Health Share of Oregon/Providence (Medicaid) To help find a drug see the back of the document for an alphabetical listing Drug Name Status* Requirements/Limits Analgesics 8 HOUR OTC 8 HOUR PAIN RELIEF OTC 8 HOUR PAIN RELIEVER OTC ACEPHEN (325 MG, 650 MG) OTC ACETADRYL OTC acetaminophen (80mg/0.8ml drops susp, 120 mg supp.rect, 160 mg/5ml oral susp, 160 mg/5ml solution, 160 mg/5ml elixir, 160 mg/5ml liquid, 325/10.15 solution, 325 mg tablet, 500 mg tablet, 500 mg/5ml liquid, 650mg/20.3 solution, 650 mg tablet er, 650 mg supp.rect) OTC ACETAMINOPHEN PM OTC ACETAMINOPHEN PM XTRA STRENGTH OTC acetaminophen/diphenhydramine hcl OTC alagesic lq Generic ARTHRITIS PAIN OTC ARTHRITIS PAIN RELIEF (ARTHRITIS ER 650 MG CAPLT, ARTHRITIS RELF ER 650 MG, ARTHRITIS RLF ER 650 MG, CVS ARTHRITIS ER 650 MG, GNP ARTHRIT RLF ER 650 MG, HM ARTHRITIS ER 650 MG, KRO ARTHRIT RLF ER 650 MG, PUB ARTHRITIS ER 650 MG, PV ARTHRITIS ER 650 MG, QC ARTHRITIS ER 650 MG, RA ARTHRITIS ER 650 MG, SB ARTHRITIS ER 650 MG, SM ARTHRITIS ER 650 MG, SM ARTHRITIS RELF ER 650) OTC ARTHRITIS PAIN RELIEVER OTC aspirin (500 mg tablet dr, 600 mg supp.rect, 650 mg tablet dr) OTC ATHENOL OTC BETATEMP OTC *Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 1 LAST UPDATE 10/2015
160
Embed
Health Share of Oregon/Providence (Medicaid)/media/files...Health Share of Oregon/Providence (Medicaid) To help find a drug see the back of the document for an alphabetical listing
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access1 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsbutalbital/acetaminophen Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access2 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsEAZZZE THE PAIN OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access3 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsNIGHT TIME PAIN MEDICINE OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access4 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Q-PAP (80 MG/0.8 ML DROPS, 160MG/5 ML LIQUID, 160 MG/5 MLSOLUTION, 325 MG TABLET)
OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access5 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsQ-PAP EXTRA STRENGTH OTC
celecoxib 400 mg capsule Generic PA, QL (1 PER DAY)
CHILD IBUPROFEN OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access6 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsCHILDREN'S ADVIL OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access7 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsINFANTS IBU-DROPS OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access8 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsWAL-PROXEN OTC
morphine sulfate (15 mg tablet er, 30mg cap er pel, 30 mg tablet er, 50 mgcap er pel, 60 mg cap er pel, 60 mgtablet er, 80 mg cap er pel, 100 mg caper pel, 100 mg tablet er, 200 mg tableter)
Generic
oxycodone hcl (10 mg tab er 12h, 20 mgtab er 12h, 40 mg tab er 12h, 80 mg taber 12h)
Brand PA, QL (90 PER 30 DAYS)
OXYCONTIN Brand PA, QL (90 PER 30 DAYS)
tramadol hcl (100 mg tbmp 24hr, 100mg tab er 24h, 200 mg tbmp 24hr, 200mg tab er 24h, 300 mg tab er 24h, 300mg tbmp 24hr)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access9 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsbutorphanol tartrate 10 mg/ml spray Generic
co-gesic Generic
codeinephosphate/butalbital/aspirin/caffeine
Generic PA
codeine phosphate/carisoprodol/aspirin Generic PA (PA for ages 5 and under)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access10 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsmorphine sulfate (5 mg supp.rect, 10mg supp.rect, 10 mg/5 ml solution, 15mg tablet, 20 mg supp.rect, 20 mg/5 mlsolution, 30 mg tablet, 30 mg supp.rect,100 mg/5ml solution)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access11 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsrelador pak Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access12 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsapexicon e Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access13 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsfluticasone propionate (0.05 % lotion,0.05 % cream (g))
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access14 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsprednisone intensol Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access15 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsbacitracin (500 oint. (g), 500 packet) OTC
bacitracin zinc (500 oint. (g), 500oint.(ea))
OTC
bacitracin/polymyxin b sulfate (500-10k/g oint. (g), packet)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access16 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsparoex Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access17 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitscefprozil (125 mg/5ml susp recon, 250mg tablet, 250 mg/5ml susp recon, 500mg tablet)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access18 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsazithromycin (100 mg/5ml susp recon,200 mg/5ml susp recon, 250 mg tablet,500 mg tablet, 600 mg tablet)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access19 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsofloxacin (0.3 % drops, 200 mg tablet,300 mg tablet, 400 mg tablet)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access20 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access21 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsONFI 2.5 MG/ML SUSPENSION Brand PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access22 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsphenytoin sodium extended Generic
NAMENDA 10 MG/5 ML SOLUTION Brand QL (360 ML PER 30 DAYS)
Antidepressants
Antidepressants, Otherbudeprion sr 150 mg tablet Generic
bupropion hcl 150 mg tablet er Generic
Antiemetics
Antiemetics, OtherAMBIZINE OTC
compro Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access23 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsDICLEGIS Brand QL (60 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access24 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitstrimethobenzamide hcl 300 mg capsule Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access25 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsclotrimazole (1 % cream/appl, 2 %cream/appl, 100 mg tablet)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access26 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsmiconazole nitrate 200 mg supp.vag Generic
MICONAZORB AF OTC
MICRO-GUARD OTC
MIRANEL AF OTC
MONISTAT 3 (3 4% CREAM, 3 COMBOPACK)
OTC
NOXAFIL (40 MG/ML SUSPENSION, DR100 MG TABLET)
Brand
NUZOLE OTC
nyamyc Generic
nystatin (50mm unit powder(ea),150mm unit powder(ea), 500mm unitpowder(ea), 500k unit tablet,100000/ml oral susp, 100000/g powder,100000/g cream (g), 100000/g oint. (g))
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access27 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsvoriconazole (200 mg tablet, 200mg/5ml susp recon)
Generic
ZEASORB 2% POWDER OTC
Antigout Agents
allopurinol (100 mg tablet, 300 mgtablet)
Generic
colchicine 0.6 mg tablet Brand QL (60 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access28 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitszolmitriptan (2.5 mg tab rapdis, 2.5 mgtablet, 5 mg tab rapdis, 5 mg tablet)
isoniazid (50 mg/5 ml solution, 100 mgtablet, 300 mg tablet)
Generic
pyrazinamide Generic
RIFAMATE Brand
rifampin (150 mg capsule, 300 mgcapsule)
Generic
SIRTURO Specialty LA
Antineoplastics
Alkylating AgentsALKERAN 2 MG TABLET Brand PA
CEENU Brand
CYCLOPHOSPHAMIDE CAPSULES Brand
cyclophosphamide tablets Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access29 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsGLEOSTINE Brand
LEUKERAN Brand
lomustine Brand
MATULANE Specialty
MYLERAN Brand
temozolomide Specialty PA
VALCHLOR Specialty LA
Antiangiogenic AgentsPOMALYST Specialty PA
REVLIMID Specialty PA, LA
THALOMID Specialty
Antiestrogens/ModifiersEMCYT Specialty
FARESTON Brand
SOLTAMOX Brand
tamoxifen citrate (10 mg tablet, 20 mgtablet)
Generic
Antimetabolitescapecitabine Generic
DROXIA Brand
hydroxyurea 500 mg capsule Generic
mercaptopurine 50 mg tablet Generic
methotrexate sodium (2.5 mg tablet, 25mg/ml vial)
Generic
methotrexate sodium/pf (1 g vial, 25mg/ml vial)
Generic
PURIXAN Brand
RHEUMATREX Brand
TABLOID Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access30 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsTREXALL Brand
Antineoplastics, OtherALFERON N Specialty PA
FARYDAK Specialty PA, QL (6 PER 21 DAYS)
flutamide Generic
HEXALEN Specialty
imiquimod 5 % cream pack Generic
INTRON A (6 MILLION UNIT/ML VL, 10MILLION UNIT/ML, 10 MILLION UNITSVIL, 18 MILLION UNITS VIL, 50 MILLIONUNITS VIL)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access31 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsTAFINLAR Specialty PA
VOTRIENT Specialty PA
ZELBORAF Specialty PA
ZYTIGA Specialty PA
Molecular Target InhibitorsAFINITOR Specialty PA
AFINITOR DISPERZ Specialty PA
CAPRELSA Specialty PA
COMETRIQ Specialty PA, LA
ERIVEDGE Specialty PA
GLEEVEC Specialty PA
IBRANCE Specialty PA
ICLUSIG Specialty PA
LENVIMA Specialty PA, LA
NEXAVAR Specialty PA
SPRYCEL Specialty PA
STIVARGA Specialty PA
SUTENT Specialty PA
TARCEVA Specialty PA
TASIGNA Specialty PA
TYKERB Specialty PA
vandetanib Specialty PA
XALKORI Specialty PA, LA
ZOLINZA Specialty PA
ZYDELIG Specialty PA, QL (60 PER 30 DAYS)
ZYKADIA Specialty PA
Retinoidsbexarotene Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access32 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsTARGRETIN 1% GEL Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access33 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Monoamine Oxidase B (MAO-B) InhibitorsAZILECT Brand
selegiline hcl (5 mg tablet, 5 mgcapsule)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access34 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access35 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsTRUVADA Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access36 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsPREZISTA (75 MG TABLET, 100 MG/MLSUSPENSION, 150 MG TABLET, 400 MGTABLET, 600 MG TABLET, 800 MGTABLET)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access37 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsPEGINTRON Specialty
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access38 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limits
Blood Glucose Regulators
Antidiabetic Agentsacarbose Generic
ACTOPLUS MET XR Brand
BYDUREON Brand ST
BYDUREON PEN Brand ST
BYETTA Brand ST
chlorpropamide Generic
FARXIGA Brand PA
glimepiride Generic
glipizide (2.5 mg tab er 24, 5 mg tablet,5 mg tab er 24, 10 mg tab er 24, 10 mgtablet)
Generic
glipizide/metformin hcl Generic
glyburide Generic
glyburide,micronized Generic
glyburide/metformin hcl Generic
GLYXAMBI Brand PA
INVOKAMET Brand PA
INVOKANA Brand PA
JANUMET Brand PA
JANUMET XR Brand PA
JANUVIA Brand PA
JARDIANCE Brand PA
JENTADUETO Brand PA
KAZANO Brand PA
KOMBIGLYZE XR Brand PA
metformin hcl (500 mg tablet, 500 mgtab er 24h, 750 mg tab er 24h, 850 mgtablet, 1000 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access39 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsNESINA Brand PA
ONGLYZA Brand PA
OSENI Brand PA
pioglitazone hcl Generic
pioglitazone hcl/glimepiride Generic
pioglitazone hcl/metformin hcl Generic
RIOMET Brand
SYMLINPEN 120 Brand PA
SYMLINPEN 60 Brand PA
tolazamide Generic
TRADJENTA Brand PA
VICTOZA 2-PAK Brand ST
VICTOZA 3-PAK Brand ST
XIGDUO XR Brand PA
Glycemic AgentsGLUCAGEN 1MG HYPOKIT Brand
GLUCAGON EMERGENCY KIT Brand
InsulinsAPIDRA Brand
APIDRA SOLOSTAR Brand
HUMALOG Brand
HUMALOG KWIKPEN U-100 Brand
HUMALOG KWIKPEN U-200 Brand
HUMALOG MIX 50-50 Brand
HUMALOG MIX 50-50 KWIKPEN Brand
HUMALOG MIX 75-25 Brand
HUMALOG MIX 75-25 KWIKPEN Brand
HUMULIN 70-30 OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access40 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsHUMULIN 70/30 KWIKPEN OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access41 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsheparin sodium,porcine/pf (10 unit/mlsyringe, 10 unit/ml vial, 100/ml (1) vial,500/5 ml syringe, 1000/10 ml syringe,1000/ml vial)
Generic
jantoven Generic
monoject prefill advanced (30 units/3ml (10/ml), 100 unit/10 ml (10/ml), 500unit/5 ml (100/ml), 1,000 unit/10(100/ml))
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access42 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access43 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limits
Angiotensin II Receptor Antagonistscandesartan cilexetil Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access44 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitspacerone 200 mg tablet Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access45 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitspindolol Generic
propranolol hcl (10 mg tablet, 20 mg/5ml solution, 20 mg tablet, 40 mg tablet,40mg/5ml solution, 60 mg cap sa 24h,60 mg tablet, 80 mg tablet, 80 mg capsa 24h, 120 mg cap sa 24h, 160 mg capsa 24h)
diltiazem hcl (30 mg tablet, 60 mg caper 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120mg cap er 24h, 120 mg cap er deg, 120mg capsule er, 120 mg tablet, 180 mgcap er 24h, 180 mg capsule er, 180 mgtab er 24h, 180 mg cap er deg, 240 mgtab er 24h, 240 mg cap er deg, 240 mgcap er 24h, 240 mg capsule er, 300 mgcapsule er, 300 mg cap er 24h, 360 mgcap er 24h, 360 mg capsule er, 360 mgtab er 24h, 420mg tab er 24h, 420mgcapsule er)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access46 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsnifediac cc Generic
nifedical xl Generic
nifedipine (10 mg capsule, 20 mgcapsule, 30 mg tab er 24, 30 mg tableter, 60 mg tablet er, 60 mg tab er 24, 90mg tab er 24, 90 mg tablet er)
Generic
nimodipine 30 mg capsule Generic
nisoldipine (8.5mg tab er 24h, 17 mgtab er 24h, 25.5 mg tab er 24h, 34 mgtab er 24h)
digoxin (50 mcg/ml solution, 125 mcgtablet, 250 mcg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access47 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsenalapril maleate/hydrochlorothiazide Generic
fosinopril sodium/hydrochlorothiazide Generic
irbesartan/hydrochlorothiazide Generic
LANOXIN (62.5 MCG TABLET, 187.5MCG TABLET)
Brand
lisinopril/hydrochlorothiazide Generic
losartan potassium/hydrochlorothiazide Generic
methyldopa/hydrochlorothiazide Generic
metoprololtartrate/hydrochlorothiazide
Generic
pentoxifylline 400 mg tablet er Generic
propranolol hcl/hydrochlorothiazide Generic
quinapril hcl/hydrochlorothiazide Generic
spironolactone/hydrochlorothiazide Generic
triamterene/hydrochlorothiazide Generic
valsartan/hydrochlorothiazide Generic
Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 500 mg capsule er Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access48 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium Generic
CRESTOR Brand
fluvastatin sodium (20 mg capsule, 40mg capsule)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access49 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitslovastatin Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access50 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Attention Deficit Hyperactivity Disorder Agents, Amphetaminesdextroamphetamine sulf-saccharate/amphetamine sulf-aspartate (5 mg cap er 24h, 10 mg caper 24h, 15 mg cap er 24h, 25 mg cap er24h, 30 mg cap er 24h)
dextroamphetamine sulfate (5 mgtablet, 5 mg capsule er, 10 mg tablet,10 mg capsule er, 15 mg capsule er)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access51 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsdextroamphetamine/amphetamine 20mg cap er 24h
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access52 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access53 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access54 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitscalcitrene Generic
STELARA 45 MG/0.5 ML SYRINGE Specialty QL (0.5 ML PER 90 DAYS)
STELARA 90 MG/ML SYRINGE Specialty QL (1 ML PER 90 DAYS)
tacrolimus (0.03 % oint. (g), 0.1 % oint.(g))
Generic PA
trianex Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access55 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsvaseline white petroleum Generic
VOLTAREN Brand
Enzyme Replacement/ Modifiers
BUPHENYL 500 MG TABLET Specialty PA
CARBAGLU Brand
CERDELGA Specialty
CREON Brand
ELELYSO Specialty
KUVAN Specialty PA, LA
ORFADIN 2 MG CAPSULE Specialty
pancrelipase 5,000 Generic
RAVICTI Specialty LA
sodium phenylbutyrate 0.94 g/g powder Specialty PA
ZENPEP (DR 3,000 CAPSULE, DR 10,000CAPSULE, DR 15,000 CAPSULE, DR20,000 CAPSULE, DR 25,000 CAPSULE,DR 40,000 CAPSULE)
Brand
Gastrointestinal Agents
Antispasmodics, GastrointestinalANTI-DIARRHEA OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access56 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Gastrointestinal Agents, OtherACID CONTROL (150 MG TABLET, GNP150 MG TABLET)
OTC
ACID GONE OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access57 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsACID GONE ANTACID OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access58 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
ANTACID MAXIMUM STRENGTH (EQTABLET CHEWABLE, MAXIMUMSTRENGTH LIQ, PV MAX STRENGTHSUSP)
OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access59 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsANTACID PLUS ANTI-GAS OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access60 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitscalcium carbonate (200(500)mg tabchew, 300mg(750) tab chew, 400(1000)tab chew, 500 mg/5ml oral susp,500(1250) tab chew)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access61 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsGAS RELIEF (CVS GAS RELIEF 80 MG TABCHEW, CVS GAS RELIEF 125 MG CHEWTAB, CVS GAS RELIEF 125 MG SOFTGEL,CVS GAS RELIEF EX-STR DROPS, EQ GASRELIEF 125 MG SOFTGEL, EQL GASRELIEF 125 MG SOFTGEL, EQL GASRELIEF 180 MG SOFTGEL, EQL GASRELIEF DROPS, GAS RELIEF 20 MG/0.3ML DROPS, GAS RELIEF 40 MG/0.6 MLDROPS, GAS RELIEF 80 MG TABLETCHEW, GAS RELIEF 125 TABLET CHEW,GAS RELIEF 125 MG SOFTGEL, GASRELIEF 125 MG CHEW TABLET, GASRELIEF 180 MG SOFTGEL, GAS RELIEFDROPS, GNP GAS RELIEF 125 MG CHEWTAB, GNP GAS RELIEF 125 MG SFTG,GNP GAS RELIEF 125 MG SOFTGEL, GNPGAS RELIEF 125 TAB CHEW, GNP GASRELIEF DROPS, GS GAS RELIEF 125 MGSOFTGEL, HM GAS RELIEF 80 MG TABCHEW, HM GAS RELIEF 125 MGSOFTGEL, KRO GAS RELIEF 180 MGSOFTGEL, PUB GAS RELIEF 125 MGSOFTGEL, PUB GAS RELIEF 180 MGSOFTGEL, PV GAS RELIEF 125 MG CHEWTAB, PV GAS RELIEF 125 MG SOFTGEL,PV GAS RELIEF 180 MG SOFTGEL, QCGAS RELIEF 80 MG TAB CHEW, QC GASRELIEF 125 MG TAB CHEW, RA GASRELIEF 40 MG/0.6 ML DP, RA GASRELIEF 80 MG TAB CHEW, RA GASRELIEF 125 MG TAB CHEW, RA GASRELIEF 125 MG SOFTGEL, SB GAS RELIEF40 MG/0.6 ML DRP, SM GAS RELANTIFLATUENT 180 MG, SM GAS RELIEF125 MG SOFTGEL, V-R GAS RELIEF 80MG TAB CHEW)
OTC
GAS RELIEF 80 OTC
GAS-X EXTRA STRENGTH SOFTGEL OTC
GAS-X ULTRA STRENGTH OTC
GATTEX Specialty PA
GAVISCON 80-14.2 MG TAB CHEW OTC
GELUSIL ANTACID & ANTIGAS LIQ OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access62 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsGERI-LANTA OTC
MI-ACID (MI ACID SUSPENSION, MI-ACID GAS 80 MG TAB CHEW)
OTC
MILANTEX OTC
MINTOX OTC
MINTOX MAXIMUM STRENGTH OTC
MYLANTA GAS MAXIMUM STRENGTH OTC
MYLANTEX DOUBLE-STRENGTH OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access63 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsMYTAB GAS OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access64 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitssulfazine Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access65 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsPEPCID AC 20 MG TABLET OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access66 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsDOCUSIL OTC
DOK 100 MG TABLET OTC
DOK PLUS OTC
DSS OTC
DUCODYL OTC
DULCOLAX STOOL SOFTENER OTC
ENEMA (ENEMA, ENEMA READY TOUSE, ENEMA READY-TO-USE, ENEMATWIN PACK, EQ ENEMA, EQL ENEMAREADY TO USE, GNP ENEMA READY TOUSE, HM ENEMA READY TO USE, HMENEMA READY TO USE TWIN PAK, PVENEMA, PV ENEMA READY TO USE, QCREADY TO USE ENEMA, RA ENEMATWIN PACK, SM ENEMA READY TO USE)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access67 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access68 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsKRISTALOSE Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access69 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsNATURAL FIBER LAXATIVE OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access70 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsSEN-O-TAB OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access71 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access72 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsWOMEN'S LAXATIVE OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access73 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsPROTONIX 40 MG SUSPENSION Brand
rabeprazole sodium Generic
Genitourinary Agents
Antispasmodics, Urinaryflavoxate hcl Generic
oxybutynin chloride (5 mg/5 ml syrup, 5mg tablet, 5 mg tab er 24, 10 mg tab er24, 15 mg tab er 24)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access74 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access75 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsFLONASE ALLERGY RELIEF OTC PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access76 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsEGRIFTA Specialty PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access77 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsamethia lo Generic
amethyst Generic
apri Generic
aranelle Generic
ashlyna Generic
aubra Generic
aviane Generic
azurette Generic
balziva Generic
briellyn Generic
camrese Generic
camrese lo Generic
caziant Generic
chateal Generic
cryselle Generic
cyclafem Generic
cyred Generic
dasetta Generic
daysee Generic
delyla Generic
desogestrel-ethinyl estradiol Generic
desogestrel-ethinyl estradiol/ethinylestradiol
Generic
DUAVEE Brand
ECONTRA EZ OTC
elinest Generic
emoquette Generic
enpresse Generic
enskyce Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access78 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsESTRACE 0.01% CREAM Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access79 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitslarin fe Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access80 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsnortrel (1-35 tablet, 7-7-7-28 tablet) Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access81 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsvelivet Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access82 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitssharobel Generic
levothyroxine sodium (25 mcg tablet, 50mcg tablet, 75 mcg tablet, 88 mcgtablet, 100 mcg tablet, 112 mcg tablet,125 mcg tablet, 137 mcg tablet, 150mcg tablet, 175mcg tablet, 200 mcgtablet, 300 mcg tablet)
Generic
levoxyl Generic
liothyronine sodium (5 mcg tablet, 25mcg tablet, 50 mcg tablet)
Generic
NATPARA Specialty PA, LA, QL (2 PER 28 DAYS)
THYROLAR-1 Brand
THYROLAR-1/2 Brand
THYROLAR-1/4 Brand
THYROLAR-2 Brand
THYROLAR-3 Brand
unithroid (25 mcg tablet, 50 mcg tablet,75 mcg tablet, 88 mcg tablet, 100 mcgtablet, 112 mcg tablet, 125 mcg tablet,150 mcg tablet, 175 mcg tablet, 200mcg tablet, 300 mcg tablet)
Generic
Hormonal Agents, Suppressant (Adrenal)
LYSODREN Brand
SIGNIFOR Specialty PA, LA
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcgcapsule, 1 mcg/ml solution)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access83 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsparicalcitol (1 mcg capsule, 2 mcgcapsule, 4mcg capsule)
Angioedema (HAE) AgentsBERINERT Specialty PA, QL (3 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access84 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limits
Immune SuppressantsASTAGRAF XL Brand
azathioprine 50 mg tablet Generic
cyclosporine (25 mg capsule, 100 mgcapsule)
Generic
cyclosporine, modified 100 mg capsule Generic
ENBREL (50 MG/ML SYRINGE, 50MG/ML SURECLICK SYR)
Specialty QL (3.92 ML PER 28 DAYS)
ENBREL 25 MG KIT Specialty QL (8 PER 28 DAYS)
ENBREL 25 MG/0.5 ML SYRINGE Specialty QL (4.08 ML PER 28 DAYS)
hecoria Generic
HUMIRA (10 MG/0.2 ML SYRINGE, 20MG/0.4 ML SYRINGE)
Specialty QL (2 PER 28 DAYS)
HUMIRA (40 ML SYRINGE, 40 ML PEN) Specialty QL (1 PER 28 DAYS)
HUMIRA CROHN'S Specialty QL (1 PER 28 DAYS)
HUMIRA PEDIATRIC CROHN'S Specialty QL (1 PER 28 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access85 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limits
Immunizing Agents, PassiveGAMMAKED Specialty PA
GAMUNEX-C Specialty PA
HIZENTRA (1 GRAM/5 ML VIAL, 2GRAM/10 ML VIAL, 4 GRAM/20 MLVIAL)
Specialty PA
HYQVIA Specialty PA
ImmunomodulatorsACTIMMUNE Specialty PA
FIRAZYR Specialty PA, QL (9 ML PER 30 DAYS)
leflunomide Generic
OTEZLA (28 DAY PACK, PACK) Specialty PA
OTEZLA 30 MG TABLET Specialty PA, QL (2 PER DAY)
Inflammatory Bowel Disease Agents
Aminosalicylatesbalsalazide disodium Generic
DIPENTUM Brand
Glucocorticoidscolocort Generic
hydrocortisone 100mg/60ml enema Generic
proctosol-hc Generic
proctozone-hc Generic
UCERIS 9 MG ER TABLET Brand PA
MISCELLANEOUS THERAPEUTIC AGENTS
adenosine phosphate OTC
ALTAMIST OTC
CHILDREN'S SALINE NASAL SPRAY OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access86 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access87 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limits
Miscellaneous
Glucose TestingACCU-CHECK (METERS & TEST STRIPS) DME Benefit QL
LIFESCAN (METERS & TEST STRIPS) DME Benefit QL
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost Generic ST, QL (2.5 ML PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access88 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsLUBRICATING RELIEF OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access89 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitssulfacetamide sodium/prednisolonesodium phosphate
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access90 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsdorzolamide hcl/timolol maleate Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access91 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsBREO ELLIPTA 100-25 MCG INH Brand
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access92 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
ALLERGY MEDICINE (MEDICINE 25 MGTABLET, PV MEDICINE 25 MG CAP, RAMED 25 MG TABLET, SB 12.5 MG/5 MLELIXIR, SB MED 25 MG TABLET, SBMEDICINE 25 MG CAP)
OTC
ALLERGY RELIEF (CVS 25 MG/10 ML LIQ,CVS 50 MG/20 ML LIQ, CVS RELIEF 4MG TABLET, EQ RELIEF 25 MG CAP, EQRELIEF 25 MG TABLET, HM RELIEF 4 MGTABLET, RA RELIEF 25 MG TABLET,RELIEF 4 MG TABLET, RELIEF 25 MGSOFTGEL, RELIEF 25 MG CAPSULE,RELIEF 25 MG TABLET, SM RELIEF 1.34MG TAB, SM RELIEF 12.5 MG/5 ML, SMRELIEF 25 MG CAP, SM RELIEF 25 MGSFTGEL, SM RELIEF 25 MG TABLET)
OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access93 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access94 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitscetirizine hcl 1 mg/ml solution Generic PA
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access95 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsCHLORTABS OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access96 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsED CHLORPED JR OTC
NIGHTTIME SLEEP AID (CVS NIGHTTIMEAID CAPLET, EQ NIGHTTIME 25 MGCPLT, EQL NIGHTTIME AID CAPLET, GNPNIGHTTIME AID CAPLET, GNPNIGHTTIME AID CPLT, KRO NIGHTTIME25 MG CPLT, NIGHT TIME 25 MGCAPLET, NIGHTTIME AID 25 MG CPLT,NIGHTTIME AID CPLT, QC NIGHTTIME25 MG TAB, RA NIGHTTIME 25 MG TAB,RA NIGHTTIME AID CPLT)
OTC
NON-DROWSY ALLERGY OTC PA
NYT-TIME SLEEP OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access97 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsNYTOL QUICKCAPS OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access98 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsWAL-DRYL (25 MG MINITAB, 25 MGCAPSULE, 25 MG SOFTGEL)
OTC
WAL-DRYL ALLERGY 12.5 MG/5 ML OTC
WAL-FEX ALLERGY OTC PA
WAL-FEX D 24 HOUR OTC PA
WAL-FINATE OTC
WAL-ITIN (CHILD 5 MG/5 ML SYRUP, 5MG/5 ML SYRUP, 10 MG TABLET, 10MG ODT)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access99 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitstheophylline anhydrous (80 mg/15mlelixir, 80 mg/15ml solution, 100 mg taber 12h, 200 mg tab er 12h, 300 mg taber 12h, 450 mg tab er 12h)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access100 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limits
Mast Cell Stabilizerscromolyn sodium 20 mg/2 ml ampul-neb
Generic
Pulmonary AntihypertensivesADCIRCA Specialty PA, QL (60 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access101 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsALLERGY RELIEF-NASAL DECONGEST OTC PA
ALLERGY-CONGESTION RELIEF OTC PA
ALLERGY-CONGESTION RELIEF-D OTC PA
AMBITUSSIN AC OTC PA (PA for ages 5 and under)
ANTITUSSIVE DM OTC
APRODINE OTC
benzonatate Generic
BIO-S-PRES DX OTC
BIOCOTRON OTC
BIOGIL OTC
bromfed dm Generic
BRONTUSS SF OTC
CHERATUSSIN AC OTC PA (PA for ages 5 and under)
CHERATUSSIN DAC OTC PA (PA for ages 5 and under)
CHEST CONGESTION RELIEF D OTC
CHILD MUCINEX CHEST CONGESTION OTC
CHILDREN'S CHEST CONGESTION OTC
CHILDREN'S COLD & ALLERGY ELXR OTC
CHILDREN'S MUCUS RELIEF OTC
CLARITIN 5 MG REDITABS OTC PA
CONGEST-EZE OTC
CONGESTAC OTC
COUGH OTC
COUGH & COLD SYRUP OTC
COUGH AND COLD MULTI-SYMPTOM OTC
COUGH CONTROL CF OTC
COUGH CONTROL DM OTC
COUGH FORMULA DM OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access102 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsCOUGH SYRUP OTC
COUGH SYRUP DM OTC
COUGH-HEAD CONGESTION RELIEF OTC
COUGHTAB OTC
CREO-TERPIN OTC
d-methorphan hb/p-epd hcl/bpm 10-30-2/5 syrup
OTC
DAY TIME LIQUID CAPSULE OTC
DESGEN DM OTC
DESPEC DM OTC
DESPEC EDA COUGH & COLD DROPS OTC
DIABETIC SILTUSSIN DAS-NA OTC
DIABETIC SILTUSSIN-DM OTC
DIABETIC TUSSIN DM LIQUID OTC
DIABETIC TUSSIN EX OTC
DOMETUSS-DMX OTC
ED A-HIST PSE OTC
ESBRIET Specialty PA, LA
EXEFEN IR OTC
EXPECTORANT (100 MG/5 ML SYRUP,200 MG TABLET, RA COUGH SYRUP)
OTC
EXPECTORANT COUGH SYRUP OTC
EXPECTORANT DM COUGH SYRUP OTC
EXTRA ACTION COUGH OTC
G-TRON LIQUID OTC
GERI-TUSSIN OTC
GERI-TUSSIN DM OTC
GRASTEK Brand PA
GUAIASORB DM OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access103 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsGUAIATUSSIN AC OTC PA (PA for ages 5 and under)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access104 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsMEDI-TUSSIN DM DIABETIC OTC
promethazine hcl/codeine Generic PA (PA for ages 5 and under)
promethazine hcl/dextromethorphanhbr
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access105 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitspromethazine/phenylephrinehcl/codeine
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access106 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitssodium chloride for inhalation 7 % vial-neb
Generic
SORBUGEN NR OTC
SUDOGEST OTC
SUPHEDRIN (GNP 30 MG TABLET, 30MG TABLET)
OTC
SUPHEDRIN 12-HOUR OTC
SUPHEDRINE OTC
SUPHEDRINE 12-HOUR OTC
SUPHEDRINE SINUS CONGESTION OTC
TRIACTING EXPECTORANT OTC
TUSNEL C OTC PA (PA for ages 5 and under)
TUSNEL DIABETIC OTC
TUSNEL PEDIATRIC DROPS OTC
tussigon Generic
TUSSIN (CVS 100 MG/5 ML LIQUID, EQL100 MG/5 ML LIQUID, GNP 100 MG/5ML SYRUP, KRO 200 MG/10 ML SYRUP,PUB 100 MG/5 ML SYRUP, PV 100MG/5 ML LIQUID, SM 100 MG/5 MLLIQUID, 100 MG/5 ML SYRUP, QC 100MG/5 ML LIQUID, RA 100 MG/5 MLSYRUP)
OTC
TUSSIN CF OTC
TUSSIN CHEST CONGESTION OTC
TUSSIN COLD SEVERE CONGESTION OTC
TUSSIN COUGH (CVS LIQUID, RALIQUID)
OTC
TUSSIN COUGH DM OTC
TUSSIN COUGH-CHEST CONGESTION OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access107 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsTUSSIN DM (CLEAR LIQUID, COUGH &CHEST SYRUP, COUGH SYRUP, CVSLIQUID, EQ COUGH-CHEST SYR, EQLCOUGH-CHEST SYR, EQL SYRUP, GNPSYRUP, KRO LIQUID, LIQUID, PUBLIQUID, PV LIQUID, PV SYRUP, QCSYRUP, RA SYRUP, SM SYRUP, SYRUP)
OTC
TUSSIN DM CLEAR OTC
TUSSIN DM COUGH OTC
TUSSIN DM COUGH & CHEST LIQUID OTC
TUSSIN DM COUGH-CHEST CONGEST OTC
TUSSIN DM MAX (LIQUID, PV LIQUID) OTC
TUSSIN HONEY OTC
TUSSIN MUCUS-CHEST CONGESTION OTC
TYLENOL COLD SEVERE CONGESTION OTC
ULTRA DM FREE & CLEAR OTC
ULTRA TUSS OTC
V-R TUSSIN PE SYRUP OTC
VALU-TAPP OTC
VALU-TAPP DECONGESTANT OTC
VIRTUSSIN AC OTC PA (PA for ages 5 and under)
VIRTUSSIN DAC OTC PA (PA for ages 5 and under)
WAL-ACT D COLD & ALLERGY OTC
WAL-ITIN D OTC PA
WAL-PHED 12 HOUR OTC
WAL-PHED 30 MG TABLET OTC
WAL-TUSSIN COUGH & COLD CF OTC
WAL-TUSSIN DM OTC
WAL-TUSSIN SYRUP OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access108 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access109 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitskionex powder Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access110 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsB COMPLETE OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access111 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access112 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsCERTAVITE-ANTIOXIDANT (LIQUID,TABLET)
OTC
CHEWABLE MULTI VITAMIN OTC
CHILD CHEW VITAMIN OTC
CHILD VITAMIN WITH MINERALS OTC
CHILD'S VITAMIN WITH VITAMIN C OTC
CHILDREN'S CHEW MULTIVIT-IRON OTC
CHILDREN'S CHEWABLE COMPLETE OTC
CHILDREN'S CHEWABLE VITAMIN OTC
CHILDREN'S IRON OTC
CHILDREN'S MULTIVIT W-EXTRA C OTC
CHILDREN'S MULTIVIT-MINERALS OTC
cholecalciferol (vitamin d3) (400 unittablet, 400/ml drops, 400 unit capsule,1000 unit capsule, 1000 unit tablet,2000 unit tablet, 2000 unit capsule,5000 unit capsule, 5000 unit tablet)
OTC
COMPLETE (ADVANCED TABLET,TABLET)
OTC
COMPLETE 50+ OTC
COMPLETE MULTI OTC
COMPLETE MULTI 50+ OTC
COMPLETE MULTI-VIT-MINERAL OTC
COMPLETE MULTIVITAMIN OTC
COMPLETE PREMIUM VITAMIN OTC
COMPLETE SENIOR OTC
completenate Generic
CVS IRON 27 MG TABLET OTC
CVS SPECTRAVITE ADULT 50+ TABS OTC
CVS SPECTRAVITE LIQUID OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access113 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitscyanocobalamin (vitamin b-12) (100mcg tablet, 500 mcg tablet, 1000 mcgtablet, 1000 mcg tab subl, 1000 mcgtablet er)
OTC
cyanocobalamin (vitamin b-12)1000mcg/ml vial
Generic
D-VI-SOL OTC
D-VITA OTC
D3 DOTS OTC
D3-2000 OTC
DAILY MULTIPLE (CVS DAILY TABLET,DAILY TABLET)
OTC
DAILY MULTIPLE VITAMIN OTC
DAILY MULTIVITAMIN WITH IRON OTC
DAILY MULTIVITAMIN-IRON OTC
DAILY TEEN MULTI-VITAMIN OTC
DAILY VALUE OTC
DAILY VITAMIN OTC
DAILY VITAMIN + IRON OTC
DAILY VITAMIN FORMULA OTC
DAILY VITAMIN FORMULA + IRON OTC
DAILY VITAMIN FORMULA-MINERALS OTC
DAILY VITE TABLET OTC
DECUBI VITE OTC
DELTA D3 OTC
dialyvite Generic
DIALYVITE 800 OTC
DIALYVITE VITAMIN D OTC
DIALYVITE ZINC Brand
DINO-LIFE OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access114 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsDINO-LIFE WITH EXTRA C OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access115 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsferrous sulfate (15 mg/ml drops, 47.5iron tablet er, 134mg tablet, 142(45)mgtablet er, 143(45) mg tablet er,220(44)/5 solution, 324(65)mg tabletdr, 325(65) mg tablet dr, 325(65) mgtablet)
OTC
FERROUSUL OTC
FERUS OTC
FLINTSTONES COMPLETE TABLET OTC
FLINTSTONES EXTRA C TAB CHEW OTC
FLINTSTONES PLUS CALCIUM OTC
FLINTSTONES TABLET CHEWABLE OTC
FLINTSTONES WITH IRON OTC
fluoride/iron/vitamins a,c,and d Generic
flura-drops Generic
folbee plus Generic
folic acid (0.4 mg tablet, 0.8 mg tablet) OTC
folic acid 1 mg tablet Generic
folic acid/vitamin b complex & c/ricebran
OTC
FOSFREE OTC
FRUIT C-500 OTC
FRUITY CHEWS OTC
FULL SPECTRUM B OTC
GERAVIM OTC
GERIATON OTC
GERITOL COMPLETE OTC
GERITOL TONIC OTC
GUMMI BEAR MULTIVITAMIN OTC
GUMMY SWIRLS OTC
HAIR VITAMIN OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access116 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsHAIR, SKIN & NAILS (CVS SKIN &TABLET, HM SKIN & CAPLET, PV SKIN &TABLET, SKIN & CAPLET, SM SKIN &CAPLET)
OTC
HAIR,SKIN & NAILS OTC
HEALTHY EYES OTC
HI B COMPLEX OTC
HIGH POTENCY CALCIUM OTC
HIGH POTENCY IRON OTC
HIGH POTENCY MULTIVITAMIN OTC
HIGH PROTEIN OTC
HONEY BEARS OTC
ICAPS PLUS OTC
IFEREX 150 OTC
inatal advance Generic
iron asp gly&ps cmplx/ascorb.cal/vitb12/fa/ca-thr/succ.acid
Generic
k-sol 10% (20 meq/15 ml) liq Generic
KENWOOD THERAPEUTIC OTC
KID'S GUMMY BEAR VITAMINS OTC
KID'S VITAMINS OTC
KID'S VITAMINS + EXTRA C OTC
KID'S VITAMINS COMPLETE OTC
klor-con 10 Generic
klor-con 8 Generic
klor-con m10 Generic
klor-con m15 Generic
klor-con m20 Generic
klor-con sprinkle Generic
MACUVITE OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access117 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsMACUVITE EYE CARE OTC
MAG DELAY OTC
MAG64 OTC
magnesium 250 mg tablet OTC
magnesium oxide (400 mg tablet, 500mg capsule)
OTC
MEGA MULTI W-CHELATED MINERALS OTC
MEGA MULTIVITAMIN WITH MINERAL OTC
MEN'S DAILY MULTIVIT-MINERAL OTC
MEN'S MULTI-VITAMIN OTC
MEPHYTON Brand
MG-PLUS-PROTEIN OTC
MGO OTC
MILLTRIUM SENIOR OTC
MULTI COMPLETE-IRON OTC
MULTI-DAY PLUS IRON OTC
MULTI-DELYN LIQUID OTC
MULTI-VITAMIN DAILY OTC
MULTI-VITE OTC
MULTI-VITE 50 & OVER OTC
multivit with calcium, iron, and otherminerals
OTC
MULTIVITAL OTC
MULTIVITAL PERFORMANCE OTC
MULTIVITAL PLATINUM OTC
multivitamin OTC
multivitamin w-minerals/ferrousgluconate
OTC
multivitamin with minerals OTC
multivitamins with iron OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access118 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsmultivitamins,ther w-minerals OTC
MY FAVORITE MULTIPLE OTC
MYFERON 150 OTC
mynatal advance Generic
mynephrocaps Generic
MYVITALIFE OTC
natal-v rx Generic
NATURAL B-100 OTC
niacin (50 mg tablet, 100 mg tablet, 125mg capsule er, 250 mg capsule er, 250mg tablet er, 250 mg tablet, 400 mgcapsule er, 500 mg capsule er, 750 mgtablet er)
ONE DAILY (DAILY TABLET, GNP DAILYTABLET, RA DAILY MULTI-VITAMIN TAB,RA DAILY TABLET)
OTC
ONE DAILY 50 PLUS OTC
ONE DAILY ESSENTIAL (DAILY TABLET,EQL DAILY TABLET, GNP DAILY TABLET)
OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access119 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsONE DAILY FOR MEN OTC
ONE DAILY FOR WOMEN OTC
ONE DAILY FOR WOMEN 50+ ADV OTC
ONE DAILY MAXIMUM (DAILY TABLET,GNP DAILY TABLET, RA DAILY TABLET)
OTC
ONE DAILY MEN'S HEALTH OTC
ONE DAILY MULTIVITAMIN (DAILY TAB,DAILY TABLET)
OTC
ONE DAILY MULTIVITAMIN-IRON OTC
ONE DAILY PLUS IRON OTC
ONE DAILY PLUS MINERALS OTC
ONE DAILY WITH CALCIUM-IRON OTC
ONE DAILY WITH IRON OTC
ONE DAILY WOMEN'S OTC
ONE DAILY WOMEN'S 50+ OTC
ONE DAILY WOMEN'S HEALTH OTC
ONE-A-DAY ESSENTIAL OTC
ONE-A-DAY MAXIMUM FORMULA OTC
ONE-A-DAY TEEN ADVANTAGE OTC
ONE-A-DAY WOMEN'S OTC
OPTI-VITAMIN OTC
ORALYTE OTC
OS-CAL 500+D3 OTC
OYSCO 500+D OTC
OYSCO-500 OTC
OYSTERCAL-D OTC
PARVA-CAL 500 OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access120 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsPEDIATRIC ELECTROLYTE (CVSPEDIATRIC POPS, CVS PEDIATRIC SOLN,EQL PEDIATRIC SOLN, GNP PEDIATRICSOLN, HEB PEDIATRIC SOLN, HMPEDIATRIC SOLN, PEDI FREEZER POP,PEDIATRIC SOLN, PEDIATRIC SOLUTION,PV PEDI FREEZE POP, PV PEDIATRICSOLN, RA PEDIATRIC SOLN, SBPEDIATRIC SOLN, SM PEDIATRIC SOLN)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access121 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsPOLYSACCHARIDE IRON OTC
POLYVITAMIN WITH IRON (W-IRONDROPS, WITH IRON TAB CHEW)
OTC
potassium chloride (8 meq capsule er, 8meq tablet er, 10 meq tablet er, 10 meqtab er prt, 10 meq capsule er,20meq/15ml liquid, 20 meq tablet er,20 meq tab er prt)
prenatal vitamins with calcium/ferrousfumarate/folic acid
OTC
prenatal vits with calcium #72/ferrousfumarate/folic acid
Generic
prenatal vits with calcium#72/iron,carbonyl/folic acid
Generic
prenatal vits with calcium #74/ferrousfumarate/folic acid
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access122 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsprenatal vits with calcium #95/ferrousfumarate/folic acid
OTC
prenatal vits with calcium #96/ferrousfumarate/folic acid
OTC
prenatal vits with calcium#118/ferrousfumarate/folic acid
OTC
prenatal vits without calc no5/ferrousfumarate/folic acid
Generic
preplus Generic
PROSIGHT OTC
PROTEIN OTC
PROTEINEX TABLET OTC
PV B-100 COMPLEX OTC
PV B-50 COMPLEX OTC
PV KIDS VITAMINS+IRON TAB CHEW OTC
pyridoxine hcl 50 mg tablet OTC
QC CHILDREN'S CHEWABLE TABLET OTC
QUFLORA (0.25 MG/ML DROP, 0.5MG/ML DROP)
Brand
RA HI-CAL PLUS VITAMIN D TAB OTC
RA ONE DAILY ENERGY TABLET OTC
RA ONE DAILY MEN'S 50+ TABLET OTC
RENA-VITE OTC
rena-vite rx Generic
renal caps Generic
reno caps Generic
RIGHT STEP PRENATAL VITAMINS OTC
RISANOID PLUS OTC
salmon oil/omega-3 fatty acids 500-100mg capsule
OTC
SCOOBY-DOO ONE A DAY TABLET OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access123 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsse-natal 19 Generic
SENIOR TABS OTC
SENTRY OTC
SENTRY SENIOR OTC
sodium fluoride 0.5 mg/ml drops Generic
SOOTHING PUREWAY-C OTC
SPECTRAVITE ADVANCED FORM OTC
SPECTRAVITE ADVANCED FORMULA OTC
SPECTRAVITE PERFORMANCE OTC
SPECTRAVITE SENIOR OTC
SPECTRAVITE ULTRA WOMEN OTC
STRESS 500 OTC
STRESS 500 PLUS ZINC OTC
STRESS B OTC
STRESS B WITH ZINC OTC
STRESS FORMULA (CVS TABLET,TABLET)
OTC
STRESS FORMULA WITH ZINC OTC
STRESS-C OTC
STUART PRENATAL OTC
SUPER AMINO ACIDS OTC
SUPER B COMPLEX-VITAMIN C OTC
SUPER B-50 COMPLEX OTC
SUPER B-50 COMPLEX PLUS OTC
SUPER CALCIUM OTC
SUPER MULTIPLE VIT-MINERAL TAB OTC
SUPER QUINTS B-50 TABLETS OTC
SUPER THERAVITE-M OTC
SUPERPLEX-T OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access124 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/LimitsSV FISH OIL EC 1,200 MG SOFTGL OTC
TAB-A-VITE OTC
TAB-A-VITE WITH IRON OTC
TAB-A-VITE-MINERALS OTC
THERA OTC
THERA-D (RAPID REPLETION TABLET,SPORT 2,000 UNIT TAB, 2000 TABLET)
OTC
THERA-M CAPLET OTC
THERA-TABS OTC
THERADEX M OTC
THERAMILL FORTE OTC
therapeutic hematinic Generic
THERAPEUTIC M (STABLET, TABLET) OTC
THERAPEUTIC-M (, GNP) OTC
THERATRUM COMPLETE OTC
THERATRUM COMPLETE 50 PLUS OTC
THEREMS OTC
THEREMS-M OTC
thiamine hcl 100 mg tablet OTC
thiamine mononitrate OTC
thrivite 19 Generic
TL FOLATE Brand
tl-fluorivite Generic
TOTAL B WITH C OTC
TRI-VITA OTC
triadvance Generic
TRICARE Brand
trinatal gt Generic
trinatal rx 1 Generic
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access125 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitstriphrocaps Generic
triveen-u Generic
ULTRA B-100 COMPLEX (TAB, TABLET) OTC
v-c forte Generic
vic-forte Generic
vinate gt Generic
vinate one Generic
vinate pn care Generic
vinate-m Generic
virt nate Generic
virt-advance Generic
virt-caps Generic
virt-nate Generic
virt-vite gt Generic
VISION OTC
VISION FORMULA OTC
VISION PLUS LUTEIN OTC
VISION VITAMINS OTC
vit b complex/vit c/folic acid/ferrousfumarate/vit e acet
OTC
vitamin a 10000 unit capsule OTC
vitamin a palmitate 10000 unit capsule OTC
vitamin b complex (capsule, talet) OTC
VITAMIN B-100 COMPLEX OTC
vitamin e (100 unit capsul, 200 unitcapsul, 400 unit capsul)
OTC
vitamin e (dl-alpha tocopheryl acetate)((dl,tocophryl act) 200 unit capsul,(dl,tocophryl act) 400 unit capsul)
OTC
vitamin e acetate (actat200 unit capsul,actat400 unit capsul, actat600 unitcapsul)
OTC
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access126 LAST UPDATE 10/2015
Health Share of Oregon/Providence (Medicaid)To help find a drug see the back of the document for an alphabetical listing
Drug Name Status* Requirements/Limitsvitamin e acid succinate 200 unit tablet OTC
vitamin e mixed (mixd 200 unit tablt,mixd 400 unit capsul)
*Specialty medications are only available through the Providence specialty network. See introduction.^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access127 LAST UPDATE 10/2015