1 HMSA QUEST Integration Managed Medicaid Formulary (Effective 07/01/2018) LEGEND AL Age Limit OTC Over the Counter PA Prior Authorization QL Quantity Limit SP Specialty Drug ST Step Therapy + Indicates both the generic is covered as well as the brand-name product equivalent, with dispense as written code 1 (DAW 1). This includes State-mandated drug classes (HIV and AIDS, Antidepressants, Antipsychotics, Antianxiety Agents, and Immunosuppressants). lowercase lowercase type indicates generic availability UPPERCASE UPPERCASE type indicates brand availability NOTE The status of a drug on this list is current as of the date of this publication. The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process. Not all generic drugs may be listed. Coverage of a drug will depend on your drug plan. HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care system that improves the overall health and well-being of our state.
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1
HMSA QUEST Integration Managed Medicaid
Formulary
(Effective 07/01/2018)
LEGEND
AL Age Limit
OTC Over the Counter
PA Prior Authorization
QL Quantity Limit
SP Specialty Drug
ST Step Therapy
+ Indicates both the generic is covered as well as the brand-name
product equivalent, with dispense as written code 1 (DAW 1). This
includes State-mandated drug classes (HIV and AIDS,
Antidepressants, Antipsychotics, Antianxiety Agents, and
Immunosuppressants).
lowercase lowercase type indicates generic availability
UPPERCASE UPPERCASE type indicates brand availability
NOTE
The status of a drug on this list is current as of the date of this publication.
The list serves as a guide to product selection for our providers and
members. The list is subject to change. Participating pharmacies have the
most up-to-date formulary information at the time prescriptions are filled.
New drugs, strengths, forms, and/or therapeutic categories introduced in the
marketplace will be reflected in the formulary, as applicable, following the
completion of HMSA’s review process.
Not all generic drugs may be listed.
Coverage of a drug will depend on your drug plan.
HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health
care system that improves the overall health and well-being of our state.
This document contains references to brand-name prescription drugs that are
trademarks or registered trademarks of pharmaceutical manufacturers.
Plan member privacy is important to us. Our employees are trained regarding
the appropriate way to handle members' private health information.
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
3
Drug Name Requirements/Limits
ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg ST (Must have recently been
on 30 days supply of NSAID or GI protectant OR be taking a drug that could
cause adverse GI events)
celecoxib cap 100 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be
taking a drug that could cause adverse GI events)
celecoxib cap 200 mg ST (Must have recently been on 30 days supply of NSAID
or GI protectant OR be taking a drug that could cause adverse GI events)
celecoxib cap 400 mg ST (Must have recently been on 30 days supply of NSAID
or GI protectant OR be taking a drug that could
cause adverse GI events)
GOUT allopurinol tab 100 mg
allopurinol tab 300 mg
colchicine tab 0.6 mg QL (30 per month)
probenecid tab 500 mg
NON-OPIOID ANALGESICS acetaminophen cap 500 mg OTC
acetaminophen chew tab 80 mg OTC
acetaminophen chew tab 160 mg OTC
acetaminophen disintegrating tab 80 mg OTC
acetaminophen disintegrating tab 160 mg OTC
acetaminophen elixir 160 mg/5ml OTC
acetaminophen liquid 160 mg/5ml OTC
acetaminophen liquid 167 mg/5ml OTC
acetaminophen soln 160 mg/5ml OTC
acetaminophen suppos 120 mg OTC
acetaminophen suppos 325 mg OTC
acetaminophen suppos 650 mg OTC
acetaminophen susp 80 mg/0.8ml OTC
acetaminophen susp 160 mg/5ml OTC
acetaminophen tab 325 mg OTC
acetaminophen tab 500 mg OTC
acetaminophen tab er 650 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
4
Drug Name Requirements/Limits
butalbital-acetaminophen-caffeine cap 50-325-40 mg
butalbital-aspirin-caffeine cap 50-325-40 mg QL (60 per month)
FEBROL SOL 325/5ML OTC
FEVERALL INF SUP 80MG OTC
NON-ASPIRIN TAB 500MG QM OTC
NSAIDS diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 25 mg
diclofenac sodium tab delayed release 50 mg
diclofenac sodium tab delayed release 75 mg
diclofenac sodium tab er 24hr 100 mg
diflunisal tab 500 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
etodolac tab er 24hr 400 mg
etodolac tab er 24hr 500 mg
etodolac tab er 24hr 600 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen cap 200 mg OTC
ibuprofen chew tab 100 mg OTC
ibuprofen susp 40 mg/ml OTC
ibuprofen susp 100 mg/5ml
ibuprofen susp 100 mg/5ml OTC
ibuprofen tab 100 mg OTC
ibuprofen tab 200 mg OTC
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
ketoprofen cap 75 mg
ketorolac tromethamine tab 10 mg QL (20 per month)
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen sodium cap 220 mg OTC
naproxen sodium tab 220 mg OTC
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
5
Drug Name Requirements/Limits
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
naproxen tab ec 375 mg
naproxen tab ec 500 mg
oxaprozin tab 600 mg
sulindac tab 150 mg
sulindac tab 200 mg
NSAIDS, TOPICAL diclofenac sodium gel 1% QL (500 grams per month)
OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 mg/5ml QL (5000 mL per month)
acetaminophen w/ codeine tab 300-15 mg QL (400 per month)
acetaminophen w/ codeine tab 300-30 mg QL (400 per month)
acetaminophen w/ codeine tab 300-60 mg QL (400 per month)
fentanyl td patch 72hr 12 mcg/hr QL (20 per month)
fentanyl td patch 72hr 25 mcg/hr QL (20 per month)
fentanyl td patch 72hr 50 mcg/hr QL (20 per month)
fentanyl td patch 72hr 75 mcg/hr QL (20 per month)
fentanyl td patch 72hr 100 mcg/hr QL (20 per month)
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
QL (5540 mL per month)
hydrocodone-acetaminophen tab 5-325 mg QL (375 per month)
hydrocodone-acetaminophen tab 7.5-325 mg QL (375 per month)
hydrocodone-acetaminophen tab 10-325 mg QL (375 per month)
hydromorphone hcl tab 2 mg QL (180 per month)
hydromorphone hcl tab 4 mg QL (180 per month)
hydromorphone hcl tab 8 mg QL (180 per month)
methadone hcl tab 5 mg
methadone hcl tab 10 mg
morphine sulfate oral soln 10 mg/5ml QL (900 mL per month)
morphine sulfate oral soln 20 mg/5ml QL (900 mL per month)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml) QL (180 mL per month)
morphine sulfate suppos 5 mg QL (180 per month)
morphine sulfate suppos 10 mg QL (180 per month)
morphine sulfate suppos 20 mg QL (180 per month)
morphine sulfate tab 15 mg QL (180 per month)
morphine sulfate tab 30 mg QL (180 per month)
morphine sulfate tab er 15 mg QL (120 per month)
morphine sulfate tab er 30 mg QL (120 per month)
morphine sulfate tab er 60 mg QL (120 per month)
morphine sulfate tab er 100 mg QL (60 per month)
morphine sulfate tab er 200 mg QL (60 per month)
oxycodone hcl cap 5 mg QL (180 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
6
Drug Name Requirements/Limits
oxycodone hcl conc 100 mg/5ml (20 mg/ml) QL (180 mL per month)
oxycodone hcl soln 5 mg/5ml QL (180 mL per month)
oxycodone hcl tab 5 mg QL (180 per month)
oxycodone hcl tab 10 mg QL (180 per month)
oxycodone hcl tab 15 mg QL (180 per month)
oxycodone hcl tab 20 mg QL (180 per month)
oxycodone hcl tab 30 mg QL (180 per month)
oxycodone w/ acetaminophen soln 5-325 mg/5ml QL (1846 mL per month)
oxycodone w/ acetaminophen tab 2.5-325 mg QL (375 per month)
oxycodone w/ acetaminophen tab 5-325 mg QL (375 per month)
oxycodone w/ acetaminophen tab 7.5-325 mg QL (375 per month)
oxycodone w/ acetaminophen tab 10-325 mg QL (375 per month)
oxycodone-aspirin tab 4.8355-325 mg QL (308 per month)
tramadol hcl tab 50 mg QL (240 per month)
tramadol hcl tab er 24hr 100 mg QL (30 per month)
tramadol hcl tab er 24hr 200 mg QL (30 per month)
tramadol hcl tab er 24hr 300 mg QL (30 per month)
tramadol hcl tab er 24hr biphasic release 300 mg QL (30 per month)
tramadol-acetaminophen tab 37.5-325 mg QL (240 per month)
ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin cap 750 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
cephalexin tab 250 mg
cephalexin tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
7
Drug Name Requirements/Limits
cefdinir for susp 250 mg/5ml
ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml
azithromycin for susp 200 mg/5ml
azithromycin powd pack for susp 1 gm
azithromycin tab 250 mg
azithromycin tab 500 mg
azithromycin tab 600 mg
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
clarithromycin tab 250 mg
clarithromycin tab 500 mg
clarithromycin tab er 24hr 500 mg
erythromycin ethylsuccinate for susp 200 mg/5ml
erythromycin ethylsuccinate tab 400 mg
erythromycin stearate tab 250 mg
erythromycin tab 250 mg
erythromycin tab 500 mg
erythromycin tab delayed release 250 mg
erythromycin tab delayed release 333 mg
erythromycin tab delayed release 500 mg
erythromycin w/ delayed release particles cap 250 mg
ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)
ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
levofloxacin tab 500 mg
levofloxacin tab 750 mg
ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-28.5 mg
amoxicillin & k clavulanate chew tab 400-57 mg
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
amoxicillin & k clavulanate for susp 400-57 mg/5ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
8
Drug Name Requirements/Limits
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
9
Drug Name Requirements/Limits
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole tab 50 mg
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
griseofulvin microsize susp 125 mg/5ml
griseofulvin ultramicrosize tab 125 mg
griseofulvin ultramicrosize tab 250 mg
itraconazole cap 100 mg PA
nystatin oral powder
nystatin susp 100000 unit/ml
nystatin tab 500000 unit
terbinafine hcl tab 250 mg QL (1 tab per day; 90 days per year)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
10
Drug Name Requirements/Limits
TRUVADA TAB 100-150 SP
TRUVADA TAB 133-200 SP
TRUVADA TAB 167-250 SP
TRUVADA TAB 200-300 SP
ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML SP
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
12
Drug Name Requirements/Limits
APTIVUS CAP 250MG SP
APTIVUS SOL SP
atazanavir sulfate cap 150 mg (base equiv) SP
atazanavir sulfate cap 200 mg (base equiv) SP
atazanavir sulfate cap 300 mg (base equiv) SP
CRIXIVAN CAP 200MG SP
CRIXIVAN CAP 400MG SP
fosamprenavir calcium tab 700 mg (base equiv) SP
INVIRASE CAP 200MG SP
INVIRASE TAB 500MG SP
KALETRA SOL SP, +
KALETRA TAB 100-25MG SP
KALETRA TAB 200-50MG SP
LEXIVA SUS 50MG/ML SP
LEXIVA TAB 700MG SP, +
lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)
SP
NORVIR CAP 100MG SP
NORVIR SOL 80MG/ML SP
NORVIR TAB 100MG SP, +
PREZISTA SUS 100MG/ML SP
PREZISTA TAB 75MG SP
PREZISTA TAB 150MG SP
PREZISTA TAB 600MG SP
PREZISTA TAB 800MG SP
REYATAZ CAP 150MG SP, +
REYATAZ CAP 200MG SP, +
REYATAZ CAP 300MG SP, +
REYATAZ POW 50MG SP
ritonavir tab 100 mg SP
VIRACEPT TAB 250MG SP
VIRACEPT TAB 625MG SP
ANTITUBERCULAR AGENTS ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid syrup 50 mg/5ml AL (covered for ages 18 and under; refer to Dept of
Health if > 18 years old)
isoniazid tab 100 mg AL (covered for ages 18 and
under; refer to Dept of Health if > 18 years old)
isoniazid tab 300 mg AL (covered for ages 18 and under; refer to Dept of
Health if > 18 years old)
pyrazinamide tab 500 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
entecavir tab 0.5 mg
entecavir tab 1 mg
EPIVIR HBV SOL 5MG/ML
lamivudine tab 100 mg (hbv)
VEMLIDY TAB 25MG
ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C MAVYRET TAB 100-40MG PA; SP; for genotypes 1, 2,
3, 4, 5, 6
MODERIBA PAK 800/DAY PA; SP
MODERIBA PAK 1200/DAY PA; SP
moderiba tab 200mg PA; SP
MODERIBA TAB 600/DAY PA; SP
MODERIBA TAB 1000/DAY PA; SP
REBETOL SOL 40MG/ML PA; SP
RIBAPAK PAK 800/DAY PA; SP
RIBAPAK PAK 1200/DAY PA; SP
RIBAPAK TAB 600/DAY PA; SP
RIBAPAK TAB 1000/DAY PA; SP
ribasphere cap 200mg PA; SP
ribasphere tab 200mg PA; SP
ribasphere tab 400mg PA; SP
ribasphere tab 600mg PA; SP
ribavirin cap 200 mg PA; SP
ribavirin tab 200 mg PA; SP
ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
famciclovir tab 125 mg
famciclovir tab 250 mg
famciclovir tab 500 mg
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base equiv) QL (28 caps per 6 months)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
14
Drug Name Requirements/Limits
oseltamivir phosphate cap 45 mg (base equiv) QL (14 caps per 6 months)
oseltamivir phosphate cap 75 mg (base equiv) QL (14 caps per 6 months)
oseltamivir phosphate for susp 6 mg/ml (base equiv)
QL (180 mL per 6 months)
MISCELLANEOUS atovaquone susp 750 mg/5ml
clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg
clindamycin palmitate hcl for soln 75 mg/5ml
(base equiv)
dapsone tab 25 mg
dapsone tab 100 mg
DARAPRIM TAB 25MG
EMVERM CHW 100MG QL (12 tabs per 365 days)
ivermectin tab 3 mg
linezolid for susp 100 mg/5ml PA
linezolid tab 600 mg PA
metronidazole cap 375 mg
metronidazole tab 250 mg
metronidazole tab 500 mg
nitrofurantoin macrocrystalline cap 25 mg
nitrofurantoin macrocrystalline cap 50 mg
nitrofurantoin macrocrystalline cap 100 mg
nitrofurantoin monohydrate macrocrystalline cap 100 mg
nitrofurantoin susp 25 mg/5ml
PINWORM TAB MEDICINE OTC
pyrantel pamoate susp 144 mg/ml (50 mg/ml base
equiv)
OTC
rifabutin cap 150 mg
trimethoprim tab 100 mg
vancomycin hcl cap 125 mg ST (Must have recently been on a 10 days supply of metronidazole)
vancomycin hcl cap 250 mg ST (Must have recently been
on a 10 days supply of metronidazole)
ANTINEOPLASTIC AGENTS ALKYLATING AGENTS cyclophosphamide cap 25 mg
cyclophosphamide cap 50 mg
GLEOSTINE CAP 5MG
GLEOSTINE CAP 10MG
GLEOSTINE CAP 40MG
GLEOSTINE CAP 100MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
16
Drug Name Requirements/Limits
CABOMETYX TAB 20MG QL (30 tabs / 30 days), PA; SP
CABOMETYX TAB 40MG QL (30 tabs / 30 days), PA; SP
CABOMETYX TAB 60MG QL (30 tabs / 30 days), PA; SP
CALQUENCE CAP 100MG PA; SP
CAPRELSA TAB 100MG PA; SP
CAPRELSA TAB 300MG PA; SP
COMETRIQ KIT 60MG PA; SP
COMETRIQ KIT 100MG PA; SP
COMETRIQ KIT 140MG PA; SP
GILOTRIF TAB 20MG PA; SP
GILOTRIF TAB 30MG PA; SP
GILOTRIF TAB 40MG PA; SP
IBRANCE CAP 75MG PA; SP
IBRANCE CAP 100MG PA; SP
IBRANCE CAP 125MG PA; SP
IMBRUVICA CAP 140MG PA; SP
INLYTA TAB 1MG PA; SP
INLYTA TAB 5MG PA; SP
JAKAFI TAB 5MG PA; SP
JAKAFI TAB 10MG PA; SP
JAKAFI TAB 15MG PA; SP
JAKAFI TAB 20MG PA; SP
JAKAFI TAB 25MG PA; SP
LENVIMA CAP 8 MG PA; SP
LENVIMA CAP 10 MG PA; SP
LENVIMA CAP 14 MG PA; SP
LENVIMA CAP 18 MG PA; SP
LENVIMA CAP 20 MG PA; SP
LENVIMA CAP 24 MG PA; SP
MEKINIST TAB 0.5MG PA; SP
MEKINIST TAB 2MG PA; SP
NEXAVAR TAB 200MG PA; SP
RYDAPT CAP 25MG PA; SP
STIVARGA TAB 40MG PA; SP
SUTENT CAP 12.5MG PA; SP
SUTENT CAP 25MG PA; SP
SUTENT CAP 37.5MG PA; SP
SUTENT CAP 50MG PA; SP
TAFINLAR CAP 50MG PA; SP
TAFINLAR CAP 75MG PA; SP
TARCEVA TAB 25MG PA; SP
TARCEVA TAB 100MG PA; SP
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan tab 75 mg
irbesartan tab 150 mg
irbesartan tab 300 mg
losartan potassium tab 25 mg
losartan potassium tab 50 mg
losartan potassium tab 100 mg
valsartan tab 40 mg
valsartan tab 80 mg
valsartan tab 160 mg
valsartan tab 320 mg
ANTIARRHYTHMICS amiodarone hcl tab 100 mg
amiodarone hcl tab 200 mg
amiodarone hcl tab 400 mg
BETAPACE AF TAB 80MG +
BETAPACE AF TAB 120MG +
BETAPACE AF TAB 160MG +
BETAPACE TAB 80MG +
BETAPACE TAB 120MG +
BETAPACE TAB 160MG +
disopyramide phosphate cap 100 mg
disopyramide phosphate cap 150 mg
dofetilide cap 125 mcg (0.125 mg) PA; SP
dofetilide cap 250 mcg (0.25 mg) PA; SP
dofetilide cap 500 mcg (0.5 mg) PA; SP
flecainide acetate tab 50 mg
flecainide acetate tab 100 mg
flecainide acetate tab 150 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
21
Drug Name Requirements/Limits
MULTAQ TAB 400MG
NORPACE CAP 100MG +
NORPACE CAP 100MG CR
NORPACE CAP 150MG +
NORPACE CAP 150MG CR
propafenone hcl cap er 12hr 225 mg
propafenone hcl cap er 12hr 325 mg
propafenone hcl cap er 12hr 425 mg
propafenone hcl tab 150 mg
propafenone hcl tab 225 mg
propafenone hcl tab 300 mg
RYTHMOL SR CAP 225MG +
RYTHMOL SR CAP 325MG +
RYTHMOL SR CAP 425MG +
sotalol hcl (afib/afl) tab 80 mg
sotalol hcl (afib/afl) tab 120 mg
sotalol hcl (afib/afl) tab 160 mg
sotalol hcl tab 80 mg
sotalol hcl tab 120 mg
sotalol hcl tab 160 mg
sotalol hcl tab 240 mg
TIKOSYN CAP 125MCG PA; SP, +
TIKOSYN CAP 250MCG PA; SP, +
TIKOSYN CAP 500MCG PA; SP, +
ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose
ANTILIPEMICS, FIBRATES fenofibrate micronized cap 67 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate tab 48 mg
fenofibrate tab 54 mg
fenofibrate tab 145 mg
fenofibrate tab 160 mg
gemfibrozil tab 600 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
23
Drug Name Requirements/Limits
metoprolol succinate tab er 24hr 25 mg (tartrate equiv)
metoprolol succinate tab er 24hr 50 mg (tartrate equiv)
metoprolol succinate tab er 24hr 100 mg (tartrate equiv)
metoprolol succinate tab er 24hr 200 mg (tartrate equiv)
CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINES diltiazem hcl cap er 12hr 60 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
24
Drug Name Requirements/Limits
diltiazem hcl cap er 12hr 90 mg
diltiazem hcl cap er 12hr 120 mg
diltiazem hcl cap er 24hr 120 mg
diltiazem hcl cap er 24hr 180 mg
diltiazem hcl cap er 24hr 240 mg
diltiazem hcl coated beads cap er 24hr 120 mg
diltiazem hcl coated beads cap er 24hr 180 mg
diltiazem hcl coated beads cap er 24hr 240 mg
diltiazem hcl coated beads cap er 24hr 300 mg
diltiazem hcl coated beads cap er 24hr 360 mg
diltiazem hcl coated beads tab er 24hr 180 mg
diltiazem hcl coated beads tab er 24hr 240 mg
diltiazem hcl coated beads tab er 24hr 300 mg
diltiazem hcl coated beads tab er 24hr 360 mg
diltiazem hcl coated beads tab er 24hr 420 mg
diltiazem hcl extended release beads cap er 24hr
120 mg
diltiazem hcl extended release beads cap er 24hr
180 mg
diltiazem hcl extended release beads cap er 24hr
240 mg
diltiazem hcl extended release beads cap er 24hr
300 mg
diltiazem hcl extended release beads cap er 24hr
360 mg
diltiazem hcl extended release beads cap er 24hr
420 mg
diltiazem hcl tab 30 mg
diltiazem hcl tab 60 mg
diltiazem hcl tab 90 mg
diltiazem hcl tab 120 mg
verapamil hcl tab er 120 mg
verapamil hcl tab er 180 mg
verapamil hcl tab er 240 mg
DIGITALIS GLYCOSIDES digoxin oral soln 0.05 mg/ml
digoxin tab 125 mcg (0.125 mg)
digoxin tab 250 mcg (0.25 mg)
LANOXIN TAB 0.0625MG
LANOXIN TAB 0.1875MG
DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
methazolamide tab 25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
DIURETICS, THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
HEART FAILURE CORLANOR TAB 5MG
CORLANOR TAB 7.5MG
ENTRESTO TAB 24-26MG
ENTRESTO TAB 49-51MG
ENTRESTO TAB 97-103MG
MISCELLANEOUS hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
26
Drug Name Requirements/Limits
hydralazine hcl tab 100 mg
RANEXA TAB 500MG ST (Must try a nitrate plus a beta blocker or calcium
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML
alprazolam orally disintegrating tab 0.5 mg
alprazolam orally disintegrating tab 0.25 mg
alprazolam orally disintegrating tab 1 mg
alprazolam orally disintegrating tab 2 mg
alprazolam tab 0.5 mg
alprazolam tab 0.25 mg
alprazolam tab 1 mg
alprazolam tab 2 mg
alprazolam tab er 24hr 0.5 mg
alprazolam tab er 24hr 1 mg
alprazolam tab er 24hr 2 mg
alprazolam tab er 24hr 3 mg
ATIVAN INJ 2MG/ML +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
28
Drug Name Requirements/Limits
ATIVAN INJ 4MG/ML +
ATIVAN TAB 0.5MG +
ATIVAN TAB 1MG +
ATIVAN TAB 2MG +
chlordiazepoxide hcl cap 5 mg
chlordiazepoxide hcl cap 10 mg
chlordiazepoxide hcl cap 25 mg
clonazepam orally disintegrating tab 0.5 mg
clonazepam orally disintegrating tab 0.25 mg
clonazepam orally disintegrating tab 0.125 mg
clonazepam orally disintegrating tab 1 mg
clonazepam orally disintegrating tab 2 mg
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
clorazepate dipotassium tab 3.75 mg
clorazepate dipotassium tab 7.5 mg
clorazepate dipotassium tab 15 mg
diazepam conc 5 mg/ml
diazepam inj 5 mg/ml
DIAZEPAM INJ 10MG/2ML
diazepam oral soln 1 mg/ml
diazepam tab 2 mg
diazepam tab 5 mg
diazepam tab 10 mg
KLONOPIN TAB 0.5MG +
KLONOPIN TAB 1MG +
KLONOPIN TAB 2MG +
lorazepam conc 2 mg/ml
lorazepam inj 2 mg/ml
lorazepam inj 4 mg/ml
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
TRANXENE T TAB 7.5MG +
VALIUM TAB 2MG +
VALIUM TAB 5MG +
VALIUM TAB 10MG +
XANAX TAB 0.5MG +
XANAX TAB 0.25MG +
XANAX TAB 1MG +
XANAX TAB 2MG +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
29
Drug Name Requirements/Limits
XANAX XR TAB 0.5MG +
XANAX XR TAB 1MG +
XANAX XR TAB 2MG +
XANAX XR TAB 3MG +
ANTIANXIETY, MISCELLANEOUS ANAFRANIL CAP 25MG +
ANAFRANIL CAP 50MG +
ANAFRANIL CAP 75MG +
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
clomipramine hcl cap 25 mg
clomipramine hcl cap 50 mg
clomipramine hcl cap 75 mg
fluvoxamine maleate cap er 24hr 100 mg
fluvoxamine maleate cap er 24hr 150 mg
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 mg
meprobamate tab 200 mg
meprobamate tab 400 mg
ANTICONVULSANTS APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT SOL 10MG/ML
BRIVIACT TAB 10MG
BRIVIACT TAB 25MG
BRIVIACT TAB 50MG
BRIVIACT TAB 75MG
BRIVIACT TAB 100MG
carbamazepine cap er 12hr 100 mg
carbamazepine cap er 12hr 200 mg
carbamazepine cap er 12hr 300 mg
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
carbamazepine tab 200 mg
carbamazepine tab er 12hr 100 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
30
Drug Name Requirements/Limits
carbamazepine tab er 12hr 200 mg
carbamazepine tab er 12hr 400 mg
CARBATROL CAP 100MG +
CARBATROL CAP 200MG +
CARBATROL CAP 300MG +
CELONTIN CAP 300MG
DEPAKENE CAP 250MG +
DEPAKENE SOL 250/5ML +
DEPAKOTE ER TAB 250MG +
DEPAKOTE ER TAB 500MG +
DEPAKOTE SPR CAP 125MG +
DEPAKOTE TAB 125MG DR +
DEPAKOTE TAB 250MG DR +
DEPAKOTE TAB 500MG DR +
DIASTAT ACDL GEL 5-10MG +
DIASTAT ACDL GEL 12.5-20 +
DIASTAT PED GEL 2.5M GEL +
diazepam rectal gel delivery system 2.5 mg
diazepam rectal gel delivery system 10 mg
diazepam rectal gel delivery system 20 mg
DILANTIN CAP 30MG
DILANTIN CAP 100MG +
DILANTIN CHW 50MG +
DILANTIN-125 SUS 125/5ML +
divalproex sodium cap delayed release sprinkle
125 mg
divalproex sodium tab delayed release 125 mg
divalproex sodium tab delayed release 250 mg
divalproex sodium tab delayed release 500 mg
divalproex sodium tab er 24 hr 250 mg
divalproex sodium tab er 24 hr 500 mg
epitol tab 200mg
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
FANATREX SUS 25MG/ML
felbamate susp 600 mg/5ml
felbamate tab 400 mg
felbamate tab 600 mg
FELBATOL SUS 600/5ML +
FELBATOL TAB 400MG +
FELBATOL TAB 600MG +
FYCOMPA SUS 0.5MG/ML
FYCOMPA TAB 2MG
FYCOMPA TAB 4MG
FYCOMPA TAB 6MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
31
Drug Name Requirements/Limits
FYCOMPA TAB 8MG
FYCOMPA TAB 10MG
FYCOMPA TAB 12MG
gabapentin cap 100 mg QL (1080 per month)
gabapentin cap 300 mg QL (360 per month)
gabapentin cap 400 mg QL (270 per month)
gabapentin oral soln 250 mg/5ml QL (2100 mL per month)
gabapentin tab 600 mg QL (180 per month)
gabapentin tab 800 mg QL (120 per month)
GABITRIL TAB 2MG +
GABITRIL TAB 4MG +
GABITRIL TAB 12MG +
GABITRIL TAB 16MG +
KEPPRA SOL 100MG/ML +
KEPPRA TAB 250MG +
KEPPRA TAB 500MG +
KEPPRA TAB 750MG +
KEPPRA TAB 1000MG +
KEPPRA XR TAB 500MG +
KEPPRA XR TAB 750MG +
LAMICTAL CHW 5MG +
LAMICTAL CHW 25MG +
LAMICTAL KIT START 35 +
LAMICTAL KIT START 49 +
LAMICTAL KIT START 98 +
LAMICTAL ODT KIT +
LAMICTAL ODT TAB 25MG +
LAMICTAL ODT TAB 50MG +
LAMICTAL ODT TAB 100MG +
LAMICTAL ODT TAB 200MG +
LAMICTAL TAB 25MG +
LAMICTAL TAB 100MG +
LAMICTAL TAB 150MG +
LAMICTAL TAB 200MG +
LAMICTAL XR KIT
LAMICTAL XR TAB 25MG +
LAMICTAL XR TAB 50MG +
LAMICTAL XR TAB 100MG +
LAMICTAL XR TAB 200MG +
LAMICTAL XR TAB 250MG +
LAMICTAL XR TAB 300MG +
lamotrigine orally disintegrating tab 25 mg
lamotrigine orally disintegrating tab 50 mg
lamotrigine orally disintegrating tab 100 mg
lamotrigine orally disintegrating tab 200 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
33
Drug Name Requirements/Limits
NEURONTIN TAB 600MG QL (180 per month); +
NEURONTIN TAB 800MG QL (120 per month); +
ONFI SUS 2.5MG/ML
ONFI TAB 10MG
ONFI TAB 20MG
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
oxcarbazepine tab 150 mg
oxcarbazepine tab 300 mg
oxcarbazepine tab 600 mg
OXTELLAR XR TAB 150MG
OXTELLAR XR TAB 300MG
OXTELLAR XR TAB 600MG
PEGANONE TAB 250MG
phenobarbital elixir 20 mg/5ml
phenobarbital tab 15 mg
phenobarbital tab 16.2 mg
phenobarbital tab 30 mg
phenobarbital tab 32.4 mg
phenobarbital tab 60 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
phenobarbital tab 100 mg
PHENYTEK CAP 200MG +
PHENYTEK CAP 300MG +
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin sodium extended cap 200 mg
phenytoin sodium extended cap 300 mg
phenytoin susp 125 mg/5ml
primidone tab 50 mg
primidone tab 250 mg
SABRIL POW 500MG PA; SP, +
SABRIL TAB 500MG PA; SP
SPRITAM TAB 250MG
SPRITAM TAB 500MG
SPRITAM TAB 750MG
SPRITAM TAB 1000MG
TEGRETOL SUS 100/5ML +
TEGRETOL TAB 200MG +
TEGRETOL-XR TAB 100MG +
TEGRETOL-XR TAB 200MG +
TEGRETOL-XR TAB 400MG +
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg
tiagabine hcl tab 12 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
memantine hcl oral solution 2 mg/ml PA only applies to members less than 30 years of age
memantine hcl tab 5 mg PA only applies to members
less than 30 years of age
memantine hcl tab 5 mg (28) & 10 mg (21)
titration pak
PA only applies to members
less than 30 years of age
memantine hcl tab 10 mg PA only applies to members
less than 30 years of age
rivastigmine tartrate cap 1.5 mg PA
rivastigmine tartrate cap 3 mg PA
rivastigmine tartrate cap 4.5 mg PA
rivastigmine tartrate cap 6 mg PA
rivastigmine td patch 24hr 4.6 mg/24hr PA
rivastigmine td patch 24hr 9.5 mg/24hr PA
rivastigmine td patch 24hr 13.3 mg/24hr PA
ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG
APLENZIN TAB 348MG
APLENZIN TAB 522MG
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab er 12hr 100 mg
bupropion hcl tab er 12hr 150 mg
bupropion hcl tab er 12hr 200 mg
bupropion hcl tab er 24hr 150 mg
bupropion hcl tab er 24hr 300 mg
chlordiazepoxide-amitriptyline tab 5-12.5 mg
chlordiazepoxide-amitriptyline tab 10-25 mg
FORFIVO XL TAB 450MG
maprotiline hcl tab 25 mg
maprotiline hcl tab 50 mg
maprotiline hcl tab 75 mg
mirtazapine orally disintegrating tab 15 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
37
Drug Name Requirements/Limits
escitalopram oxalate soln 5 mg/5ml (base equiv)
escitalopram oxalate tab 5 mg (base equiv)
escitalopram oxalate tab 10 mg (base equiv)
escitalopram oxalate tab 20 mg (base equiv)
fluoxetine hcl (pmdd) cap 10 mg
fluoxetine hcl (pmdd) cap 20 mg
fluoxetine hcl (pmdd) tab 10 mg
fluoxetine hcl (pmdd) tab 20 mg
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl cap delayed release 90 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluoxetine hcl tab 60 mg
FLUOXETINE TAB 60MG +
LEXAPRO TAB 5MG +
LEXAPRO TAB 10MG +
LEXAPRO TAB 20MG +
paroxetine hcl tab 10 mg
paroxetine hcl tab 20 mg
paroxetine hcl tab 30 mg
paroxetine hcl tab 40 mg
paroxetine hcl tab er 24hr 12.5 mg
paroxetine hcl tab er 24hr 25 mg
paroxetine hcl tab er 24hr 37.5 mg
PAXIL CR TAB 12.5MG +
PAXIL CR TAB 25MG +
PAXIL CR TAB 37.5MG +
PAXIL SUS 10MG/5ML
PAXIL TAB 10MG +
PAXIL TAB 20MG +
PAXIL TAB 30MG +
PAXIL TAB 40MG +
PEXEVA TAB 10MG
PEXEVA TAB 20MG
PEXEVA TAB 30MG
PEXEVA TAB 40MG
PROZAC CAP 10MG +
PROZAC CAP 20MG +
PROZAC CAP 40MG +
SARAFEM TAB 10MG +
SARAFEM TAB 20MG +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
38
Drug Name Requirements/Limits
sertraline hcl oral concentrate for solution 20 mg/ml
duloxetine hcl enteric coated pellets cap 20 mg (base eq)
duloxetine hcl enteric coated pellets cap 30 mg (base eq)
duloxetine hcl enteric coated pellets cap 40 mg (base eq)
duloxetine hcl enteric coated pellets cap 60 mg (base eq)
EFFEXOR XR CAP 37.5MG +
EFFEXOR XR CAP 75MG +
EFFEXOR XR CAP 150MG +
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
39
Drug Name Requirements/Limits
FETZIMA CAP 120MG
FETZIMA CAP TITRATIO
KHEDEZLA TAB 50MG ER +
KHEDEZLA TAB 100MG ER +
PRISTIQ TAB 25MG +
PRISTIQ TAB 50MG +
PRISTIQ TAB 100MG +
venlafaxine hcl cap er 24hr 37.5 mg (base
equivalent)
venlafaxine hcl cap er 24hr 75 mg (base
equivalent)
venlafaxine hcl cap er 24hr 150 mg (base
equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
venlafaxine hcl tab er 24hr 37.5 mg (base equivalent)
venlafaxine hcl tab er 24hr 75 mg (base equivalent)
venlafaxine hcl tab er 24hr 150 mg (base equivalent)
venlafaxine hcl tab er 24hr 225 mg (base equivalent)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
42
Drug Name Requirements/Limits
ABILIFY TAB 2MG +
ABILIFY TAB 5MG +
ABILIFY TAB 10MG +
ABILIFY TAB 15MG +
ABILIFY TAB 20MG +
ABILIFY TAB 30MG +
aripiprazole oral solution 1 mg/ml
aripiprazole orally disintegrating tab 10 mg
aripiprazole orally disintegrating tab 15 mg
aripiprazole tab 2 mg
aripiprazole tab 5 mg
aripiprazole tab 10 mg
aripiprazole tab 15 mg
aripiprazole tab 20 mg
aripiprazole tab 30 mg
ARISTADA INJ 441MG/1.
ARISTADA INJ 662MG/2
ARISTADA INJ 882MG/3
ARISTADA INJ 1064MG
clozapine orally disintegrating tab 12.5 mg
clozapine orally disintegrating tab 25 mg
clozapine orally disintegrating tab 100 mg
clozapine orally disintegrating tab 150 mg
clozapine orally disintegrating tab 200 mg
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
CLOZARIL TAB 25MG +
CLOZARIL TAB 100MG +
FANAPT PAK
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FANAPT TAB 10MG
FANAPT TAB 12MG
FAZACLO TAB 12.5 ODT +
FAZACLO TAB 25MG ODT +
FAZACLO TAB 100 ODT +
FAZACLO TAB 150 ODT +
FAZACLO TAB 200 ODT +
GEODON CAP 20MG +
GEODON CAP 40MG +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
43
Drug Name Requirements/Limits
GEODON CAP 60MG +
GEODON CAP 80MG +
GEODON INJ 20MG
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
INVEGA SUST INJ 117/0.75
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234/1.5
INVEGA TAB 1.5MG +
INVEGA TAB 3MG +
INVEGA TAB 6MG +
INVEGA TAB 9MG +
INVEGA TRINZ INJ 273MG
INVEGA TRINZ INJ 410MG
INVEGA TRINZ INJ 546MG
INVEGA TRINZ INJ 819MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LATUDA TAB 120MG
NUPLAZID TAB 17MG SP
olanzapine for im inj 10 mg
olanzapine orally disintegrating tab 5 mg
olanzapine orally disintegrating tab 10 mg
olanzapine orally disintegrating tab 15 mg
olanzapine orally disintegrating tab 20 mg
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
olanzapine tab 15 mg
olanzapine tab 20 mg
olanzapine-fluoxetine hcl cap 3-25 mg
olanzapine-fluoxetine hcl cap 6-25 mg
olanzapine-fluoxetine hcl cap 6-50 mg
olanzapine-fluoxetine hcl cap 12-25 mg
olanzapine-fluoxetine hcl cap 12-50 mg
paliperidone tab er 24hr 1.5 mg
paliperidone tab er 24hr 3 mg
paliperidone tab er 24hr 6 mg
paliperidone tab er 24hr 9 mg
quetiapine fumarate tab 25 mg
quetiapine fumarate tab 50 mg
quetiapine fumarate tab 100 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
44
Drug Name Requirements/Limits
quetiapine fumarate tab 200 mg
quetiapine fumarate tab 300 mg
quetiapine fumarate tab 400 mg
quetiapine fumarate tab er 24hr 50 mg
quetiapine fumarate tab er 24hr 150 mg
quetiapine fumarate tab er 24hr 200 mg
quetiapine fumarate tab er 24hr 300 mg
quetiapine fumarate tab er 24hr 400 mg
REXULTI TAB 0.5MG
REXULTI TAB 0.25MG
REXULTI TAB 1MG
REXULTI TAB 2MG
REXULTI TAB 3MG
REXULTI TAB 4MG
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
RISPERDAL M TAB 0.5MG +
RISPERDAL SOL 1MG/ML +
RISPERDAL TAB 0.5MG +
RISPERDAL TAB 0.25MG +
RISPERDAL TAB 1MG +
RISPERDAL TAB 2MG +
RISPERDAL TAB 3MG +
RISPERDAL TAB 4MG +
risperidone orally disintegrating tab 0.5 mg
risperidone orally disintegrating tab 0.25 mg
risperidone orally disintegrating tab 1 mg
risperidone orally disintegrating tab 2 mg
risperidone orally disintegrating tab 3 mg
risperidone orally disintegrating tab 4 mg
risperidone soln 1 mg/ml
risperidone tab 0.5 mg
risperidone tab 0.25 mg
risperidone tab 1 mg
risperidone tab 2 mg
risperidone tab 3 mg
risperidone tab 4 mg
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL TAB 25MG +
SEROQUEL TAB 50MG +
SEROQUEL TAB 100MG +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
45
Drug Name Requirements/Limits
SEROQUEL TAB 200MG +
SEROQUEL TAB 300MG +
SEROQUEL TAB 400MG +
SEROQUEL XR TAB 50MG +
SEROQUEL XR TAB 150MG +
SEROQUEL XR TAB 200MG +
SEROQUEL XR TAB 300MG +
SEROQUEL XR TAB 400MG +
VERSACLOZ SUS 50MG/ML
VRAYLAR CAP 1.5-3MG
VRAYLAR CAP 1.5MG
VRAYLAR CAP 3MG
VRAYLAR CAP 4.5MG
VRAYLAR CAP 6MG
ziprasidone hcl cap 20 mg
ziprasidone hcl cap 40 mg
ziprasidone hcl cap 60 mg
ziprasidone hcl cap 80 mg
ZYPREXA INJ 10MG +
ZYPREXA RELP INJ 210MG
ZYPREXA RELP INJ 300MG
ZYPREXA RELP INJ 405MG
ZYPREXA TAB 2.5MG +
ZYPREXA TAB 5MG +
ZYPREXA TAB 7.5MG +
ZYPREXA TAB 10MG +
ZYPREXA TAB 15MG +
ZYPREXA TAB 20MG +
ZYPREXA ZYDI TAB 5MG +
ZYPREXA ZYDI TAB 10MG +
ZYPREXA ZYDI TAB 15MG +
ZYPREXA ZYDI TAB 20MG +
ANTIPSYCHOTICS, MISCELLANEOUS ADASUVE INH 10MG
CHLORPROMAZ INJ 25MG/ML
CHLORPROMAZ INJ 50MG/2ML
chlorpromazine hcl tab 10 mg
chlorpromazine hcl tab 25 mg
chlorpromazine hcl tab 50 mg
chlorpromazine hcl tab 100 mg
chlorpromazine hcl tab 200 mg
fluphenazine decanoate inj 25 mg/ml
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl inj 2.5 mg/ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
46
Drug Name Requirements/Limits
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
fluphenazine hcl tab 10 mg
haloperidol decanoate im soln 50 mg/ml
haloperidol decanoate im soln 100 mg/ml
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
loxapine succinate cap 5 mg
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 50 mg
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
perphenazine-amitriptyline tab 2-10 mg
perphenazine-amitriptyline tab 2-25 mg
perphenazine-amitriptyline tab 4-10 mg
perphenazine-amitriptyline tab 4-25 mg
perphenazine-amitriptyline tab 4-50 mg
thioridazine hcl tab 10 mg
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg
trifluoperazine hcl tab 1 mg (base equivalent)
trifluoperazine hcl tab 2 mg (base equivalent)
trifluoperazine hcl tab 5 mg (base equivalent)
trifluoperazine hcl tab 10 mg (base equivalent)
ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap er 24hr 5
mg QL (360 per month)
amphetamine-dextroamphetamine cap er 24hr 10 mg
QL (180 per days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
47
Drug Name Requirements/Limits
amphetamine-dextroamphetamine cap er 24hr 15 mg
QL (120 per month)
amphetamine-dextroamphetamine cap er 24hr 20 mg
QL (90 per month)
amphetamine-dextroamphetamine cap er 24hr 25 mg
QL (60 per month)
amphetamine-dextroamphetamine cap er 24hr 30 mg
QL (60 per month)
amphetamine-dextroamphetamine tab 5 mg QL (360 per month)
amphetamine-dextroamphetamine tab 7.5 mg QL (240 per month)
amphetamine-dextroamphetamine tab 10 mg QL (180 per days)
amphetamine-dextroamphetamine tab 12.5 mg QL (135 per month)
amphetamine-dextroamphetamine tab 15 mg QL (120 per month)
amphetamine-dextroamphetamine tab 20 mg QL (90 per month)
amphetamine-dextroamphetamine tab 30 mg QL (60 per month)
atomoxetine hcl cap 10 mg (base equiv) QL (120 per month); ST
(Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
atomoxetine hcl cap 18 mg (base equiv) QL (120 per month); ST (Must have recently been on
30 days of generic immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate cap sr 24hr)
atomoxetine hcl cap 25 mg (base equiv) QL (120 per month); ST
(Must have recently been on 30 days of generic immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate
cap sr 24hr)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
48
Drug Name Requirements/Limits
atomoxetine hcl cap 40 mg (base equiv) QL (60 per month); ST (Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
atomoxetine hcl cap 60 mg (base equiv) QL (30 per month); ST (Must have recently been on
30 days of generic immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
atomoxetine hcl cap 80 mg (base equiv) QL (30 per month); ST
(Must have recently been on 30 days of generic immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate
cap sr 24hr)
atomoxetine hcl cap 100 mg (base equiv) QL (30 per month); ST
(Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
dexmethylphenidate hcl tab 2.5 mg QL (600 per month)
dexmethylphenidate hcl tab 5 mg QL (300 per month)
dexmethylphenidate hcl tab 10 mg QL (150 per month)
dextroamphetamine sulfate cap er 24hr 5 mg QL (360 per month)
dextroamphetamine sulfate cap er 24hr 10 mg QL (180 per days)
dextroamphetamine sulfate cap er 24hr 15 mg QL (120 per month)
dextroamphetamine sulfate tab 5 mg QL (360 per month)
dextroamphetamine sulfate tab 10 mg QL (180 per days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
49
Drug Name Requirements/Limits
metadate tab 20mg er QL (150 per month); ST (Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl cap er 10 mg (cd) QL (300 per month)
methylphenidate hcl cap er 20 mg (cd) QL (150 per month)
methylphenidate hcl cap er 24hr 20 mg (la) QL (150 per month); ST
(Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl cap er 24hr 30 mg (la) QL (90 per month); ST (Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl cap er 24hr 40 mg (la) QL (60 per month); ST (Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl cap er 30 mg (cd) QL (90 per month)
methylphenidate hcl cap er 40 mg (cd) QL (60 per month)
methylphenidate hcl cap er 50 mg (cd) QL (60 per month)
methylphenidate hcl cap er 60 mg (cd) QL (30 per month)
methylphenidate hcl soln 5 mg/5ml QL (3000 mL per month)
methylphenidate hcl soln 10 mg/5ml QL (1500 mL per day)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
50
Drug Name Requirements/Limits
methylphenidate hcl tab 5 mg QL (600 per month)
methylphenidate hcl tab 10 mg QL (300 per month)
methylphenidate hcl tab 20 mg QL (150 per month)
methylphenidate hcl tab er 10 mg QL (300 per month); ST
(Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl tab er 20 mg QL (150 per month); ST (Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl tab er 24hr 18 mg QL (180 per days); ST (Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er 24hr 27 mg QL (120 per month); ST
(Must have recently been on 30 days of generic immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate
cap sr 24hr)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
51
Drug Name Requirements/Limits
methylphenidate hcl tab er 24hr 36 mg QL (90 per month); ST (Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl tab er 24hr 54 mg QL (60 per month); ST (Must have recently been on
30 days of generic immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er osmotic release (osm)
18 mg
QL (180 per days); ST
(Must have recently been on 30 days of generic immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er osmotic release (osm)
27 mg
QL (120 per month); ST
(Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
52
Drug Name Requirements/Limits
methylphenidate hcl tab er osmotic release (osm) 36 mg
QL (90 per month); ST (Must have recently been on 30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl tab er osmotic release (osm) 54 mg
QL (60 per month); ST (Must have recently been on
30 days of generic immediate-release ADHD drug, methylphenidate cap
HYPNOTICS, BENZODIAZEPINES temazepam cap 7.5 mg QL (15 per month)
temazepam cap 15 mg QL (15 per month)
temazepam cap 22.5 mg QL (15 per month)
temazepam cap 30 mg QL (15 per month)
HYPNOTICS, NON-BENZODIAZEPINES diphenhydramine hcl (sleep) cap 50 mg OTC
diphenhydramine hcl (sleep) tab 25 mg OTC
diphenhydramine hcl (sleep) tab 50 mg OTC
doxylamine succinate (sleep) tab 25 mg OTC
zolpidem tartrate tab 5 mg QL (30 per month)
zolpidem tartrate tab 10 mg QL (30 per month)
zolpidem tartrate tab er 6.25 mg QL (30 per month)
zolpidem tartrate tab er 12.5 mg QL (30 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
53
Drug Name Requirements/Limits
MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate nasal spray 4 mg/ml QL (8 units (1 kit) per
month)
ergotamine w/ caffeine tab 1-100 mg
MIGRAINE, SELECTIVE SEROTONIN AGONISTS naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST
(Must have recently been on
9 days of sumatriptan)
naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST
(Must have recently been on 9 days supply of sumatriptan)
naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST
(Must have recently been on 9 days of sumatriptan)
naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST (Must have recently been on 9 days supply of
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
54
Drug Name Requirements/Limits
sumatriptan succinate tab 50 mg QL (12 per month)
sumatriptan succinate tab 100 mg QL (12 per month)
zolmitriptan orally disintegrating tab 2.5 mg QL (12 per month); ST (Must have recently been on
9 days supply of sumatriptan)
zolmitriptan orally disintegrating tab 5 mg QL (12 per month); ST (Must have recently been on
9 days supply of sumatriptan)
zolmitriptan tab 2.5 mg QL (12 per month); ST (Must have recently been on
9 days supply of sumatriptan)
zolmitriptan tab 5 mg QL (12 per month); ST (Must have recently been on 9 days supply of
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
mg QL (Max 180 days per year); AL (covered for ages
18 and over)
CHANTIX PAK 0.5& 1MG QL (Max 180 days per
year); AL (covered for ages 18 and over)
CHANTIX PAK 1MG QL (Max 180 days per year); AL (covered for ages
18 and over)
CHANTIX TAB 0.5MG QL (Max 180 days per
year); AL (covered for ages 18 and over)
CHANTIX TAB 1MG QL (Max 180 days per year); AL (covered for ages
18 and over)
nicotine polacrilex gum 2 mg QL (Max 180 days per
year); OTC; AL (covered for ages 18 and over)
nicotine polacrilex gum 4 mg QL (Max 180 days per year); OTC; AL (covered for
ages 18 and over)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
57
Drug Name Requirements/Limits
nicotine td patch 24hr 7 mg/24hr QL (Max 180 days per year); OTC; AL (covered for ages 18 and over)
nicotine td patch 24hr 14 mg/24hr QL (Max 180 days per year); OTC; AL (covered for
ages 18 and over)
nicotine td patch 24hr 21 mg/24hr QL (Max 180 days per year); OTC; AL (covered for ages 18 and over)
ENDOCRINE AND METABOLIC ANDROGENS danazol cap 50 mg
INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
JANUMET TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer)
JANUMET XR TAB 50-500MG ST (Must try metformin, sulfonylurea, or insulin
sensitizer)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
58
Drug Name Requirements/Limits
JANUMET XR TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer)
JANUMET XR TAB 100-1000 ST (Must try metformin, sulfonylurea, or insulin
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
INVOKAMET TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin
sensitizer)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
60
Drug Name Requirements/Limits
INVOKAMET TAB 150-500 ST (Must try metformin, sulfonylurea, or insulin sensitizer)
INVOKAMET TAB 150-1000 ST (Must try metformin, sulfonylurea, or insulin
sensitizer)
INVOKAMET XR TAB 50-500MG ST (Must try metformin, sulfonylurea, or insulin sensitizer)
INVOKAMET XR TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin
sensitizer)
INVOKAMET XR TAB 150-500 ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
INVOKAMET XR TAB 150-1000 ST (Must try metformin, sulfonylurea, or insulin
INHIBITORS INVOKANA TAB 100MG ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
INVOKANA TAB 300MG ST (Must try metformin, sulfonylurea, or insulin
sensitizer)
ANTIDIABETICS, SULFONYLUREAS glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab er 24hr 2.5 mg
glipizide tab er 24hr 5 mg
glipizide tab er 24hr 10 mg
glyburide micronized tab 1.5 mg
glyburide micronized tab 3 mg
glyburide micronized tab 6 mg
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
ANTIDIABETICS, SUPPLIES ALCOHOL SWAB PAD QL (400 per month); OTC
BD INSULIN SYRINGE 0.3/30G OTC
BD INSULIN SYRINGE 0.3/31G OTC
BD INSULIN SYRINGE 0.5/30G OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
CONTRACEPTIVES, BIPHASIC desogest-eth estrad & eth estrad tab 0.15-
0.02/0.01 mg(21/5) Females only
CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA TAB 30MG QL (2 per year); Females
only
levonorgestrel tab 1.5 mg QL (2 per year); OTC; Females only
CONTRACEPTIVES, INJECTABLE medroxyprogesterone acetate im susp 150 mg/ml QL (1 mL per 3 months);
Females only
medroxyprogesterone acetate im susp prefilled syr
150 mg/ml
QL (1 mL per 3 months);
Females only
CONTRACEPTIVES, MISCELLANEOUS CONDOMS MIS QL (24 per month); OTC;
Males only
DIAPHRAGM QL (1 per year)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
62
Drug Name Requirements/Limits
ENCARE SUP 100MG OTC
GYNOL II GEL 3% OTC
nonoxynol-9 gel 4% OTC
SHUR-SEAL GEL 2% OTC
VCF VAGINAL AER CONTRACP OTC
VCF VAGINAL MIS CONTRACP OTC
CONTRACEPTIVES, MONOPHASIC, 20 mcg Estrogen drospirenone-ethinyl estradiol tab 3-0.02 mg Females only
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
Females only
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
Females only
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
63
Drug Name Requirements/Limits
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg
ESTROGEN/PROGESTIN, TRANSDERMAL COMBIPATCH DIS .05/.14 Females only
COMBIPATCH DIS .05/.25 Females only
ESTROGENS, ORAL estradiol tab 0.5 mg Females only
estradiol tab 1 mg Females only
estradiol tab 2 mg Females only
estropipate tab 0.75 mg Females only
estropipate tab 1.5 mg Females only
ESTROGENS, TRANSDERMAL estradiol td patch weekly 0.1 mg/24hr Females only
estradiol td patch weekly 0.05 mg/24hr Females only
estradiol td patch weekly 0.06 mg/24hr Females only
estradiol td patch weekly 0.025 mg/24hr Females only
estradiol td patch weekly 0.075 mg/24hr Females only
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)
Females only
ESTROGENS, VAGINAL estradiol vaginal tab 10 mcg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol oral soln 1 mcg/ml
doxercalciferol cap 0.5 mcg
doxercalciferol cap 1 mcg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
aprepitant capsule 80 mg QL (16 caps per 21 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
69
Drug Name Requirements/Limits
aprepitant capsule 125 mg QL (4 caps per 21 days), PA
ANTISPASMODICS chlordiazepoxide hcl-clidinium bromide cap 5-2.5
mg
dicyclomine hcl cap 10 mg
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
hyoscyamine sulfate elixir 0.125 mg/5ml
hyoscyamine sulfate soln 0.125 mg/ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
71
Drug Name Requirements/Limits
IRRITABLE BOWEL SYNDROME WITH CONSTIPATION/CHRONIC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
72
Drug Name Requirements/Limits
simethicone cap 180 mg OTC
simethicone chew tab 80 mg OTC
simethicone chew tab 125 mg OTC
simethicone liquid 40 mg/0.6ml OTC
simethicone susp 40 mg/0.6ml OTC
sucralfate tab 1 gm
OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG
MOVANTIK TAB 25MG
PANCREATIC ENZYMES CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
VIOKACE TAB
VIOKACE TAB 20880
ZENPEP CAP
ZENPEP CAP 3000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
PROSTAGLANDINS misoprostol tab 100 mcg
misoprostol tab 200 mcg
PROTON PUMP INHIBITORS esomeprazole magnesium cap delayed release 20
mg (base eq)
QL (30 per month)
lansoprazole cap delayed release 15 mg QL (30 per month); OTC
NEXIUM 24HR TAB 20MG QL (30 per month); OTC
NEXIUM GRA 2.5MG DR QL (30 per month); AL (Covered for ages less than
1 only)
NEXIUM GRA 5MG DR QL (30 per month); AL
(Covered for ages less than 1 only)
NEXIUM GRA 10MG DR QL (30 per month); AL (Covered for ages less than
1 only)
omeprazole cap delayed release 10 mg QL (30 per month)
omeprazole cap delayed release 20 mg QL (30 per month)
omeprazole cap delayed release 40 mg QL (30 per month)
omeprazole magnesium cap dr 20.6 mg (20 mg base equiv)
QL (30 per month); OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
73
Drug Name Requirements/Limits
OMEPRAZOLE TAB 20MG OTC
omeprazole-sodium bicarbonate cap 20-1100 mg QL (30 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
cyclosporine cap 25 mg
cyclosporine cap 100 mg
cyclosporine modified cap 25 mg
cyclosporine modified cap 50 mg
cyclosporine modified cap 100 mg
cyclosporine modified oral soln 100 mg/ml
ENVARSUS XR TAB 0.75MG
ENVARSUS XR TAB 1MG
ENVARSUS XR TAB 4MG
gengraf cap 25mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
77
Drug Name Requirements/Limits
gengraf cap 50mg
gengraf cap 100mg
gengraf sol 100mg/ml
NEORAL CAP 25MG +
NEORAL CAP 100MG +
NEORAL SOL 100MG/ML +
PROGRAF CAP 0.5MG +
PROGRAF CAP 1MG +
PROGRAF CAP 5MG +
SANDIMMUNE CAP 25MG +
SANDIMMUNE CAP 100MG +
SANDIMMUNE SOL 100MG/ML
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML
RAPAMUNE TAB 0.5MG +
RAPAMUNE TAB 1MG +
RAPAMUNE TAB 2MG +
sirolimus tab 0.5 mg
sirolimus tab 1 mg
sirolimus tab 2 mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
VACCINES ADACEL INJ AL (covered for ages 19 and
over)
BOOSTRIX INJ AL (covered for ages 19 and over)
DAPTACEL INJ AL (covered for ages 19 and over)
DIP/TET PED INJ 25-5LFU AL (covered for ages 19 and over)
ENGERIX-B INJ 10/0.5ML QL (3 vaccines per lifetime); AL (covered for ages 19 and
over)
ENGERIX-B INJ 20MCG/ML QL (3 vaccines per lifetime);
AL (covered for ages 19 and over)
GARDASIL 9 INJ QL (3 vaccines per lifetime); AL (covered for ages 19-26)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
78
Drug Name Requirements/Limits
HAVRIX INJ 720UNIT QL (2 vaccines per lifetime); AL (covered for ages 19 and over)
HAVRIX INJ 1440UNIT QL (2 vaccines per lifetime); AL (covered for ages 19 and
over)
INFANRIX INJ AL (covered for ages 19 and over)
M-M-R II INJ AL (covered for ages 19 and over)
MENACTRA INJ AL (covered for ages 19 and over)
MENVEO INJ AL (covered for ages 19 and over)
PNEUMOVAX 23 INJ 25/0.5 AL (covered for ages 19 and over)
RECOMBIVA HB INJ 5MCG/0.5 QL (3 vaccines per lifetime); AL (covered for ages 19 and
over)
RECOMBIVA HB INJ 10MCG/ML QL (3 vaccines per lifetime);
AL (covered for ages 19 and over)
RECOMBIVA-HB INJ 40MCG/ML QL (3 vaccines per lifetime); AL (covered for ages 19 and
over)
TENIVAC INJ 5-2LF AL (covered for ages 19 and
over)
TET/DIP TOX INJ 2-2 LF AL (covered for ages 19 and
over)
TWINRIX INJ QL (3 vaccines per lifetime);
AL (covered for ages 19 and over)
VAQTA INJ 25/0.5ML QL (2 vaccines per lifetime); AL (covered for ages 19 and
over)
VAQTA INJ 50UNT/ML QL (2 vaccines per lifetime);
AL (covered for ages 19 and over)
VARIVAX INJ AL (covered for ages 19 and over)
ZOSTAVAX INJ AL (covered for ages 60 and over)
MISCELLANEOUS DIAGNOSTIC AGENTS CHEMSTRIP 2 TES GP QL (100 per month); OTC
CHEMSTRIP 5 TES OB QL (100 per month); OTC
CHEMSTRIP 7 TES QL (100 per month); OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
79
Drug Name Requirements/Limits
CHEMSTRIP 9 TES STRIPS QL (100 per month); OTC
CHEMSTRIP 10 TES MD QL (100 per month); OTC
CHEMSTRIP TES -10 SG QL (100 per month); OTC
COMBISTIX TES QL (100 per month); OTC
HEMA-COMBIST TES QL (100 per month); OTC
LABSTIX TES QL (100 per month); OTC
MULTISTIX 5 TES QL (100 per month); OTC
MULTISTIX 7 TES QL (100 per month); OTC
MULTISTIX 8 TES SG QL (100 per month); OTC
MULTISTIX 9 TES QL (100 per month); OTC
MULTISTIX 9 TES SG QL (100 per month); OTC
MULTISTIX 10 TES SG QL (100 per month); OTC
MULTISTIX TES QL (100 per month); OTC
URISTIX 4 TES QL (100 per month); OTC
URISTIX TES QL (100 per month); OTC
MEDICAL SUPPLIES bandages: adhesive, elastic, gauze OTC
calcium carbonate-cholecalciferol cap 600 mg-500 unit
OTC
calcium carbonate-cholecalciferol chew tab 500 mg-400 unit
OTC
calcium carbonate-cholecalciferol chew tab 500 mg-600 unit
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
80
Drug Name Requirements/Limits
calcium carbonate-cholecalciferol tab 250 mg-125 unit
OTC
calcium carbonate-cholecalciferol tab 500 mg-125 unit
OTC
calcium carbonate-cholecalciferol tab 500 mg-200 unit
OTC
calcium carbonate-cholecalciferol tab 500 mg-400 unit
OTC
calcium carbonate-cholecalciferol tab 600 mg-200 unit
OTC
calcium carbonate-cholecalciferol tab 600 mg-400 unit
OTC
calcium carbonate-cholecalciferol tab 600 mg-800 unit
OTC
calcium carbonate-vitamin d cap 600 mg-200 unit OTC
calcium carbonate-vitamin d chew tab 600 mg-400
unit
OTC
calcium carbonate-vitamin d tab 250 mg-125 unit OTC
calcium carbonate-vitamin d tab 500 mg-125 unit OTC
calcium carbonate-vitamin d tab 500 mg-200 unit OTC
calcium carbonate-vitamin d tab 500 mg-400 unit OTC
calcium carbonate-vitamin d tab 600 mg-125 unit OTC
calcium carbonate-vitamin d tab 600 mg-200 unit OTC
calcium carbonate-vitamin d tab 600 mg-400 unit OTC
calcium w/ vitamin d & k chew tab 500 mg-100 unit-40 mcg
OTC
calcium w/ vitamin d & k chew tab 500 mg-200 unit-40 mcg
OTC
calcium w/ vitamin d & k chew tab 500 mg-500 unit-40 mcg
OTC
calcium w/ vitamin d tab 600 mg-200 unit OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
81
Drug Name Requirements/Limits
calcium-mag-vit c-vit d cap 185 mg-28 mg-2.5 mg-200 unit
OTC
calcium-magnesium-zinc tab 333-133-5 mg OTC
calcium-magnesium-zinc tab 333-133-8.3 mg OTC
oyster shell calcium tab 500 mg OTC
VITAMINS AND MINERALS, FOLIC ACID/COMBINATIONS folic acid tab 1 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
82
Drug Name Requirements/Limits
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)
OTC
ferrous sulfate tab er 47.5 mg (elemental fe) OTC
ferrous sulfate tab er 50 mg (elemental fe) OTC
ferrous sulfate tab er 142 mg (45 mg fe
equivalent)
OTC
iron combination cap
iron combination cap OTC
iron polysacch complex-vit b12-fa cap 150-0.025-1 mg
iron polysacch complex-vit b12-fa cap 150-0.025-1 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
multiple vitamin cap OTC; AL (covered for ages 20 and under)
multiple vitamin tab OTC; AL (covered for ages
20 and under)
multiple vitamins w/ calcium tab OTC; AL (covered for ages
20 and under)
multiple vitamins w/ iron tab OTC; AL (covered for ages
20 and under)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
84
Drug Name Requirements/Limits
multiple vitamins w/ minerals & fa tab 1.25 mg AL (covered for ages 20 and under)
multiple vitamins w/ minerals cap AL (covered for ages 20 and under)
multiple vitamins w/ minerals cap OTC; AL (covered for ages 20 and under)
multiple vitamins w/ minerals chew tab OTC; AL (covered for ages 20 and under)
multiple vitamins w/ minerals effer tab OTC; AL (covered for ages 20 and under)
multiple vitamins w/ minerals liquid OTC; AL (covered for ages 20 and under)
multiple vitamins w/ minerals tab AL (covered for ages 20 and under)
multiple vitamins w/ minerals tab OTC; AL (covered for ages 20 and under)
multiple vitamins w/ minerals tab er OTC; AL (covered for ages 20 and under)
NASCOBAL SPR 500MCG
niacin cap er 250 mg OTC
niacin cap er 500 mg OTC
niacin oral powder
niacin tab 50 mg OTC
niacin tab 100 mg OTC
niacin tab 250 mg OTC
niacin tab 500 mg OTC
niacin tab er 250 mg OTC
niacin tab er 500 mg OTC
niacin tab er 750 mg OTC
niacin w/ inositol cap 400-100 mg OTC
niacinamide tab 100 mg OTC
niacinamide tab 500 mg OTC
omega-3 fatty acids - oral liquid OTC
omega-3 fatty acids cap 300 mg OTC
omega-3 fatty acids cap 435 mg OTC
omega-3 fatty acids cap 500 mg OTC
omega-3 fatty acids cap 1000 mg OTC
omega-3 fatty acids cap 1200 mg OTC
omega-3 fatty acids chew tab 113.5 mg OTC
pantothenic acid tab 500 mg OTC
pediatric multiple vitamin liq OTC; AL (covered for ages
20 and under)
pediatric multiple vitamin w/ c & fa chew tab OTC; AL (covered for ages
20 and under)
pediatric multiple vitamin w/ c soln 35 mg/ml OTC; AL (covered for ages 20 and under)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
85
Drug Name Requirements/Limits
pediatric multiple vitamin w/ extra c & fa chew tab OTC; AL (covered for ages 20 and under)
pediatric multiple vitamin w/ minerals & c chew tab
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
87
Drug Name Requirements/Limits
EPIPEN 2-PAK INJ 0.3MG QL (8 per year)
EPIPEN-JR INJ 2-PAK QL (8 per year)
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER 62.5-25 QL (1 inhaler per month)
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT
ACTING COMBIVENT AER 20-100 QL (2 inhalers per month)
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml QL (540 mL per month)
ANTICHOLINERGICS INCRUSE ELPT INH 62.5MCG QL (1 inhaler per month)
ipratropium bromide inhal soln 0.02% QL (313 mL per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
89
Drug Name Requirements/Limits
dextromethorphan-guaifenesin tab er 12hr 30-600 mg
OTC
dextromethorphan-guaifenesin tab er 12hr 60-1200 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
90
Drug Name Requirements/Limits
albuterol sulfate tab 4 mg
albuterol sulfate tab er 12hr 4 mg
albuterol sulfate tab er 12hr 8 mg
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
CYSTIC FIBROSIS BETHKIS NEB 300/4ML PA; SP
KALYDECO PAK 50MG PA; SP
KALYDECO PAK 75MG PA; SP
KALYDECO TAB 150MG PA; SP
ORKAMBI TAB 100-125 PA; SP
ORKAMBI TAB 200-125 PA; SP
PULMOZYME SOL 1MG/ML PA; SP
tobramycin nebu soln 300 mg/5ml PA; SP
DECONGESTANT/EXPECTORANT COMBINATIONS pseudoephedrine-guaifenesin tab er 12hr 60-600
mg OTC
pseudoephedrine-guaifenesin tab er 12hr 120-1200 mg
cromolyn sodium soln nebu 20 mg/2ml QL (240 mL per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
91
Drug Name Requirements/Limits
MEDICAL SUPPLIES AERCHMBR PLS MIS LRG MASK QL (2 per year)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
TOPICAL DERMATOLOGY, ACNE, Oral claravis cap 10mg PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
93
Drug Name Requirements/Limits
claravis cap 20mg PA
claravis cap 30mg PA
claravis cap 40mg PA
myorisan cap 10mg PA
myorisan cap 20mg PA
myorisan cap 30mg PA
myorisan cap 40mg PA
zenatane cap 10mg PA
zenatane cap 20mg PA
zenatane cap 30mg PA
zenatane cap 40mg PA
DERMATOLOGY, ACNE, Topical BENZOYL PER GEL 2.5% OTC
benzoyl peroxide cream 2.5% OTC
benzoyl peroxide cream 10% OTC
benzoyl peroxide gel 5% OTC
benzoyl peroxide gel 10% OTC
benzoyl peroxide liq 2.5%
benzoyl peroxide liq 4% OTC
benzoyl peroxide liq 5% OTC
benzoyl peroxide liq 5.25%
benzoyl peroxide liq 5.25% OTC
benzoyl peroxide liq 7%
benzoyl peroxide liq 10%
benzoyl peroxide liq 10% OTC
benzoyl peroxide lotion 6%
benzoyl peroxide lotion 6% OTC
benzoyl peroxide-erythromycin gel 5-3%
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
erythromycin gel 2%
erythromycin soln 2%
sulfacetamide sodium lotion 10% (acne)
tretinoin cream 0.1% ST (Members 35 years and older must have recently
been on 30 days of a topical formulary alternative)
tretinoin cream 0.05% ST (Members 35 years and older must have recently
been on 30 days of a topical formulary alternative)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
94
Drug Name Requirements/Limits
tretinoin cream 0.025% ST (Members 35 years and older must have recently been on 30 days of a topical
formulary alternative)
tretinoin gel 0.01% ST (Members 35 years and
older must have recently been on 30 days of a topical
formulary alternative)
tretinoin gel 0.025% ST (Members 35 years and
older must have recently been on 30 days of a topical
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
alclometasone dipropionate oint 0.05% QL (120 grams per 25 days)
desonide cream 0.05% QL (120 grams per 25 days)
desonide lotion 0.05% QL (120 mL per 25 days)
desonide oint 0.05% QL (120 grams per 25 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
96
Drug Name Requirements/Limits
fluocinolone acetonide soln 0.01%
hydrocortisone acetate cream 1% OTC
hydrocortisone cream 0.5% OTC
hydrocortisone cream 1%
hydrocortisone cream 1% OTC
hydrocortisone cream 2.5%
hydrocortisone gel 1% OTC
hydrocortisone lotion 1% OTC
hydrocortisone lotion 2.5%
hydrocortisone oint 0.5% OTC
hydrocortisone oint 1%
hydrocortisone oint 1% OTC
hydrocortisone oint 2.5%
hydrocortisone soln 1% OTC
DERMATOLOGY, CORTICOSTEROIDS, Medium Potency betamethasone valerate cream 0.1% (base
desoximetasone cream 0.05% QL (120 grams per 25 days)
fluocinolone acetonide cream 0.025% QL (120 grams per 25 days)
fluocinolone acetonide oint 0.025% QL (120 grams per 25 days)
fluticasone propionate cream 0.05% QL (120 grams per 25 days)
fluticasone propionate oint 0.005% QL (120 grams per 25 days)
hydrocortisone butyrate cream 0.1% QL (120 grams per 25 days)
hydrocortisone butyrate oint 0.1% QL (120 grams per 25 days)
hydrocortisone butyrate soln 0.1%
hydrocortisone valerate cream 0.2% QL (120 grams per 25 days)
hydrocortisone valerate oint 0.2% QL (120 grams per 25 days)
mometasone furoate cream 0.1% QL (120 grams per 25 days)
mometasone furoate oint 0.1% QL (120 grams per 25 days)
mometasone furoate solution 0.1% (lotion)
triamcinolone acetonide cream 0.1%
triamcinolone acetonide cream 0.025%
triamcinolone acetonide lotion 0.1%
triamcinolone acetonide lotion 0.025%
triamcinolone acetonide oint 0.1%
triamcinolone acetonide oint 0.025%
DERMATOLOGY, CORTICOSTEROIDS, Very High Potency betamethasone dipropionate augmented gel
0.05% QL (120 grams per 25 days)
betamethasone dipropionate augmented oint 0.05%
QL (120 grams per 25 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
97
Drug Name Requirements/Limits
clobetasol propionate cream 0.05% QL (120 grams per 25 days)
clobetasol propionate foam 0.05%
clobetasol propionate gel 0.05% QL (120 grams per 25 days)
clobetasol propionate oint 0.05% QL (120 grams per 25 days)
clobetasol propionate soln 0.05%
diflorasone diacetate oint 0.05% QL (120 grams per 25 days)
halobetasol propionate cream 0.05% QL (120 grams per 25 days)
halobetasol propionate oint 0.05% QL (120 grams per 25 days)
NATRAPEL 12H SPR 20% QL (2 per 30 days); OTC; Females aged 14-45 years
old only
OFF DEEP WDS AER 25% QL (2 per 30 days); OTC; Females aged 14-45 years old only
REPEL SPORTS AER 25% QL (2 per 30 days); OTC; Females aged 14-45 years
old only
SAWYER REPEL SPR 20% QL (2 per 30 days); OTC;
Females aged 14-45 years old only
DERMATOLOGY, LOCAL ANALGESICS lidocaine patch 5% PA
DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl soln 4%
lidocaine-prilocaine cream 2.5-2.5% QL (30 grams per month)
lidocaine-prilocaine cream kit 2.5-2.5%
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA CRE 10% OTC
CALAMINE LOT OTC
CALAMINE LOT 8-8% OTC
imiquimod cream 5%
podofilox soln 0.5%
SM CALAMINE LOT OTC
DERMATOLOGY, ROSACEA metronidazole cream 0.75%
metronidazole gel 0.75%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
98
Drug Name Requirements/Limits
metronidazole gel 1% ST (Must have recently been on 60 days of metronidazole 0.075%)
metronidazole lotion 0.75%
DERMATOLOGY, SCABICIDES AND PEDICULICIDES malathion lotion 0.5% ST (Must have recently been
on 14 days of permethrin)
permethrin aerosol 0.5% OTC
permethrin cream 5%
permethrin creme rinse 1% OTC
permethrin lotion 1% OTC
spinosad susp 0.9% ST (Must have recently been on 14 days of permethrin)
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol 1.75-10000-
0.025mg-unt-mg/ml
ofloxacin ophth soln 0.3%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy SP - Specialty Drug OTC - Over the Counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit
101
Drug Name Requirements/Limits
brimonidine tartrate ophth soln 0.15%
OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRODEX SUS 0.3-0.1%
XOLAIR SOL 150MG ......................... 91 Y YODEFAN-NF LIQ 200-5ML ................ 90 Z ZARONTIN CAP 250MG ..................... 34 ZARONTIN SOL 250/5ML ................... 34
ZEJULA CAP 100MG .......................... 17 ZELBORAF TAB 240MG...................... 17
zenatane cap 10mg .......................... 93 zenatane cap 20mg .......................... 93
zenatane cap 30mg .......................... 93
zenatane cap 40mg .......................... 93 ZENPEP CAP .................................... 72
ZENPEP CAP 10000UNT ..................... 72 ZENPEP CAP 15000UNT ..................... 72
ZENPEP CAP 20000UNT ..................... 72 ZENPEP CAP 25000UNT ..................... 72
ZENPEP CAP 3000UNIT ..................... 72 ZERIT CAP 15MG .............................. 11
ZERIT CAP 20MG .............................. 11 ZERIT CAP 30MG .............................. 11
ZERIT CAP 40MG .............................. 11 ZERIT SOL 1MG/ML .......................... 11
ZIAGEN SOL 20MG/ML ...................... 11 ZIAGEN TAB 300MG ......................... 11