .......................................................................................74
DL-E AC/ GRAPE/ HYALURONIC ACID .........................................48
DOCYCYCLINE .............................................................................33
DOFETILIDE .................................................................................26
DOLASETRON MESYLATE ............................................................22
DOLOBID.....................................................................................38
DOLOPHINE ................................................................................39
DOMEBORO................................................................................59
DONEPEZIL .................................................................................67
DONNATAL .................................................................................23
DONNATAL ER ............................................................................23
DORNASE ALFA ..................................................................... 44, 45
DORYX ........................................................................................33
DORZOLAMIDE ...........................................................................56
DORZOLAMIDE/TIMOLOL ...........................................................55
DOVONEX CRM ..........................................................................49
DOVONEX SOLN .........................................................................49
DOXAZOSIN .......................................................................... 30, 87
DOXEPIN ............................................................................... 60, 61
DOXYCYCLINE ....................................................................... 33, 35
DOXYCYCLINE/ EYELID CLNS NO.2&3 .........................................57
DOXYCYCLINE/SALICY/OCT/ZINC OX ..........................................33
DRONEDARONE HYDROCHLORIDE .............................................26
DROSPIR/ETH ESTRA/LEVOMEF OL CA .......................................68
DROSPIR/ETHESTRA/LEVOMEFOL CA .........................................73
DROXIA .......................................................................................90
DUAC ..........................................................................................51
DUET DHA BALANCED ................................................................82
DUETACT ....................................................................................80
DULERA ......................................................................................44
DULOXETINE ......................................................................... 60, 89
DUONEB .....................................................................................44
DURAGESIC PATCH .....................................................................39
DUTASTERIDE .............................................................................87
DUTASTERIDE/...................................................................... 30, 88
DUTOPROL .................................................................................29
DYAZIDE......................................................................................26
DYMISTA .....................................................................................42
DYNACIRC CR ..............................................................................29
DYRENIUM..................................................................................26
E
E.E.S. ...........................................................................................33
E.E.S. GRANULES ........................................................................34
ECHOTHIOPHATE ........................................................................56
EDARBI .......................................................................................28
EDARBYCLOR ..............................................................................28
EDEX ...........................................................................................86
EDLUAR ......................................................................................61
EFFEXOR XR ................................................................................60
EFFIENT ......................................................................................54
EGRIFTA ......................................................................................90
ELESTAT ......................................................................................58
ELETRIPTAN ................................................................................66
ELIDEL .........................................................................................49
ELIQUIS .......................................................................................53
ELIXOPHYLLIN ELIXIR ..................................................................45
ELMIRON ....................................................................................87
ELOCON ......................................................................................46
EMADINE ....................................................................................58
EMBEDA .....................................................................................39
EMEDASTINE DIFUMARATE ........................................................58
EMEND .......................................................................................23
EMOLLIENT COMBO ............................................................. 48, 49
EMSAM PATCH ...........................................................................60
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE ..............90
E-MYCIN .....................................................................................34
ENABLEX .....................................................................................87
ENALAPRIL ..................................................................................27
ENALAPRIL/ HCTZ .......................................................................27
ENBREL .......................................................................................86
ENFUVIRTIDE ..............................................................................90
ENJUVIA......................................................................................74
ENOXAPARIN ..............................................................................54
ENPRESSE ...................................................................................68
ENTACAPONE .............................................................................67
ENTEX ER ....................................................................................43
ENTEX LIQUID .............................................................................43
ENTOCORT EC .............................................................................21
ENZALUTAMIDE ..........................................................................90
EPANED SOLUTION.....................................................................27
EPICERAM...................................................................................48
EPIDUO .......................................................................................51
EPINASTINE ................................................................................58
EPLERENONE ........................................................................ 26, 31
EPOETIN ALFA.............................................................................54
EPOGEN ......................................................................................54
EPROSARTAN ..............................................................................28
EPROSARTAN/ HCTZ ...................................................................28
ERGOTAMINE/ CAFFEINE ...........................................................65
ERRIN..........................................................................................69
205
ERTACZO.....................................................................................50
ERYPRED .....................................................................................34
ERY-TAB ................................................................................ 34, 37
ERYTHROCIN ...............................................................................34
ERYTHROMYCIN .........................................................................57
ERYTHROMYCIN BASE .......................................................... 34, 37
ERYTHROMYCIN BASE/ BENZOYL PEROXIDE ..............................51
ERYTHROMYCIN ETHYLSUCCINATE ...................................... 33, 34
ERYTHROMYCIN STEARATE ........................................................34
ERYTHROMYCIN/ BENZOYL PEROXIDE .......................................51
ESCITALOPRAM ..........................................................................60
ESKALITH, CR ..............................................................................62
ESOMEPRAZOLE .........................................................................20
ESOMEPRAZOLE STRONTIUM ....................................................20
ESOMEPRAZOLE/ ........................................................................38
ESTRACE .....................................................................................74
ESTRACE VAGINAL CREAM .........................................................74
ESTRADERM ...............................................................................74
ESTRADIOL..................................................................................74
ESTRADIOL VALERATE/DIENOGEST ............................................70
ESTRADIOL, TRANSDERMAL ................................................. 74, 75
ESTRADIOL/ DROSPIRENONE .....................................................75
ESTRADIOL/ LEVONORGESTREL..................................................75
ESTRADIOL/ NORETHINDRONE ACETATE ...................................75
ESTRADIOL/ NORGESTIMATE .....................................................75
ESTRASORB.................................................................................74
ESTRATEST ..................................................................................75
ESTRING......................................................................................74
ESTROGEL GEL ............................................................................74
ESTROGENS ................................................................................74
ESTROPIPATE ..............................................................................74
ESTROSTEP FE .............................................................................69
ESZOPICLONE .............................................................................61
ETANERCEPT ...............................................................................86
ETHAMBUTOL.............................................................................36
ETHINYL ESTRADIOL ............................... 68, 69, 70, 71, 72, 73, 74
ETHINYL ESTRADIOL 20MCG .................................... 68, 69, 70, 73
ETHINYL ESTRADIOL 20MCG/ FE/ ...............................................70
ETHINYL ESTRADIOL 30MCG ........................ 68, 69, 70, 71, 72, 73
ETHINYL ESTRADIOL 35MCG ......................................................72
ETHINYL ESTRADIOL 35MG....................................... 70, 71, 72, 73
ETHINYL ESTRADIOL 50MCG ................................................ 72, 73
ETHINYL ESTRADIOL/ NORETHINDRONE ACETATE .....................75
ETHINYL ESTRADION 20MCG......................................................69
ETHIONAMIDE ............................................................................36
ETHOSUXIMIDE ..........................................................................65
ETHOTOIN ..................................................................................65
ETIDRONATE ...............................................................................77
ETONOGESTREL ..........................................................................74
EURAX ........................................................................................53
EVEROLIMUS ..............................................................................86
EVISTA ........................................................................................77
EXALGO ......................................................................................39
EXELDERM ..................................................................................50
EXELON .......................................................................................67
EXELON SOLN AND PATCH .........................................................67
EXENATIDE .................................................................................80
EXENATIDE EXTENDED RELEASE .................................................80
EXFORGE ....................................................................................28
EXFORGE HCT .............................................................................28
EXJADE........................................................................................84
EXTAVIA ......................................................................................89
EXTINA ........................................................................................50
EZETIMIBE ..................................................................................32
EZETIMIBE/ ATORVASTATIN .......................................................31
EZETIMIBE/ SIMVASTATIN ..........................................................32
EZOGABINE .................................................................................65
F
FABIOR FOAM ............................................................................49
FACTIVE ......................................................................................34
FAMCICLOVIR .............................................................................37
FAMOTIDINE...............................................................................20
FAMVIR.......................................................................................37
FANAPT.......................................................................................62
FANATREX ..................................................................................64
FAZACLO .....................................................................................62
FEBUXOSTAT ..............................................................................81
FELBAMATE ................................................................................64
FELBATOL ...................................................................................64
FELDENE .....................................................................................38
FEMCON FE ................................................................................69
FEMHRT ......................................................................................75
FEMHRT 0.5MG-2.5MCG ............................................................75
FEMRING ....................................................................................74
FEMTRACE ..................................................................................74
FENOFIBRATE ....................................................................... 31, 32
FENOFIBRIC ACID .................................................................. 31, 32
FENOGLIDE .................................................................................31
FENTANYL ............................................................................. 39, 40
FENTANYL CITRATE............................................................... 39, 40
FENTANYL SL ..............................................................................39
FENTANYL SL SPRAY ...................................................................40
FENTORA ....................................................................................39
FESOTERODINE FUMARATE........................................................88
FEXMID .......................................................................................66
FEXOFENADINE...........................................................................41
FEXOFENADINE/ .........................................................................42
FEXOFENADINE/ PSEUDOEPHEDRINE ........................................43
FIBRICOR ....................................................................................31
FIDAXOMICIN .............................................................................33
FILGRASTIM ................................................................................54
FINACEA .....................................................................................51
FINASTERIDE...............................................................................88
FINGOLIMOD ..............................................................................89
FIORICET .....................................................................................39
FIORICET 50-300-40....................................................................39
FIORINAL ....................................................................................65
FIORINAL W/CODEINE #3 ...........................................................39
FIRST-LANSOPRAZOLE ................................................................20
FIRST-OMEPRAZOLE ...................................................................20
FLAGYL............................................................................ 34, 37, 52
FLAGYL 375MG ...........................................................................34
FLAGYL ER....................................................................... 34, 37, 52
FLAREX........................................................................................56
FLECAINIDE .................................................................................26
FLECTOR .....................................................................................38
FLEXERIL .....................................................................................66
FLOMAX ................................................................................ 30, 87
FLONASE .....................................................................................42
FLOVENT HFA .............................................................................44
206
FLUCONAZOLE ...................................................................... 36, 52

FLUCYTOSINE..............................................................................35
FLUMADINE TABS .......................................................................37
FLUOCINOLONE ACETONIDE ......................................................46
FLUOCINOLONE SOLN/ CLEANSER .............................................47
FLUOCINONIDE ...........................................................................47
FLUORABON DROPS ...................................................................84
FLUOROMETHOLONE .................................................................56
FLUOXETINE ...............................................................................60
FLUOXYMESTERONE...................................................................76
FLURANDRENOLIDE ....................................................................46
FLURBIPROFEN ...........................................................................38
FLUTICASONE ....................................................................... 42, 44
FLUTICASONE FUROATE .............................................................42
FLUTICASONE PROPIONATE .......................................................46
FLUTICASONE/ SALMETEROL .....................................................43
FLUTICASONE/ VILANTEROL .......................................................44
FLUVASTATIN .............................................................................31
FLUVOXAMINE MALEATE ...........................................................60
FML.............................................................................................56
FML FORTE .................................................................................56
FML S.O.P. ..................................................................................56
FOCALIN .....................................................................................63
FOCALIN XR ................................................................................63
FOLIC ACID............................................................................ 81, 91
FOLLISTIM AQ .............................................................................76
FOLLITROPIN ALPHA,RECOMB ...................................................76
FOLLITROPIN BETA,RECOMB ......................................................76
FORADIL .....................................................................................44
FORFIVO XL.................................................................................60
FORMOTEROL FUMARATE .........................................................44
FORTAMET .................................................................................79
FORTEO ......................................................................................77
FORTESTA ...................................................................................76
FORTICAL ....................................................................................77
FOSAMAX ...................................................................................77
FOSAMAX PLUS D .......................................................................77
FOSFOMYCIN TROMETHAMINE .................................................35
FOSINOPRIL ................................................................................27
FOSINOPRIL/ HCTZ .....................................................................27
FOSRENOL ..................................................................................90
FRAGMIN ....................................................................................54
FROVA ........................................................................................65
FROVATRIPTAN ..........................................................................65
FULVICIN U/F ..............................................................................36
FULYZAQ .....................................................................................22
FURAZOLIDONE ..........................................................................35
FUROSEMIDE ..............................................................................26
FUROXONE .................................................................................35
FUZEON ......................................................................................90
G
GABAPENTIN ........................................................................ 64, 89
GABAPENTIN ENACARBIL ...........................................................89
GABITRIL .....................................................................................64
GABITRIL12,16MG ......................................................................64
GALANTAMINE ...........................................................................67
GARAMYCIN ......................................................................... 49, 57
GASTROCROM ............................................................................22
GELNIQUE ...................................................................................87
GEMFIBROZIL .............................................................................31
GEMIFLOXACIN MESYLATE .........................................................34
GENERESS FE ..............................................................................69
GENGRAF ....................................................................................86
GENOTROPIN..............................................................................90
GENTAMICIN ........................................................................ 49, 57
GEODON .....................................................................................62
GESTICARE, DHA .........................................................................82
GIAZO .........................................................................................21
GILENYA......................................................................................89
GLATIRAMER ACETATE ...............................................................89
GLIMEPIRIDE ..............................................................................79
GLIPIZIDE ....................................................................................79
GLUCAGON .................................................................................81
GLUCOPHAGE XR ........................................................................79
GLUCOSE TEST STRIPS ................................................................80
GLUCOTROL XL ...........................................................................79
GLUCOVANCE .............................................................................79
GLUMETZA .................................................................................79
GLYBURIDE .................................................................................79
GLYBURIDE/ METFORMIN ..........................................................79
GLYNASE PRESTAB......................................................................79
GLYSET ........................................................................................81
GOLIMUMAB ..............................................................................87
GOLYTELY ...................................................................................24
GONADOTROPIN, CHORIONIC,HUMAN......................................77
GONAL-F .....................................................................................76
GORDO-UREA .............................................................................48
GRALISE ......................................................................................89
GRANISETRON ............................................................................23
GRANULEX ..................................................................................53
GRIFULVIN-V...............................................................................36
GRISEOFULVIN............................................................................36
GRISEOFULVIN, ULTRAMICROSIZE .............................................36
GRIS-PEG ....................................................................................36
GUAIFENESIN/ PHENYLEPHRINE.................................................43
GUANFACINE ........................................................................ 31, 63
H
HALCINONIDE .............................................................................46
HALDOL ......................................................................................62
HALOBETASOL PROP/ AMMONIUM LAC ....................................47
HALOG ........................................................................................46
HALOPERIDOL.............................................................................62
HCG ALPHA,RECOMBINANT .......................................................77
HEMENATAL OB MIS + DHA .......................................................82
HEMOCYTE-F TABLET .................................................................82
HIPREX ........................................................................................35
HOMATROPINE ..........................................................................55
HORIZANT...................................................................................89
HUMALOG ..................................................................................78
HUMALOG MIX ...........................................................................78
HUMATROPE ..............................................................................90
HUMIRA......................................................................................86
HUMULIN INSULINS....................................................................78
HYDRALAZINE .............................................................................28
HYDRO 40 ...................................................................................48
HYDROCODONE BIT/ ACETAMINOPHEN ....................................41
HYDROCODONE/ CHLORPHEN POLIS .........................................42
HYDROCODONE/ CHLORPHENIRAMINE .....................................42
207
HYDROCODONE/ IBUUPROFEN ..................................................39

HYDROCORTISONE .....................................................................68
HYDROCORTISONE ACETATE ......................................................21
HYDROCORTISONE BUTYRATE 0.1% ...........................................46
HYDROCORTISONE BUTYRATE/ EMOLL ......................................47
HYDROCORTISONE PROBUTATE .................................................47
HYDROCORTISONE SUPP ............................................................22
HYDROCORTISONE VALERATE ....................................................47
HYDROCORTISONE/ EMOLLIENT ................................................47
HYDROCORTISONE/ NEOMYCIN/ POLYMYXIN ...........................59
HYDROCORTISONE/ NEOMYCIN/ POLYMYXIN/ BACITRACIN .....58
HYDROCORTISONE/ NEOMYCIN/POLYMYXIN/ BACITRACIN ......49
HYDROCORTISONE/ PRAMOXINE ...............................................22
HYDROCORTISONE/ALOE VERA ..................................................47
HYDROCORTISONE/BENZOYL PEROXIDE ....................................47
HYDROCORTISONE/UREA ...........................................................47
HYDROMORPHONE ....................................................................39
HYDROXYCHOLORO- ..................................................................37
HYDROXYUREA ...........................................................................90
HYDROXYZINE PAMOATE ...........................................................61
HYLATOPIC .................................................................................48
HYLATOPIC PLUS ........................................................................48
HYOSCYAMINE ..................................................................... 23, 24
HYZAAR ......................................................................................28
I
IBANDRONATE............................................................................77
IBUDONE 10/200 ........................................................................39
IBUPROFEN.................................................................................38
IBUPROFEN/ HYDROCODONE .............................................. 40, 41
ICLUSIG .......................................................................................90
ICOSAPENT ETHYL ......................................................................32
ILEVRO ........................................................................................59
ILOPERIDONE..............................................................................62
ILOTYCIN.....................................................................................57
IMDUR ........................................................................................25
IMIPRAMINE PAMOATE .............................................................60
IMIQUIMOD ...............................................................................53
IMITREX KIT ................................................................................65
IMITREX SPRAY ...........................................................................65
IMITREX TABLET .........................................................................65
IMMUNE GLOBULIN ...................................................................91
IMODIUM ...................................................................................23
IMURAN......................................................................................86
INCIVEK.......................................................................................88
INDACATEROL.............................................................................44
INDAPAMIDE ..............................................................................26
INDERAL .....................................................................................65
INDERAL LA.................................................................................66
INDERAL, LA................................................................................29
INDOCIN .....................................................................................38
INDOCIN SUSP ............................................................................81
INDOMETHACIN ........................................................... 38, 81, See
INFLIXIMAB.................................................................................91
INH .............................................................................................36
INSPRA.................................................................................. 26, 31
INSULIN ................................................................................ 78, 79
INSULIN ASPART .........................................................................79
INSULIN DETEMIR .......................................................................78
INSULIN DETIMIR ........................................................................78
INSULIN GLARGINE .....................................................................78

INSULIN GLULISINE .....................................................................78
INSULIN LISPRO ..........................................................................78
INSULIN SYRINGES ......................................................................79
INTERFERON BETA-1A ................................................................89
INTERFERON BETA-1A/ALBUMIN ...............................................89
INTERFERON BETA-1B ................................................................89
INTERMEZZO ..............................................................................61
INTUNIV ......................................................................................63
INVEGA .......................................................................................62
INVOKANA ..................................................................................79
IODOQUINOL ..............................................................................38
IOPIDINE .....................................................................................55
IPRATROPIUM BROMIDE ...................................................... 42, 44
IPRATROPIUM/ ALBUTEROL SULFATE ........................................44
IQUIX ..........................................................................................57
IRBESARTAN ...............................................................................27
IRBESARTAN/ HCTZ ....................................................................27
IRON SUPPLEMENTS...................................................................91
ISOETHARINE ..............................................................................44
ISONIAZID ...................................................................................36
ISOPTIN ......................................................................................29
ISOPTO CARBACHOL ...................................................................55
ISOPTO CARBACHOL1%, 2%, 4%.................................................55
ISOPTO HOMATROPINE..............................................................55
ISORDIL 5, 10 ..............................................................................25
ISOSORBIDE DINITRATE ..............................................................25
ISOSORBIDE DINITRATE/ HYDRALAZINE .....................................25
ISOSORBIDE MONONITRATE ......................................................25
ISRADIPINE .................................................................................29
ISTALOL ......................................................................................55
ITRACONAZOLE ..........................................................................36
IVERMECTIN ......................................................................... 37, 53
IVIG .............................................................................................91
J
JAKAFI .........................................................................................90
JALYN .................................................................................... 30, 88
JANUMET....................................................................................79
JANUVIA .....................................................................................80
JENTADUETO ..............................................................................80
JOLIVETTE ...................................................................................69
JUVISYNC ....................................................................................80
JUXTAPID ....................................................................................31
K
KADIAN .......................................................................................39
KADIAN 10, 40, 70, 130, 150, 200MG .........................................39
KAPVAY.......................................................................................63
KARIVA .......................................................................................69
KAYEXALATE ...............................................................................87
KAZANO ......................................................................................80
KEFLEX ........................................................................................33
KENALOG ....................................................................................46
KENALOGAEROSOL SPRAY ..........................................................46
KEPPRA .......................................................................................64
KEPPRA XR ..................................................................................64
KERAFOAM .................................................................................48
KERALAC .....................................................................................48
208
KERLONE.....................................................................................29
KEROL 50% SUSPENSION ............................................................48
KEROL AD ...................................................................................48
KETEK..........................................................................................34
KETOCONAZOLE .........................................................................50
KETOCONAZOLE FOAM/ CLEANSER ...........................................50
KETODAN KIT ..............................................................................50
KETOROLAC ................................................................................38
KETOROLAC TROMETHAMINE ....................................................58
KETOTIFEN ..................................................................................58
KINERET ......................................................................................87
KLONOPIN ..................................................................................64
KLOR-CON ..................................................................................83
KOMBIGLYZE XR .........................................................................80
KORLYM ......................................................................................79
K-PHOS ORIGINAL.......................................................................83
KYNAMRO ..................................................................................31
L
LABETALOL .................................................................................30
LAC-HYDRIN................................................................................48
LACOSAMIDE ..............................................................................65
LACTULOSE .................................................................................24
LACTULOSE SOLN .......................................................................24
LAMICTAL 5, 25MG DISPER TABLET............................................64
LAMICTAL ODT ...........................................................................64
LAMICTAL XR, STARTER KIT ........................................................64
LAMICTAL/XR .............................................................................64
LAMISIL .......................................................................................36
LAMISIL SOLN .............................................................................50
LAMOTRIGINE ............................................................................64
LANCETS .....................................................................................81
LANOXIN 125MCG ................................................................ 25, 26
LANSOPRAZOLE ..........................................................................20
LANTHANUM CARBONATE .........................................................90
LANTUS .......................................................................................78
LANTUS SOLOSTAR .....................................................................78
LASIX ...........................................................................................26
LASTACAFT .................................................................................58
LATANOPROST............................................................................56
LATUDA ......................................................................................62
LAZANDA ....................................................................................40
LEFLUNOMIDE ............................................................................86
LESCOL........................................................................................31
LESCOL, XL ..................................................................................31
LESSINA ......................................................................................69
LEUKINE ......................................................................................54
LEUPROLIDE ACETATE ................................................................77
LEVALBUTEROL ...........................................................................45
LEVAQUIN...................................................................................34
LEVATOL .....................................................................................30
LEVEMIR .....................................................................................78
LEVEMIR FLEXPEN ......................................................................78
LEVETIRACETAM .........................................................................64
LEVITRA ......................................................................................86
LEVOBUNOLOL ...........................................................................55
LEVOCARNITINE..........................................................................84
LEVOCETIRIZINE..........................................................................42
LEVODAPA/ CARBIDOPA ............................................................67
LEVOFLOXACIN ..................................................................... 34, 57
LEVORA.......................................................................................69
LEVOTHROID ..............................................................................78
LEVOTHYROXINE SODIUM ..........................................................78
LEVOXYL .....................................................................................78
LEVSIN ........................................................................................23
LEXAPRO .....................................................................................60
LIALDA ........................................................................................21
LIBRAX ........................................................................................24
LIDOCAINE ..................................................................................87
LIDOCAINE/ TETRACAINE ...........................................................87
LIDODERM 5% PATCH ................................................................87
LIDORX GEL.................................................................................87
LINACLOTIDE ..............................................................................89
LINAGLIPTIN ...............................................................................80
LINAGLIPTIN/ ..............................................................................80
LINEZOLID ...................................................................................35
LINZESS .......................................................................................89
LIOTHYRONINE SODIUM ............................................................78
LIOTRIX .......................................................................................78
LIPITOR .......................................................................................31
LIPOFEN ......................................................................................31
LIPTRUZET ..................................................................................31
LIRAGLUTIDE ..............................................................................81
LISDEXAMFETAMINE DIMESYLATE .............................................63
LISINOPRIL ..................................................................................27
LISINOPRIL/ HCTZ .......................................................................27
LITHIUM .....................................................................................62
LITHOBID ....................................................................................62
LIVALO ........................................................................................31
L-NORGEST-ETH ESTR/ETHIN ESTRA..................................... 70, 73
LO MINASTRIN FE .......................................................................70
LO/OVRAL ...................................................................................69
LOCOID .......................................................................................46
LOCOID LOTN, LIPOCREAM ........................................................47
LODOSYN ....................................................................................67
LODOXAMIDE TROMETHAMINE .................................................58
LOESTRIN 21 1.5/30 ...................................................................69
LOESTRIN 21 1/20 ......................................................................69
LOESTRIN 24 FE ..........................................................................70
LOESTRIN FE 1/20 .......................................................................69
LOFIBRA ......................................................................................31
LOMITAPIDE MESYLATE .............................................................31
LOMOTIL.....................................................................................23
LOPERAMIDE ..............................................................................23
LOPID..........................................................................................31
LOPRESSOR .................................................................................30
LOPRESSOR HCT .........................................................................30
LOPROX ......................................................................................50
LORATADINE...............................................................................41
LORATIDINE/ PSEUDOEPHEDRINE ..............................................43
LORAZEPAM ...............................................................................61
LORCET, PLUS .............................................................................40
LORZONE ....................................................................................66
LOSARTAN ..................................................................................28
LOSARTAN/ HCTZ .......................................................................28
LOSEASONIQUE ..........................................................................70
LOTEMAX....................................................................................56
LOTENSIN ...................................................................................27
LOTENSIN HCT ............................................................................27
LOTEPREDNOL ETABONATE .......................................................56
LOTEPREDNOLETABONATE ........................................................56
209
LOTREL 2.5-10, 5-10, 5-20, 10-20 ......................................... 27, 29

LOTRIMIN ...................................................................................50
LOTRISONE .................................................................................50
LOTRONEX ............................................................................ 22, 89
LOVASTATIN ......................................................................... 31, 32
LOVAZA ......................................................................................31
LOVENOX ....................................................................................54
LOW-OGESTREL ..........................................................................70
LOXAPINE ...................................................................................62
LOXITANE ...................................................................................62
LOZOL .........................................................................................26
LUBIPROSTONE .................................................................... 22, 89
LUMIGAN....................................................................................55
LUNESTA .....................................................................................61
LUPRON DEPOT 3.75 KIT ............................................................77
LURASIDONE ..............................................................................62
LUVOX CR ...................................................................................60
LUXIQ..........................................................................................47
LYBREL ........................................................................................70
LYRICA .................................................................................. 64, 89
M
MACROBID .................................................................................35
MACRODANTIN 25MG ...............................................................35
MACRODANTIN 50, 100MG........................................................35
MAFENIDE ACETATE ...................................................................49
MALARONE.................................................................................37
MALATHION ...............................................................................53
MAVIK ........................................................................................27
MAXAIR ......................................................................................44
MAXALT, MLT .............................................................................66
MAXIDEX ....................................................................................56
MAXITROL ..................................................................................58
MAXZIDE.....................................................................................26
MECLIZINE ..................................................................................22
MEDROL .....................................................................................68
MEDROXY-PROGESTERONE/ MPA..............................................75
MEFENAMIC ACID ......................................................................38
MELOXICAM ...............................................................................38
MEMANTINE...............................................................................67
MENEST ......................................................................................74
MENOTROPINS ...........................................................................77
MENTAX .....................................................................................50
MEPENZOLATE BROMIDE ...........................................................23
MEPERIDINE ...............................................................................39
MEPHYTON.................................................................................84
MEPROBAMATE .........................................................................61
MEPRON .....................................................................................37
MESALAMINE .............................................................................21
MESTINON ..................................................................................66
MESTINON 180 ...........................................................................67
MESTRANOL 50MCG ............................................................ 71, 72
METADATE CD ............................................................................63
METADATE ER ............................................................................63
METAPROTERENOL SYRUP .........................................................45
METAPROTERENOL, 10MG/5ML ................................................45
METAXALONE .............................................................................66
METFORMIN ...............................................................................79
METHADONE .................................................................. 39, 40, 85
METHAMPHETAMINE.................................................................63
METHAZOLAMIDE ......................................................................56
METHENAMINE ..........................................................................35
METHENAMINE/METH BLUE/SALICYLATE ..................................35
METHENAMINE/METH BLUE/SALICYLATE/NA PHOS/HYOSCY ...35
METHERGINE ..............................................................................88
METHIMAZOLE ...........................................................................78
METHITEST .................................................................................76
METHOCARBAMOL.....................................................................66
METHOTREXATE .........................................................................49
METHOTREXATE TABS ................................................................49
METHSCOPOLAMINE BROMIDE .................................................24
METHSCOPOLAMINE COMBO ....................................................24
METHSUXIMIDE..........................................................................64
METHYLDOPA .............................................................................30
METHYLDOPA/ HCTZ ..................................................................30
METHYLERGONOVINE ................................................................88
METHYLIN CHEW TAB ................................................................63
METHYLIN SOLN 5MG/5ML ........................................................63
METHYLPHENIDATE....................................................................63
METHYLPHENIDATE ORAL SUSP .................................................63
METHYLPHENIDATE PATCH ........................................................63
METHYLPHENIDATE, SUST. RELEASE ..........................................63
METHYLPREDNISOLONE .............................................................68
METHYLTESTOSTERONE .............................................................76
METIPRANOLOL..........................................................................56
METOCLOPRAMIDE ....................................................................23
METOLAZONE .............................................................................26
METOPROLOL .............................................................................30
METOPROLOL SUCCINATE ..........................................................30
METOPROLOL/ HCTZ ..................................................................30
METOPROLOL/HCTZ ...................................................................29
METROGEL 0.75%.......................................................................50
METROGEL-VAGINAL ............................................................ 50, 52
METRONIDAZOLE ..................................................... 34, 37, 50, 52
METRONIDAZOLE/ CLEANSER ....................................................50
MEVACOR ...................................................................................32
MIACALCIN NASAL ......................................................................77
MICARDIS ...................................................................................28
MICARDIS HCT ............................................................................28
MICONAZOLE .............................................................................36
MICONAZOLE NITRATE/ZINC OXIDE ...........................................50
MICROGESTIN FE 1.5/30 ............................................................70
MICROGESTIN FE 1/20 ...............................................................70
MICRO-K 10MEQ ........................................................................83
MICRONASE ................................................................................79
MIFEPRISTONE ...........................................................................79
MIGLITOL ....................................................................................81
MIGRANAL NASAL SPRAY ...........................................................66
MILNACIPRAN ...................................................................... 89, 90
MILTOWN ...................................................................................61
MINICYCLINE KIT ........................................................................33
MINIPRESS ..................................................................................30
MINOCIN ....................................................................................33
MINOCIN PAC .............................................................................33
MINOCYCLINE.............................................................................33
MIPOMERSEN.............................................................................31
MIRABEGRON .............................................................................88
MIRAPEX.....................................................................................67
MIRAPEX ER................................................................................67
MIRCETTE ...................................................................................70
MIRTAZAPINE .............................................................................60
210
MIRVASO ....................................................................................53
MISOPROSTOL ............................................................................20
MOBAN ......................................................................................62
MOBIC ........................................................................................38
MODAFINIL .................................................................................63
MODICON ...................................................................................70
MOEXIPRIL..................................................................................27
MOEXIPRIL/ HCTZ .......................................................................27
MOLINDONE ...............................................................................62
MOMETASONE ...........................................................................42
MOMETASONE FUROATE ..................................................... 44, 46
MOMETASONE FUROATE/AMMONIUM LAC .............................47
MOMETASONE/ .........................................................................44
MOMEXIN...................................................................................47
MONODOX .................................................................................33
MONOKET ..................................................................................25
MONONESSA ..............................................................................70
MONOPRIL .................................................................................27
MONOPRIL HCT ..........................................................................27
MONTELUKAST ..................................................................... 42, 45
MONUROL ..................................................................................35
MORPHINE .................................................................................40
MORPHINE SULFATE ............................................................ 39, 40
MORPHINE SULFATE/ .................................................................39
MORPHINE TABLETS ...................................................................40
MORPHINE, SUSTAINED RELEASE ...............................................40
MOTOFEN...................................................................................23
MOTRIN ......................................................................................38
MOVIPREP ..................................................................................24
MOXATAG 775 MG ER ................................................................32
MOXIFLOXACIN .................................................................... 34, 57
MS CONTIN.................................................................................40
MULTAQ .....................................................................................26
MUPIROCIN 2% ..........................................................................49
MUPIROCIN 2% CRM ..................................................................49
MUPIROCIN 2% OINT .................................................................49
MUSE ..........................................................................................86
MYAMBUTOL..............................................................................36
MYCELEX TROCHES.....................................................................36
MYCOBUTIN ...............................................................................36
MYCOPHENOLATE ......................................................................86
MYCOPHENOLATE MOFETIL .......................................................86
MYCOSTATIN ........................................................................ 50, 52
MYDRIACYL.................................................................................56
MYFORTIC...................................................................................86
MYRBETRIQ ................................................................................88
MYSOLINE...................................................................................64
N
NA PICOSUL/MAG-OX/ CITRIC ACID ...........................................24
NABUMETONE............................................................................38
NADOLOL....................................................................................29
NADOLOL/ BENDROFLUMETHIAZIDE .........................................29
NAFARELIN ACETATE ..................................................................77
NAFTIFINE...................................................................................50
NAFTIN .......................................................................................50
NALTREXONE ..............................................................................85
NAMENDA ..................................................................................67
NAMENDA XR ............................................................................67
NAPHOS MB-MH/NAPHOS, DI-BA ..............................................24
NAPRELAN CR DOSEPAK .............................................................38

NAPROSYN..................................................................................38
NAPROXEN .................................................................................38
NAPROXEN SODIUM...................................................................38
NARATRIPTAN ............................................................................65
NARDIL .......................................................................................60
NASACORT AQ ............................................................................42
NASONEX ....................................................................................42
NATACYN ....................................................................................57
NATALIZUMAB............................................................................91
NATALVIT....................................................................................82
NATAMYCIN ...............................................................................57
NATAZIA .....................................................................................70
NATEGLINIDE ..............................................................................79
NATELLE ONE..............................................................................82
NAVANE ......................................................................................62
NAVANE 20 .................................................................................62
NEBIVOLOL .................................................................................29
NEBUPENT ..................................................................................37
NECON 0.5/35 ............................................................................71
NECON 1/35 ...............................................................................71
NECON 1/50 ...............................................................................71
NECON 10/11 .............................................................................71
NECON 7/7/7 ..............................................................................71
NEDOCROMIL SODIUM ..............................................................58
NEOMY SULF/ COLIST SUL/ HC/ THONZ .....................................59
NEORAL ......................................................................................86
NEOSALUS ..................................................................................48
NEOSPORIN ................................................................................57
NEPAFENAC ................................................................................59
NEPTAZANE ................................................................................56
NESINA .......................................................................................80
NESTABS .....................................................................................82
NESTABS DHA .............................................................................82
NEUPOGEN .................................................................................54
NEUPRO......................................................................................67
NEURIN-SL ..................................................................................83
NEURONTIN................................................................................64
NEVANAC ...................................................................................59
NEXA SELECT ..............................................................................82
NEXICLON XR ..............................................................................31
NEXIUM ......................................................................................20
NIACIN ........................................................................................32
NIACIN/ SIMVASTATIN ...............................................................32
NIACIN/LOVASTATIN ..................................................................31
NIASPAN .....................................................................................32
NICARDIPINE ..............................................................................28
NICORETTE GUM OTC ................................................................85
NICOTINE INHALER .....................................................................85
NICOTINE LOZENGE OTC ............................................................85
NICOTINE NASAL SPRAY .............................................................85
NICOTINE PATCH ........................................................................85
NICOTINE PATCH OTC.................................................................85
NICOTINE PATCH, RX ..................................................................85
NICOTINE POLACRILEX ...............................................................85
NICOTROL INHALER ....................................................................85
NICOTROL NS..............................................................................85
NIDOLDIPINE ..............................................................................29
NIFEDIPINE ........................................................................... 28, 29
NIMODIPINE ...............................................................................29
NIMOTOP ...................................................................................29
211
NIRAVAM....................................................................................61
NITAZOXANIDE ...........................................................................37
NITRO-BID OINT .........................................................................25
NITRO-DUR PATCHES 0.1, 0.2, 0.4, 0.6MG/HR ...........................25
NITRO-DUR PATCHES 0.3, 0.8MG/HR .........................................25
NITROFURANTOIN ......................................................................35
NITROGLYCERIN .........................................................................25
NITROGLYCERIN SUBLINGUAL ....................................................25
NITROGLYCERIN TRANSDERMAL ................................................25
NITROLINGUAL SPRAY ................................................................25
NITROSTAT .................................................................................25
NIZATIDINE .................................................................................20
NIZORAL .....................................................................................50
NORA-BE.....................................................................................71
NORDETTE ..................................................................................71
NORDITROPIN ............................................................................90
NORETH A-ET ESTRA/FE FUMARATE ..........................................69
NORETH-ETHINYL ESTRADIOL/IRON ...........................................69
NORETHINDRONE 0.35MG ....................................... 68, 69, 71, 72
NORETHINDRONE ACETATE .......................................................75
NORFLEX .....................................................................................66
NORFLOXACIN ............................................................................34
NORINYL 1/35.............................................................................71
NORINYL 1+50 ............................................................................71
NORMODYNE .............................................................................30
NOROXIN ....................................................................................34
NORPACE ....................................................................................26
NORPACE CR 100MG ..................................................................26
NORPRAMIN ...............................................................................60
NORTREL 0.5/35 .........................................................................71
NORTREL 1/35 ............................................................................71
NORTREL 7/7/7...........................................................................71
NORTRIPTYLINE ..........................................................................60
NORVASC ....................................................................................29
NOVAREL ....................................................................................77
NOVOLIN INSULINS ....................................................................79
NOVOLOG INSULINS ...................................................................79
NOVOLOG MIX ...........................................................................79
NOXAFIL .....................................................................................36
NUCORT......................................................................................47
NUCYNTA....................................................................................40
NUCYNTA ER...............................................................................40
NULEV.........................................................................................24
NUMORPHAN .............................................................................40
NUOX GEL ...................................................................................51
NUTROPIN ..................................................................................90
NUVARING ..................................................................................74
NUVIGIL ......................................................................................63
NYSTATIN ....................................................................... 50, 52, 53
NYSTATIN VAGINAL TABS ...........................................................53
NYSTATIN/EMOLLIENT ...............................................................50
O
OB COMPLETE, PREMIER, ONE, 400, DHA ..................................82
OBSTETRIX EC .............................................................................82
OCUFLOX ....................................................................................57
OFLOXACIN .................................................................................57
OGEN ..........................................................................................74
OGESTREL ...................................................................................72
OLANZAPINE ...............................................................................62
OLANZAPINE/ FLUOXETINE ........................................................62

OLEPTRO ER................................................................................60
OLMESARTAN .............................................................................27
OLMESARTAN MED/ AMLODIPINE/HCTZ ...................................28
OLMESARTAN/ HCTZ ..................................................................27
OLOPATADINE ...................................................................... 42, 58
OLSALAZINE ................................................................................21
OLUX...........................................................................................47
OLUX-E .......................................................................................47
OMECLAMOX-PAK ......................................................................20
OMEGA-3-ACID ETHYL ESTERS ...................................................31
OMEPRAZOLE ....................................................................... 20, 21
OMEPRAZOLE MAGNESIUM .......................................................20
OMEPRAZOLE-CLARITHROMYCIN- AMOXICILLIN .......................20
OMNARIS ....................................................................................42
OMNITROPE ...............................................................................90
ONDANSETRON ..........................................................................23
ONFI ...........................................................................................65
ONFI SUSPENSION ......................................................................65
ONGLYZA ....................................................................................80
ONMEL .......................................................................................36
ONSOLIS .....................................................................................40
OPANA ........................................................................................40
OPANA, ER ..................................................................................40
OPTASE .......................................................................................53
OPTIVAR .....................................................................................58
ORACEA ......................................................................................33
ORAL FLUORIDE ..........................................................................91
ORAMORPH SR ...........................................................................40
ORAP ..........................................................................................62
ORAVIG.......................................................................................36
ORBIVAN CF................................................................................40
ORENCIA SQ...............................................................................87
ORENCIA IV .................................................................................91
ORPHENADRINE .........................................................................66
ORTHO EVRA PATCH ..................................................................74
ORTHO MICRONOR ....................................................................72
ORTHO TRI-CYCLEN ....................................................................72
ORTHO TRI-CYCLEN LO ...............................................................72
ORTHO-CEPT ..............................................................................72
ORTHO-CYCLEN ..........................................................................72
ORTHO-NOVUM 1/35 .................................................................72
ORTHO-NOVUM 1/50 .................................................................72
ORTHO-NOVUM 7/7/7 ...............................................................72
OSELTAMIVIR .............................................................................37
OSENI..........................................................................................80
OSMOPREP .................................................................................24
OSPEMIFENE ..............................................................................77
OSPHENA ....................................................................................77
OTC ASPIRIN ...............................................................................91
OTC NICOTINE PATCHES .............................................................91
OVCON 35 ..................................................................................72
OVCON 50 ..................................................................................72
OVIDE .........................................................................................53
OVIDREL .....................................................................................77
OXANDRIN ..................................................................................76
OXANDROLONE ..........................................................................76
OXAPROZIN ................................................................................38
OXCARBAZEPINE.........................................................................65
OXICONAZOLE NITRATE..............................................................50
OXISTAT ......................................................................................50
212
OXTELLAR XR ..............................................................................65
OXYBUTYNIN ........................................................................ 87, 88
OXYBUTYNIN CHLORIDE .............................................................87
OXYCODONE...............................................................................40
OXYCONTIN ................................................................................40
OXYMORPHONE .........................................................................40
OXYMORPHONE ER (NON-CRUSH RESISTANT) ...........................40
OXYTROL PATCH .........................................................................88
P
PACERONE ..................................................................................26
PACNEX ......................................................................................52
PACNEX MX ................................................................................52
PALIPERIDONE ............................................................................62
PALIVIZUMAB .............................................................................91
PAMELOR ...................................................................................60
PAMINE ......................................................................................24
PAMINE FORTE ...........................................................................24
PAMINE FQ .................................................................................24
PANCREAZE ................................................................................22
PANDEL.......................................................................................47
PANRETIN ...................................................................................53
PANTOPRAZOLE .........................................................................20
PAPAVERINE ...............................................................................25
PARAFON FORTE DSC .................................................................66
PARCOPA ....................................................................................67
PARICALCITOL.............................................................................78
PARLODEL ...................................................................................67
PARNATE ....................................................................................60
PAROXETINE ...............................................................................60
PATADAY ....................................................................................58
PATANASE ..................................................................................42
PATANOL ....................................................................................58
PAXIL, CR ....................................................................................60
PCE .............................................................................................34
PEDIADERM AF ...........................................................................50
PEDIADERM HC 2% KIT ...............................................................47
PEDIADERM TA ...........................................................................47
PEDIAPRED LIQUID .....................................................................68
PEG3350/NA SULF/ BICARB/KCL ................................................24
PEG3350/NA SULF/BICARB/CL/KCL ............................................24
PEG3350/SOD SUL/NACL/ASB/CL/KCL .......................................24
PEGANONE .................................................................................65
PEGASYS .....................................................................................88
PEGINTERFERON ALFA-2A ..........................................................88
PEGINTERFERON ALFA-2B ..........................................................88
PEG-INTRON ...............................................................................88
PENBUTOLOL ..............................................................................30
PENICILLAMINE ..........................................................................84
PENLAC .......................................................................................50
PENTAMIDINE ISETHIONATE ......................................................37
PENTASA.....................................................................................21
PENTOSAN POLYSULFATE ...........................................................87
PENTOXIFYLLINE .........................................................................54
PEPCID RPD ................................................................................20
PEPCID TABS ...............................................................................20
PERCOCET...................................................................................40
PERCODAN .................................................................................40
PERINDOPRIL ..............................................................................27
PERIOSTAT ..................................................................................33
PERSANTINE ...............................................................................54
PERTZYE ......................................................................................22
PEXEVA .......................................................................................60
PHENAZOPYRIDINE .....................................................................88
PHENELZINE................................................................................60
PHENERGAN ......................................................................... 23, 41
PHENOBARBITAL ........................................................................65
PHENOXYBENZAMINE ................................................................30
PHENYLEPHRINE/ CHLORPHENIRAMINE ....................................43
PHENYTOIN ................................................................................64
PHOSLO ......................................................................................90
PHOSPHOLINE IODIDE SOLN ......................................................56
PHYTONADIONE .........................................................................84
PILOCAR......................................................................................56
PILOCARPINE ..............................................................................56
PILOPINE HS ...............................................................................56
PIMECROLIMUS ..........................................................................49
PIMOZIDE ...................................................................................62
PIOGLITAZONE ...........................................................................80
PIOGLITAZONE/ ..........................................................................80
PIOGLITAZONE/ GLIMEPIRIDE ....................................................80
PIOGLITAZONE/ METFORMIN ....................................................80
PIRBUTEROL ...............................................................................44
PIROXICAM .................................................................................38
PITAVASTATIN CALCIUM ............................................................31
PLAQUENIL .................................................................................37
PLAVIX ........................................................................................54
PLETAL ........................................................................................54
PLIAGLIS .....................................................................................87
PODOFILOX.................................................................................53
POLYMYXIN/ BACITRACIN ..........................................................57
POLYMYXIN/ BACITRACIN/ NEOMYCIN ......................................57
POLYMYXIN/ TRIMETHOPRIM ....................................................57
POLYSPORIN ...............................................................................57
POLYTRIM ...................................................................................57
PONATINIB .................................................................................90
PONSTEL .....................................................................................38
PORTIA .......................................................................................73
POSACONAZOLE .........................................................................36
POTASSIUM CHLORIDE ...............................................................83
POTASSIUM CITRATE ..................................................................84
POTASSIUM PHOSPHATE............................................................83
POTIGA .......................................................................................65
PRADAXA ....................................................................................54
PRAMIPEXOLE ............................................................................67
PRAMIPEXOLE DI-HCL.................................................................67
PRAMLINTIDE ACETATE ..............................................................81
PRAMOXINE ...............................................................................22
PRANDIMET ................................................................................79
PRANDIN ....................................................................................79
PRASUGREL HYDROCHLORIDE....................................................54
PRAVACHOL................................................................................32
PRAVASTATIN .............................................................................32
PRAZIQUANTEL...........................................................................37
PRAZOSIN ...................................................................................30
PRECOSE .....................................................................................81
PRED FORTE................................................................................56
PRED MILD..................................................................................56
PREDNISOLONE .................................................................... 56, 68
PREDNISONE ..............................................................................87
PREFERA-OB ONE .......................................................................82
213
PREFERA-OB PLUS DHA ..............................................................82

PREFEST ......................................................................................75
PREFFERA OB ..............................................................................82
PREGABALIN ......................................................................... 64, 89
PREGNYL .....................................................................................77
PREMARIN ORAL ........................................................................74
PREMARIN VAG CREAM .............................................................74
PREMPHASE ...............................................................................75
PREMPRO ...................................................................................76
PRENATA ....................................................................................82
PRENATAL COMPLETE ................................................................82
PRENATAL PLUS..........................................................................83
PRENATE ELITE ...........................................................................83
PRENATE MINI ............................................................................83
PRENEXA.....................................................................................83
PREPOPIK....................................................................................24
PREQUE 10 .................................................................................83
PREVACID ...................................................................................20
PREVACID SOLUTAB ...................................................................20
PREVALITE ..................................................................................32
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM
COVERED AT A ZERO COPAY WITH PRESCRIPTION ...............91
PREVIDENT 5000 BOOSTER GEL .................................................84
PREVIDENT 5000 PLUS CREAM ...................................................84
PREVIDENT 5000 SENSITIVE 1.1%-5%.........................................84
PREVIDENT DENTAL RINSE .........................................................84
PREVIDENT GEL ..........................................................................84
PRIFTIN .......................................................................................36
PRILOSEC ....................................................................................20
PRILOSEC 40MG .........................................................................20
PRILOSEC DR SUSP......................................................................20
PRIMAQUINE ..............................................................................37
PRIMIDONE ................................................................................64
PRINIVIL ......................................................................................27
PRINZIDE ....................................................................................27
PRISTIQ .......................................................................................60
PROAIR HFA ................................................................................44
PRO-BANTHINE 7.5MG ...............................................................24
PROBENECID...............................................................................81
PROCAINAMIDE ..........................................................................26
PROCARDIA, XL ...........................................................................29
PROCHLORPERAZINE ............................................................ 22, 23
PROCRIT .....................................................................................54
PROCTOFOAM ............................................................................22
PROCTOFOAM HC ......................................................................22
PRODRIN.....................................................................................66
PROGESTERONE .........................................................................75
PROGRAF ....................................................................................86
PROLENSA ..................................................................................59
PROMETHAZINE ................................................................... 23, 41
PROMETRIUM ............................................................................75
PROMISEB ..................................................................................48
PROMISEB COMPLETE ................................................................48
PRONESTYL 375, 500 ..................................................................26
PROPAFENONE ...........................................................................26
PROPANTHELINE ........................................................................24
PROPINE .....................................................................................56
PROPRANOLOL ..................................................................... 29, 65
PROPRANOLOL SR ......................................................................66
PROPYLTHIOURACIL ...................................................................78
PROQUIN XR ...............................................................................34
PROSCAR ....................................................................................88
PROTONIX ..................................................................................20
PROTONIX PAK ...........................................................................20
PROTOPIC ...................................................................................53
PROTRIPTYLINE...........................................................................60
PROVENTIL HFA ..........................................................................44
PROVERA ....................................................................................75
PROVIGIL ....................................................................................63
PROZAC ......................................................................................60
PROZAC WEEKLY ........................................................................60
PSEUDOEPHEDRINE/ ACRIVAS ...................................................43
PSEUDOEPHEDRINE/ CHLORPHENIRAMINE ...............................43
PSEUDOEPHEDRINE/ DESLORATADINE ......................................43
PULMICORT ................................................................................44
PULMICORT 0.25MG/2ML AND 0.5MG/2ML RESPULE ..............44
PULMICORT 1MG/2ML RESPULE, FLEXHALER AND TURBUHALER
..............................................................................................44
PULMOZYME ........................................................................ 44, 45
PYRAZINAMIDE ...........................................................................36
PYRIDIUM ...................................................................................88
PYRIDOSTIGMINE ................................................................. 66, 67
PYRIMETHAMINE........................................................................37
Q
QNASL ........................................................................................42
QUESTRAN BULK ........................................................................32
QUETIAPINE FUMARATE ............................................................62
QUILLIVANT XR ...........................................................................63
QUINAPRIL..................................................................................26
QUINAPRIL/ HCTZ .......................................................................27
QUININE SULFATE ......................................................................84
QUIXIN ........................................................................................57
QVAR ..........................................................................................45
R
RABEPRAZOLE ............................................................................20
RALOXIFENE ...............................................................................77
RAMELTEON ...............................................................................61
RAMIPRIL ....................................................................................27
RANEXA ......................................................................................26
RANITIDINE ........................................................................... 20, 21
RANOLAZINE...............................................................................26
RAPAFLO.....................................................................................88
RAPAMUNE ................................................................................86
RASAGILINE ................................................................................67
RAYOS.........................................................................................87
RAZADYNE ..................................................................................67
REBETOL .....................................................................................88
REBETOL ORAL SOLUTION ..........................................................88
REBIF ..........................................................................................89
RECTIV OINT ...............................................................................25
REGLAN ......................................................................................23
RELAFEN .....................................................................................38
RELENZA .....................................................................................37
RELPAX .......................................................................................66
REMERON ...................................................................................60
REMICADE ..................................................................................91
RENAGEL ....................................................................................90
RENVELA .....................................................................................90
214
REPAGLINIDE ..............................................................................79
REPAGLINIDE/METFORMIN ........................................................79
REPREXAIN .................................................................................40
REPRONEX ..................................................................................77
REQUIP .......................................................................................67
REQUIP XL...................................................................................67
RESTASIS .....................................................................................58
RESTORIL ....................................................................................61
RETAPAMULIN ............................................................................49
RETIN A .......................................................................................52
RETIN A MICRO...........................................................................52
RETIN A MICRO 0.1% ................................................................ See
REVATIO .....................................................................................30
REVIA ..........................................................................................85
RHINOCORT AQUA .....................................................................42
RIAX ............................................................................................52
RIBAPAK .....................................................................................88
RIBASPHERE................................................................................88
RIBATAB .....................................................................................88
RIBAVIRIN ............................................................................. 88, 89
RIDAURA.....................................................................................87
RIFABUTIN ..................................................................................36
RIFADIN ......................................................................................36
RIFAMATE ...................................................................................36
RIFAMPIN ...................................................................................36
RIFAMPIN/ INH/ PYRAZINAMIDE ................................................36
RIFAMPIN/ ISONIAZID ................................................................36
RIFAPENTINE ..............................................................................36
RIFATER ......................................................................................36
RIFAXIMIN ..................................................................................35
RIMANTADINE ............................................................................37
RIMEXOLONE..............................................................................57
RISEDRONATE .............................................................................77
RISEDRONATE SODIUM ..............................................................77
RISPERDAL ..................................................................................62
RISPERDAL CONSTA ....................................................................62
RISPERIDONE ..............................................................................62
RISPERIDONE MICROSPHERES....................................................62
RITALIN .......................................................................................63
RITALIN LA ..................................................................................63
RITALIN SR ..................................................................................63
RITUXAN .....................................................................................91
RITUXIMAB .................................................................................91
RIVAROXABAN ............................................................................54
RIVASTIGMINE ............................................................................67
RIZATRIPTAN ..............................................................................66
ROBAXIN.....................................................................................66
ROCALTROL ................................................................................83
ROFLUMILAST.............................................................................45
ROPINIROLE ................................................................................67
ROSADAN KIT .............................................................................50
ROSANIL .....................................................................................52
ROSIGLITAZONE..........................................................................80
ROSIGLITAZONE/ GLIMEPIRIDE ..................................................80
ROSIGLITAZONE/ METFORMIN ..................................................80
ROSUVASTATIN ..........................................................................31
ROTIGOTINE ...............................................................................67
ROWASA ENEMA ........................................................................21
ROZEREM ...................................................................................61
RUFINAMIDE ..............................................................................64
RUXOLITINIB ...............................................................................90
RYBIX ODT ..................................................................................40

RYTHMOL SR ..............................................................................26
RYZOLT .......................................................................................40
S
SABRIL ........................................................................................65
SAFYRAL .....................................................................................73
SALMETEROL ..............................................................................45
SANCTURA ..................................................................................88
SANCTURA, XR ............................................................................88
SANCUSO ....................................................................................23
SANDIMMUNE ............................................................................86
SAPHRIS ......................................................................................62
SARAFEM ....................................................................................60
SARGRAMOSTIM ........................................................................54
SAVELLA................................................................................ 89, 90
SAXAGLIPTIN HYDROCHLORIDE..................................................80
SAXAGLIPTIN/ .............................................................................80
SCOPOLAMINE ...........................................................................23
SEASONALE.................................................................................73
SEASONIQUE ..............................................................................73
SECTRAL................................................................................ 26, 30
SELECT-OB ..................................................................................83
SELECT-OB + DHA .......................................................................83
SELEGILINE ........................................................................... 60, 67
SELENIUM SULFIDE.....................................................................50
SEMPREX-D.................................................................................43
SEREVENT DISKUS ......................................................................45
SEROMYCIN PULVULES ...............................................................36
SEROQUEL ..................................................................................62
SEROQUEL, XR ............................................................................62
SERTACONAZOLE NITRATE .........................................................50
SERTRALINE ................................................................................61
SEVELAMER ................................................................................90
SEVELAMER CARBONATE ...........................................................90
SILDENAFIL .................................................................................86
SILDENAFIL CITRATE ...................................................................30
SILENOR ......................................................................................61
SILODOSIN ..................................................................................88
SILVADENE..................................................................................49
SILVER SULFADIAZINE .................................................................49
SIMBRINZA .................................................................................56
SIMCOR ......................................................................................32
SIMPONI .....................................................................................87
SIMVASTATIN .............................................................................32
SINEMET, CR ...............................................................................67
SINGULAIR ............................................................................ 42, 45
SIROLIMUS .................................................................................86
SIRTURO .....................................................................................36
SITAGLIPTIN PHOS/ METFORMIN ...............................................79
SITAGLIPTIN PHOSPHATE ...........................................................80
SITAGLIPTIN/ ..............................................................................80
SKELAXIN ....................................................................................66
SKLICE .........................................................................................53
SODIUM /POTASSIUM/MAG SULFATES .....................................24
SODIUM FLUORIDE .....................................................................84
SODIUM OXYBATE ......................................................................63
SODIUM POLYSTYRENE SULFONATE ..........................................87
SOLARAZE ...................................................................................53
SOLIFENACIN SUCCINATE ...........................................................87
215
SOLODYN ....................................................................................33
SOMA .........................................................................................66
SOMATROPIN .............................................................................90
SOMNOTE...................................................................................61
SONATA ......................................................................................61
SORIATANE .................................................................................49
SOTALOL .....................................................................................25
SPECTRACEF ...............................................................................33
SPIRIVA .......................................................................................45
SPIRONOLACTONE......................................................................26
SPIRONOLACTONE/ HCTZ ...........................................................26
SPORANOX CAPS ........................................................................36
SPORANOX SOLN ........................................................................36
SPRINTEC ....................................................................................73
STALEVO .....................................................................................67
STARLIX.......................................................................................79
STAXYN .......................................................................................86
STRATTERA .................................................................................63
STRIPS .........................................................................................80
STROMECTOL .............................................................................37
SUBOXONE .................................................................................85
SUBSYS .......................................................................................40
SUBUTEX ....................................................................................85
SUCLEAR .....................................................................................24
SUCRALFATE ...............................................................................20
SULAR 20, 30, 10 ........................................................................29
SULCONAZOLE NITRATE .............................................................50
SULFACETAMD/ SULFR/ SKNCLNSR10 ........................................52
SULFACETAMIDE SODIUM ..........................................................57
SULFACETAMIDE/ PREDNISOLONE ....................................... 57, 58
SULFAMETHOXAZOLE/ TRIMETHOPRIM .............................. 34, 35
SULFAMETHOXAZOLE/ TRIMETHOPRIM DS ......................... 34, 35
SULFAMYLON .............................................................................49
SULFANILAMIDE .........................................................................52
SULFASALAZINE ..........................................................................21
SULINDAC ...................................................................................38
SUMATRIPTAN INJECTION .................................................... 65, 66
SUMATRIPTAN NASAL SPRAY .....................................................65
SUMATRIPTAN TABLET ...............................................................65
SUMATRIPTAN/ NAPROXEN .......................................................66
SUMAVEL DOSEPRO ...................................................................66
SUMYCIN ....................................................................................33
SUPRAX.......................................................................................33
SUPREP .......................................................................................24
SURMONTIL ................................................................................60
SYMAX DUOTAB .........................................................................24
SYMAX, DUOTAB ........................................................................24
SYMBICORT ................................................................................45
SYMBYAX ....................................................................................62
SYMLIN .......................................................................................81
SYMLINPEN.................................................................................81
SYNAGIS......................................................................................91
SYNALAR TS ................................................................................47
SYNAREL NASAL SPRAY...............................................................77
SYNTHROID.................................................................................78
SYRINGES ....................................................................................79
T
TACLONEX OINT .........................................................................49
TACROLIMUS ........................................................................ 53, 86
TADALAFIL ............................................................................ 30, 85

TAFLUPROST ...............................................................................56
TAGAMET ...................................................................................20
TAMBOCOR ................................................................................26
TAMIFLU .....................................................................................37
TAMSULOSIN ........................................................................ 30, 87
TAPAZOLE ...................................................................................78
TAPENTADOL HYDROCHLORIDE .................................................40
TARGRETIN .................................................................................53
TARKA .........................................................................................27
TASMAR ......................................................................................67
TAVIST ........................................................................................42
TAZAROTENE ..............................................................................49
TAZORAC ....................................................................................49
TECFIDERA ..................................................................................89
TEGRETOL XR ..............................................................................65
TEKAMLO....................................................................................29
TEKTURNA ..................................................................................31
TEKTURNA HCT ...........................................................................31
TELAPREVIR ................................................................................88
TELITHROMYCIN .........................................................................34
TELMISARTAN.............................................................................28
TELMISARTAN/ ...........................................................................28
TELMISARTAN/ HCTZ ..................................................................28
TEMAZEPAM ..............................................................................61
TEMOVATE .................................................................................47
TENEX .........................................................................................31
TENORETIC .................................................................................30
TENORMIN .................................................................................30
TERAZOL .....................................................................................53
TERBINAFINE ........................................................................ 36, 50
TERBINAFINE/ .............................................................................50
TERBINEX ....................................................................................50
TERCONAZOLE ............................................................................53
TERIFLUNOMIDE.........................................................................89
TERIPARATIDE ............................................................................77
TERSI...........................................................................................50
TESSALON PERLES ......................................................................43
TEST STRIPS ................................................................................81
TESTIM .......................................................................................76
TESTOSTERONE ..........................................................................76
TESTOSTERONE, TRANSDERMAL ................................................76
TESTRED .....................................................................................76
TETRACYCLINE ............................................................................33
TEVETEN .....................................................................................28
TEVETEN HCT..............................................................................28
THEO-24 SR ................................................................................45
THEOPHYLLINE ...........................................................................45
THIOTHIXENE..............................................................................62
THYROID, DESSICATED ...............................................................78
THYROLAR ..................................................................................78
TIAGABINE ..................................................................................64
TICAGRELOR ...............................................................................53
TIGAN .........................................................................................23
TIKOSYN......................................................................................26
TIMOLOL......................................................................... 29, 55, 56
TIMOLOL/ DORZOLAM ...............................................................55
TIMOPTIC ...................................................................................56
TIMOPTIC OCUDOSE...................................................................56
TIMOPTIC XE...............................................................................56
TINDAMAX..................................................................................37
216
TINIDAZOLE ................................................................................37
TIOTROPIUM BROMIDE ..............................................................45
TIROSINT ....................................................................................78
TIZANIDINE .................................................................................66
TIZANIDINE COMBO ...................................................................66
TOBI INHALATION /PODHALER...................................................89
TOBRADEX ..................................................................................58
TOBRADEX ST .............................................................................58
TOBRAMYCIN ....................................................................... 57, 89
TOBRAMYCIN/ ............................................................................58
TOBRAMYCIN/LOTEPRED ETAB ..................................................57
TOBREX OINT..............................................................................57
TOBREX SOLN .............................................................................57
TOFACITINIB ...............................................................................87
TOFRANIL PM .............................................................................60
TOLCAPONE ................................................................................67
TOLTERODINE TARTRATE ...........................................................87
TOPAMAX ...................................................................................65
TOPICORT ...................................................................................47
TOPICORT GENERIC PRODUCTS..................................................47
TOPIRAMATE ..............................................................................65
TOPROL XL ..................................................................................30
TORADOL ....................................................................................38
TORSEMIDE ................................................................................26
TOVIAZ........................................................................................88
TRACLEER ...................................................................................30
TRADJENTA .................................................................................80
TRAMADOL ..................................................................... 39, 40, 41
TRAMADOL ER ............................................................................40
TRAMADOL SUST. RELEASE ........................................................41
TRAMADOL/ ACETAMINOPHEN .................................................41
TRANDATE ..................................................................................30
TRANDOLAPRIL ...........................................................................27
TRANDOLAPRIL/ VERAPAMIL .....................................................27
TRANSDERM-SCOP .....................................................................23
TRANXENE T ...............................................................................61
TRANYLCYPROMINE ...................................................................60
TRAVATAN Z ...............................................................................56
TRAVOPROST ..............................................................................56
TRAZODONE HYDROCHLORIDE EXTENDED RELEASE ..................60
TREAGAN OTIC ...........................................................................59
TRECATOR ..................................................................................36
TRENTAL .....................................................................................54
TREPROSTINIL/NEBULIZER KIT....................................................30
TRETIN X .....................................................................................52
TRETINOIN ............................................................................ 51, 52
TRETINOIN MICROSPHERES........................................................52
TREXIMET ...................................................................................66
TRIAMCINOLONE .................................................................. 46, 68
TRIAMCINOLONE, AQUEOUS .....................................................42
TRIAMCINOLONE/ ......................................................................47
TRIAMTERENE ............................................................................26
TRIAMTERENE/ HCTZ..................................................................26
TRIAZ CLEANER/PADS.................................................................52
TRIBENZOR .................................................................................28
TRICOR .......................................................................................32
TRIFLURIDINE .............................................................................57
TRIGLIDE .....................................................................................32
TRILEPTAL ...................................................................................65
TRILIPIX.......................................................................................32
TRIMETHOBENZAMIDE...............................................................23
TRIMETHOPRIM..........................................................................35
TRIMIPRAMINE MALEATE ..........................................................60
TRINESSA ....................................................................................73
TRI-NORINYL ...............................................................................73
TRIOXIN ......................................................................................59
TRI-SPRINTEC..............................................................................73
TRIVORA .....................................................................................73
TROKENDI XR ..............................................................................65
TROPAZONE ...............................................................................48
TROPICAMIDE.............................................................................56
TROSPIUM CHLORIDE .................................................................88
TRUSOPT ....................................................................................56
TRUVADA....................................................................................90
TRYPSIN/ BALSAM PERU/ CASTOR OIL .......................................53
TUDORZA PRESSAIR....................................................................45
TUSSIONEX PENNKINETIC ...........................................................42
TWYNSTA ...................................................................................28
TYLENOL W/CODEINE .................................................................41
TYLOX .........................................................................................41
TYSABRI ......................................................................................91
TYVASO.......................................................................................30
U
UCERIS ........................................................................................21
U-CORT 1%-10% CREAM ............................................................47
ULESFIA ......................................................................................53
ULORIC .......................................................................................81
ULTRACET ...................................................................................41
ULTRAM......................................................................................41
ULTRAM ER.................................................................................41
ULTRASE .....................................................................................22
ULTRASE MT 12, 18 ....................................................................22
ULTRAVATE PAC .........................................................................47
ULTRESA .....................................................................................22
UMECTA .....................................................................................48
UMECTA EMULSION ...................................................................48
UNIRETIC ....................................................................................27
UNIVASC .....................................................................................27
URAMAXIN .................................................................................48
URAMAXIN GT ............................................................................48
URAMAXIN GT KIT ......................................................................48
UREA...........................................................................................48
UREA/ LACTIC ACID/ SALICYL ACID .............................................48
UREA/LACTIC AC/ZN UNDECYLENATE ........................................48
URECHOLINE...............................................................................88
URELLE........................................................................................35
UROCIT-K ....................................................................................84
UROCIT-K 15MEQ .......................................................................84
UROFOLLITROPIN (FSH) ..............................................................76
UROXATRAL ................................................................................88
URSODIOL...................................................................................84
UTA .............................................................................................35
UTOPIC .......................................................................................48
V
VAGIFEM ....................................................................................74
VALACYCLOVIR ...........................................................................37
VALIUM ......................................................................................61
VALPROIC ACID ...........................................................................64
217
VALSARTAN ................................................................................28
VALSARTAN/ HCTZ .....................................................................28
VALTREX .....................................................................................37
VALTURNA ............................................................................ 28, 31
VANCOCIN ..................................................................................35
VANCOMYCIN, ORAL ..................................................................35
VANOS ........................................................................................47
VANOXIDE HC .............................................................................52
VANOXIDE-HC 0.5%-5% LOTION.................................................47
VARDENAFIL ...............................................................................86
VARENICLINE TARTRATE.............................................................85
VASCEPA .....................................................................................32
VASERETIC ..................................................................................27
VASOTEC.....................................................................................27
VECTICAL ....................................................................................53
VELTIN ........................................................................................52
VENLAFAXINE .............................................................................60
VENTOLIN ...................................................................................45
VENTOLIN HFA............................................................................45
VERAMYST ..................................................................................42
VERAPAMIL .................................................................... 25, 28, 29
VERDESO ....................................................................................47
VERELAN .....................................................................................29
VESICARE ....................................................................................88
VEXOL .........................................................................................57
VFEND ........................................................................................36
VIAGRA .......................................................................................86
VIBRAMYCIN......................................................................... 33, 35
VIBRAMYCIN SUSP......................................................................33
VIBRAMYCIN SYRUP ...................................................................33
VICODIN .....................................................................................41
VICODIN 10/300 .........................................................................41
VICODIN 5/300 ...........................................................................41
VICODIN 7.5/300 ........................................................................41
VICODIN ES .................................................................................41
VICODIN HP ................................................................................41
VICOPROFEN ..............................................................................41
VICTOZA .....................................................................................81
VICTRELIS....................................................................................89
VIGABATRIN ...............................................................................65
VIGAMOX ...................................................................................57
VIIBRYD.......................................................................................60
VILAZODONE ..............................................................................60
VIMOVO .....................................................................................38
VIMPAT.......................................................................................65
VIOKASE 8...................................................................................22
VIRAZOLE ....................................................................................89
VIROPTIC ....................................................................................57
VISTARIL .....................................................................................61
VITAFOL-OB ................................................................................83
VITAFOL-ONE..............................................................................83
VITAFOL-PLUS.............................................................................83
VITAMED MD ONE RX/QUATREFOLIC ........................................83
VITAMED MD PLUS.....................................................................83
VITAMED MD REDICHEW RX/QUATREFOLIC ..............................83
VITAMINS, PRENATAL..................................................... 81, 82, 83
VITAMINS, PRENATAL PREP........................................................82
VITMAINS, PRENATAL.................................................................82
VITUZ ..........................................................................................42
VIVA CT PRENATAL .....................................................................83
VIVACTIL .....................................................................................60
VIVELLE-DOT...............................................................................75
VOLTAREN GEL ...........................................................................38
VOLTAREN XR .............................................................................38
VORICONAZOLE ..........................................................................36
VOSOL ........................................................................................59
VOSOL HC ...................................................................................59
VOSPIRE ER .................................................................................45
VUSION .......................................................................................50
VYTORIN .....................................................................................32
VYVANSE ....................................................................................63
W
WARFARIN ..................................................................................53
WELCHOL ...................................................................................32
WELLBUTRIN ..............................................................................60
WELLBUTRIN XL ..........................................................................61
WESTCORT .................................................................................47
X
XALATAN ....................................................................................56
XANAX ........................................................................................61
XANAX XR ...................................................................................61
XARELTO 10mg ...........................................................................54
XARELTO 15mg , 20mg ...............................................................54
XELJANZ ......................................................................................87
XIFAXAN .....................................................................................35
XODOL ........................................................................................41
XOLEGEL .....................................................................................50
XOPENEX NEB SOLN ...................................................................45
XOPENEX, HFA ............................................................................45
XTANDI .......................................................................................90
X-VIATE .......................................................................................48
XYREM ........................................................................................63
XYZAL ..........................................................................................42
Y
YASMIN ......................................................................................73
YAZ .............................................................................................73
YODOXIN ....................................................................................38
Z
ZACARE KIT .................................................................................52
ZADITOR OTC..............................................................................58
ZAFIRLUKAST ........................................................................ 41, 45
ZALEPLON ...................................................................................61
ZANAFLEX TABLETS ....................................................................66
ZANAMIVIR .................................................................................37
ZANTAC ......................................................................................20
ZANTAC EFFERDOSE ...................................................................21
ZARONTIN...................................................................................65
ZAROXOLYN ................................................................................26
ZEBETA .......................................................................................30
ZEGERID ......................................................................................21
ZEGERID SUSP.............................................................................21
ZELAPAR .....................................................................................67
ZEMPLAR ....................................................................................78
ZENIEVA......................................................................................49
218
ZENPEP .......................................................................................22
ZENZEDI 2.5, 7.5MG ...................................................................64
ZESTORETIC ................................................................................27
ZESTRIL .......................................................................................27
ZETIA ..........................................................................................32
ZETONNA ....................................................................................42
ZIAC ............................................................................................30
ZIANA .........................................................................................52
ZILEUTON ...................................................................................45
ZIOPTAN .....................................................................................56
ZIPRASIDONE MESYLATE ............................................................62
ZIPSOR ........................................................................................38
ZITHRANOL .................................................................................49
ZITHROMAX ................................................................................34
ZMAX ..........................................................................................34
ZOCOR ........................................................................................32
ZOFRAN ODT ..............................................................................23
ZOLMITRIPTAN ...........................................................................66
ZOLMITRIPTAN NASAL SPRAY ....................................................66
ZOLOFT .......................................................................................61
ZOLPIDEM...................................................................................61
ZOLPIDEM SL ..............................................................................61
ZOLPIDEM TARTRATE .................................................................61
ZOLPIMIST ..................................................................................61
ZOMIG NASAL SPRAY..................................................................66
ZOMIG, ZMT ...............................................................................66
ZONEGRAN .................................................................................65
ZONISAMIDE ...............................................................................65
ZORTRESS 0.25MG .....................................................................86
ZORTRESS 0.5, 0.75MG...............................................................86
ZOTEX .........................................................................................43
ZOTEX GP....................................................................................43
ZOVIA 1/35 .................................................................................73
ZOVIA 1/50 .................................................................................73
ZOVIRAX .....................................................................................37
ZOVIRAX CREAM.........................................................................37
ZUBSOLV.....................................................................................85
ZUPLENZ .....................................................................................23
ZYBAN .........................................................................................85
ZYCLARA .....................................................................................53
ZYFLO, CR ...................................................................................45
ZYLET ..........................................................................................57
ZYLOPRIM ...................................................................................81
ZYPREXA ZYDIS ...........................................................................62
ZYRTEC OTC ................................................................................42
ZYVOX .........................................................................................35
219

Health Plus 2013-14 Drug Formulary

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Health Plus 2013-14 Drug Formulary

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2013-2014 Drug Formulary

For Commercial, Medicaid, Point-of-Service, PPO,

The Drug Formulary for Commercial, Medicaid, Point-of-Service, PPO,

PREFACE TO THE EIGHTEENTH EDITION

TABLE OF FORMULARY SECTIONS

COLONY STIMULATING FACTORS ......................................................................................... 54

SELECTIVE ESTROGEN RECEPTOR MODULATOR............................................................... 77

HEPATITIS C PRODUCTS ........................................................................................................ 88

HOW TO USE THIS FORMULARY

MEMBER PRESCRIPTION BENEFIT

Toll-free phone (877) 710-0993

ASK FOR 90 RX PROGRAM

HEALTHPLUS DENTAL FORMULARY

KEFLEX* (NOT 750MG)

MEDROL DOSE PAK*

PHARMACY & THERAPEUTICS COMMITTEE

SMOKING CESSATION PHARMACOTHERAPY

HealthPlus Partners Medicaid

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

NAPHOS MBMH/NAPHOS, DI-BA

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

ADOXA, PAK , 150

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.

FORMULARY DRUG PRODUCT

*A 4 tier copay applies for plans that have a 4 tier.